Tuesday, August 12, 2008
Mesenteric ischemia
Mesenteric ischemia
In the earlier days the surgical treatment of mesenteric ischemia was removal of infracted bowel before the patient was moribund. Klass, in 1951 was the first surgeon to focus on restoration of arterial supply to salvage the gut and performed the first SMA embolectomy. In the next two decades, many more reports of mesenteric revascularization came in but mortality remained high, to the tune of 70 – 90%.
Presently with improved surgical and endovascular techniques and improvement in anesthesia and critical care, morbidity and mortality still remains high. Delay in diagnosis remains the greatest obstacle to the reduction of morbidity and mortality surrounding this disease.
Anatomy
Three major branches from the abdominal aorta supply the GI tract. Celiac artery arises at level T12-L1 and divides into common hepatic, left gastric and splenic arteries. The superior mesenteric artery arises at level of L1 and branches into inferior pancreaticoduodenal, middle colic and jejunal and ilieal branches. The inferior mesenteric artery arises at level of L3 and divides into left colic and sigmoidal branches. The splanchnic circulation is characterized by a wide network of collateral blood pathways that impart redundancy and resultant protection from ischemia or infarction. The celiac axis and SMA are connected by the superior and inferior pancreatico-duodenal arteries and the SMA and IMA by the marginal artery of Drummond.
Pathophysiology
Splanchnic blood flow can range from 10 to 35% of cardiac output. The increase occurs in response to food intake. Two of the three mesenteric arteries must be significantly diseased to cause symptoms of chronic mesenteric ischemia (CMI) and SMA must be one of them. Sudden occlusion of SMA alone can cause acute ischemia.
Acute mesenteric ischemia
It can be due to emboli to SMA or thrombosis of SMA. Most emboli are cardiac in origin and sometimes are from proximal aorta. Sudden onset of abdominal pain in a patient with cardiac disease must alert the clinician to the possibility of mesenteric embolism. Thrombosis usually occurs on pre-existing chronic disease.
For diagnosis, a clinical suspicion is mandatory. Patient with cardiac disease, sudden onset of severe, continuous abdominal pain, often accompanied by diarrhea or vomiting must alert the clinician. There is accompanying leucocytosis. Other lab parameters and x-ray findings are seen only later in the course of the disease once bowel is infarcted. Elevated levels of intestinal fatty acid binding protein may offer some promise as a diagnostic tool.
Duplex scan requires the presence of a trained vascular radiologist, a fasting patient and bowel bereft of gas: a combination nearly impossible to achieve in an emergency setting. Multi-slice CT scan can demonstrate occluded vessels (upto second generation branches), bowel wall edema, stranding in the mesentery. In addition, other pathologies could also be easily detected.
A high index of suspicion followed up by multi-slice CT on emergency basis is likely to provide the best chance of diagnosis and an opportunity for revascularization.
On angiography, SMA is found occluded at or near origin in case of thrombosis and affects the entire bowel from ligament of Treitz to mid transverse colon. In contrast, an embolus lodges at a branch point and the proximal jejunal branches are often spared.
Treatment
Initial management includes correction of fluid and electrolyte imbalances, baseline cardiac assessment, broad spectrum parenteral antibiotics and anticoagulation.
Endovascular therapy with fibrinolysis should not be attempted since there is a very high risk of ongoing bowel damage during the period of lysis.
Surgery is the mainstay of treatment and begins with a complete exploratory laparotomy and assessment of bowel viability. Lower limbs must be included in draping for vein harvesting. In case there is extensive bowel infarction incompatible with life, it is appropriate to close with no further intervention. Revascularization is done either by SMA embolectomy or superior mesenteric artery bypass, usually from the infra-renal aorta. Bowel viability must be re-assessed after restoring blood supply and appropriate resection done. When there is doubt about bowel viability, re-look laparotomy is done after 12-36 hours.
Chronic mesenteric ischemia
It is a life-threatening problem that can result in death due to inanition or bowel infarction. The underlying pathophysiology is the failure to achieve post-prandial hyperemic blood flow. While atherosclerosis is the leading cause for CMI, other etiologies include Takayasu’s disease, aortic dissection, fibromuscular disease, SLE, Rheumatoid arthritis and drugs like cocaine and ergot.
