Vascular Surgery
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Vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The specialty evolved from general and cardiac surgery. Early pioneers of the field include Russian surgeon Nikolai Korotkov, noted for developing early surgical techniques, and the Australian Robert Paton, often credited with helping the field achieve recognition as a speciality. 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. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system except that of the heart and brain. Cardiothoracic surgeons manage surgical disease of the heart and its vessels. Neurosurgeons and interventional neuroradiologists manage surgical disease of the vessels in thebrain (e.g. intracranial aneurysms).
The Evolution of Endovascular Surgery Medical science has advanced significantly since 1507, when Leonardo da Vinci drew this diagram of the internal organs and vascular systems of a woman. 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, chiefly Dr. Charles Dotter, who invented angioplasty. Further development of the field has occurred via joint efforts between interventional radiology, 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 can now form the bulk of a vascular surgeons practice. The development of endovascular surgery has been accompanied by a gradual separation of vascular surgery from its origin in general surgery. Most vascular surgeons would now confine their practice to vascular surgery and similarly general surgeons would not be trained or practice the larger vascular surgery operations or most endovascular procedures. More recently, professional vascular surgery societies and their training programme have formally separated “Vascular Surgery” into a separate specialty with its own training program, meetings, accreditation. Notable societies are Society of Vascular Surgery (SVS), USA; Australia and New Zealand Society of Vascular Surgeons (ANZ SVS). Local societies also exist e.g. Melbourne Society of Vascular Surgeons (MVSA). Larger societies of surgery actively separate and encourage specialty surgical societies under their umbrella e.g. Royal Australasian College of Surgeons (RACS). Common Professional Associations Associated areas of interest and operative surgical practice for vascular surgeons are access surgery for hemodialysis and peritoneal dialysis, organ harvesting for transplantation, renal transplantation, pancreatic solid organ transplantation Organ transplant. Vascular surgeons will frequently have close associations with specialist interventional radiologists for a combined treatment of certain conditions. The radiologists contribute to endovascular cases management, sometimes with angioplasty and stenting, but also in specific areas of expertise e.g. sclerotherapy for vascular anomalies and arteriovenous malformations (AVMs), coil embolisation of bleeding visceral arteries in trauma or for occlusion of tumour supplying arteries as a prelude to operation, CT-guided procedures such as lumbar chemical sympathectomy. Common medical associations are the involvement providing surgical opinions and treatment for a multidisciplinary clinic with vascular surgeons, vascular nurses, wound management nurses, podiatrists, prosthetists, rehabilition physicians, vascular physicians, endocrinologists, etc. to manage high risk foot disease patients. Less common operative surgical associations are: sympathectomy (ETS, Endoscopic thoracic sympathectomy), lumbar sympathectomy, Hyperhidrosis surgery); vascular access for chemotherapy etc. patients; dialysis/ECMO (extra-corporeal membrane oxygenation) for patients in Intensive Care Wards; vascular mobilisation for access associated with other specialist operations e.g. extensive orthopaedic spinal and pelvic surgery, retroperitoneal cancer dissections, renal tumour surgery. Vascular Surgery in the Third Millennium Arterial and venous disease treatment by angiography, stenting, and non-operative varicose vein treatment sclerotherapy, endovenous laser treatment 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. 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 ischaemic 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 USA 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. An emerging trend based on such venous clinics is the treatment of varicose veins by non-vascular surgeons e.g. cosmetic physicians, phlebologists, radiologists, etc. These practices aim to offer a complete varicose and surface vein treatment without surgery. Breadth of discipline
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