Vascular Surgical services

Both arterial and venous diseases are common in the community and their incidence and severity increase with age, the presence of diabetes, obesity, affluence and increased prevalence of smoking.

Vascular surgery is concerned with the prevention of:

• Cardiovascular and cerebrovascular disease
• Death from ruptured aortic aneurysm
• Stroke due to carotid artery disease
• Lower limb amputation from peripheral arterial disease
• Diabetic foot care
• Venous ulceration in the lower limb

At present, a co-ordinated approach to tackle these problems with trained vascular surgical specialists is rudimentary or does not exist in many parts of the country. Trained vascular surgical specialists are extremely rare in India due to the lack of focus in training to tackle these disorders. There is strong evidence that clinical outcomes for the above conditions are dramatically improved if treated by a trained vascular surgeon, rather than a surgeon who occasionally deals with these disorders. KokilabenDhirubhaiAmbani Hospital is one of the first hospitals in the country to address this issue.

• Vascular services deal with disorders of the arteries, veins and lymphatics. Although related in some areas to cardiac surgery, the two services are quite separate and their training and expertise differ.
• A majority of the patients with diseases of the arteries, referred to a vascular surgeon by their GP, do not require surgical treatment. Many require simple reassurance and lifestyle advice (stop smoking, lose weight, undertake regular exercise) coupled with measures to reduce their future risk of heart disease and stroke (aspirin and lipid lowering therapy, blood pressure control). Some will require further investigation by vascular technologists or radiologists, with a view to interventional radiology treatments, such as balloon angioplasty or stenting. Only a small proportion will require surgery.
• The medical management of peripheral vascular disease is provided in most hospitals by vascular surgeons.
• Access to interventional radiology also occurs through referral from vascular surgeons in most centres.
• It is important for surgeons to be involved in the care of these patients in case they need surgery for radiological complications. Increasing numbers of vascular surgeons are undertaking interventional radiology procedures themselves, in the emerging field of endovascular surgery.
• Vascular services are ideally provided by multidisciplinary teams. Vascular teams can provide claudication, diabetic foot and lifestyle advice to clinics as well as manage dedicated vascular wards.
• Physiotherapists offer supervised exercise classes for claudicants and rehabilitation to amputees, where they work closely with limb fitting services.
• Occupational therapists assist in the return of amputees to the community.
• Vascular technologists offer diagnostic services and post-operative graft surveillance.
• Radiographers and radiologists offer diagnostic and interventional radiology. Vascular surgeons undertake surgical management and usually offer an overall co-ordinating role.
• Patients are better cared for by specialist vascular teams than by general surgeons without a vascular interest.
• Specialist vascular teams achieve superior clinical outcomes in general, and specifically have lower mortality rates after abdominal aortic aneurysm repair, lower amputation rates for critical lower limb ischaemia and lower stroke risks after carotid artery surgery.
• The National Confidential Enquiry into Perioperative Deaths (NCEPOD), UK, has continually emphasised the need for patients with acute vascular conditions to be treated by a specialist vascular team.
• The vascular team at Kokilaben Hospital will be one of the first to provide such comprehensive vascular services to the people of Mumbai and indeed, for the rest of the country.

• The prevalence of vascular disease increases with age and more than 16% of the population is over the age of 65. The complexity, outcome and costs of vascular intervention are age dependant.
• Average life expectancy continues to rise and this factor alone suggests that demand for vascular services is not likely to decline and may well increase with time.
• There are between 2000 and 3000 diabetics per 1,00,000 population and the prevalence rises steeply with age.
• Type 2 diabetes is up to six times more common in people of South Asian decent. Morbidity from the complications of diabetes is five times higher than non-diabetic vascular patients. Vascular disease is a major cause of morbidity in diabetes and the risks of disease progression are higher.
• Over 25% of patients admitted under the care of vascular surgeons are diabetic. Lack of exercise, poor diet, obesity and increasing age are all associated with an increasing incidence of type 2 diabetes.
• Smoking is a major cause of vascular disease and over 80% of vascular patients are current or ex-smokers. Smokers are more at risk of complications from vascular interventions because of cardiac and respiratory co-morbidity and the long-term success of vascular intervention is reduced in patients who continue to smoke.
• The incidence of vascular disease is unlikely to decline in future without a reduction in the prevalence of smoking.
• The affluence of modern society encourages high-fat diets, obesity and lack of exercise. These factors all contribute to the development of hyperlipidaemia and hypertension, both potent risk factors for vascular disease.
• Childhood obesity has also been linked to the development of diabetes and hypertension in later life.
• There is clear evidence that secondary prevention by antiplatelet therapy, lipid lowering therapy, control of hypertension, smoking cessation, exercise and weight loss play a major role in reducing the morbidity and mortality of atherosclerosis.
• Vascular services will take on the additional role of advising primary care physicians in this growing field of secondary prevention for patients whose atherosclerosis affects their peripheral arterial system.