A typical patient is cachectic, middle-aged, with history of smoking who presents with post-prandial abdominal pain and weight loss. The pain is usually epigastric and causes patients to avoid certain foods or eating altogether (food fear). Most patients often undergo extensive GI checkup before someone suspects CMI. Gastric ulceration or gastroduodenitis are often seen due to ischemia.
A Duplex ultrasound is a good screening modality. Angiography is diagnostic and helps in planning revascularization strategies.
Treatment
All patients with CMI should be taken up for revascularization even if co-morbid factors increase risk of surgery. While long term total parenteral nutrition has been considered an option in high risk patients, it is practically inconvenient, carries risk of catheter related infections and does not alleviate the risk of bowel infarction.
Revascularization options include angioplasty and stenting and mesenteric artery bypass. There is no clear cut agreement in literature as to which is the better option and as to how many vessels should be revascularized. Synthetic grafts or femoral veins are best conduits for mesenteric bypass. Inflow may be taken from supraceliac aorta, infra-renal aorta or an aortic graft. All patients are maintained on anti-platelet agents and statins.
Median arcuate ligament syndrome
The median arcuate ligament of the diaphragm compresses the origin of celiac axis which is augmented by full expiration in a large number of individuals. Its contribution to CMI is uncertain and it is unlikely to be able to produce CMI on its own. It is a diagnosis of exclusion. Surgical therapy may offer relief in patients who are females, have postprandial pain, weight loss more than 8 kgs, absence of drug abuse or psychiatric history and angiographic confirmation of celiac axis compression with post-stenotic dilatation. Effective treatment includes relief of compression and mesenteric bypass. Another option could be laparoscopic division of the ligament followed by angioplasty of celiac axis.
Non-Occlusive Mesenteric Ischemia (NOMI)
NOMI is caused by primary splanchnic vasoconstriction and has high mortality. It is associated with shock state, cardiopulmonary bypass and use of vasoactive drugs like digoxin, vasopression and α-adrenergic agents.
Management
Early arteriographic diagnosis and subsequent intervention offer the best chance for better outcome and survival. Pain out of proportion to physical findings and normal radiographic findings are suggestive of early ischemia and should prompt consideration of immediate diagnostic arteriography. Other biochemical and radiological findings as seen in acute ischemia, are indicative of bowel infarction. Arteriographic criteria for diagnosis of NOMI include narrowing origins of multiple branches of SMA, string of sausage sign, spasm of mesenteric arcades and impaired filling of intramural branches.
Treatment includes immediate management of precipitating factors like shock and cardiac events and use of vasodilators that diminish cardiac preload and afterload. Definitive treatment is selective intra-arterial infusion of papaverine into the SMA. It is best to start with 30 mg/hr. Arteriography is repeated once pain resolves and infusion is continued for 24 hours. One needs to be vigilant for signs of bowel infarction and intervene appropriately.
Mesenteric venous thrombosis
It is a rare disorder with a wide range of clinical presentations. It usually involves the superior mesenteric and splenic veins and may involve inferior mesenteric and portal veins.
One should suspect this diagnosis in patients with acute abdomen with history of previous thrombotic episodes or known thrombophilia. Others may present pain and loss of appetite, often of a few days duration, diarrhea, occult GI bleed and occasionally bowel infarction and peritonitis. There may be mild leucocytosis and slightly elevated LDH. Diagnosis can be confirmed by venous phase of CT scan or with contrast enhanced MR venography. Color Doppler can often show presence of thrombi in the veins.
Treatment is usually conservative with life-long anticoagulation. Aggressive management with surgery or thrombolysis can be done in selected patients. Any associated hypercoagulable state must be appropriately treated.
In the earlier days the surgical treatment of mesenteric ischemia was removal of infracted bowel before the patient was moribund. Klass, in 1951 was the first surgeon to focus on restoration of arterial supply to salvage the gut and performed the first SMA embolectomy. In the next two decades, many more reports of mesenteric revascularization came in but mortality remained high, to the tune of 70 – 90%.
