Vascular services exist to treat patients with disorders of the arteries, veins and lymphatics. Patients with these disorders should expect to be cared for by a vascular specialist with a thorough understanding of their condition, who is able to organise all the appropriate investigations and treatments, including lifestyle advice, drug therapy, interventional radiology and surgery.
The pressure for change in the way vascular services are delivered should be driven by patient outcomes. Poor patient outcomes in vascular disease include unnecessary deaths, strokes and limb amputations. These devastating outcomes are minimised by the presence of a specialist vascular service dealing in high volumes of such cases.
Patients should be able to obtain a specialist vascular opinion through out-patient clinics at the hospital. Without this service, patients are often managed in primary care rather than being referred, until such time as they either die, have a stroke or develop a gangrenous leg.
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.
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.
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 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)
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.
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.
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.
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.