Vascular Surgery
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Vascular surgery is a surgical subspecialty in which diseases of the vascular system, or
arteries An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pu ...
,
vein Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
s and lymphatic circulation, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from
general A general officer is an Officer (armed forces), officer of highest military ranks, high rank in the army, armies, and in some nations' air forces, space forces, and marines or naval infantry. In some usages the term "general officer" refers t ...
and
cardiac surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...
and includes treatment of the body's other major and essential veins and arteries. Open surgery techniques, as well as endovascular techniques are used to treat vascular diseases. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons often assist other physicians to address traumatic vascular injury, hemorrhage control, and safe exposure of vascular structures.


History

Early leaders of the field included Russian surgeon
Nikolai Korotkov Nikolai Sergeyevich Korotkov (also romanized Korotkoff; russian: Никола́й Серге́евич Коротко́в) ( – 14 March 1920) was a Russian Empire surgeon, a pioneer of 20th-century vascular surgery, and the inventor of auscul ...
, noted for developing early surgical techniques, American
interventional radiologist Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs bo ...
Charles Theodore Dotter Charles Theodore Dotter (14 June 1920 – 15 February 1985) was a pioneering US vascular radiologist who is credited with developing interventional radiology. Dotter, with his trainee Dr Melvin P. Judkins, described angioplasty in 1964. Dotte ...
who is credited with inventing minimally invasive angioplasty (1964), and Australian Robert Paton, who helped the field achieve recognition as a specialty. Edwin Wylie of San Francisco was one of the early American pioneers who developed and fostered advanced training in vascular surgery and pushed for its recognition as a specialty in the United States in the 1970s.


Evolution

The specialty continues to be based on operative arterial and venous surgery but since the early 1990s has evolved greatly. There is now considerable emphasis on minimally invasive alternatives to surgery. The field was originally pioneered by
interventional radiologists Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as Fluoroscopy, x-ray fluoroscopy, CT scan, computed tomography, magnetic resonance imaging, or ultraso ...
, chiefly Dr.
Charles Dotter Charles Theodore Dotter (14 June 1920 – 15 February 1985) was a pioneering US vascular radiologist who is credited with developing interventional radiology. Dotter, with his trainee Dr Melvin P. Judkins, described angioplasty in 1964. Dott ...
, who invented angioplasty. Of note, Dr. Thomas Fogarty invented the balloon catheter which enabled angioplasty. Further development of the field has occurred via joint efforts between
interventional radiology Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs bo ...
, vascular surgery, and interventional cardiology. This area of vascular surgery is called Endovascular Surgery or Interventional Vascular Radiology, a term that some in the specialty append to their primary qualification as Vascular Surgeon. Endovascular and endovenous procedures (e.g.,
EVAR Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then spe ...
) can now form the bulk of a vascular surgeon's practice. The treatment of the aorta, the body's largest artery, dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century AD. Modern treatment of aortic diseases stems from development and advancements from
Michael DeBakey Michael Ellis DeBakey (September 7, 1908 – July 11, 2008) was a Lebanese-American general and cardiovascular surgeon, scientist and medical educator who became Chairman of the Department of Surgery, President, and Chancellor of Baylor College ...
and
Denton Cooley Denton Arthur Cooley (August 22, 1920 – November 18, 2016) was an American heart and cardiothoracic surgeon famous for performing the first implantation of a total artificial heart. Cooley was also the founder and surgeon in-chief of The T ...
. In 1955, DeBakey and Cooley performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the
Dacron Polyethylene terephthalate (or poly(ethylene terephthalate), PET, PETE, or the obsolete PETP or PET-P), is the most common thermoplastic polymer resin of the polyester family and is used in fibres for clothing, containers for liquids and foo ...
graft, resulting in a revolution for surgeons in the repair of aortic aneurysms. He also was first to perform cardiopulmonary bypass to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery. Dr. Edward "Ted" Dietrich, one of Dr. DeBakey's associates, went on to pioneer many of the
minimally invasive Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definition ...
techniques that later became hallmarks of endovascular surgery. Dietrich later founded the Arizona Heart Hospital in 1998 and served as its medical director from 1998 to 2010. In 2000, Diethrich performed the first endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm. Dietrich trained several future leaders in the field of endovascular surgery at the Arizona Heart Hospital including Venkatesh Ramaiah, MD who served as medical director of the institution following Dietrich's death in 2017. The development of endovascular surgery has been accompanied by a gradual separation of vascular surgery from its origin in
general surgery General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid ...
. Most vascular surgeons would now confine their practice to vascular surgery and, similarly, general surgeons would not be trained or practise the larger vascular surgery operations or most endovascular procedures. More recently, professional vascular surgery societies and their training program have formally separated vascular surgery into a separate specialty with its own training program, meetings and accreditation. Notable societies are
Society for Vascular Surgery The Society for Vascular Surgery (SVS) is the major national academic society for vascular surgery in the United States. Its mission includes education, research, career development and advocacy. The SVS is the national advocate for more than 6, ...
(SVS), USA; Australia and New Zealand Society of Vascular Surgeons (ANZSVS). Local societies also exist (e.g., New South Wales Vascular and Melbourne Vascular Surgical Association (MVSA)). Larger societies of surgery actively separate and encourage specialty surgical societies under their umbrella (e.g.,
Royal Australasian College of Surgeons The Royal Australasian College of Surgeons (RACS) is the leading advocate for surgical standards, professionalism and surgical education in Australia and New Zealand. Known by its common acronym RACS, it is a not-for-profit organisation, sup ...
(RACS)).


