TREATMENT / SURGERY

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Peripheral Arterial Occlusive Disease: Surgical vs. Endovascular Treatment

Both endartrectomy with patch plastic and bypass grafting are commonly used operative procedures to treat peripheral arterial occlusive disease.

During endartrectomy, the surgeon opens the artery and removes the atherosclerotic plaque together with the inner wall of the affected artery – hence the name “Endarterectomy”. Then the artery is closed using a patch (autologous vein, bovine pericardium, synthetic material) to increase the size of the lumen.

A vascular bypass is aimed at bridging an occluded arterial segment, redirecting blood flow from the vessel area with apparently normal blood flow to the vessel area without normal flow. For example, if a superficial femoral artery is occluded, then a bypass from a common femoral artery to a popliteal artery may be used.

The best graft material is an autologous vein, but if not available/suitable, synthetic materials (PTFE, Dacron) are used.

A narrowed/occluded segment of an artery may also be widened/opened using balloon dilatation – percutaneous transluminal angioplasty (PTA). For this purpose, through percutaneous access, a balloon catheter will be placed into the narrowed segment of the artery and the balloon will be inflated. Stent implantation during PTA procedure prevents possible re-stenosis of the dilated vessel, which may occur when the balloon is deflated and the catheter removed.

Although PTA is a low-risk procedure compared to surgery, potentially dangerous complications can occur. The most frequent complication is hematoma or pseudoaneurysm formation at the puncture site. If there are no complications, the patient can leave hospital the next day after PTA.

Limb salvage treatment allows the restoration of blood supply to an ischemic extremity suffering from circulatory disorders, which reduces the risk of major amputation.

For disease pattern see “Diseases”.

Stenosis of the Carotid Artery: Operative Stroke Prevention by Carotid Endarterectomy

Carotid endarterectomy (CEA) is the surgical removal of atherosclerotic plaque together with the inner wall of an artery to correct stenosis (narrowing) of the internal carotid artery.

The operation is usually performed under general anaesthesia. The carotid vessels (common, external and internal carotid arteries) should be dissected precisely and gently – “non-touch technique” – in order to avoid intraoperative break off of atherosclerotic plaque and consequent embolization of the brain. After intravenous introduction of heparin and brain-protecting medicaments, the arterial blood pressure should be pharmacologically increased to ensure blood supply of the brain from the contralateral arteries during the clamping time. Alternatively, an intraoperative temporary intraluminal shunt may be placed. Under these circumstances, the affected vessels will be clamped. The surgeon opens the artery and removes the plaque together with the inner wall of the affected artery – hence the name “Endarterectomy”. Then the artery will be closed using a patch (autologous vein, bovine pericardium, synthetic material) to increase the size of the lumen.

The rate of intra/postoperative complications (death, permanent major neurologic deficit) is extremely low at our institution, amounting to 0.8%.

The patient is usually mobilized on the second postoperative day and will be discharged after 3 to 4 days, if there are no other complications.

In selected cases, a less invasive procedure – endovascular angioplasty and stenting (PTA-stent) of the narrowed carotid artery is recommended. Indications for PTA-stent are: high stenosis, “hostile neck” (e.g. patients with prior radical oncological neck surgery or radiation therapy), and, sometimes, recurrent carotid stenosis.

Today, carotid endarterectomy is a safe operation with low perioperative complication rates. It may be recommended in patients with high-grade asymptomatic carotid stenosis or in symptomatic patients with more than 70% carotid stenosis as an effective operation for stroke prevention.

For disease pattern see “Diseases”.

Stenosis of the Renal Artery: Endovascular Treatment of Renal Hypertension

Nowadays, atherosclerotic stenosis/occlusion of the renal artery is exclusively treated with balloon dilatation (angioplasty) with or without stenting.

For this purpose, through percutaneous access, a balloon catheter will be placed into the narrowed segment of the artery and the balloon will be inflated. Stent implantation during the PTA procedure prevents possible re-stenosis of the dilated vessel after the balloon is deflated and the catheter removed. If there are no complications, the patient can leave hospital the next day after PTA.

