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.