Presently with improved surgical and endovascular techniques and improvement in anesthesia and critical care, morbidity and mortality still remains high. Delay in diagnosis remains the greatest obstacle to the reduction of morbidity and mortality surrounding this disease.
Anatomy
Three major branches from the abdominal aorta supply the GI tract. Celiac artery arises at level T12-L1 and divides into common hepatic, left gastric and splenic arteries. The superior mesenteric artery arises at level of L1 and branches into inferior pancreaticoduodenal, middle colic and jejunal and ilieal branches. The inferior mesenteric artery arises at level of L3 and divides into left colic and sigmoidal branches. The splanchnic circulation is characterized by a wide network of collateral blood pathways that impart redundancy and resultant protection from ischemia or infarction. The celiac axis and SMA are connected by the superior and inferior pancreatico-duodenal arteries and the SMA and IMA by the marginal artery of Drummond.
Pathophysiology
Splanchnic blood flow can range from 10 to 35% of cardiac output. The increase occurs in response to food intake. Two of the three mesenteric arteries must be significantly diseased to cause symptoms of chronic mesenteric ischemia (CMI) and SMA must be one of them. Sudden occlusion of SMA alone can cause acute ischemia.
Acute mesenteric ischemia
It can be due to emboli to SMA or thrombosis of SMA. Most emboli are cardiac in origin and sometimes are from proximal aorta. Sudden onset of abdominal pain in a patient with cardiac disease must alert the clinician to the possibility of mesenteric embolism. Thrombosis usually occurs on pre-existing chronic disease.
For diagnosis, a clinical suspicion is mandatory. Patient with cardiac disease, sudden onset of severe, continuous abdominal pain, often accompanied by diarrhea or vomiting must alert the clinician. There is accompanying leucocytosis. Other lab parameters and x-ray findings are seen only later in the course of the disease once bowel is infarcted. Elevated levels of intestinal fatty acid binding protein may offer some promise as a diagnostic tool.
Duplex scan requires the presence of a trained vascular radiologist, a fasting patient and bowel bereft of gas: a combination nearly impossible to achieve in an emergency setting. Multi-slice CT scan can demonstrate occluded vessels (upto second generation branches), bowel wall edema, stranding in the mesentery. In addition, other pathologies could also be easily detected.
A high index of suspicion followed up by multi-slice CT on emergency basis is likely to provide the best chance of diagnosis and an opportunity for revascularization.
On angiography, SMA is found occluded at or near origin in case of thrombosis and affects the entire bowel from ligament of Treitz to mid transverse colon. In contrast, an embolus lodges at a branch point and the proximal jejunal branches are often spared.
Treatment
Initial management includes correction of fluid and electrolyte imbalances, baseline cardiac assessment, broad spectrum parenteral antibiotics and anticoagulation.
Endovascular therapy with fibrinolysis should not be attempted since there is a very high risk of ongoing bowel damage during the period of lysis.
Surgery is the mainstay of treatment and begins with a complete exploratory laparotomy and assessment of bowel viability. Lower limbs must be included in draping for vein harvesting. In case there is extensive bowel infarction incompatible with life, it is appropriate to close with no further intervention. Revascularization is done either by SMA embolectomy or superior mesenteric artery bypass, usually from the infra-renal aorta. Bowel viability must be re-assessed after restoring blood supply and appropriate resection done. When there is doubt about bowel viability, re-look laparotomy is done after 12-36 hours.
Chronic mesenteric ischemia
It is a life-threatening problem that can result in death due to inanition or bowel infarction. The underlying pathophysiology is the failure to achieve post-prandial hyperemic blood flow. While atherosclerosis is the leading cause for CMI, other etiologies include Takayasu’s disease, aortic dissection, fibromuscular disease, SLE, Rheumatoid arthritis and drugs like cocaine and ergot.
A typical patient is cachectic, middle-aged, with history of smoking who presents with post-prandial abdominal pain and weight loss. The pain is usually epigastric and causes patients to avoid certain foods or eating altogether (food fear). Most patients often undergo extensive GI checkup before someone suspects CMI. Gastric ulceration or gastroduodenitis are often seen due to ischemia.
