Atherosclerosis affects blood vessels in the body causing circulatory disorders in the affected organ (myocardial infarction, stroke, gangrene). The man risk factors of atherosclerosis are: cigarette smoking, diabetes, high blood pressure, elevated blood lipids (cholesterol), and obesity.

Peripheral arterial occlusive disease (PAOD) is a narrowing of the arteries, commonly affecting the legs. Although about 1/5^th of people over the age of 65 have this disease it often remains without symptoms. As atherosclerosis progresses, so too does arterial narrowing.

It should be stressed that a patient sometimes has no risk factors but nevertheless develops extensive PAOD.

The classic symptom of PAOD is ”claudicatio intermittens” i.e. leg muscle pain during walking, which resolves with rest. Muscle pain during exercise occurs due to inadequate blood flow and thereby poor oxygen supply.

If not treated, PAOD progresses, reducing the distance a sufferer is able to walk. It results sometimes in critical circulatory disorder with “rest pain” (i.e. pain without walking) and, finally, gangrene without infection (“mummification”) or with infection (abscess, phlegmon) develops. Without limb salvage treatment this critical circulatory disorder can lead to a major amputation.

Thereby it is of paramount importance to consult a doctor in case of signs of leg circulatory disorders: cold/pale legs, intermittent claudication, pain in the toes or feet, foot ulcerations that fail to heal.  

Medical examinations needed to diagnose PAOD: Anamnesis, clinical examination, and uncle/brachial index measurement. To glean further information and to determine whether an operation is advisable, duplex ultrasonography and vascular imaging techniques are needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), magnetic resonance imaging angiography (MR-Angiography), or invasive investigation – conventional digital subtraction angiography (DSA).

For treatment modalities see “Treatment/Surgery”.  

Carotid stenosis is the narrowing of the lumen of carotid artery that supplies the brain with arterial blood.

The usual cause of stenosis is atherosclerotic plaque, particularly among the elderly. Other less common diseases can also lead to carotid narrowing such as vessel wall dissection, which mostly occurs in younger people.

Carotid stenosis is the most common cause of so-called ischaemic stroke. Plaque became unstable, pieces can break off and, as a result, an embolization of small cerebral arteries occurs.

A stroke is often a life threatening/fatal disease. If a patient survives, he or she often remains mentally and/or physically disabled.

There are some warning symptoms – transient ischaemic attacks (TIA) – which are often followed by a stroke. These temporary symptoms are: arm and/or leg paralysis (weakness) and numbness on one side of the body, slurred speech, and blurred vision.

The signs of TIA signify the need to see a doctor immediately in order to avoid a progressive and irreversible stroke. We advocate screening with duplex ultrasonography in people aged 65-70.

Medical examinations needed to diagnose carotid stenosis: Anamnesis, clinical examination, and duplex ultrasonography. Vascular imaging techniques are seldom needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), or magnetic resonance imaging angiography (MR-Angiography).

For treatment modalities see “Treatment/Surgery”.

Renal artery stenosis is the narrowing of the lumen of the renal artery that supplies the kidneys with arterial blood.

The usual cause of stenosis is atherosclerotic plaque, particularly among the elderly. Other less common diseases can also lead to renal artery narrowing such as fibromuscular dysplasia mostly occurring in younger people.

Particular kidney cells are involved in the regulation of systemic blood pressure. The kidney responds to decreased blood pressure (e.g. after blood loss) by activation of these cells, secreting hormones and counteracting low blood pressure (renin-angiotensin-aldosterone system).

Renal artery stenosis causes a decrease in blood flow to the kidneys and activates this system, leading to hypertension – high blood pressure that is often refractory to treatment with antihypertensive medicaments. Longstanding renal ischemia leads to kidney atrophy and failure.

In patients (particularly those who are young) with arterial hypertension, which is refractory to antihypertensive treatment, the renal artery stenosis should be controlled.   

Medical examinations needed to diagnose renal artery stenosis: Anamnesis, clinical examination, and duplex ultrasonography. Vascular imaging techniques are always needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), or magnetic resonance imaging angiography (MR-Angiography). Invasive investigation – conventional digital subtraction angiography (DSA) is a golden standard not only for diagnosis but also simultaneous intraluminal treatment.

For treatment modalities see “Treatment/Surgery”.

