Indications and risks

By Angela Ryan Lee, MD 

Published on July 13, 2023

 Medically reviewed by David Strosberg, MD

Vascular surgery is a surgical subspecialty that treats conditions affecting the blood vessels. These blood vessels include arteries and veins, which many conditions can affect. These conditions can include congenital malformations, complications from diabetes, and high blood pressure, among others.

Blood vessel surgery is performed through open surgery or endovascular procedures. In open surgery, surgeons directly access blood vessels through an incision in the skin. Endovascular surgery is a less invasive option for reaching the affected blood vessel and entails inserting catheters into another blood vessel.

Vascular surgeons perform many types of complex surgeries and procedures, and this article provides summaries of these various types and their indications, as well as a discussion about the risks of vascular surgery.

 Rubberball / Nicole Hill / Getty Images.

Who Performs Vascular Surgery?

Though several healthcare providers treat problems with blood vessels, vascular surgeons specifically operate on blood vessels from the neck to the feet, excluding the brain and heart. These include the carotid arteries, aorta, and leg arteries and veins. After medical school, doctors spend five or more years training to become vascular surgeons.

However, if you need surgery on your heart or brain, you aren't likely to be referred to a vascular surgeon. Neurosurgeons and interventional neuroradiologists perform procedures on the blood vessels in the brain. Cardiothoracic surgeons and cardiologists perform procedures on the blood vessels in the heart.

Indications and Types of Vascular Surgery

There are many reasons a person may need vascular surgery. The following is a list of the conditions that may require vascular surgery and the various approaches to treatment for each one.

Vein Conditions

Vascular surgery can treat several conditions involving the veins, though oftentimes, nonsurgical therapy comes first. These conditions include:

• Venous insufficiency, by which blood refluxes backward through the veins, causing blood to pool in the legs. This can cause varicose veins, leg pain, and ulcers.¹

• Venous obstruction such as from blood clots or nearby structures.²

• May-Thurner syndrome, a form of venous obstruction, is a condition in which an artery compresses the vein leading from the pelvis, resulting in leg swelling and blood clots.³

Carotid Artery Disease

The carotid arteries are located in the neck and bring blood up to the brain. The most common indication for surgery on carotid arteries is carotid artery stenosis. In this condition, there is atherosclerosis, or a buildup of cholesterol plaques, that impairs blood flow and increases the risk of stroke. There are two main types of intervention for carotid artery stenosis: an endovascular procedure to place a stent or surgery to remove the plaque, which is known as a carotid endarterectomy.⁴

Another condition affecting the carotid arteries is carotid dissection. In this condition, there is a tear in the carotid artery. It's typically treated with blood thinners, but in rare cases, carotid dissection may require the placement of a stent.⁵

Peripheral Artery Disease (PAD)

Peripheral artery disease (PAD) is the obstruction of blood flow in the arteries of the legs. It most often results from atherosclerosis, which is the buildup of fatty cholesterol plaques in the arteries. Smoking, high cholesterol, and diabetes increase the risk of this condition. PAD can lead to pain with walking (claudication), poor wound healing, and foot ulcers.⁶

Treatment of chronic PAD includes exercise and medication; however, vascular surgery is often necessary to restore blood flow and improve symptoms.⁷ This can be achieved through endovascular procedures or with a surgical bypass procedure. Endovascular procedures are less invasive and can include angioplasty (using a balloon to dilate the narrowed artery) and/or the placement of a stent.⁸

Bypass, on the other hand, is a more invasive procedure that involves cutting the skin and tissues to access the affected arteries. The blocked artery is bypassed with either a synthetic graft or a vein that has been surgically harvested from elsewhere, typically from the leg.⁹

Arterial Blood Clots

Blood clots in arteries can form directly inside arteries or travel from elsewhere, such as the heart, which is a condition known as an embolism. When blood clots form rapidly, they may require urgent intervention by a vascular surgeon. This is because blocking blood flow causes the death of tissues near the blockage.

Procedures for treating arterial blood clots include the local delivery of medication to break the clot, known as thrombolysis, removing the clot with a thrombectomy or embolectomy procedure, or bypassing the blocked artery.¹⁰

Aneurysms

An aneurysm is a bulge in an artery due to the weakening of the arterial walls. Aneurysms can occur in arteries throughout the body but are particularly serious when they occur in the aorta, the body's main artery, which spans the chest and abdomen. This can lead to potentially life-threatening complications.¹¹

Aneurysms of the aorta in the chest are known as thoracic aortic aneurysms, and those in the abdomen are known as abdominal aortic aneurysms. Aortic aneurysms cause blood clots and stroke and can rupture and lead to death.¹²

Aneurysms can also occur elsewhere in the body:

• Popliteal artery aneurysms may occur in the artery that courses behind the knee¹³

• Visceral artery aneurysms occur in the arteries that feed the abdominal organs, such as the hepatic artery, the splenic artery (leading to the spleen), or the renal arteries¹⁴

Aneurysms can be repaired with open surgery or with the placement of a stent through an endovascular procedure. In the aorta, this is known as endovascular aortic repair (EVAR). Some specific risks related to aortic aneurysm repair include heart attack, stroke, and injury to the spinal cord.¹²

End-Stage Renal Disease

People with end-stage renal disease (ESRD) who need to start hemodialysis must have access to dialysis to filter their blood and connect to the tubes of the dialysis machine.