Currently

Arterial and venous disease treatment by
angiography Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is performe ...
, stenting, and non-operative varicose vein treatment
sclerotherapy Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'') is a procedure used to treat blood vessel malformations (vascular malformations) and also malformations of the lymphatic system. A medicine is injected into the vessels, wh ...
,
endovenous laser treatment Endovenous laser treatment (ELT) is a minimally invasive ultrasound-guided technique used for treating varicose veins using laser energy commonly performed by a phlebologist, interventional radiologist or vascular surgeon. Methods Endovenous las ...
are rapidly replacing major surgery in many first world countries. These newer procedures provide reasonable outcomes that are comparable to surgery with the advantage of short hospital stay (day or overnight for most cases) with lower morbidity and mortality rates. Historically performed by interventional radiologists, vascular surgeons have become increasingly proficient with endovascular methods. The durability of endovascular arterial procedures is generally good, especially when viewed in the context of their common clinical usage i.e. arterial disease occurring in elderly patients and usually associated with concurrent significant patient comorbidities especially ischemic heart disease. The cost savings from shorter hospital stays and less morbidity are considerable but are somewhat balanced by the high cost of imaging equipment, construction and staffing of dedicated procedural suites, and of the implant devices themselves. The benefits for younger patients and in venous disease are less persuasive but there are strong trends towards nonoperative treatment options driven by patient preference, health insurance company costs, trial demonstrating comparable efficacy at least in the medium term. A recent trend in the United States is the stand-alone day angiography facility associated with a private vascular surgery clinic, thus allowing treatment of most arterial endovascular cases conveniently and possibly with lesser overall community cost. Similar non-hospital treatment facilities for non-operative vein treatment have existed for some years and are now widespread in many countries.
NHS England NHS England, officially the NHS Commissioning Board, is an executive non-departmental public body of the Department of Health and Social Care. It oversees the budget, planning, delivery and day-to-day operation of the commissioning side of the ...
conducted a review of all 70 vascular surgery sites across England in 2018 as part of its Getting It Right First Time programme. The review specified that vascular hubs should perform at least 60 abdominal aortic aneurysm procedures and 40 carotid endarterectomies a year. 12 trusts missed both targets and many more missed one of them. A programme of concentrating vascular surgery in fewer centres is proceeding. Vascular surgery encompasses surgery of the
aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
,
carotid arteries In anatomy, the left and right common carotid arteries (carotids) (Entry "carotid"
in
lower extremities, including the iliac, femoral, vascular trauma and tibial arteries. Vascular surgery also involves surgery of veins, for conditions such as
May–Thurner syndrome May–Thurner syndrome (MTS), also known as the iliac vein compression syndrome, is a condition in which compression of the common venous outflow tract of the left lower extremity may cause discomfort, swelling, pain or clots (deep venous thrombo ...
and for
varicose veins Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. These veins typically develop in the legs, just under the skin. Varicose veins usually cause few symptoms. However, some indiv ...
. In some regions, vascular surgery also includes dialysis access surgery and
transplant surgery Organ transplantation is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ. The donor and recipient may be at the same location, or organs may be transpor ...
.


Management of Arterial Diseases

The management of arterial pathology excluding coronary and intracranial disease is within the scope of vascular surgeons. Disease states generally arise from narrowing of the arterial system known as
stenosis A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' ...
or abnormal dilation referred to as an
aneurysm An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus (s ...
. There are multiple mechanisms by which the arterial lumen can narrow, the most common of which is
atherosclerosis Atherosclerosis is a pattern of the disease arteriosclerosis in which the wall of the artery develops abnormalities, called lesions. These lesions may lead to narrowing due to the buildup of atheroma, atheromatous plaque. At onset there are usu ...
. Symptomatic stenosis may also result from a complication of arterial dissection. Other less common causes of stenosis include
fibromuscular dysplasia Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory disease of the blood vessels that causes abnormal growth within the wall of an artery. FMD has been found in nearly every arterial bed in the body although the most common ...
, radiation induced fibrosis or cystic adventitial disease. Dilation of an artery which retains histologic layers is called an aneurysm. An aneurysms can be fusiform (concentric dilation), saccular (outpouching) or a combination of the two. Arterial dilation which does not contain three histologic layers is considered a
pseudoaneurysm A pseudoaneurysm, also known as a false aneurysm, is a locally contained hematoma outside an artery or heart due to damage to the vessel wall. The injury goes through all the three layers of the arterial wall causing a leak, which is contained b ...
. Additionally, there are a number of congenital vascular anomalies which lead to symptomatic disease that are managed by the vascular surgeon, a few of which include
aberrant subclavian artery Aberrant subclavian artery, or aberrant subclavian artery syndrome, is a rare anatomical variant of the origin of the right or left subclavian artery. This abnormality is the most common congenital vascular anomaly of the aortic arch, occurring i ...
,
popliteal artery entrapment syndrome The popliteal artery entrapment syndrome (PAES) is an uncommon pathology that occurs when the popliteal artery is compressed by the surrounding popliteal fossa myofascial structures. This results in claudication and chronic leg ischemia. This co ...
or persistent sciatic artery. Vascular surgeons treat arterial diseases with a range of therapies including lifestyle modification, medications, endovascular therapy and surgery.


