The development and progress of medicine has always moved forward with the advancement of society and the changing spectrum of diseases. Along with the advent of aging, changes in diet structure and accelerated pace of life, new changes in diseases are constantly emerging. Vascular diseases, one of the major diseases that threaten people’s lives, are also increasingly in front of medical workers. Vascular surgery, which was born in response to this, is also developing rapidly as a vital and cutting-edge discipline. Vascular surgery is an emerging independent discipline in the field of surgery, which combines the latest clinical treatment methods and fine surgical operations, especially with the improvement of detection methods and treatment methods, vascular surgery has become one of the fastest expanding, fastest updating technology and fastest theoretical development.
1.Carotid endarterectomy: prevention and treatment of cerebral infarction (stroke) and Alzheimer’s disease caused by atheromatous plaque formation in extracranial carotid arteries.
Cerebral infarction mostly occurs in middle-aged and elderly patients, and is a common disease threatening the lives of middle-aged and elderly people, accounting for the third cause of total death. The paralysis, aphasia and dementia caused by cerebrovascular disorders are a heavy burden to the patient’s family and society. Carotid artery stenosis and plaque detachment caused by carotid intimal hyperplasia and atheromatous plaque formation are the main causes.
Carotid endarterectomy is the standard procedure for the treatment of carotid artery stenosis, which can prevent cerebral infarction and Alzheimer’s disease by removing the hyperplastic endothelium and atheromatous plaque, eliminating the source of emboli, correcting carotid stenosis, and improving cerebral circulation. Endoluminal stent implantation can fix atheromatous plaque and dilate carotid artery, which has similar efficacy with endarterectomy and is suitable for patients who are not suitable for carotid endarterectomy.
2.Treatment of aortic coarctation
Aortic coarctation is a condition in which blood in the aortic lumen enters the aortic mesentery from the endothelial tear, causing the mesentery to separate and expand in the direction of the long axis of the aorta, forming a two-layer separation of the aortic wall. The onset of the disease is rapid and critical, and about 65-70% of patients die in the acute phase (within 2 weeks) from clamping rupture or cardiac complications such as pericardial tamponade and arrhythmia. Endoluminal stent implantation is a mature and effective method for the treatment of acute and chronic aortic coarctation formation, with lower mortality and complication rates, less trauma and faster recovery than conventional open-heart surgery.
3. Abdominal aortic aneurysm artificial vessel replacement and abdominal aortic aneurysm endoluminal artificial vessel replacement: treatment of abdominal aortic aneurysm and prevention of death due to rupture of abdominal aortic aneurysm.
4. Axillary-axillary, axillary-femoral, femoral-femoral, iliac-femoral and femoral-N vascular bypass: treatment of peripheral arterial occlusive diseases caused by diabetes, hypertension, hyperlipidemia and other pathogenic factors to restore and improve blood supply to the limbs and avoid amputation.
Arteriosclerotic occlusive disease is most commonly seen in men, aged 45 years or older, and occurs mostly in the lower extremities, manifesting as lower limb ischemia. Hyperlipidemia, hypertension, smoking, diabetes mellitus, obesity and low high-density lipoprotein are high-risk factors. It can cause atherosclerotic plaques in the intima, mesothelial degeneration or calcification, and secondary thrombosis in the lumen, eventually narrowing the lumen or even completely occluding it. Ischemic lesions occur in the affected limb, which can cause limb necrosis in severe cases. Early symptoms of lower limb atherosclerotic occlusive disease are intermittent claudication, i.e. pain in the lower leg can occur when walking, forcing the patient to stop walking and relieving the pain after a few moments of rest.
In chronic ischemia of the limbs, there is atrophy of the skin with thinning and shining, osteoporosis, muscle atrophy, hair loss, and thickening and deformation of the toenails. In later stages, there may be persistent pain even at rest, markedly reduced skin temperature, cyanosis, and gangrene and ulceration of the distal limb. Control and management of the susceptibility factors of this disorder has a positive preventive effect. Surgical treatment may be considered when symptoms significantly affect life and workers.
1.Non-surgical treatment methods include: lowering blood lipids and blood pressure, improving blood hypercoagulability, promoting the formation of collateral circulation, reducing weight in obese people, strictly abstaining from smoking and appropriate activities; commonly used drugs include aspirin, dipyridamole (Pansentin), prostaglandin, etc.
2.Surgical treatment
(1) Percutaneous endoluminal angioplasty: for single or multiple short-segment stenosis, a balloon catheter can be inserted through percutaneous puncture to the stenotic segment of the artery, and the balloon can be inflated with appropriate pressure to expand the diseased lumen and restore blood flow. If combined with the application of endovascular stents, the long-term patency rate can be improved.
(2) Endarterectomy: It is mainly applied to short segments of occlusive lesions of the main-iliac artery. The thickened intima, atheromatous plaque and secondary thrombus of the diseased segment are removed without the need for artificial vessel implantation and without the risk of infection.
(3) Bypass diversion: using an autologous vein or artificial vessel to make a bypass between the proximal and distal ends of the occluded segment.
Diabetic foot is a foot with loss of sensation due to ischemia and peripheral neuropathy caused by vascular disease in diabetic patients and complicated by infection, called diabetic foot, also known as extremity gangrene. Diabetic gangrene is not limited to the foot; ulcers or gangrene can occur in the upper extremities and hands, back, head and face, neck, and hip and sacral areas. It is one of the most important causes of disability and death in diabetic patients, seriously threatening their quality of life and healthy longevity.
