Vascular Surgery

Flow, and what happens in the minutes and years after it stops.

• Vascular surgery manages arteries and veins outside the heart: aneurysms that must not rupture, carotid plaques that must not embolise, and limbs whose blood supply is failing slowly or has stopped suddenly.
• Its two clocks could not be more different: chronic disease is measured in years of risk factors, acute ischaemia in the six hours before muscle dies.
• Every plan is a plumbing sentence: inflow, outflow and conduit. If you can say where blood enters, how it leaves and what carries it, you can present any vascular patient.
• The specialty is now half endovascular: wires, stents and grafts placed from inside compete with and complement open sewing, and most decisions weigh one against the other.

Educational illustration

What should I notice?

• The acutely ischaemic leg

  “Six hours of a cold, painful, pale foot in a patient with atrial fibrillation who stopped her anticoagulant last month.”

  • The six Ps tell the time: pain, pallor, pulselessness first; paraesthesia and paralysis mean nerve and muscle are already dying; perishing cold throughout.
  • Embolus or thrombosis? Sudden onset, AF and a normal contralateral leg say embolus; a history of claudication with absent contralateral pulses says thrombosis on chronic disease. The distinction changes the operation.
  • Fixed mottling and rigid muscles mean the limb is dead: revascularising it releases potassium, myoglobin and acid into the circulation, and the operation becomes amputation.

  Live it as a case Femoral embolectomy

• TIA with a carotid stenosis

  “Twenty minutes of right-arm weakness and word-finding difficulty, fully resolved: duplex shows a 75% left internal carotid stenosis.”

  • A TIA in a carotid territory with an ipsilateral stenosis is a warning shot: the risk of completed stroke is front-loaded into the next days.
  • Symptomatic stenosis above 50% earns intervention, and the benefit decays with every week of delay: the operation is urgent, ideally within two weeks.
  • Endarterectomy removes the plaque that is embolising; best medical therapy runs alongside, never instead, in the symptomatic patient.

  Live it as a case Carotid endarterectomy

• Back pain and a pulsatile mass

  “A 74-year-old smoker with sudden back pain, a syncopal episode, and an expansile mass above the umbilicus. BP 96/60.”

  • Ruptured abdominal aortic aneurysm until proven otherwise: this triad does not wait for confirmation to start moving toward control.
  • Permissive hypotension: enough pressure to talk, not enough to blow the contained haematoma. Chasing a normal number kills these patients.
  • Stable enough for CT decides the door: the scan sizes the neck for an endovascular repair; the unstable patient goes straight to theatre.

  Live it as a case EVAR (endovascular aneurysm repair)

• The diabetic foot with tissue loss

  “A heel ulcer six weeks old, now with exposed bone, in a diabetic with absent pedal pulses and a toe pressure of 22 mmHg.”

  • Three diseases share this foot: neuropathy that silenced the warning, arteriopathy that starved the healing, and infection exploiting both.
  • Tissue loss plus rest pain is chronic limb-threatening ischaemia: without revascularisation this foot is on an amputation pathway.
  • Map the anatomy: duplex and angiography find the level of disease, and the plan is that plumbing sentence, inflow, outflow, conduit.

  Live it as a case

• The cold hand with a fistula

  “A dialysis patient with a brachiocephalic fistula: hand pain during dialysis, now constant, fingertips cool and dusky.”

  • A fistula is a controlled short circuit: when it steals more flow than the hand can spare, the fingers pay.
  • Grade it: cool hand on dialysis only is watchable; rest pain, ulceration or weakness is a hand at risk and a surgical problem.
  • The fistula is also the patient's lifeline: the repertoire (banding, revision, ligation) balances the hand against the access.

  Live it as a case