PTA of the renal artery, if performed sufficiently and accurately timed, protects the kidneys from atrophy and simultaneously is a causal treatment for renal hypertension.   

For disease pattern see please Page “Diseases”.   

Diabetic Angiopathy, Diabetic Foot: Surgical Treatment, VAC-treatment, Bypass Operation

Diabetic foot ulceration due to neuropathy and/or bone/joint degeneration (“Charcot foot”) needs active conservative and surgical treatment.

Conservative treatment includes optimisation of blood sugar levels, administration of antibiotics and anti-inflammatory drugs.

Surgical treatment aims to excise necrotic and infected soft and bone tissues on the affected foot. After surgical excision, a big lesion with intensive wound secretion remains. To evacuate a mass of secretion and promote wound healing, negative-pressure wound therapy – VAC therapy (“Vacuum Assisted Closure”) – is used. This technique includes a sealed wound dressing connected to a vacuum pump. Open cell foam or gauze is used as dressing material. The continuous removal of wound secretion ensures cleansing and good drainage of deep wounds. The dressing should be changed two to three times a week.

VAC therapy emerged as an effective tool in the treatment of chronic wounds, proving to be particularly useful for diabetic ulcers.

Diabetic foot ulceration progresses rapidly if facilitated by concomitant peripheral arterial occlusive disease.

For review of surgical and interventional facilities in these cases see: “Peripheral arterial occlusive disease: surgical vs. endovascular treatment”.

For disease pattern see “Diseases”.    

Aortic Aneurysm: Open Operative vs. Endovascular Treatment (Stent-Graft)

Open surgical and/or endovascular treatments are advocated for a rupture-threatening aortic aneurysm (AA). Conservative therapy (observation and control) is reserved for patients with small aneurysms or for patients where the risk of an operation exceeds the risk of natural history of disease.

Conservative therapy includes the control of hypertension, smoking cessation, and cholesterol-lowering medicaments (statins).

Open surgical treatment of an abdominal AA is performed through midline abdominal incision. A thoracic AA is approached through thoracotomy.

After aortic dissection, heparin will be introduced, and the affected aorta will be clamped proximally and distally to the diseased segment. Then the affected aorta will be opened and a prosthetic graft will be sewn. In treating an abdominal AA, a tube graft or bifurcated prosthesis is used.

Immediately after surgery, the patient will be transferred to an intensive care unit for 1 to 3 days, followed by 5 to 10 days on a normal ward.

The perioperative mortality rate of open AA repair amounts to 2-4% at our institution.

A rare complication after surgical repair of an AA is a graft infection that remains a challenge in vascular surgery. The infected prosthesis has to be removed and replaced with autologous material. The deep femoral veins are used as ersatz components to create an autologous bifurcated graft.

 Endovascular aneurysm repair of an abdominal AA (EVAR) or a thoracic AA (TEVAR) involves endovascular placement of stent graft, usually through inguinal access, without direct surgical preparation of the affected aorta.

Standard bifurcated stent-grafts are used for AAs distal the renal arteries.

There are some limitations and contraindications of EVAR/TEVAR treatment in AA patients. First of all, the anatomy of an AA may be unsuitable for endovascular repair (inappropriate neck anatomy, small or occluded iliac/femoral arteries). Advances in EVAR/TVAR technique make it possible to overcome these limitations and to offer endovascular repair to previously unsuitable patients.

These new technical advances include fenestrated and branched stent-grafts.

The most frequent complication of EVAR/TEVAR is a leak into the aneurysm sac (endoleak) that sometimes requires additional intervention. Rare complications are related to implantation procedure (vessel damage, embolization, infection) or to mechanical device failure.

After intervention, only elderly and critically ill patients need intensive care. The patient is discharged after 2 to 4 days spent on a normal ward.

