Imagine flying in a helicopter over a busy city. Looking down, you can see the system of major expressways, the smaller highways exiting off of them, and even the back roads. That’s one way to think of your circulatory system, which includes all the arteries and veins that do the critical job of transporting blood throughout your body. Similar to a traffic jam, a blood clot, or buildup of plaque in any one spot, can restrict the flow and throw the whole system off.
Fortunately, there are sophisticated surgical approaches to treating vascular problems, which can be serious, sometimes causing critical complications.
“The most exciting breakthrough in vascular surgery has been the evolution of minimally invasive surgery (operating through small incisions with tiny instruments). “This has transformed the specialty completely,” says Yale Medicine vascular surgeon Uwe Fischer, MD, PhD.
What is vascular disease?
The term vascular disease covers any condition that affects the arteries, blood vessels, veins, and tiny capillaries that carry blood. It also covers the lymphatic system—the small vessels through which a fluid called lymph, containing infection-fighting white blood cells, travels from the tissues into the blood. Vascular disease includes a long list of conditions, some of which can become life-threatening:
- Acute venous thrombosis
- Aortic aneurysm (abdominal, thoracic)
- Carotid artery disease
- Critical limb ischemia
- Diabetes vascular disease and limb salvage
- Diseases of the aorta
- Dialysis graft and fistula management
- Non-healing wounds caused by vascular disease
- Peripheral artery disease (PAD)
- Thoracic outlet syndrome
- Varicose veins
- Vascular malformations
- Visceral artery disease
Who is at risk for vascular problems?
Vascular disease becomes more common with age, but people with a family history of vascular and heart disease are at higher risk, as well as women who are pregnant, or anyone who has a cardiac-related condition such as high cholesterol or hypertension.
An unhealthy lifestyle also can lead to vascular problems, which are more prevalent among people who smoke, or are obese or sedentary, or who routinely stand still or sit for long periods of time.
When is surgery necessary for vascular problems?
It depends on the problem. Some people will not need surgery if their vascular disease is diagnosed early and they follow their doctor’s advice, which can be as simple as making lifestyle changes and/or taking medications. For example, a regular walking routine coupled with aspirin, statins, and other medications can be an effective remedy for early PAD, which affects the arteries in the legs and feet.
For other people, surgery may improve quality of life, sometimes relieving pain and improving mobility—and it may be critical to help some people with vascular disease avoid such serious problems as heart attack and stroke.
What types of surgeries are available to treat vascular diseases?
Even though there are different vascular problems, there are essentially two surgical approaches to treatment:
- Open surgery: The surgeon makes a long incision in order to have direct access to view and treat the problem.
- Endovascular surgery: This is a minimally invasive approach that involves inserting a catheter (a slender, flexible tube) with medications or tiny instruments through the skin and into the blood vessel.
In some complex cases, the surgeon may use a combination of minimally invasive and open approaches.
Below are three common vascular diseases treated by surgery:
- Abdominal aortic aneurysm: An aneurysm is a bulging, weakened area that develops in the wall of the aorta, the largest blood vessel in the body. An aneurysm can grow in size until it becomes life-threatening. It may require open surgery, meaning the surgeon will make a large incision in the abdomen, and replace the weakened area with a coil-like tube made of metallic mesh called a stent, or with living tissue, called a graft. Eligible patients may be able to have a minimally invasive endovascular aneurysm repair, in which the surgeon uses small incisions in the groin and X-ray guidance while working with small instruments to insert the stent or graft.
- Peripheral Artery Disease (PAD): Atherosclerosis, or plaque, can build up in the arteries that bring blood to the arms and legs causing the arteries to narrow and even become blocked. This condition is known as PAD. Several minimally invasive endovascular approaches can be used to treat severe PAD. The surgeon makes a tiny incision in the groin and threads a catheter with miniature surgical instruments, into the artery. Using X-ray guidance, he or she finds the blockage and opens it up, maybe with a stent, or scrapes out the plaque. Balloon angioplasty is a minimally invasive procedure that involves inserting a catheter with a balloon on the end to open the vessel. The surgeon often places a stent in the artery to keep it open. Some cases of PAD are complex enough to require an open surgery, in which the surgeon creates an alternative route for the blood to go around the blockage.
- Varicose veins: While they don’t commonly lead to serious conditions, many people find swollen enlarged varicose veins uncomfortable and unsightly. They develop when damage to the valves in the veins causes blood to collect in them, affecting blood flow in the body. Two types of surgery can remove varicose veins: Vein-stripping involves making two incisions in the leg and pulling out the entire vein; phlebectomy uses several tiny incisions along the length of the vein and pulling it out in pieces.
For some conditions, alternatives to surgeries are making treatment easier. For example, radiofrequency ablation is a way to use electromagnetic waves to close off blood flow to varicose veins. But since every patient is different, it’s important to talk to a vascular surgeon about the best care for each situation.
What are the risks of vascular surgery?
Like all surgeries, vascular surgery poses some risks of complications, which increase if the patient smokes, is obese, and has other serious conditions like chronic lung disease. There is additional risk when the surgeon operates on the chest or a major blood vessel. But for a serious vascular condition, the benefits often outweigh the risks.
What is recovery and follow-up like after vascular surgery?
Depending on the surgery, patients may spend time in the intensive care unit and the hospital. Some varicose vein procedures may be done on an outpatient basis.
Vascular disease is a chronic condition, so many patients continue to follow up with their vascular surgeon throughout their life.
How is Yale Medicine unique in surgery for vascular problems?
Yale Medicine Vascular & Endovascular Surgery specialists care for a broad spectrum of vascular conditions, ranging from the most common to the most complex, including PAD, chronic wounds and potential limb loss. We are one of the first and largest centers in the world for clinical care of patients with aneurysm, and one of the most active centers for basic science and clinical research in aortic diseases.
In caring for our patients, we harness the latest minimally invasive technologies, including radiofrequency ablation and endovenous laser ablation (a minimally invasive laser treatment) for painless removal of varicose veins. But all of our surgeons also have extensive training in complicated open surgeries such as aortic aneurysm repairs. We use the most advanced techniques available to help reduce post-surgical discomfort, recovery time, and scarring.
Research and development play a dominant role in the ongoing success of Yale Medicine’s vascular and endovascular surgery program. This means our patients may have access to treatments and clinical trials that are difficult to find elsewhere.