• Around 20% of the population over 60 years has peripheral arterial disease, although only a quarter of these are symptomatic.
• Smokers, diabetics and patients with coronary artery disease are of particularly high incidence.
• Even if there are no symptoms, the presence of reduced blood pressure at the ankle signifies a 3 to 4 fold increase in the risk of cardiac and cerebrovascular morbidity and mortality. As this morbidity and mortality can be significantly reduced by the use of secondary prevention, there is a case for population screening using the ankle/brachial pressure index to identify patients at risk.
• Peripheral arterial disease produces pain in the leg on walking (claudication) in around 5% of the above 60 years population.
• Symptoms become severe and progressive in only around 20% of these patients, but the remainder still need lifestyle advice, secondary prevention and the opportunity of supervised exercise classes.
• While many patients with mild symptoms are managed in primary care, there is still a large cohort with more severe symptoms who are referred to the vascular service for assessment.
• Some pose difficult diagnostic dilemmas and may require investigation and treatment for risk factors and associated diseases.
• A minority will require interventional treatment with balloon angioplasty or surgery, if the symptoms are particularly disabling.
• Peripheral arterial disease may progress to critical limb ischaemia with constant and intractable pain, preventing sleep, often with ulceration or gangrene of the extremity. These patients are at particular risk of losing their limb without treatment and a high proportion present as emergencies.
• Interventional treatment is essential to avoid amputation. Such treatment is both clinically valuable and cost-effective.
• When loss of the limb becomes unavoidable, amputation and early post-operative rehabilitation is the responsibility of the vascular surgeon.
• Around 1-2% of patients with claudication will eventually progress to amputation, although the risk is higher (5%) in diabetics.
• There is evidence that hospitals providing high levels of interventional treatment also perform significantly fewer amputations (6 per 1,00,000 per annum vs 10 per 1,00,000 per annum, P=0.02 in one example).
• They also perform a higher proportion of below knee amputations compared to above knee, which is beneficial because around 50% of below knee amputees become independently mobile with an artificial limb compared to only 25% of above knee amputees.
• Kokilaben Hospital will provide a comprehensive limb salvage and limb loss prevention service, with special focus on diabetics. A smoking cessation, lifestyle and secondary prevention multidisciplinary clinic will also help with this increasingly complex problem. A joint diabetic foot clinic with an endocrinologist will aid speedy treatment of the diabetic foot.

• Aortic aneurysms occur when the aortic wall weakens and stretches, causing the aorta to expand like a balloon.
• They are more common in the elderly and the incidence is rising as people live longer. When an aortic aneurysm grows to a critical size, the risk of rupture becomes significant as the wall becomes thinner and thinner.
• Rupture of an aneurysm is fatal if untreated and many patients die rapidly from exsanguination before they can reach the hospital. Emergency surgery is the only solution, but the patients are so ill from loss of blood that only half of those who reach the operating theatre survive.
• It is better to repair aortic aneurysms before rupture occurs but as few patients have symptoms or signs, aneurysms can be difficult to detect clinically.
• Ultrasound scanning provides a cheap and effective method of detection and is the basis of selective population screening. Thus, ultrasound screening can be used as a part of cardiovascular screening to pick up undiagnosed aneurysms.
• Minimally invasive treatment using covered aortic stent grafts (EVAR) has reduced the mortality and morbidity of aneurysm repair.
• Kokilaben Hospital will be able to provide a comprehensive EVAR (keyhole aneurysm surgery) service and a screening service for the early detection of aneurysms.

• When the main blood vessels to the brain, the carotid arteries, become narrowed by arterial disease, disabling or fatal strokes may result. Around 80% of strokes are due to impaired blood supply and around half of these arise as a result of narrowing of the carotid artery in the neck. There is overwhelming evidence that carotid artery surgery is better than best medical therapy in reducing the risk of stroke in fit patients.
• This benefit is greatest in patients with a symptomatic >70% internal carotid stenosis without near-occlusion, but there is also a marginal benefit in symptomatic patients with a 50-69% stenosis and in those with a near occlusion.
• Patients under the age of 75 with asymptomatic carotid stenosis >75% also benefit from surgery but more asymptomatic patients need to be treated to prevent stroke compared to symptomatic patients, and it does take over 4 years after the operation for the overall stroke risk to show a benefit over best medical therapy.
• Carotid endarterectomy is one of the few surgical operations shown to offer proven efficacy over medical and interventional radiology therapy in randomised controlled trials.
• Kokilaben Hospital will be able to provide an evidence-based comprehensive stroke prevention service, including screening for carotid disease and carotid endarterectomy.