Aortic Aneurysms


Abdominal Aortic Aneurysm

An
abdominal aortic aneurysm Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta such that the diameter is greater than 3 cm or more than 50% larger than normal. They usually cause no symptoms, except during rupture. Occasionally, abdominal, ...
(AAA) refers to aneurysmal dilation of the aorta confined to the abdominal cavity. Most commonly, aneurysms are asymptomatic and located in the infrarenal position. Often, they are discovered incidentally or on screening exams in patients with risk factors such as a history of smoking. Patients with aneurysms which have a diameter less than 5 cm are at <1% rupture risk per year. When the aneurysm meets size criteria it can be treated with aortic replacement or
EVAR Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then spe ...
.


Thoracic Aortic Aneurysm

Thoracic aneurysms are contained in the chest. Aneurysms of the descending aorta can often be treated with thoracic endovascular aortic repair or
TEVAR ''Tevar'' () is a 2015 Indian Hindi-language action film directed by debutante Amit Ravindernath Sharma and produced by Boney Kapoor, Sanjay Kapoor, Sunil Lulla, Naresh Agarwal and Sunil Manchanda, based on a script by Sharma and Shantanu Shri ...
. Treating aneurysms which involve the ascending aorta are generally within the scope of cardiac surgeons, but upcoming endovascular technology may allow for a more minimally invasive approach in some patients.


Thoracoabdominal Aneurysm

Thoroacoabdominal aneurysms are those which span the chest and abdominal cavities. The Crawford Classification was developed and describes five types of thoracoabdominal aneurysms. File:AAA-X4.jpg, Abdominal aortic aneurysms can be classified as infrarenal, juxtarenal, pararenal or suprarenal as depicted in the illustration. File:D3ON0p6B.jpg, The Crawford Classification for thoracoabdominal aortic aneurysms is pictured above.


Other Arterial Aneurysms

In addition to treating aneurysms which arise from the
aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
, vascular surgeons also treat aneurysms elsewhere in the body.


Visceral Artery Aneurysm

Visceral artery aneurysms include those isolated to the
renal artery The renal arteries are paired arteries that supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle. The renal arteries carry a large portion of total blood flow to the kidneys. Up to a ...
,
splenic artery In human anatomy, the splenic artery or lienal artery is the blood vessel that supplies oxygenated blood to the spleen. It branches from the celiac artery, and follows a course superior to the pancreas. It is known for its tortuous path to the s ...
,
celiac artery The celiac () artery (also spelled ''coeliac''), also known as the celiac trunk or truncus coeliacus, is the first major branch of the abdominal aorta. It is about 1.25 cm in length. Branching from the aorta at thoracic vertebra 12 (T12) in ...
, and
hepatic artery The common hepatic artery is a short blood vessel that supplies oxygenated blood to the liver, pylorus of the stomach, duodenum, pancreas, and gallbladder. It arises from the celiac artery and has the following branches: Additional images ...
. Of these, data shows that splenic artery aneurysms are the most common. Indications for repair differ slightly between arteries. For instance, current guidelines recommend repair of renal and splenic artery aneurysms greater than 3 cm, and those of any size in women of childbearing age; whereas celiac and hepatic artery aneurysms are indicated for repair when their size is greater than 2 cm. This is in contrast to superior mesenteric artery aneurysms which should be repaired regardless of size when they are discovered.


Popliteal Artery Aneurysm

A popliteal artery aneurysm is an arterial aneurysm localized in the
popliteal artery The popliteal artery is a deeply placed continuation of the femoral artery opening in the distal portion of the adductor magnus muscle. It courses through the popliteal fossa and ends at the lower border of the popliteus muscle, where it branches ...
which courses behind the
knee In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia (tibiofemoral joint), and one between the femur and patella (patellofemoral joint). It is the largest joint in the hu ...
. Unlike aneurysms located in the abdomen, popliteal artery aneurysm rarely present with rupture but rather with symptoms of
acute limb ischemia Acute limb ischaemia (ALI) occurs when there is a sudden lack of blood flow to a limb. Acute limb ischaemia is caused by embolism or thrombosis, or rarely by dissection or trauma. Thrombosis is usually caused by peripheral vascular disease (ath ...
due to embolization of thrombus. Thus, when a patient presents with an asymptomatic popliteal aneurysm that is greater than 2 cm in diameter a vascular surgeon are able to offer vascular bypass or endovascular exclusion depending on several factors.