In the short term, a catheter may enter a blood vessel for dialysis access. However, a connection between an artery and a vein in the arm is necessary for longer-term or permanent dialysis. This is achieved with surgery to place synthetic material to connect the two blood vessels, known as a graft. It can also be called an arteriovenous (AV) fistula.¹⁵

Vascular Trauma

Vascular surgeons may also be involved in the repair of injury due to trauma, such as blunt or penetrating injuries from motor vehicle accidents or stab or gunshot wounds. If there is a significant injury to blood vessels, a vascular surgeon may be called to assist a trauma surgeon in the operating room.

Treatment of vascular trauma often involves open surgery, but newer endovascular techniques are an option in some cases.¹⁶

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a condition in which there is compression of blood vessels and nerves leading to the arm. It can lead to arm fatigue, weakness, numbness, and coldness of the hand. If surgical treatment is needed, vascular surgeons can perform thoracic outlet decompression surgery to remove structures, such as part of a rib bone, to relieve the compression on blood vessels.¹⁷

Weighing the Risks of Vascular Surgery

Any type of vascular surgery or procedure involves a risk of bleeding, blood clots, infection, and injury to nearby structures. Some procedures, such as those for carotid arteries and aorta, carry a risk of stroke. Aorta surgery carries the highest risk of all vascular surgeries, with higher rates of heart attack, stroke, death, and injury to organs that require blood flow from the aorta, such as the kidneys and spinal cord.¹²

Sometimes there may be an option between more or less invasive procedures, such as endovascular as opposed to open surgery. In general, endovascular procedures are less risky. However, they are not always preferred, since the overall success rate may be lower.¹⁸ Open surgery may have better success rates in some cases, but may not be an option depending on underlying conditions.

Your vascular surgeon will take into account your individual situation, anatomic considerations, and success rates of possible procedures to make a recommendation on your plan of care.

Where Do Patients Have Vascular Surgery?

Vascular surgeons perform vascular procedures in hospitals or outpatient centers such as ambulatory surgical centers (ASCs) and office-based labs (OBLs).

Certain complex surgeries, such as open surgeries or complex endovascular procedures, need to be performed in an operating room in a hospital. There is often a period of hospitalization for recovery after these procedures.

Other less complicated procedures that carry a lower risk, such as procedures on varicose veins, are performed in ASCs or OBLs.¹⁹ These locations vary based on the availability of anesthesia providers who can give sedative medications. However, both places provide same-day procedures without any expectation of an overnight stay.

Timeline of Vascular Surgery Recovery

Recovery from a vascular surgery varies widely based on the exact procedure performed and the type procedure of performed. Recovery may involve rest, pain control, and physical therapy to get back to everyday activities.

Recovery can range from just a couple of days for simple vein or endovascular procedures to weeks for complex open surgeries on the aorta. Speak with your vascular surgeon about what to expect regarding recovery, length of hospitalization, and when you can get back to activities like driving, walking, and working.

Ongoing Care and Follow-Up After Vascular Surgery

After a vascular surgery, your team will come up with a plan for follow-up to address long-term care. This includes postoperative risks and management of underlying conditions that affect the blood vessels.

You will have a postoperative checkup with your vascular surgeon within a couple of weeks of surgery to check on any incision sites to ensure proper healing. People who have undergone stenting or bypasses generally require lifelong follow-up with their vascular surgeon. In these cases, imaging tests like ultrasound or computed tomography (CT) may monitor any implanted stents or grafts as well as the disease's progression.

Additionally, vascular disease increases the risk of future heart attack and death. Suppose you experience a heart attack after a major vascular surgery. In that case, the risk of early death increases by up to 30%, particularly for people with underlying conditions like diabetes and heart failure.²⁰

A very important part of ongoing care is managing any underlying conditions contributing to vascular disease. Your primary care doctor and other healthcare team members can help manage blood pressure, cholesterol, diabetes, and kidney disease to help lower your risk of future complications.

Summary

Vascular surgery involves procedures performed on the blood vessels in the body from the neck to the feet, excluding the heart and brain. Vascular procedures range from minor cosmetic vein procedures to major complex surgery on blood vessels due to aneurysms and blockages from cholesterol plaques. Your vascular surgeon will discuss risks and benefits specific to your condition and whether or not a less invasive endovascular surgery is a potential option, or if open surgery is necessary.

Long-term follow-up is essential to help manage any underlying conditions that lead to vascular disease, including high blood pressure, high cholesterol, and diabetes.