Diabetic foot is a sequel of diabetes mellitus. Diabetes affects all peripheral nerves leading to degeneration of pain, motor and autonomic fibres. Numbness and tingling of extremities develop gradually with time. Decreased sensation occurs in the toes and feet – so called “glove-stocking” distribution of neuropathy. Sensory (touch and pain) loss leads to a situation when a bagatelle lesion of the foot is overlooked until a deep ulceration occurs.

Another cause of foot ulceration is the progressive degeneration of foot bones and joints leading to bone destruction and foot deformity – so-called “Charcot foot”.

Foot ulceration progresses rapidly if facilitated by concomitant peripheral arterial occlusive disease, which often accompanies diabetic patients.

Chronic ulceration and infection could result in a loss of function, amputation or even death.

Early identification of skin/joint changes and even minor ulcerations can limit morbidity and prevent amputation in diabetic patients.

Medical examinations needed to diagnose diabetic foot: Anamnesis, clinical examination, and neurologist consultation. Duplex ultrasonography, vascular imaging techniques are needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), or magnetic resonance imaging angiography (MR-Angiography). Invasive investigation – conventional digital subtraction angiography (DSA) is a golden standard not only for diagnosis but also simultaneous intraluminal treatment.

For treatment modalities see “Treatment/Surgery”.

An aortic aneurysm (AA) is an expansion in the diameter of the aorta.

AA usually causes no symptoms save occasionally pains in the abdomen or in the back. Localization occurs most commonly in the abdominal aorta and less frequently in the thoracic aorta.

The wall of an AA is thin and weak, which increases the risk of aortic rupture. If rupture occurs, it leads to massive intra-abdominal bleeding and shock. Every second patient with an aortic rupture dies immediately or en route to hospital. About 50% of patients with a ruptured aorta will not survive an operation in spite of immediate treatment. The mortality rate of a ruptured AA reaches about 75%.

The rate of enlargement of an AA is unpredictable. The risk of rupture increases with the diameter of the aneurysm. If an abdominal AA reaches 5-5.5 cm and a thoracic AA 6 cm, the risk of rupture exceeds the risk of surgical repair, in which case correction of the AA should be considered. Sometimes even a small-sized AA has to be treated depending on the shape of the aneurysm, e.g. a “saccular” (bulbous) AA.

Another possible complication of an AA is the embolization of different vessels by pieces of thrombi that usually line the AA interiorly.

The risk factors of an AA are smoking and high blood pressure.

The extremely high mortality rate of a ruptured AA (75%) and the excellent perioperative results of elective treatment (2-5% mortality rate) underline the importance of early identification of patients with an AA. We advocate screening for AA with abdominal ultrasound in patients aged 65-70.

Medical examinations needed to diagnose an AA: Anamnesis, clinical examination, and ultrasound. To perform a topical diagnosis and to plan an operation vascular imaging techniques are needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), and magnetic resonance imaging angiography (MR-Angiography).

For treatment modalities see “Treatment/Surgery”.

Visceral artery aneurysms (VAA) are rare aneurysms. Most common sites for VAA are the splenic artery and the hepatic artery. VAAs are more commonly diagnosed as either an asymptomatic incidental finding or in a state of rupture. Despite recent improvements in diagnosis and therapy, this represents a potential fatal condition with mortality rates of up to 75%.

Popliteal artery aneurysms (PAA) represent about 70% of peripheral aneurysms. PAA mainly affect people aged over 65. This aneurysm is often bilateral and in 50% of cases, aneurysmal disease is also observed at other levels. Asymptomatic, small aneurysms (less than 2 cm) may be treated conservatively. Repair is advocated when symptoms are present (embolization of distal vessels, ischemia, rupture) but also for asymptomatic disease when the diameter is more than 2 cm, especially in the presence of a wall thrombus.

The morbidity/mortality associated with elective repair of visceral/peripheral aneurysms is low. Ruptured VAA/PAA, however, pose a significant risk of complications and death. A patient with visceral/peripheral aneurysms urgently needs to consult a doctor.

Medical examinations needed to diagnose VAA/PAA: Anamnesis, clinical examination, and ultrasound. To perform a topical diagnosis and to plan an operation vascular imaging techniques are needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), and magnetic resonance imaging angiography (MR-Angiography).

For treatment modalities see “Treatment/Surgery”.