A phased approach to comprehensive treatment has been adopted: Basic treatment phase: control of diabetes, anti-infection, improvement of microcirculation, supportive therapy, correction of related acute and chronic complications, and for gangrene localization to maintain unobstructed drainage. Debridement and myogenesis phase: Patients generally improve after basic treatment, followed by surgical debridement, gradual removal of necrotic tissue, and the use of various myogenic drugs to promote the growth of granulation tissue and early healing of the wound. Arterial reconstruction phase: This is one of the most important methods for treating large-vessel lesions in patients with diabetic gangrene. It can save some of the extremities gangrene caused by large vascular lesions from amputation. We commonly use the following treatment methods.
①Vascular bypass surgery ;
(ii) Endarterectomy;
(iii) Tendonoplasty with large omentum graft;
(iv) Percutaneous transluminal angioplasty;
⑤ Endovascular stenting;
(6) Atherosclerotic plaque spinotomy
(7) Laser endovascular angioplasty, etc. At the same time, we use drugs for vasodilation, anticoagulation, thrombolysis and restoration of neurological function to activate blood circulation and improve microcirculation and circulation, promote the formation of collateral circulation and granulation, and enable early healing of gangrene.
5. All kinds of disconnection and bypass surgery for cirrhotic portal hypertension: treatment of hypersplenism, fundic esophageal varices caused by cirrhotic portal hypertension and its resulting upper gastrointestinal hemorrhage.
6. Interventional and radical surgical treatment of Bu-plus syndrome
7. Arterial and venous thrombectomy: treatment of acute arterial embolism and venous thrombosis.
8. Emergency treatment of various vascular injuries: repair and reconstruction of blood vessels to save limbs and lives.
9. Surgical treatment of various arteriovenous fistulas and vascular malformations
10. Hemodialysis circulation access surgery.
Patients with chronic renal failure need long-term hemodialysis, and the establishment and maintenance of functional vascular access is a prerequisite for hemodialysis and a lifeline for patients who rely on dialysis for survival. An arteriovenous fistula is an artificial short-circuit between the arteries and veins using vascular surgery techniques to provide long-term and effective extracorporeal circulation for hemodialysis.
A direct anastomosis between the radial artery and the cephalic vein in the distal forearm is the preferred long-term vascular access for dialysis patients and is referred to as the “standard endovascular fistula” or “first level vascular access”; however, in some cases, no suitable autologous vessel can be found for anastomosis in either forearm. However, in some cases, no suitable autologous vessel can be found for anastomosis in either forearm, and a replacement vessel has to be used to create a graft endovascular fistula, also known as “second level vascular access”. Graft endovascular fistulas are used to establish vascular access between distant arteries and veins by “bridging” them with other vessels. Autologous vessels are vessels harvested from other parts of the patient’s body, most commonly the saphenous vein of the lower extremity.
Autologous vessels as vascular graft material have the advantages of high patency rate, low tissue reaction, less bleeding from puncture, and low cost; therefore, it is the material of choice for endovascular grafting. However, when autologous blood vessels are not applicable, artificial blood vessels should be chosen, which can also achieve better results.
11.Surgical treatment of saphenous varicose veins and deep vein valve repair of lower limbs.
The majority of superficial varicose veins of lower limbs are saphenous varicose veins, which are extremely common clinically, the onset of which is often related to genetic factors and can be triggered by long-term standing and heavy physical labor. The causes include: (1) weakness of the vein wall (2) venous valve insufficiency leading to blood reflux (3) elevated pressure in the superficial veins. The main manifestations are lower limbs, especially in the calves, superficial veins bulging, expanding and bending, even curling into a mass, soreness and swelling, weakness, swelling of the feet after standing for a long time, brown pigmentation, eczema and ulcers on the skin of the calves and ankles in the late stage; commonly known as “old rotten legs”.
The treatment methods of the disease are.
(1) Palliative treatment: It is suitable for those who have mild clinical manifestations during pregnancy, early stage of the disease, advanced age or poor general condition and cannot tolerate the surgery, patients should take appropriate bed rest, elevate the affected limbs and avoid standing for a long time. Medical elastic stockings have good elasticity and binding force, which can reduce the superficial venous hypertension produced by muscle contraction during activity, together with appropriate medication to increase the elasticity of the vein wall and reduce exudation;
(2) local sclerotherapy injection: the so-called “injection”, “injection therapy”, “liquid knife”, etc., is a non-cause-specific treatment means, high recurrence rate, more complications (such as sclerosing agent allergy, loss of peripheral nerves and cause intractable pain in the limbs, leakage of sclerosing agent into the subcutis leading to skin and subcutaneous fat necrosis and formation of intractable ulcers), only as an adjunctive treatment for patients with mild local recurrence after surgery;
(3) Topical drug treatment: there is no topical drug with definite effect on varicose veins of lower limbs;
(4) Surgery: High ligation + stripping of saphenous vein, which is suitable for most patients with varicose veins. Saphenous vein high ligation + stripping + deep vein valve repair is suitable for some patients with deep vein valve insufficiency, which is not effective with saphenous vein high ligation + stripping alone. Saphenous vein high ligation + stripping + (laparoscopic) traffic branch ligation for patients with traffic branch valve insufficiency and persistent lower extremity ulcers even after high ligation and stripping alone;
(5) Endovenous laser treatment: It is a minimally invasive treatment method for saphenous varicose veins developed in recent years, which uses laser energy to produce reversible blood bubbles in the venous cavity and transmits heat energy to the vessel wall in its unique way, and the vessel wall fibrosis contracts and closes while the skin remains intact. The procedure is performed under local anesthesia and is minimally invasive, with only minor skin puncture incisions, a quick recovery, and a short hospital stay. These include high ligation of the saphenous vein with aspiration and various minimally invasive surgical methods: endovenous laser therapy (EVLT), percutaneous superficial vein continuous circumferential suture (PCCS), and deep subfascial ligation of the traffic vein (SEPS).