Aortic Dissection

Arteries are composed of three concentric layers: the
intima The tunica intima (New Latin "inner coat"), or intima for short, is the innermost tunica (layer) of an artery or vein. It is made up of one layer of endothelial cells and is supported by an internal elastic lamina. The endothelial cells are in ...
,
media Media may refer to: Communication * Media (communication), tools used to deliver information or data ** Advertising media, various media, content, buying and placement for advertising ** Broadcast media, communications delivered over mass e ...
and
adventitia The adventitia () is the outer layer of fibrous connective tissue surrounding an organ. The outer layer of connective tissue that surrounds an artery, or vein – the tunica externa, is also called the ''tunica adventitia''. To some degree, its ...
. Generally speaking, an arterial dissection is an injury to the innermost layer of an artery which allows blood to flow between layers in what is sometimes referred to as a dissection plane. An
aortic dissection Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. In most cases, this is associated with a sudden onset of severe chest or ...
is an arterial dissection that occurs in the
aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
. Patients who experience aortic dissection may have tearing chest or back pain, depending on the origination of the tear as well as the extent. Whereas
cardiac surgeons Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart ( heart disease), lungs (lung disease), and other pleural or mediastinal st ...
are usually in charge of managing type A dissections, type B dissections are typically managed by the vascular surgeon. The most common risk factor for type B aortic dissection is
hypertension Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...
. The first line treatment for type B aortic dissection is aimed at reducing both
heart rate Heart rate (or pulse rate) is the frequency of the heartbeat measured by the number of contractions (beats) of the heart per minute (bpm). The heart rate can vary according to the body's physical needs, including the need to absorb oxygen and excr ...
and
blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
and is referred to as anti-impulse therapy. Should initial medical management fail or the patient experience compromise of a major branch of the aorta, the vascular surgeon is an expert in both the surgical management of these type B dissections. Treatment may include thoracic endovascular aortic repair (TEVAR) with or without extra-anatomic bypass such as carotid-carotid bypass, carotid-subclavian bypass, subclavian-carotid transposition.


Visceral Artery Dissection

Visceral artery dissections are arterial dissections involving the
superior mesenteric artery In human anatomy, the superior mesenteric artery (SMA) is an artery which arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies blood to the intestine from the lower part of the ...
,
celiac artery The celiac () artery (also spelled ''coeliac''), also known as the celiac trunk or truncus coeliacus, is the first major branch of the abdominal aorta. It is about 1.25 cm in length. Branching from the aorta at thoracic vertebra 12 (T12) in ...
,
renal arteries The renal arteries are paired arteries that supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle. The renal arteries carry a large portion of total blood flow to the kidneys. Up to a ...
,
hepatic artery The common hepatic artery is a short blood vessel that supplies oxygenated blood to the liver, pylorus of the stomach, duodenum, pancreas, and gallbladder. It arises from the celiac artery and has the following branches: Additional images ...
and others. When they are an extension of an aortic dissection, this condition is managed simultaneously with aortic treatment. In isolation, visceral artery dissections are discovered incidentally in up to a third of patients and in these cases my be managed medically by a vascular surgeon. In cases where the dissection results in organ damage it is generally accepted by vascular surgeons that surgery is necessary. Surgical management strategies depend on the associated complications, surgical ability and patient preference.


Mesenteric Ischemia

Mesenteric ischemia results from the acute or chronic obstruction of the
superior mesenteric artery In human anatomy, the superior mesenteric artery (SMA) is an artery which arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies blood to the intestine from the lower part of the ...
(SMA). The SMA arises from the abdominal aorta and usually supplies blood from the distal
duodenum The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine m ...
through two-thirds of the
transverse colon In human anatomy, the transverse colon is the longest and most movable part of the colon. Anatomical position It crosses the abdomen from the ascending colon at the right colic flexure (hepatic flexure) with a downward convexity to the descend ...
and the
pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an end ...
.


Chronic Mesenteric Ischemia

The symptoms of chronic mesenteric ischemia can be classified as
abdominal angina Abdominal angina is abdominal pain after eating that occurs in individuals with ongoing poor blood supply to their small intestines known as chronic mesenteric ischemia. Although the term ''angina'' alone usually denotes angina pectoris (a type o ...
which is abdominal pain which occurs a fixed period of time after eating. Due to this, patient's may avoid eating, resulting in unintended weight loss. The first surgical treatment is thought to be performed by R.S. Shaw and described in the
New England Journal of Medicine ''The New England Journal of Medicine'' (''NEJM'') is a weekly medical journal published by the Massachusetts Medical Society. It is among the most prestigious peer-reviewed medical journals as well as the oldest continuously published one. His ...
in 1958. The procedure Shaw described is referred to as mesenteric
endarterectomy Endarterectomy is a surgical procedure to remove the atheromatous ''plaque'' material, or blockage, in the lining of an artery constricted by the buildup of deposits. It is carried out by separating the plaque from the arterial wall. It was firs ...
. Since then, many advances in treatment have been made in minimally invasive,
endovascular Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs b ...
techniques including
angioplasty Angioplasty, is also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atheroscle ...
and stenting.


Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) results from the sudden
occlusion Occlusion may refer to: Health and fitness * Occlusion (dentistry), the manner in which the upper and lower teeth come together when the mouth is closed * Occlusion miliaria, a skin condition * Occlusive dressing, an air- and water-tight trauma ...
of the
superior mesenteric artery In human anatomy, the superior mesenteric artery (SMA) is an artery which arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies blood to the intestine from the lower part of the ...
.


Renovascular Hypertension

The renal arteries supply oxygenated blood to the kidneys. The kidneys serve to filter the flood and control blood pressure through the renin-angiotensin system. One cause of resistant hypertension is atherosclerotic disease in the renal arteries and is generally referred to as
renovascular hypertension Renovascular hypertension is a condition in which high blood pressure is caused by the kidneys' hormonal response to narrowing of the arteries supplying the kidneys. When functioning properly this hormonal axis regulates blood pressure. Due to l ...
. If renovascular hypertension is diagnosed and maximal medical fails to control high blood pressure, the vascular surgeon may offer surgical treatment, either endovascular or open surgical reconstruction.


Cerebrovascular Disease

Vascular surgeons are responsible for treating extracranial cerebrovascular disease as well as the interpretation of non-invasive vascular imaging relating to extracranial and intracranial circulation such as
carotid ultrasonography Carotid ultrasonography is an ultrasound-based diagnostic imaging technique to evaluate structural details of the carotid arteries. Carotid ultrasound is used to diagnose carotid artery stenosis (CAS) and can assess atherosclerotic plaque morpholo ...
and
transcranial doppler Transcranial Doppler (TCD) and transcranial color Doppler (TCCD) are types of Doppler ultrasonography that measure the velocity of blood flow through the brain's blood vessels by measuring the echoes of ultrasound waves moving transcranially (th ...
. The most common of cerebrovascular conditions treated by vascular surgeons is
carotid artery stenosis Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis. Signs and symptoms The common carotid artery is the large artery whose pulse can be felt on both sides of the neck ...
which is a narrowing of the
carotid arteries In anatomy, the left and right common carotid arteries (carotids) (Entry "carotid"
in
atherosclerosis Atherosclerosis is a pattern of the disease arteriosclerosis in which the wall of the artery develops abnormalities, called lesions. These lesions may lead to narrowing due to the buildup of atheroma, atheromatous plaque. At onset there are usu ...
whereby the buildup of
atheromatous plaque An atheroma, or atheromatous plaque, is an abnormal and reversible accumulation of material in the inner layer of an arterial wall. The material consists of mostly macrophage cells, or debris, containing lipids, calcium and a variable amount o ...
inside an the artery causes narrowing. Symptoms of carotid artery stenosis can include
transient ischemic attack A transient ischemic attack (TIA), commonly known as a mini-stroke, is a minor stroke whose noticeable symptoms usually end in less than an hour. TIA causes the same symptoms associated with strokes, such as weakness or numbness on one side of ...
or
stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
. Both symptomatic and asymptomatic carotid stenosis can be diagnosed with the aid of carotid duplex ultrasound which allows for the estimation of severity of narrowing as well as characterize the plaque. Treatment can include medical therapy,
carotid endarterectomy Carotid endarterectomy is a surgery, surgical procedure used to reduce the risk of stroke from carotid artery stenosis (narrowing the internal carotid artery). In endarterectomy, the surgeon opens the artery and removes the plaque. The plaque for ...
or
carotid stenting Carotid artery stenting is an endovascular procedure where a stent is deployed within the lumen of the carotid artery to treat narrowing of the carotid artery and decrease the risk of stroke. It is used to treat narrowing of the carotid artery i ...
. The
Society for Vascular Surgery The Society for Vascular Surgery (SVS) is the major national academic society for vascular surgery in the United States. Its mission includes education, research, career development and advocacy. The SVS is the national advocate for more than 6, ...
publishes clinical practice guidelines for the management of extracranial cerebrovascular disease. Less common diseases involving cerebral circulation treated by vascular surgeons include
vertebrobasilar insufficiency Vertebrobasilar insufficiency (VBI) describes a temporary set of symptoms due to decreased blood flow (ischemia) in the posterior circulation of the brain. The posterior circulation supplies the medulla, pons, midbrain, cerebellum and (in 70-8 ...
,
subclavian steal syndrome In general, Subclavian means beneath the clavicle, and it may refer to: * Subclavian vein * Subclavian artery In human anatomy, the subclavian arteries are paired major arteries of the upper thorax, below the clavicle. They receive blood from t ...
,
carotid artery dissection Carotid artery dissection is a separation of the layers of the artery wall supplying oxygen-bearing blood to the head and brain and is the most common cause of stroke in young adults. (Dissection is a blister-like de-lamination between the oute ...
,
vertebral artery dissection Vertebral artery dissection (VAD) is a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. After the tear, blood enters the arterial wall and forms a blood clot, thickening t ...
,
carotid body tumor A paraganglioma is a rare neuroendocrine neoplasm that may develop at various body sites (including the head, neck, thorax and abdomen). When the same type of tumor is found in the adrenal gland, they are referred to as a pheochromocytoma. They ar ...
and carotid artery aneurysm among others.