Varicose veins (VV) are pathologically enlarged and twisted subcutaneous veins commonly on the leg (vena saphena magna/parva). Subcutaneous veins have valves that enable blood flow from periphery to the heart and prevent blood flow backwards. The valves in VV became insufficient, thereby allowing blood to flow back, which enlarges veins even more – the so-called “circulus vitiosus” is closed.

VV are frequently found in women aged over 40. There is a strict familiar predisposition factor in varicose disease. Correlation between the number of varicose parents and the risk for the child: both parents – 90% risk for the child, single parent – 45%, neither parents – 20%.

VV is not only a cosmetic problem. The most common complains of patients with clinically relevant VV are: pains, swelling, aching, heavy legs, and cramps.

VV may lead to serious complications.

• Chronic blood stasis and leg swelling can lead to eczema, skin thickening, hyperpigmentation, and finally ulceration.
• A thrombus formation in VV is known as thrombophlebitis accompanied by pain, skin redness, localised warmth in the part of the affected vein, leg swelling, and a palpable stiff vein. Although it is rare, thrombi can move to deep veins (phlebothrombosis), which may be life threatening.
• If injured, VV may lead to extensive bleeding.

Because of the above-mentioned complications, we advocate operative treatment of varicose veins.

Medical examinations needed to diagnose varicose veins: Anamnesis, clinical examination, and a duplex ultrasonography. Invasive investigation – phlebography is seldom needed.

For treatment modalities see “Treatment/Surgery”.

Deep vein thrombosis (DVT) is a thrombus formation in a deep vein, predominantly in the leg.

Several diseases increase the risk of DVT, e.g. cancer, older age, trauma, hereditary or acquired blood coagulation disorders, surgery, immobilization (bedridden), immobilization and narrow seat during long flights (“economy class syndrome”), orthopaedic casts, pregnancy/postnatal period, contraceptive and smoking, etc.

The symptoms of DVT include pain, tenderness, swelling of the affected leg, although sometimes symptoms are not present (distal thrombosis).

When DVT has been diagnosed, the search of the cause of thrombosis is strictly indicated in order to determine the type and duration of secondary prophylaxis.

The most frequent complication of DVT is post-thrombotic syndrome (PTS) – venous blood stasis in the veins with reduction of venous blood flow to the heart. About 50% of DVT patients develop venous ulcerations on the affected leg.

The most dangerous complication of DVT is a pulmonary embolism (PE), which may have a fatal outcome. PE is caused by thrombus migration from the deep veins to the pulmonary artery that induces lung infarction.

DVT is a potentially fatal disease. Carefully and individually selected primary/secondary prophylaxes help to avoid DVT and fatal PE.

Medical examinations needed to diagnose DVT: Anamnesis, clinical examination, laboratory investigations, and a duplex ultrasonography. Vascular imaging techniques are needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), magnetic resonance imaging angiography (MR-Angiography), or invasive investigation – conventional phlebography.

For treatment modalities see “Treatment/Surgery”.

Chronic venous insufficiency (CVI) may be caused by the following diseases:

• Varicose veins without or with thrombophlebitis,
• Deep vein thrombosis (DVT) – post-thrombotic syndrome (PTS),
• Obesity (adipositas permagna),
• Arteriovenous fistula

For more information see “Varicose Veins”, “Deep Vein Thrombosis, Thromboembolism”

For treatment modalities see “Treatment/Surgery”.

Vascular reconstructions in orthopaedic tumour operations: the surgical treatment of bone tumours involves radical resection therapy. The major vessels are often included in the tumour mass. They have to be resected with tumour and for limb salvage reconstructed using autologous or synthetic materials.

Vascular interventions in urology: Renal cell carcinoma represents about 3% of all neoplastic diseases. The tumour tends to spread intravascularly, leading to tumour invasion and thrombosis within the inferior caval vein. Surgical resection of both tumour and thrombus contributes to the improvement of the patient’s prognosis.

Vascular interventions allow radical resection therapy of malignant tumours, playing an important role in the improvement of the patient’s prognosis.

Medical examinations needed: Anamnesis, clinical examination, and ultrasound. To perform a topical diagnosis and to plan an operation vascular imaging techniques are needed, e.g. non-invasive investigations as a computed tomography angiogram (CT-Angiography), and magnetic resonance imaging angiography (MR-Angiography). Appropriate orthopaedic/urologic investigations are needed.

For treatment modalities see “Treatment/Surgery”.