A Duplex ultrasound is a good screening modality. Angiography is diagnostic and helps in planning revascularization strategies.
Treatment
All patients with CMI should be taken up for revascularization even if co-morbid factors increase risk of surgery. While long term total parenteral nutrition has been considered an option in high risk patients, it is practically inconvenient, carries risk of catheter related infections and does not alleviate the risk of bowel infarction.
Revascularization options include angioplasty and stenting and mesenteric artery bypass. There is no clear cut agreement in literature as to which is the better option and as to how many vessels should be revascularized. Synthetic grafts or femoral veins are best conduits for mesenteric bypass. Inflow may be taken from supraceliac aorta, infra-renal aorta or an aortic graft. All patients are maintained on anti-platelet agents and statins.
Median arcuate ligament syndrome
The median arcuate ligament of the diaphragm compresses the origin of celiac axis which is augmented by full expiration in a large number of individuals. Its contribution to CMI is uncertain and it is unlikely to be able to produce CMI on its own. It is a diagnosis of exclusion. Surgical therapy may offer relief in patients who are females, have postprandial pain, weight loss more than 8 kgs, absence of drug abuse or psychiatric history and angiographic confirmation of celiac axis compression with post-stenotic dilatation. Effective treatment includes relief of compression and mesenteric bypass. Another option could be laparoscopic division of the ligament followed by angioplasty of celiac axis.
Non-Occlusive Mesenteric Ischemia (NOMI)
NOMI is caused by primary splanchnic vasoconstriction and has high mortality. It is associated with shock state, cardiopulmonary bypass and use of vasoactive drugs like digoxin, vasopression and α-adrenergic agents.
Management
Early arteriographic diagnosis and subsequent intervention offer the best chance for better outcome and survival. Pain out of proportion to physical findings and normal radiographic findings are suggestive of early ischemia and should prompt consideration of immediate diagnostic arteriography. Other biochemical and radiological findings as seen in acute ischemia, are indicative of bowel infarction. Arteriographic criteria for diagnosis of NOMI include narrowing origins of multiple branches of SMA, string of sausage sign, spasm of mesenteric arcades and impaired filling of intramural branches.
Treatment includes immediate management of precipitating factors like shock and cardiac events and use of vasodilators that diminish cardiac preload and afterload. Definitive treatment is selective intra-arterial infusion of papaverine into the SMA. It is best to start with 30 mg/hr. Arteriography is repeated once pain resolves and infusion is continued for 24 hours. One needs to be vigilant for signs of bowel infarction and intervene appropriately.
Mesenteric venous thrombosis
It is a rare disorder with a wide range of clinical presentations. It usually involves the superior mesenteric and splenic veins and may involve inferior mesenteric and portal veins.
One should suspect this diagnosis in patients with acute abdomen with history of previous thrombotic episodes or known thrombophilia. Others may present pain and loss of appetite, often of a few days duration, diarrhea, occult GI bleed and occasionally bowel infarction and peritonitis. There may be mild leucocytosis and slightly elevated LDH. Diagnosis can be confirmed by venous phase of CT scan or with contrast enhanced MR venography. Color Doppler can often show presence of thrombi in the veins.
Treatment is usually conservative with life-long anticoagulation. Aggressive management with surgery or thrombolysis can be done in selected patients. Any associated hypercoagulable state must be appropriately treated.
What are vascular diseases and Vascular Surgery
“A surgeon's skills are measured by the way he handles the blood vessels”
These prophetic words of the great American surgeon William Halstead ushered in the era of one of the most skilful surgical specialties – Vascular Surgery. This field has rapidly evolved over the last hundred years, with major advances occurring during the II World war and the Korean war. Endovascular interventions in the form of angioplasty and stenting have added an exciting new dimension for treatment of vascular diseases in the last two decades.
Vascular bypass operations in the leg preceded “heart bypass” operations by many years!