Peripheral Artery Disease

peripheral artery disease Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular dis ...
PAD is the abnormal narrowing of the arteries which supply the limbs. Patients with this condition can present with
intermittent claudication Intermittent claudication, also known as vascular claudication, is a symptom that describes muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, an ...
which is pain mainly in the calves and thighs while walking. If there is progression, a patient may also present with
chronic limb threatening ischemia Chronic limb threatening ischemia (CLTI), also known as critical limb ischemia (CLI), is an advanced stage of peripheral artery disease (PAD). It is defined as ischemic rest pain, arterial insufficiency ulcers, and gangrene. The latter two cond ...
which encompasses pain at rest and non-healing wounds. Vascular surgeons are experts in the diagnosis, medical management, endovascular and open surgical treatment of PAD. A vascular surgeon may diagnose PAD using a combination of
history History (derived ) is the systematic study and the documentation of the human activity. The time period of event before the History of writing#Inventions of writing, invention of writing systems is considered prehistory. "History" is an umbr ...
,
physical exam In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patie ...
and
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
. Medical imaging may include ankle-brachial index,
doppler ultrasonography Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of ...
and
computed tomography angiography Computed tomography angiography (also called CT angiography or CTA) is a computed tomography technique used for angiography—the visualization of arteries and veins—throughout the human body. Using contrast injected into the blood vessels, ...
, among others. Treatments are individualized and may include medical therapy, endovascular intervention or open surgical options including
angioplasty Angioplasty, is also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atheroscle ...
,
stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...
ing,
atherectomy Atherectomy is a minimally invasive technique for removing atherosclerosis from blood vessels within the body. It is an alternative to angioplasty for the treatment of peripheral artery disease, but the studies that exist are not adequate to determ ...
,
endarterectomy Endarterectomy is a surgical procedure to remove the atheromatous ''plaque'' material, or blockage, in the lining of an artery constricted by the buildup of deposits. It is carried out by separating the plaque from the arterial wall. It was firs ...
and
vascular bypass A vascular bypass is a surgical procedure performed to redirect blood flow from one area to another by reconnecting blood vessels. Often, this is done to bypass around a diseased artery, from an area of normal blood flow to another relatively nor ...
, among others. File:Peripheral Arterial Disease.gif, Illustration of
atherosclerosis Atherosclerosis is a pattern of the disease arteriosclerosis in which the wall of the artery develops abnormalities, called lesions. These lesions may lead to narrowing due to the buildup of atheroma, atheromatous plaque. At onset there are usu ...
causing arterial obstruction which clinically presents at peripheral artery disease. File:Pad abi ENG.svg, ABI testing is used by vascular surgeons in the diagnosis of PAD. The blood pressure in the arm and leg are compared as a ratio. File:Angioplasty-scheme.svg,
Angioplasty Angioplasty, is also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atheroscle ...
(pictured) and stenting are two endovascular treatments employed by the vascular surgeon.


Management of Venous Diseases


Chronic Venous Disease

Chronic venous insufficiency Chronic venous insufficiency (CVI) is a medical condition in which blood pools in the veins, straining the walls of the vein. The most common cause of CVI is superficial venous reflux which is a treatable condition. As functional venous valves are ...
is the abnormal pooling of blood in the lower extremity venous system which can lead to reticular veins, varicose veins, chronic edema and inflammation among other things. Population data suggests that chronic venous insufficiency affects up to 40% of females and 17% of males. When chronic insufficiency leads to pain, swelling and skin changes it is referred to as chronic venous disease. Chronic venous insufficiency (CVI) is distinguished from
post-thrombotic syndrome Post-thrombotic syndrome (PTS), also called postphlebitic syndrome and venous stress disorder is a medical condition that may occur as a long-term complication of deep vein thrombosis (DVT). Signs and symptoms Signs and symptoms of PTS in the leg ...
(PTS) in that CVI is primarily an issue of valvular incompetence of the
superficial Superficial may refer to: *Superficial anatomy, is the study of the external features of the body *Superficiality, the discourses in philosophy regarding social relation *Superficial charm, the tendency to be smooth, engaging, charming, slick and ...
or
deep vein A deep vein is a vein that is deep in the body. This contrasts with superficial veins that are close to the body's surface. Deep veins are almost always beside an artery with the same name (e.g. the femoral vein is beside the femoral artery). ...
s whereas PTS may occur as a long-term complication of
deep venous thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...
. The vascular surgeon has several modalities to treat lower extremity venous disease which including medical, interventional and surgical procedures. For instance, venous ulceration may be treated with
Unna's boot An Unna’s boot (also Unna boot) is a special gauze (usually 4 inches wide and 10 yards long) bandage, which can be used for the treatment of venous stasis ulcers and other venous insufficiencies of the leg. It can also be used as a supportive ...
s, superficial venous reflux with
radiofrequency Radio frequency (RF) is the oscillation rate of an alternating electric current or voltage or of a magnetic, electric or electromagnetic field or mechanical system in the frequency range from around to around . This is roughly between the upper ...
, laser ablation or
vein stripping Vein stripping is a surgical procedure done under general or local anaesthetic to aid in the treatment of varicose veins and other manifestations of chronic venous disease. The vein "stripped" (pulled out from under the skin using minimal incisio ...
if indicated. When indicated, insufficiency in the deep veins may be treated with reconstruction of the venous valves with internal or external valvuloplasty.


