VASCULAR AND ENDOVASCULAR SPECIALITY

Vascular surgery is a young, dynamic and rapidly expanding specialty that deals with the comprehensive diagnostic and therapeutic services for patients with diseases and disorders of the arteries, veins and lymphatic.

The American Board of Medical Specialties defines a vascular surgeon as “A surgeon with expertise in the management of surgical disorders of the blood vessels, excluding the intracranial vessels and the heart”. In India, dedicated peripheral vascular and endovascular surgery has evolved from the broad specialty of cardio-thoracic- vascular surgery over the past 10-15 years.

Although everyone is aware about the manifestations, diagnosis and management of heart diseases, non-cardiac vascular diseases are often overlooked as they can present with a wide variety of symptoms and signs and eventually result in increased morbidity. In fact, the magnitude of problem of vascular diseases in our country is nearly half as that of heart diseases.

Vascular & endovascular surgery has undergone many innovations within the past decade, which have significantly improved the outcomes of peripheral vascular diseases. Vascular conditions that were once deemed inoperable or untreatable are now being treated successfully by vascular specialists with improved quality of life.

With a holistic approach combining medical, non-invasive, endovascular and surgical treatments, our management of patients with vascular disorders can only get better.

Vascular specialists provide care to patients with diseases or disorders of their blood vessels except the heart or brain. There are very few surgeons in India, trained in this specialty.

Medicine is an ever-changing field. Although everyone is aware about ‘heart diseases’, very few know about vascular diseases. In fact, vascular disease kills and cripples almost as many Indians as heart disease or cancer.

Vascular surgery has undergone many innovations within the past decade, which have significantly improved the outcomes of peripheral vascular diseases.

Vascular conditions that were once deemed inoperable or untreatable are now being treated successfully world over by vascular specialists with improved quality of life.

With a holistic approach combining medical, non-invasive, endovascular and surgical treatments, our management of patients with vascular disorders can only get better.

Limb revascularization/ bypass surgery

Carotid endarterectomy

Dialysis access

Diabetic foot problems

Sequential compression pump for swollen legs and lymphedema

Graduated elastic compression stockings

Medical management of PAD

Ankle-Brachial pressures

Color-Doppler, Doppler angiography

Vascular Lab

Prevention & treatment of venous thromboembolism (VTE)

Medical management of peripheral vascular diseases

Management of thrombophilic diseases

Varicose Veins

Deep vein problems

Peripheral arterial disease

Carotid artery disease

Aortic aneurysm

Vascular malformations

Vascular trauma

Dialysis access procedures

Pneumatic Compression Treatment

Angio-embolisation of tumors & bleeding vessels

Endovenous LASER varicose veins

Deep vein thrombolysis

Peripheral angioplasty & stenting

Carotid angioplasty & stenting

Endograft placement

Sclerotherapy & embolisation

  1. Under doppler guidance, needle puncture into the vein
  2. Introduction of wire, sheath & then laser fiber in the vein up to the sapheno-femoral junction, confirmed under doppler.
  3. Cold saline infiltration around the vein for vein cushioning and preventing heat damage to skin & surrounding tissues.
  4. Laser energy is delivered in pulses, causing thermal damage to the vein wall and an eventual closure of the vein
  5. The entire procedure is over within 45- 60 minutes. Patients can go home the same day and resume their activities from the next day.
  6. Post-operatively, mild hardness and bruising may be noted over the laser treated area, but this recovers within a week. It is recommended to wear stockings for 2- 3 months after this procedure.

Understanding VASCULAR Problems 

What are Leg Ulcers?

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A leg ulcer is simply a break in the skin of the leg, which allows air and bacteria to get into the underlying tissue.

What causes Leg Ulcers?

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  • Vein problems: 85% of leg ulcers are due to varicose veins or deep vein thrombosis.
  • Arterial problems  10% of leg ulcers are due to arterial disease.
  • Miscellaneous: 5% of leg ulcers may be due to other causes like vasculitis, rheumatoid arthritis and neuropathy.
What are the diagnostic methods for Leg Ulcers?

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Usually a proper examination by a vascular specialist gives a clue about the possible cause of the ulcer, and depending on the cause, certain investigations may be performed which include:

  • Doppler
  • CT Angiography
  • Blood Investigations
  • Skin Biopsy
How are Venous Ulcers treated?