Vascular and Endovascular Surgery is a highly specialized field that deals with all the blood vessels in the body except those in the heart and the brain. Arteries that carry oxygenated blood from the heart to various organs and veins that return deoxygenated blood back to the heart, are the two main forms of blood vessels whose diseases are addressed by vascular surgeon. They are the life-lines of various body parts.The expression of vascular problems in different parts of the body is quite variable and this makes the specialty a complex, challenging field. A vascular surgeon is truly a “vascular specialist” since his expertise encompasses not only surgery, but also newer minimally invasive endovascular procedures (angioplasty, stenting) and vascular medicines. Hence vascular surgery remains one of the few “holistic” medical fields today which delivers complete, seamless care to patients with vascular disease.
How much is the problem?
What would be the magnitude of peripheral arterial disease of the legs in India? Since there are no specific data, we could extrapolate the available data to Indian population and the numbers thus obtained are quite staggering:
Among 42 million diabetics – about 1000 per million will develop Critical Limb Ischemia, which usually means if some vascular procedure is not done they will lose the leg, which also makes them high risk for heart attack or stroke. If untreated this amounts to 42,000 amputations per year!
Among rest of the population – about 500 per million (about 4,85,000) will develop critical limb ischemia needing a vascular correction or amputation!!
In rest of the population about 38,00,000 (about 380 per 1,00,000 population) will develop peripheral vascular disease – these are the patients whose future vascular events can brought down significantly if proper medical care is given.
Venous diseases are far more common and include varicose veins, venous ulcers and deep vein thrombosis. All these problems affect a person’s quality of life and deep vein thrombosis is potentially life-threatening.
Causative factors
Smoking
Diabetes mellitus
High cholesterol
Lack of exercise
Obesity
Thrombophilia: tendency for blood to clot easily.
Heredity
Aging
Symptoms of vascular disease
Majority of vascular patients have one or more of the following three symptoms:
Painful extremity
Swollen extremity
Ulcerated extremity
Other problems include arterial aneurysms (dilated arteries) that have a potential for rupture, renovascular hypertension that is correctible, mesenteric ischemia that reduces blood supply to the intestines and has a higher fatality that heart attack, carotid artery stenosis that affects blood supply to the brain and results in paralytic attack which is preventable!
There has been an exponential increase of vascular problems in India due to unabated smoking and rapid increase in diabetic population (42 million or 4.2 crores), crossing all economic barriers. Peripheral vascular disease affects mostly the legs, which initially causes pain in the calf muscles while walking. The walking distance progressively reduces and if ignored will result in severe pain in the toes even at rest and eventually will result in gangrene of the toes and the foot, which might necessitate amputation. This “leg attack” is more dangerous than heart attack as it can endanger the limb and life of the patient. But this can be easily treated in the initial stages with appropriate medicines and simple life style modification programs. Unfortunately, these patients rarely reach a qualified vascular surgeon at this stage. One of the main reasons being lack of awareness among the public and also among many of the doctors about the vascular diseases and the role of vascular surgeon. There are only about 50 vascular surgeons in India, which results in these patients seen by other specialists, resulting in delayed referral to a vascular surgeon. In fact majority of these patients are not seen by vascular surgeon at all resulting in unnecessary limb and life loss. Even when a patient presents relatively late to a vascular surgeon, most of the limbs can be salvaged with a high success and low complication rate by vascular bypass or minimally invasive endovascular procedures like angioplasty and stenting if needed.
Blocked arteries in the leg mirrors rest of the body. Early diagnosis by good clinical examination and simple tests in patients with risks (smokers, diabetics, those over 50 years) will detect the disease even before they become symptomatic. It is well established now decreased blood flow in the legs is the biggest indicator of future hear attacks, strokes and amputation of legs or in other words the blocked arteries in the legs indicate a wide spread vascular disease in the body. When a patient has blocked arteries in the heart (cause of heart attack) it indicates that there is 30% chance that he/she has vascular disease else where, but a blocked artery in the leg indicates 60 to70% chance of diffuse vascular disease. Hence it is recommended in these risks groups should be examined peripheral arterial disease in the legs and if they do, they should be started on good medical treatment and life style modification program, which would markedly decrease the chance of future heart attacks, stroke or amputations.