Varicose Veins

Lower extremity
varicose veins Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. These veins typically develop in the legs, just under the skin. Varicose veins usually cause few symptoms. However, some indiv ...
is the condition in which the superficial veins become tortuous(snakelike) and dilated (enlarged) to greater than 3mm in the upright position. Incompetent or faulty valves are often present in these veins when investigated with
duplex ultrasonography Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of a ...
. Vascular treatments can include
compression stockings Compression stockings (Flight Socks, Support Bandage) are a specialized hosiery designed to help prevent the occurrence of, and guard against further progression of, venous disorders such as edema, phlebitis and thrombosis. Compression stockings ...
, venous ablation or vein stripping, depending on specific patient presentation, severity of disease, among other things.


Nonthrombotic Iliac Vein Lesions

Nonthrombotic iliac vein lesions (NIVL) include May-Thurner Syndrome (MTS) whereby there is compression of the left iliac venous outflow usually by the right iliac artery leading to left leg discomfort, pain, swelling and varicose veins. NIVL encompasses compression of the iliac veins on either the right or left side. Vascular surgeons may offer different treatment modalities depending on the patient presentation. Minimally invasive diagnostic and therapeutic options might include
intravascular ultrasound Intravascular ultrasound (IVUS) or intravascular echocardiography is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the cath ...
, venography and iliac vein stenting whereas surgical management may be offered in refractory cases. Surgical management strategies involve reconstruction or bypass of the affected segment such as cross-pubic venous bypass, also known as the Palma procedure.


Deep Venous Thrombosis

Deep venous thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...
(DVT) is the formation of thrombus in a
deep vein A deep vein is a vein that is deep in the body. This contrasts with superficial veins that are close to the body's surface. Deep veins are almost always beside an artery with the same name (e.g. the femoral vein is beside the femoral artery). ...
. DVT is more likely to occur in the lower extremity than the upper extremity or
jugular vein The jugular veins are veins that take deoxygenated blood from the head back to the heart via the superior vena cava. The internal jugular vein descends next to the internal carotid artery and continues posteriorly to the sternocleidomastoid mu ...
. When a DVT involves the pelvic and lower extremity veins it can sometimes be classified as an iliofemoral DVT. Some evidence to suggests that performing an intervention in these cases may be beneficial whereas other evidence does not. Overall, the data shows that there may be a reduction in the incidence in
post-thrombotic syndrome Post-thrombotic syndrome (PTS), also called postphlebitic syndrome and venous stress disorder is a medical condition that may occur as a long-term complication of deep vein thrombosis (DVT). Signs and symptoms Signs and symptoms of PTS in the leg ...
in patients who undergo certain procedures for iliofemoral DVT but it is not without risks. A vascular surgeon may offer venogram, endovascular suction or mechanical thrombectomy and in some cases pharmacomechanical thrombectomy. Some lower extremity DVT can be severe enough to cause a condition called phlegmasia cerulea dolens or phlegmasia alba dolens and can be limb-threatening events. When phlegmasia is present, intervention is often warranted and may include venous thrombectomy.


Post-thrombotic syndrome

Post-thrombotic syndrome Post-thrombotic syndrome (PTS), also called postphlebitic syndrome and venous stress disorder is a medical condition that may occur as a long-term complication of deep vein thrombosis (DVT). Signs and symptoms Signs and symptoms of PTS in the leg ...
(PTS) is a medical condition that sometimes occurs as a long-term complication of DVT and is characterized by long term
edema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...
and skin changes following DVT. Presenting symptoms may include itchiness, pain, cramps and paresthesia. It is estimated that between 20% and 50% of patients will experience some degree of PTS. A treatment strategy for PTS may involve the use of compression stockings.


Pulmonary Embolism

Vascular surgeons may be a part of the treatment team in the management of patients suffering from pulmonary emboli.


Compressive Venopathies

Compression of large veins by adjacent structures or masses may lead to distinct clinical syndromes including
May–Thurner syndrome May–Thurner syndrome (MTS), also known as the iliac vein compression syndrome, is a condition in which compression of the common venous outflow tract of the left lower extremity may cause discomfort, swelling, pain or clots (deep venous thrombo ...
(MTS),
nutcracker syndrome The nutcracker syndrome (NCS) results most commonly from the compression of the left renal vein (LRV) between the abdominal aorta (AA) and superior mesenteric artery (SMA), although other variants exist. The name derives from the fact that, in the ...
and superior vena cava syndrome to name a few. Treatment modalities include
venography Venography (also called phlebography or ascending phlebography) is a procedure in which an x-ray of the veins, a venogram, is taken after a special dye is injected into the bone marrow or veins. The dye has to be injected constantly via a catheter ...
,
intravascular ultrasound Intravascular ultrasound (IVUS) or intravascular echocardiography is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the cath ...
and venous
stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...
ing as well as more invasive open venous reconstruction and bypass.


