Common Surgical Procedures - Vascular surgery
This section consists of discussions of aneurysms, varicose veins, phlebitis, and intermittent claudication.
When a blood vessel develops a balloonlike malformation the defect is called an aneurysm . A common complication of the aneurysm is that it may rupture if not treated. A ruptured aneurysm of a large blood vessel, or of a small blood vessel in a critical area such as the brain, can be fatal or severely disabling.
If the aneurysm develops at a vital site such as the aorta, heroic surgical measures may be required to correct the problem. Before the important artery can be clamped off, the patient may have to be attached to a heart-lung machine and the body temperature lowered so as to reduce normal body functions to a minimum. After the aneurysm is removed, that section of the aorta may have to be replaced with a piece of plastic artery. Not all aneurysms require such complicated methods of repair; if the ballooning section of artery develops as a saclike appendage, it frequently can be tied off and removed while the relatively small opening between the blood vessel and the sac is sewed closed.
Surgical removal of an aneurysm is the only available treatment for the disorder. The surgery is much less complicated if the abnormal section of the blood vessel is replaced before it ruptures than after. When the patient has recovered from correction of the aneurysm, he can resume a rather active, normal life style.
Varicose veins can develop in many parts of the body. But they are most obvious and commonly a problem when they appear in the legs, especially in the saphenous veins , large veins that lie close to the surface of the skin.
The cause of varicose veins is a failure of tiny valves in the blood vessels to function properly, so that venous blood destined for the heart flows backward and forms pools that can make the veins distended, tortuous, and painful. Varicose veins are related to the erect posture of humans; the heart pumps blood through arteries to the extremities, but the return flow must fight the pull of gravity. Ordinarily, venous blood gets a boost up the legs by a pumping action of leg-muscle contractions. Valves in the legs are designed to let the blood move upward but are supposed to block any backward flow. People whose jobs require them to stand all day are among those likely to suffer from a breakdown of the normal functioning of the valves. Women who have had multiple pregnancies and obese individuals are also apt to develop varicose veins.
Varicose veins can cause ulcers in the lower leg near the ankle that bleed through the skin after an injury to the area.
One kind of surgical treatment of the varicosed vein is ligation , which means “tying” or “binding”. An incision is made in the leg, usually in the area of the groin. The diseased saphenous vein is severed from its connection with the larger, femoral vein and is tied off. The function of a ligated vein is taken over by other veins in the leg. An alternate kind of surgery for varicose veins, sometimes called stripping , requires either a series of small incisions along the path of the vein, from the groin to the ankle, or an internal stripping by use of a special, long, threadlike instrument. The diseased vein is then removed and any connections with other veins ligated.
Varicose vein surgery is used for treatment of the superficial veins—those that are close to the skin. The operation is simple and can be performed under a local anesthetic in many cases. When multiple varicose veins are on both legs, all of the problem veins can be stripped and ligated at the same time. A hospital stay of several days may be required, and dressings are needed on the treated legs for two or three weeks after the operation.
A problem related to varicose veins is phlebitis , a disease that usually involves the larger, deep veins of the legs with inflammation, pain, and swelling. Phlebitis is much more serious than varicose veins because a large vein is involved and a clot usually forms, obstructing return blood flow of the limb. The danger is that the clot will break loose—that is, become an embolus —and travel to the lungs, where it can obstruct a vital blood vessel, with serious or even fatal results. The obstructing clot is called an embolism .
Causes and Treatment
Causes of phlebitis can be injury, infection, poor circulation, or simply sitting for long periods of time. Medical therapy may include wet dressings and medications, especially anticoagulant drugs to thin the blood and reduce the chances of clot formations. Supportive bandages, leg exercises, and elevation of the legs may also be recommended.
Surgery is reserved usually for cases in which medical therapy fails to control the risk of emboli forming. The surgical procedure is directed toward treatment of the deep vein that is the source of the phlebitis symptoms. The surgeon may open the vein to remove the clot, or a device can be inserted in the vein to strain out any clots that may form in the vein and travel toward the lungs. In some cases the surgeon may block the upward flow of blood from the affected vein, allowing other veins in the leg to assume that function. However, if other veins already have been stripped or ligated in the treatment of varicose veins, it is unlikely that a surgeon would occlude or block the flow of blood in a deep leg vein.
Intermittent claudication is a disorder of blood circulation of the legs involving the arteries. It is primarily a disease of aging, with gradual, progressive narrowing of the lumen (interior space) of the arteries by atherosclerosis. Atherosclerosis of the arteries occurs in other parts of the body, including the arms. Intermittent claudication is marked by muscle fatigue and pain when the leg muscles are used, as in walking. The symptoms are relieved by rest. The condition can be relieved by drugs, particularly medications that help dilate the arteries, but in severe cases surgery to reconstruct the leg arteries is the solution.
The surgeon may build a bypass artery by grafting a length of plastic tubing into the affected blood vessel and around the area blocked by atherosclerotic narrowing. Sometimes surgeons will use a piece of a vein from the patient's body to make a bypass artery; for example, a vein from the arm may be transformed into an artery for the leg. Another procedure involves simply removing the portion of the artery blocking the normal flow of blood.