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:
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.
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.
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 indexOne-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 diseasePeripheral 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 serviceAneurysm 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)
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.
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.
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.
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.
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.
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.
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.