Management of Hemodialysis Access

Patients with chronic kidney disease may have progression of disease which requires
renal replacement therapy Renal replacement therapy (RRT) is therapy that replaces the normal blood-filtering function of the kidneys. It is used when the kidneys are not working well, which is called kidney failure and includes acute kidney injury and chronic kidney di ...
to filter their blood. One strategy for this therapy is
hemodialysis Hemodialysis, also spelled haemodialysis, or simply dialysis, is a process of purifying the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as creatinin ...
, which is a procedure that involves filtering a patient's blood to remove waste products and returning their blood back to them. One method which avoids repeated arterial trauma is to create an
arteriovenous fistula An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial ...
(AVF). The first procedure described for this purpose is named the Cimino fistula, after one of the surgeons who first had success with it. Vascular surgeons may create an AVF for a patient as well as undertake minimally invasive procedures to ensure the fistula remains
patent A patent is a type of intellectual property that gives its owner the legal right to exclude others from making, using, or selling an invention for a limited period of time in exchange for publishing an enabling disclosure of the invention."A p ...
.


Management of Vascular Trauma

One way that vascular trauma may be understood is by categorizing vascular injury by three criteria: mechanism of injury, anatomical site of injury and contextual circumstances. Mechanism of injury refers to etiology, e.g.
iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 2 ...
,
blunt Blunt may refer to: * Blunt (surname), a surname (and list of people with the name) * Blunt (cigar), a term used in the cigar industry to designate blunt-tipped, usually factory-rolled cigars * Blunt (cannabis), a slang term used in cannabis cult ...
, penetrating, blast injury, etc. Anatomical site functionally refers to whether there is compressible versus non-compressible hemorrhage, while contextual circumstances refers to injuries sustained in the civilian or military realm. Each context can be further broken down: military into combatant vs. noncombatant and civil into urban vs rural trauma. This categorization scheme is of both epidemiologic and clinical significance. For instance, arterial injury in military combatants currently occurs predominantly in males in their twenties who are exposed to improvised explosive devices or gunshot wounds; whereas in the civilian realm, one study conducted in the United States showed the most common mechanisms to include motor vehicle collisions, firearm injuries, stab wounds and falls from heights.


Blunt Thoracic Aortic Injury

Advances in vascular surgery, specifically endovascular technologies, have led to a dramatic change in the operative approach to blunt thoracic aortic injury (BTAI). BTAI results from a high speed insult to the thorax such as a motor vehicle collision or a fall from a height. One widely-used classification scheme is based on the extent of injury to the anatomic layers of the aorta as seen with
computed tomography angiography Computed tomography angiography (also called CT angiography or CTA) is a computed tomography technique used for angiography—the visualization of arteries and veins—throughout the human body. Using contrast injected into the blood vessels, ...
or
intravascular ultrasound Intravascular ultrasound (IVUS) or intravascular echocardiography is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the cath ...
. Grade 1 BTAI are those which tear the aortic intima; grade 2 injuries refer to intramural hematoma; grade 3 injuries are pseudoaneurysm and are only contained by adventitial tissue; and grade 4 refer to free rupture of blood into the chest and surrounding tissue. When indicated, first line intervention involves
TEVAR ''Tevar'' () is a 2015 Indian Hindi-language action film directed by debutante Amit Ravindernath Sharma and produced by Boney Kapoor, Sanjay Kapoor, Sunil Lulla, Naresh Agarwal and Sunil Manchanda, based on a script by Sharma and Shantanu Shri ...
.


Investigations


Major trials


Training

Previously considered a field within
general surgery General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid ...
, it is now considered a specialty in its own right. As a result, there are two pathways for training in the United States. Traditionally, a five-year general surgery residency is followed by a 1-2 year (typically 2 years) vascular surgery fellowship. An alternative path is to perform a five or six year vascular surgery residency. In many countries, Vascular surgeons can opt into doing additional training in
cardiac surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...
as well as post-residency. Programs of training vary slightly between different regions of the world.


See also

*
Society for Vascular Surgery The Society for Vascular Surgery (SVS) is the major national academic society for vascular surgery in the United States. Its mission includes education, research, career development and advocacy. The SVS is the national advocate for more than 6, ...
, the major American professional society *
Ischemia-reperfusion injury of the appendicular musculoskeletal system Ischemia-reperfusion (IR) tissue injury is the resultant pathology from a combination of factors, including tissue hypoxia, followed by tissue damage associated with re-oxygenation. IR injury contributes to disease and mortality in a variety of pa ...
*
Kakish Ryskulova Kakish Ryskulova, in Kyrgyz: Какиш Рыскулова (15 October 1918) - 26 August 2018) was a medical doctor and politician from Kyrgyzstan, who was an Academician of the Kyrgyz Academy of Sciences. She was the first central Asian and firs ...
*
Vein Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
*
Phlebologist A phlebologist is a medical specialist in the diagnosis and treatment of disorders of venous origin. The specialty of phlebology has developed to enable physicians sharing an interest in venous disease and health to share knowledge and experience ...
*
Cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, h ...
*
Cardiology Cardiology () is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart d ...


References


External links


Society for Vascular Surgery
(U.S.)
European Society for Vascular Surgery
{{DEFAULTSORT:Vascular Surgery Surgical specialties