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  • Controlling the high pressure in the leg veins by leg elevation, compression bandaging or 4 layer bandages
  • Treatment of the ulcer by dressings. Different materials may be recommended depending on the type and healing pattern of ulcer
  • Treatment of underlying cause
  • Varicose veins can be treated by laser or foam sclerotherapy
  • Deep vein obstruction may need vein angioplasty & stenting
  • Non-healing ulcers may require skin grafting or muscle flaps
How are Arterial Ulcers treated?

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  • Treatment of the underlying cause by angioplasty or bypass surgery to re-establish blood flow in the leg.
  • Adjuvant medical treatment by Prostacyclin therapy injections can also help in ulcer healing.
How are Diabetic Ulcers treated?

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  • Treatment of infection by systemic antibiotics
  • Wide spread removal of all infected and bad tissues
  • Regular dressings
  • NPWT (Negative Pressure Wound Therapy) or VAC (Vacuum Assisted Closure) Dressings
  • HBOT (Hyperbaric Oxygen Therapy)

Some patients with extensive diabetic foot infections treated successfully are shown here.

Patient 1

Patient 2

Patient 3

Patient 4

Patients with chronic renal failure (Kidney failure) often require long-term hemodialysis, sometimes twice or thrice a week.  They are typically under the care of a physician or nephrologist.

In order to facilitate dialysis, an AV Fistula or graft operation is performed by vascular surgeons. In this procedure, a small connection is made between the artery and vein so that fast blood flows in the vein and a month later, the veins increase in size and can then be utilized for dialysis.

We also perform complex procedures in patients where AV fistula has been attempted earlier but has failed to give desired results. Basilic vein transposition and synthetic AV graft are two examples of such complex procedures.

Patients who have complications related to AV fistula are also successfully treated by our vascular specialist.

Developed AV Fistula
Basilic Vein Transposition
AV Graft for Hemodialysis
Successful Treatments

1. Aneurysm Repair

2. Dialysis Access Central Vein Occlusion

What is Carotid Disease?

Blockage in the carotid artery in neck is a common and important cause for development of brain stroke or paralysis, a potentially disabling and often life-threatening condition. The role of vascular specialist in removing this blockage is vital in the prevention of stroke.

The causes or risk factors for blockage in carotid artery are similar as those for heart blockage or leg artery blockage.

What are symptoms of blocked carotid arteries?

Weakness or numbness on one side (leg, arm or face), slurred speech or visual disturbances are the usual presenting symptoms of mini-stroke. Even if these events last for a few minutes or hours, they could be warning signs of carotid blockage and an impending stroke.

They need to be evaluated by a carotid doppler test which is a simple non-invasive sonography of neck. A confirmatory angiography or CT angiography is done if intervention is planned.

Patients with high blood pressure, diabetes and cholesterol or past heart problems should also undergo a baseline carotid doppler test.

What are the treatment options?

Minor blockages (less than 50 %) are treated by blood thinner and cholesterol controlling medicines. If blockage is more than 50 or 60 %, then surgery or angioplasty with stenting is recommended.

Carotid endarterectomy is a special surgical operation for removal of the carotid artery blockage. We routinely perform this procedure under a loco-regional anesthesia so that intra-operative neurologic monitoring is easy. The artery is opened and the plaque carefully removed. During this operation, we use a shunt to maintain blood flow to the brain. The artery is then repaired using a vein or graft patch to prevent narrowing.

The other treatment option we offer is carotid angioplasty with stenting under protection device. These protection devices prevent small plaque particles to dislodge to the brain during stenting and thus the complications of this procedure is reduced to less than 3%. It is mainly performed for high-risk patients or those with high carotid bifurcation.

Can a major stroke be prevented?

If the blockage is detected and treated successfully in time, the further chances of a major stroke are minimized.

Can this procedure utilized to treat stroke?

Once a patient develops stroke, some permanent damage would already have occurred in the brain. So this treatment will not cause significant improvement in the problems. This is why it is very essential to treat carotid blockage before a major stroke strikes you!