• The main health gains of the management of venous disease are relief from the symptoms and complications of varicose veins and the healing and prevention of recurrence of chronic leg ulceration.
• Surgery remains appropriate for symptomatic but uncomplicated varicose veins, where patients gain a highly significant health benefit in terms of both generic and disease-specific quality of life.
• Novel methods of varicose vein therapy, including foam sclerotherapy and radio-frequency ablation are now increasingly being adopted. There is increasing evidence that success rates, recurrence and morbidity are superior with radio-frequency ablation as compared to laser therapy.
• Chronic venous disorders rarely threaten life or limb but can have significant effects on health and quality of life. The patients are best managed by vascular surgeons, who are best-equipped to undertake the sometimes quite complex evaluation, investigation and surgical treatment.
• Over 30% of the population will develop varicose veins. Chronic venous ulcers occur in 1%-2% of the population over the age of 60.
• Some ulcers may be due to venous insufficiency alone but there are often other contributory causes and surgery has a place in the treatment of some patients to reduce the risk of recurrence.
• Vascular Surgeons particularly need to be involved in the management of arterio-venous ulcers, which are not suitable for compression therapy alone and may need some form of arterial intervention.
• Leg ulcers can therefore pose complex problems requiring a team approach to optimise management.
• Kokilaben Hospital will be able to provide a comprehensive, modern and evidence-based service for varicose veins and their complications, including one-stop clinics with duplex assessment and new methods of therapy, including radio-frequency ablation and foam sclerotherapy, thus reducing pain, morbidity and time away from work.

• Patients with impairment of the lymphatic drainage from a limb develop chronic limb swelling and are at increased risk of infection in the limb. Most patients can be treated with a combination of massage and compression bandaging but surgery is occasionally needed in severe cases.

An effective vascular service requires a team approach, with each member of the team being aware of the potential contributions of the others and all working together to provide the best possible outcomes for the patient.

Vascular Surgery

A consultant surgeon with an interest in vascular surgery has the necessary clinical and surgical skills to manage relevant diseases of arteries, veins and lymphatics and can maintain an emergency surgical service in vascular surgery. These skills will include knowledge of the relevant diagnostic imaging investigations and of the role of a vascular laboratory in the diagnosis and management of vascular disease.

He will also have a sound knowledge of the relevant aspects of basic sciences and critical care and of the roles of vascular medicine and interventional radiology in the management of vascular diseases.

Interventional Radiology

Interventional radiology is a distinct sub-speciality within radiology, although not all interventional radiologists work in the vascular field. Vascular surgeons work closely with their radiology colleagues and meet weekly for a case conference to discuss the diagnosis and best management of patients with vascular disorders.

The Vascular Laboratory

The vascular laboratory provides ankle and toe blood pressure measurements using the Doppler ultrasound, non-invasive imaging of arteries and veins using duplex ultrasound and other more complex physical tests of vascular function.

Vascular technologists are specially trained and certified in the provision of these services, which are essential components in the diagnosis, pre-operative assessment and post-operative surveillance of arterial and venous disease.

Vascular Out-Patient Clinics

The following specialist vascular clinics will be set up at Kokilaben Hospital.

Cardiovascular risk assessment and screening clinic for smoking cessation, cholesterol lowering, glycaemic control, weight reduction, blood pressure control, secondary prevention and screening for carotid disease, aortic aneurysms and reduced ankle brachial pressure index

One-stop venous clinic for the assessment of venous disease and leg ulcers, including duplex scanning and compression bandaging and R-F ablation

Diabetic foot clinic in association with the endocrinologist and vascular lab for comprehensive assessment and therapy of diabetic foot disease

Peripheral vascular clinic incorporating one-stop diagnosis for claudication, undiagnosed leg pain and critical ischemia

Stroke prevention clinic in co-operation with the neurologist for comprehensive stroke prevention and treatment service

Aneurysm and other aortic and mesenteric ischemia clinic for all aspects of aorto-illiac disease and treatment, including screening for aneurysms and their therapies, includin keyhole surgery (EVAR & TEVAR)

Operating Theatres

Vascular surgery is a complex technical area and theatre personnel are specially trained in the use of specialist instruments, prosthetics and techniques. Dedicated theatre nurses with special training in this area are available. A dedicated vascular theatre also ensures that stocks of specialist grafts, instruments and sutures are stored readily on hand as they are often needed without delay. Theatre staff are capable of operating cell saver devices for blood conservation. Radiolucent operating tables and X-ray C-arms are available for on-table arteriography and interventional radiology.

