European Society
for
Vascular Surgery
Union Europeenne des Medecins Specialistes
UEMS
Division of Vascular Surgery
&
European Board of Vascular Surgery
These pages are developed as a collaboration between The Webmasters on behalf of the European Society for Vascular Surgery - ESVS
&
the Secretary of the Division of Vascular Surgery & the European Board of Vascular Surgery, Union Europeenne des Medecins Specialistes - UEMS:
Dr Jaap Buth,
Department of Vascular Surgery,
Catharina Hospital,
Michelangelolaan 2,
NL-5623 EJ Eindhoven,
The Netherlands.
Tel: + 31 40 39 71 57.
Fax: + 31 40 44 33 70
UEMS DIVISION OF VASCULAR SURGERY WITHIN THE SPECIALITY SECTION OF GENERAL SURGERY.
DEFINITION AND SPECIFICATIONS OF VASCULAR SURGERY.
1. PRECISE DEFINITION OF VASCULAR SURGERY.
Vascular surgery is the clinical and scientific discipline concerned with the diagnosis, treatment and prevention of diseases affecting arteries, veins and lymphatics.
2. DETAILED SPECIFICATIONS OF VASCULAR SURGERY.
2.1
Introduction.
Vascular disease are currently the most common cause of death and disability in European countries. There is little evidence of any significant decline in the prevalence of these diseases despite widespread promotion of preventive measures. However, the range of available diagnostic and therapeutic techniques has broadened considerably in recent years and continues to do so. Vascular surgery has therefore become a clearly defined, highly specialised and progressively expanding discipline, with specific training requirements.
2.2
Application of basic knowledge.
The practice of vascular surgery requires extensive knowledge of the basic science and a thorough training in general surgical techniques. In addition, it is necessary to possess detailed specialised knowledge of the anatomy and physiology od arteries, veins and lymphatics and of the pathological processes which may affect them. The effects of vascular disease may be manifest by dysfunction of an organ or limb served by the affected vessel and vascular surgeons acquire and apply detailed understanding of these processes.
2.3
Relevant pathologies.
A large proportion of vascular surgical workload is concerned with the diagnosis and treatment of degenerative arterial diseases. These may cause occlusion of arteries with resultant circulatory insufficiency in the limbs or organs supplied, causing for example, muscle pain on walking (intermittent claudication), gangrene, stroke, kidney or other organ failure. It may also cause weakening of the arterial wall with distension (aneurysm formation) and life threatening rupture of the vessel. Varicose veins and venous thrombosis are common vascular disorders. The following list, is not comprehensive but includes the main pathologies treated by vascular surgeons: Degenerative arteriopathies; arterial occlusion (atherosclerosis); aneurysm; acute arterial occlusions; embolism; thrombosis; arterial trauma; inflammatory arteriopathies; congenital arteriovenous malformations and angiodysplasia; disorders of the microcirculation; vasospastic disease; acrocyanosis; vibration white finger; diabetic angiopathy; sympathetic dystonia; varicose veins; deep venous thrombosis and post-thrombotic syndrome; extracranial cerebrovascular disease; renal and mesenteric arterial disease; thoracic outlet compression syndromes; lymphoedema.
2.4 Diagnosis.
2.4.1.
Clinical Diagnosis.
The vascular surgeon applies specialised clinical skills to detect evidence of vascular disease, to assess its severity and determine its pathological effects.
2.4.2
Special investigation techniques.
2.4.2.a
Non-invasive vascular laboratory.
A non-invasive vascular laboratory is a facility for the objective assessment of the circulation, without the need for injections, harmful radiation or other potentially noxious interventions. The technology employed in such laboratories is sophisticated and a high degree of diagnostic accuracy can be achieved. The most effective type of equipment employed is that based upon the application of ultrasound. Such equipment provides images of blood vessels (B mode scans) or by application of the doppler effect gives detailed information about blood flow disturbances (Doppler scans). The two functions are combined (Duplex scan) to provide comprehensive assessment of vascular pathology. Other investigations provided by blood flow laboratories include: laser Doppler studies of microcirculation, various forms of plethysmography thermography and exercise tolerance testing. A non-invasive vascular laboratory is an indispensible component of vascular surgery.
2.4.2.b
X-ray angiography.
X-ray images of arteries, veins and lymphatics are obtained after injecting into them radio opaque contrast media. Digital systems with image enhancement improve the accuracy and safety of this investigation. Angiography is an essential component of any vascular surgery service. The vascular surgeon may also utilise imaging techniques such as computerised tomography (CT-scans), radioisotype angiography, and magnetic resonance imaging (MRI) which are provided by departments of radiology.
2.4.2.c
Intraoperative investigations.
Measurements made during an operation may assist in the planning of the procedure and are also important for effective quality control. These include blood flow measurement with electromagnetic or Doppler flow probes, measurement of pressure gradients and peripheral resistance, intraoperative angiography and angioscopy.
2.5
Prevention of vascular disease.