We recommend open surgical treatment to younger patients with less co-morbidity. However, today the open operation is not the only option for the treatment of an AA. Endovascular repair reduces the morbidity/mortality rates particularly in elderly and morbid patients. Nowadays EVAR+TEVAR accounts for more than half of operative AA repair.

For disease pattern see “Diseases”.

Visceral/Peripheral Aneurysms: Operative and Endovascular Treatment

Open surgery of a visceral aneurysm (VA) includes vascular ligation vs. reconstruction after the exclusion of the aneurysm. The decision depends on the size, location and form of the aneurysm, as well as on the downstream organ of the affected artery. Aneurysm exclusion and bypass is necessary when the target organ should be preserved, e.g. liver, pancreas. A VA of the splenic artery, especially near the hilum of the organ, is usually treated by vascular ligation and splenectomy.

Endovascular therapy (embolization, placement of stent graft) represents a promising alternative to open surgery. The selection of the appropriate technique depends on the type and size of the aneurysm and the anatomy of the affected artery.

Open surgery remains the gold standard for the management of visceral aneurysms. Endovascular approaches may contribute to a significant improvement in the morbidity and length of hospital stay of patients.

Asymptomatic and small sized (less than 2 cm) popliteal artery aneurysms (PAA) are usually treated conservatively, which includes anticoagulation in order to protect distal blood vessels from embolization and subsequent occlusion.

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.

Open repair – aneurysm exclusion and bypass is considered the gold standard procedure. During this operation, the affected artery will be ligated proximally and distally from aneurysmatic degeneration. Blood flow will be redirected using a vascular bypass from the vessel proximally to the excluded aneurysm to the vessel distally to the aneurysm.

Endovascular treatment with stent-grafts may offer several advantages over open bypass, but many concerns about complications (migration, occlusion, or stent-graft fracture) remain.

Open repair – exclusion and bypass is considered the gold standard procedure for a popliteal artery aneurysm. Endovascular treatment may provide a feasible option for selected patients only (high surgical risk).

For disease pattern see “Diseases”.

Varicose Veins: Conservative and Surgical Treatment

Conservative treatment includes elastic stockings (warning: strictly forbidden in the case of concomitant peripheral arterial occlusive disease!), exercise, frequent rest with legs elevated above heart level, lymphatic massage, and avoidance of standing and sitting positions and hot baths/saunas. Venotonic medicaments (flavonoids), and topical gel application helps to manage varicose vein symptoms.

Non-surgical treatment includes sclerotherapy, which is usually performed by dermatologists. This involves injecting the affected veins with a sclerosing solution. These veins will shrink and disappear over a period of weeks. Sclerotherapy is effective for so called “spider veins” and smaller varicose veins. The patient usually requires several treatment sessions to achieve good cosmetic results.

Surgical treatment includes a radical operation of the varicose veins. This involves crossectomy (removal of all vein tributaries at the superficial and deep vein junction), ligature of connecting (perforating) veins, removal of side branches (phlebectomy), and removal of the saphenous vein (stripping).

The patient will be mobilised on the first postoperative day and may be discharged 24 hours after the operation. No analgesic or any other medication is usually needed, merely antithrombotic subcutaneous injections for 3 days. After 10 to 12 days of postoperative wearing of elastic stockings, the stitches will be removed (the removal of stitches is often not necessary because the skin was stitched intracutaneously). The patient can resume work a couple days after the operation.

Alternative endovascular techniques such as radiofrequency ablation, endovenous laser treatment, are widely used.

Different factors may influence the choice of treatment method of varicose veins. For example, the stage and spread of varicose veins, the age and profession of the patient, and accompanying diseases and expectations of the patient may play an important role in making a decision. Therefore, individual adjustment of therapy modalities is required.      

For disease pattern see “Diseases”.

Deep Vein Thrombosis, Thromboembolism: Conservative and Operative Treatment

Anticoagulation is the basic treatment of deep vein thrombosis (DVT). A subcutaneous injection of a weight adjusted dose of low molecular heparin once or twice a day is usually recommended.