Anaesthesia, ITU & HDU

For optimal results, complex vascular cases will be done by consultant anaesthetists and intensivists with specialist vascular expertise, particularly for emergencies such as ruptured aortic aneurysm.

An ITU is essential for the care of vascular emergencies, particularly ruptured aneurysm. The majority of elective vascular patients needing special care post-operatively can be managed in an HDU rather than an ITU, and so both ITU and HDU facilities must be available on-site to the vascular service, in sufficient numbers. Physiotherapy/Occupational Therapy Vascular patients are often elderly or disabled and require specialist physiotherapy to aid in their rehabilitation following vascular intervention. Amputees, in particular, need specialist facilities and equipment in a physiotherapy gym to rehabilitate to the stage where they can be safely discharged from hospital.

Supervised exercise classes are of value in the treatment of claudication and can also be provided in the gym by suitably trained physiotherapists with experience of exercising patients with cardiovascular disease.

Limb Fitting Service/Rehabilitation

A comprehensive limb fitting and seamless rehabilitation service is available after vascular surgery to facilitate early discharge and the reduction of morbidity.

Cardiology

Patients with arterial disease frequently have cardiac co-morbidity as the risk factors are very similar. Cardiac assessment and optimisation of cardiac status are frequently required in the perioperative period. Vascular surgeons and interventional radiologists are also required on occasion to deal with the complications of cardiac catheterisation and intervention.

Cardiac Surgery

Peripheral arterial complications occur in cardiac surgery patients requiring vascular intervention. Collaborative surgery is increasingly being requested by cardiac surgeons for patients with combined cardiac and carotid or aneurysmal disease. Stroke is a significant complication in older patients undergoing coronary bypass surgery and many such patients are now screened for co-existent carotid stenosis. Where significant stenosis is found, it may need correction either before or at the same time as their coronary surgery.

Diabetology

Some 25% of patients undergoing vascular surgery are diabetic, rising to over 30% in patients with critical limb ischaemia. Patients with vascular disease frequently present through the diabetic service and vascular surgeons may need help with the medical management of their diabetic patients. So, close collaboration between the vascular and the diabetic service is essential.

Dermatology

The management of lower limb ulceration involves an integrated approach between the vascular, dermatological and leg ulcer services.

Clinical Laboratory Services

Blood disorders may initiate or exacerbate vascular problems. Close collaboration is needed with the haematology service to deal with these patients effectively. There is also a frequent need for blood replacement products in the management of arterial cases, with ready access to blood transfusion services. Infective complications of surgery have particularly serious implications for patients with prosthetic arterial grafts, needing microbiological assessment and advice.

Lipid disorders are a common cause of arterial disease and clinical chemists often offer specialist lipid clinics.

Rapid access to haematology, blood biochemistry and blood gas analysis is also essential in the perioperative management of vascular patients.

Nephrology:

Renal artery stenosis is a cause of hypertension and chronic renal failure. The management depends on collaboration between renal and vascular services.

Neurology

Neurologists or other physicians who manage the stroke service or rapid access TIA clinics collaborate closely with the vascular service, both for duplex ultrasound imaging of the carotid arteries and for vascular procedures in those patients where intervention is indicated.

Plastic Surgery

Arterial injuries in neonates or other microvascular reconstructions for ischaemia are best left to plastic surgeons with expertise in the use of operating microscopes. Once revascularisation has been achieved for limb ischaemia, collaboration with plastic surgeons is desirable to provide skin cover for soft tissue defects arising either from ulcers, from removal of gangrenous tissue or from fasciotomy incisions.

Hand surgery expertise may also be helpful in the management of gangrenous fingers to preserve maximum function.

Other Surgical Disciplines

Vascular injuries may occur during the course of any surgical intervention, in any surgical discipline. Local pressure or packing to control haemorrhage is needed until a vascular surgeon can arrive to assist.

Vascular surgeons from an adjacent site need to be consulted in advance regarding availability when vascular difficulties are anticipated before the surgery, such as when a tumour is seen to be encroaching around major vessels on pre-operative scans.

Audit & Governance

A comprehensive program for the audit of clinical outcomes will accompany vascular services. The data system will be based on an adequate IT infrastructure and will be sufficiently detailed so that analysis for clinical governance purposes can take full account of case mix and physiological status.