The causation of the common degenerative arterial diseases is multifactoral. A number of risk factors have been identified, of which the most important are cigarette smoking, unhealthy diet, and lack of exercise. Vascular surgeons are actively involved in the promotion of life style changes in the population as a whole in order to reduce the prevalence of these diseases. The value of population screening to detect and selectively treat early, asymptomatic vascular disease is currently under investigation in a number of European centres and this approach might play an important part in reducing the incidence of overt arterial disease and its serious complications in the future.
2.6
Treatment of vascular diseases.
2.6.1.
Open vascular operations.
Vascular surgery encompasses the repair of blood vessels throughout the body with the exception usually of those within the cranium and those intrinsic to the heart. The basic techniques of open reconstruction applied are direct repair by suturing, endarterectomy (rebore) and graft replacement or bypass. Grafts may be constructed from the patients own healthy blood vessel transplanted to replace one that is diseased e.g. saphenous vein bypass graft or from artificial materials. The procedures undertaken on blood vessels themselves include: Operations on arteries; repair of arteries and vein damaged by trauma; carotid and vertebral artery reconstruction; reconstruction of the thoracic aorta; upper limb arterial reconstruction; aortic and arterial aneurysm repair - elective and emergency; aorto-femoral bypass for occlusive disease; renal and mesenteric artery reconstruction; femoral and femoro-femoral bypass; femoral embolectomy and thrombectomy; femoro-popliteal bypass, using autologous vein or artificial arterial grafts; femoro-infrapopliteal bypass; tibial and pedal artery reconstruction; endovascular arterial reconstruction either percutaneously or with surgical exposure of arteries; treatment of congenital arterial or arteriovenous malformations; operations on veins; injection sclerotherapy for varicose veins; ligation and excision of varicose veins; venous thrombectomy; deep venous reconstruction including bypass, grafts, valvuloplasty and valve transplantation; subfascial ligation of perforating veins; insertion of vena caval filters; treatment of congenital venous malformations; operations on lymphatics; reconstructive and debulking surgical procedures; non-vascular operations; thoracic outlet decompression including excision of cervical and/or first ribs; cervico-dorsal sympathectomy either by open operation, thoracoscopic procedure or injection; lumbar sympathectomy by open operation or paravertebral injection; amputation of limbs. In certain circumstances vascular surgical practice may also include: Treatment of portal hypertension by construction of porta-systemic shunts; extracranial to intracranial arterial anastomosis; provision of vascular access e.g. for haemodialysis or chemotherapy; operations for vasculogenic impotence; microvascular repair of small blood vessels; excision and skin grafting of leg ulcers.
2.6.2.
Endovascular surgery. sease; e) catheter administered thrombolytic therapy; f) insertion of vena caval filters. Control of these procedures may be by a) x-ray imaging, b) ultrasound imaging using external or intraluminal devices, c) angioscopy, d) intraluminal pressure monitoring. Endovascular procedures may be undertaken by surgeons or radiologists with appropriate training. Team work to combine the expertise and skills of surgeons and radiologists is an acceptable approach. Because there is a risk of serious complications requiring surgical intervention, endovascular procedures should not be undertaken without the support and immediate availability of a fully trained vascular surgeon.
2.6.3.
General management.
Not all patients with arterial, venous or lymphatic disease require interventional therapy. Advice concerning life style changes especially with reference to smoking habits, and elimination of known causative factors, is adequate for some with mild symptoms. A large number of pharmacotherapeutic agents for the treatment of circulatory disorders are available to the vascular surgeon. These include a) substances which act on the blood vessels themselves e.g. vasodilators and atherolytic agents and b) substances which affect the blood to alter thrombogenicity, coagulation or its rheological properties. Vascular surgeons have played a leading role in identifying and promoting effective prophylactic measures against thromboembolic complications, venous thrombosis and pulmonary embolism of surgical or medical illness, and undertake treatment of patients with established venous thrombosis and the early or late complications which may ensue. Vascular surgeons may also apply or supervise the application of non-surgical physical therapies for vascular diseases, for example structured exercise programmes for patients with intermittent claudication, compression bandaging for the late complications of deep vein thrombosis and intermittent compression therapy for lymphoedema.
2.7 Research, audit and education.
The may advances which have occurred in the last 3 decades since vascular surgery has become common place have been the result of intensive research effort. Programmes of research represent an integral part of vascular surgical practice in all major centres. In the interest of ensuring high standards of practice all vascular surgeons are encouraged to maintain an accurate audit of their results and their performance is subject to peer review in some European countries. The dissemination of knowledge and information about new advances is effected through publications in text books and professional journals and through the medium of local, national and international meetings. Vascular surgeons play an important role in the training of undergraduate and postgraduate students. They also have responsibilities regarding the continuing education of primary care physicians to keep them informed of the latest advances in the prevention and treatment of vascular diseases and to encourage appropriate referral for specialist assessment.
DIVISION OF VASCULAR SURGERY
SPECIALITY SECTION OF GENERAL SURGERY
UEMS
NOVEMBER, 1993.
Last update 16 March 1996
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