Carotid Endarterectomy

PTFE patch

Excised Carotid Plaque

Angiography shows Cartoid Stenosis

Carotid Angioplasty Filter

Carotid body tumor

What is endovascular treatment?

Endovascular treatment is a non-surgical treatment of disease from within the blood vessel. Some of the common endovascular procedures include

  • Angiography
  • Peripheral angioplasty (Balloon with or without stenting)
  • Embolisation of bleeding vessels or tumors
  • Catheter thrombolysis for DVT
  • Covered stents for aneurysms

What are the benefits of endovascular treatment?

Endovascular options have following advantages as compared to conventional surgical procedures

  • Lower risk
  • Shorter hospital stay
  • Shorter recovery time
  • Less bleeding

Which doctors do endovascular treatment?

World over,   it is well known that cardiologists and interventional radiologists perform these procedures of angiography and angioplasty. However, the new generation of vascular specialists who are trained in vascular surgery as well as endovascular procedures can definitely provide comparable results.

The other major advantage of vascular specialists is that they can provide both surgical and endovascular options and choose the best one for the patient on an individual basis. New complex hybrid procedures which involve utilizing both surgical and endovascular methods are also very well performed by a team of vascular specialists.

Coil Embolisation

Carotid Angioplasty

Renal Aneurysm Coiling

Iliac Angioplasty

Aortic Aneurysm

Subclavian Angioplasty

Varicose veins are visible, bulging unsightly veins in legs. They are not just a cosmetic problem. They can often cause pain, leg heaviness, night cramps, itching or swelling. If ignored, varicose veins can compromise the nutrition of skin and lead to pigmentation, skin thickening or ulceration and bleeding. Patients with varicose veins are also at a higher risk of deep vein thrombosis (DVT).

The primary reason for development of varicose veins is reversal of blood flow due to vein wall weakness and impaired valve function. This reverse flow of impure blood is responsible for majority of complications of this disease.

Causes of varicose veins:

  • Heredity
  • Hormonal – more common after pregnancy.
  • Dysfunctional vein valves
  • Obesity and aging also play a role

Complications of varicose veins:

  • Eczema
  • Skin ulcers
  • Bleeding
  • Thrombosis

Treatment of varicose veins:

Over the recent years, lot many advances are made in the treatment of varicose veins. The type of treatment offered depends on many factors and no single method is the best!

  1. Medicines & Stockings: Good symptomatic relief, but they cannot cure large varicose veins.
  2. Surgery: Surgical ligation of the problem vein and removal of associated varicose veins is a gold standard treatment method in use for many years. The removal of these damaged veins does not harm the normal blood circulation of the leg.
  3. Endovenous LASER treatment: A minimally invasive option in which the damaged veins are treated by needle puncture and passage of thin laser fiber which heats and seals the vein from inside. The advantages are cosmetic result and rapid recovery with minimal side effects.
  4. Doppler guided foam sclerotherapy: This involves injection of a special chemical in the veins to block them. This can be used for recurrent varicose veins also. This procedure can leave behind a mild pigmentation mark.

If you are suffering from varicose veins, seek advice from a vascular specialist who is an expert in treating varicose veins by all methods. Remember, not all patients with varicose veins are identical. Vascular specialists may vary in their preferred methods for investigations, treatment and aftercare.

     

If your legs pain while walking, this may be the first indicator of a leg attack, known in medical terminology as peripheral arterial disease (PAD).

Arteries in the body can slowly become narrowed and blocked as a consequence of age, smoking, high blood cholesterol or diabetes. Blockage in the heart arteries can cause heart attack. Similar blockage in the leg arteries gives rise to leg attack.

 

In the initial stages of blockage, patients do not have any major problems and may attribute pain on walking (claudication) to old age, weak muscles or arthritis. However, if left undiagnosed and untreated, PAD often ends with severe rest pain and ulcers or gangrene and eventual amputation of the leg.

 

Who is at risk of PAD?

The risk of atherosclerosis increases with the following risk factors. If you have more than two of these risk factors, regular examination with an ABI test will detect PAD in early stages.

  • Smoking
  • Hypertension
  • Diabetes
  • Heart disease
  • High blood cholesterol
  • Family History

What can happen due to PVD?