Since poorly diagnosed and untreated vascular disease can lead to major limb and life threatening problems, it is of paramount importance that public and the medical profession is aware of early symptoms and the diagnostic methods. Early diagnoses and proper therapy will not only control the disease, but will markedly decrease the future complications and results in improved quality of life.
Vascular surgeon plays a pivotal role in diagnosing and treating these diseases, as our medical education imparts very little knowledge about vascular diseases to other specialties. Hence it is mandatory that any body suspected of these problems be evaluated by a vascular surgeon.
Patients with diabetic foot problems, which are the number one cause of admission in diabetic patients in India, usually are treated by vascular surgeon. These are of epidemic proportions, causing life and limb loss, though they can be easily prevented with proper foot care. Vascular surgeon plays a pivotal role in caring for the diabetic foot problems whether they are related to vasculopathy or neuropathy.
Vascular surgeon’s field is wide since it covers major portion of the human body. The next most important disease treated is stroke prevention surgery. Majority of strokes occur because of the narrowing of a blood vessel, called carotid artery, in the neck which carries blood to the brain. If diagnosed in time and treated with a highly successful surgical procedure called “Carotid Endarterectomy”, the chances of stroke is markedly reduced. In few, highly selected patients vascular surgeon may opt to perform “angioplasty and stenting”, but these cannot be applied to all patients at present, but might change in future. Again, it important to have these patients evaluated by a vascular surgeon, for proper diagnosis and treatment.
Vascular surgeons also deals with blood vessels in the upper limbs, those inside the abdomen supplying vital organs like the kidneys, liver intestines etc. Diseases of the veins, simplest of which is the varicose veins, also come under the purview of vascular surgeon.
“A surgeon's skills are measured by the way he handles the blood vessels”
These prophetic words of the great American surgeon William Halstead ushered in the era of one of the most skilful surgical specialties – Vascular Surgery. This field has rapidly evolved over the last hundred years, with major advances occurring during the II World war and the Korean war. Endovascular interventions in the form of angioplasty and stenting have added an exciting new dimension for treatment of vascular diseases in the last two decades.
Vascular bypass operations in the leg preceded “heart bypass” operations by many years!
Vascular and Endovascular Surgery is a highly specialized field that deals with all the blood vessels in the body except those in the heart and the brain. Arteries that carry oxygenated blood from the heart to various organs and veins that return deoxygenated blood back to the heart, are the two main forms of blood vessels whose diseases are addressed by vascular surgeon. They are the life-lines of various body parts.The expression of vascular problems in different parts of the body is quite variable and this makes the specialty a complex, challenging field. A vascular surgeon is truly a “vascular specialist” since his expertise encompasses not only surgery, but also newer minimally invasive endovascular procedures (angioplasty, stenting) and vascular medicines. Hence vascular surgery remains one of the few “holistic” medical fields today which delivers complete, seamless care to patients with vascular disease.
How much is the problem?
What would be the magnitude of peripheral arterial disease of the legs in India? Since there are no specific data, we could extrapolate the available data to Indian population and the numbers thus obtained are quite staggering:
Among 42 million diabetics – about 1000 per million will develop Critical Limb Ischemia, which usually means if some vascular procedure is not done they will lose the leg, which also makes them high risk for heart attack or stroke. If untreated this amounts to 42,000 amputations per year!
Among rest of the population – about 500 per million (about 4,85,000) will develop critical limb ischemia needing a vascular correction or amputation!!
In rest of the population about 38,00,000 (about 380 per 1,00,000 population) will develop peripheral vascular disease – these are the patients whose future vascular events can brought down significantly if proper medical care is given.
Venous diseases are far more common and include varicose veins, venous ulcers and deep vein thrombosis. All these problems affect a person’s quality of life and deep vein thrombosis is potentially life-threatening.
Causative factors
Smoking
Diabetes mellitus
High cholesterol
Lack of exercise
Obesity
Thrombophilia: tendency for blood to clot easily.