Today, new oral anticoagulants are in broad use. These medicaments are more effective, with fewer complications, and orally applicable. Unlike oral vitamin K antagonists (Warfarin, Marcoumar), they do not require frequent laboratory tests for dose adjustments.

In DVT patients, compression stockings and early mobilisation are recommended.

Determination of the duration of anticoagulation is very important. Three to six months is generally the standard length of treatment. In selected cases, extended or even life-long anticoagulation is necessary (idiopathic DVT, or congenital/acquired coagulation abnormalities – thrombophilia).

Surgery for DVT is advocated only in exceptional cases. A venous thrombectomy is recommended in patients when DVT leads to limb threatening ischemia.

 Local venous thrombolysis is seldom used for DVT. This involves the administration of clot breaking enzymes directly into the affected vein through a percutaneously inserted catheter. The results of this treatment are controversial.

Inferior vena cava filters are only recommended for patients with contraindications to anticoagulation, or when anticoagulation therapy was not effective in protecting against a pulmonary embolism.

Deep vein thrombosis (DVT) is a potentially fatal disease. The treatment strategy should be individually selected to avoid recurrent DVT and fatal pulmonary embolism.

For disease pattern see “Diseases”.

Chronic Venous Insufficiency, Venous Ulcerations: Conservative, Operative and VAC Treatment

Conservative treatment of chronic venous insufficiency (CVI) includes elastic stockings (warning: strictly forbidden in the case of concomitant peripheral arterial occlusive disease!), exercise, frequent rest with legs elevated above heart level, lymphatic massage, and avoidance of standing and sitting positions and hot baths/saunas. Venotonic medicaments (flavonoids) and topical gel application help to manage chronic venous insufficiency symptoms.

Surgical/interventional treatment depends on the disease leading to chronic venous insufficiency:

– Varicose veins – for treatment see:  Varicose Veins: Conservative and Surgical Treatment.

– Post-thrombotic syndrome (PTS). After deep vein thrombosis (DVT), about 50% of patients develop PTS whose symptoms are pain, cramps, leg heaviness, pruritis, oedema, and venous ulcerations.

The new techniques for recanalization (restoration of the lumen) of occluded large veins may improve the results of the treatment.

For example, catheter-based angioplasty with stenting can be offered to selected patients with PTS. Different percutaneous pharmacomechanical thrombectomy devices are in use too. However, further investigations are needed to prove if endovascular treatment is a safe, effective, and feasible method to correct PTS.

– Morbid obesity (Adipositas permagna) – bariatric operations are recommended.

– An arteriovenous fistula should be treated either surgically or using endovascular techniques.

– Treatment of venous ulcerations. To evacuate a mass of secretion and promote wound healing, negative-pressure wound therapy – VAC therapy (“Vacuum Assisted Closure”) – is used. This technique includes a sealed wound dressing connected to a vacuum pump. Open cell foam or gauze is used as dressing material. The continuous removal of wound secretion ensures the cleansing and good drainage of deep wounds. The dressing should be changed two to three times a week. After long lasting wound management, the surface of ulceration will be prepared for split-skin transplantation for definitive wound closure.

Venous ulceration as a consequence of chronic venous insufficiency is an onerous disease requiring long and extensive treatment. The recurrence rate after definitive closure of ulceration is relatively high.     

 For disease pattern see “Diseases”.

Vascular Surgical Reconstructions in Oncology

Malignant tumour operations with vascular involvement in orthopaedics, urology and general surgery require close cooperation between different surgical teams.

The aforementioned operations are extremely time consuming, tissue resection is extensive and is associated with high blood loss. The major vessels are often included in the tumour mass. They have to be resected with tumour and, in the case of limb or organ salvage, reconstructed using autologous or synthetic materials.

These interventions are performed as exceptional last resort (“Ultima Ratio”) operations in selected, otherwise “inoperable” patients.

These operations have increased complication rates. Nevertheless, only radical resection of malignant tumours may improve the patient’s prognosis.

For disease pattern see “Diseases”.