Known to be a naturally progressive disease, as time goes by and the blockage increases, patients may develop increasing severity in the leg pain with slow healing of ulcers or onset of black patches in toes or foot (Gangrene)

In earlier times, patients with gangrene were advised for amputation of leg, either below or sometimes above the knee. But with newer advances in vascular surgery, procedures are now being performed to prevent amputation. After all, it’s not your legs, it’s your life!

 

How do you know if you have PAD?

After a careful questionnaire and examination, a vascular specialist will perform any of the following tests to diagnose and confirm PAD.

ABI (Ankle-Brachial pressure Index)

 

Color – Doppler

CT Angiography

Digital Subtraction Angiography

What treatment is effective in preventing amputations?

Your vascular specialist can guide you and help you provide a suitable balanced option between the different available procedures based on multiple factors including age, co-existent problems, level of blockages and availability or expense of devices.

  • Angioplasty: Minimally invasive techniques through needle punctures and utilising endovascular balloons or stents have revolutionised the treatment of PAD patients. There have been substantial developments in the skills and resources utilised for endovascular procedures over the past decade. Continuously upgrading expertise has led to development of drug coated balloons, atherectomy devices and vascular mimetic stents which promise to deliver better results in reduced recovery time and are less painful. They are now regularly used for treatment of leg arterial blockages.
  • Bypass: Often, long segment blockages or multilevel blockages are better dealt with by surgical bypass. Surgical bypass can be performed by using patients own vein or a synthetic graft and can be performed from the abdomen to the foot depending on the level and extent of arterial blockage. These procedures will not cure PAD, but they can improve the blood circulation to your legs and your ability to walk and thus prevent amputation.
  • Medicines: Not all patients require major surgery if diagnosed in time. In addition to changing your lifestyle after a diagnosis and controlling of risk factors like diabetes and hypertension, certain medicines are useful in the initial stages of PAD.
  • Walking exercises: Exercise strengthens the leg muscles which are out of shape and weak. It is useful for improving claudication distance and helps you lead a healthy life. However, this may not be suitable for patients who have ulcer or gangrene.

No matter what your age, early diagnosis and treatment of vascular disease can improve the quality of your life.
We strongly recommend you to stay updated on the latest information and treatments in vascular care. You never know when you need to know.

 

Popliteo-Distal Bypass
Supra-Celiac Aorto Femoral Bypass
Femoro Popliteal Bypass using Vein Graft

We also provide specialized treatment procedures for these relatively rare but complex vascular problems.

  • Portal hypertension not well controlled by endoscopic treatment
  • Mesenteric ischemia (acute and chronic)
  • Mesenteric aneurysms and pseudoaneurysms
  • Celiac Artery Compression Syndrome (MALS – Median Arcuate Ligament Syndrome)

The therapeutic options performed include

  • Porto-systemic shunt surgery
  • Mesenteric artery bypass
  • Mesenteric angioplasty
  • Mesenteric or splenic aneurysm coil angiographic embolisation

Mesenteric Artery Aneurysm

Mesenteric Bypass

Hepatic Aneurysm Coiling

  • Swollen legs due to lymphatic and venous problems are treated by our vascular specialist.
  • The management options offered are
  • Catheter directed thrombolysis for deep vein thrombosis (DVT)
  • Pneumatic compression pumping for lymph edema
  • Custom-made compression stockings

 

 

 

 

Endophlebectomy

Vascular malformations or birthmarks (often misinterpreted as haemangioma) which are deep or extensive are treated by vascular specialist by the following methods:

  • Sessions of sclerotherapy
  • Angiographic embolisation
  • Surgical excision

Dr. Sumit Kapadia is a national expert in this difficult and often inadequately treated vascular problems and his proficiency has helped numerous patients suffering from vascular malformations.

Vascular Malformation Lip

Large Vascular Malformation of leg

The role of vascular specialist is crucial in vascular emergencies where there is injury to arteries or veins with excess bleeding.

We perform the following treatment methods for vascular emergencies:

  • Surgical repair of bleeding artery during surgery or fracture fixation
  • Endovascular embolisation of pseudoaneurysms
  • Endovascular stent-graft (covered stent) placement for large vessel injury

 

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Brachial repair in supracondylar humerus fracture

Popliteal artery injury repair

Femoral AV Fistula Repair