Heredity
Aging
Symptoms of vascular disease
Majority of vascular patients have one or more of the following three symptoms:
Painful extremity
Swollen extremity
Ulcerated extremity
Other problems include arterial aneurysms (dilated arteries) that have a potential for rupture, renovascular hypertension that is correctible, mesenteric ischemia that reduces blood supply to the intestines and has a higher fatality that heart attack, carotid artery stenosis that affects blood supply to the brain and results in paralytic attack which is preventable!
There has been an exponential increase of vascular problems in India due to unabated smoking and rapid increase in diabetic population (42 million or 4.2 crores), crossing all economic barriers. Peripheral vascular disease affects mostly the legs, which initially causes pain in the calf muscles while walking. The walking distance progressively reduces and if ignored will result in severe pain in the toes even at rest and eventually will result in gangrene of the toes and the foot, which might necessitate amputation. This “leg attack” is more dangerous than heart attack as it can endanger the limb and life of the patient. But this can be easily treated in the initial stages with appropriate medicines and simple life style modification programs. Unfortunately, these patients rarely reach a qualified vascular surgeon at this stage. One of the main reasons being lack of awareness among the public and also among many of the doctors about the vascular diseases and the role of vascular surgeon. There are only about 50 vascular surgeons in India, which results in these patients seen by other specialists, resulting in delayed referral to a vascular surgeon. In fact majority of these patients are not seen by vascular surgeon at all resulting in unnecessary limb and life loss. Even when a patient presents relatively late to a vascular surgeon, most of the limbs can be salvaged with a high success and low complication rate by vascular bypass or minimally invasive endovascular procedures like angioplasty and stenting if needed.
Blocked arteries in the leg mirrors rest of the body. Early diagnosis by good clinical examination and simple tests in patients with risks (smokers, diabetics, those over 50 years) will detect the disease even before they become symptomatic. It is well established now decreased blood flow in the legs is the biggest indicator of future hear attacks, strokes and amputation of legs or in other words the blocked arteries in the legs indicate a wide spread vascular disease in the body. When a patient has blocked arteries in the heart (cause of heart attack) it indicates that there is 30% chance that he/she has vascular disease else where, but a blocked artery in the leg indicates 60 to70% chance of diffuse vascular disease. Hence it is recommended in these risks groups should be examined peripheral arterial disease in the legs and if they do, they should be started on good medical treatment and life style modification program, which would markedly decrease the chance of future heart attacks, stroke or amputations.
Since poorly diagnosed and untreated vascular disease can lead to major limb and life threatening problems, it is of paramount importance that public and the medical profession is aware of early symptoms and the diagnostic methods. Early diagnoses and proper therapy will not only control the disease, but will markedly decrease the future complications and results in improved quality of life.
Vascular surgeon plays a pivotal role in diagnosing and treating these diseases, as our medical education imparts very little knowledge about vascular diseases to other specialties. Hence it is mandatory that any body suspected of these problems be evaluated by a vascular surgeon.
Patients with diabetic foot problems, which are the number one cause of admission in diabetic patients in India, usually are treated by vascular surgeon. These are of epidemic proportions, causing life and limb loss, though they can be easily prevented with proper foot care. Vascular surgeon plays a pivotal role in caring for the diabetic foot problems whether they are related to vasculopathy or neuropathy.
Vascular surgeon’s field is wide since it covers major portion of the human body. The next most important disease treated is stroke prevention surgery. Majority of strokes occur because of the narrowing of a blood vessel, called carotid artery, in the neck which carries blood to the brain. If diagnosed in time and treated with a highly successful surgical procedure called “Carotid Endarterectomy”, the chances of stroke is markedly reduced. In few, highly selected patients vascular surgeon may opt to perform “angioplasty and stenting”, but these cannot be applied to all patients at present, but might change in future. Again, it important to have these patients evaluated by a vascular surgeon, for proper diagnosis and treatment.
Vascular surgeons also deals with blood vessels in the upper limbs, those inside the abdomen supplying vital organs like the kidneys, liver intestines etc. Diseases of the veins, simplest of which is the varicose veins, also come under the purview of vascular surgeon.
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