a surgical specialty focused on treating diseases of the arteries, veins, and lymphatic system. These vessels form the body's circulatory system, transporting blood to and from the heart. Vascular surgeons address a wide range of conditions, including aneurysms, peripheral artery disease, carotid artery disease, and varicose veins. They utilize both open surgical techniques and minimally invasive endovascular procedures. Dr Aliya Shair Muhammad Lecturer: Bolan University of Medical and Health Sciences, Quetta

1. VASCULAR SURGERY
PART .3
Dr Aliya Shair Muhammad
Lec : BUMHS , Quetta

2. Indication of vascular surgery
 Arterial disorders
i. Ischemia Of Lower Limb: Arterial Stenosis
ii. Gangrene
iii. Abdominal Aortic Aneurysm
 Venous disorders
i. Varicose veins
ii. Venous ulcers
iii. Venous thrombosis
 Lymphatic disorder
i. Lymphangitis
ii. Lymphema
iii. Lymphadenopathy

3. Investigation in vascular disease
Non-invasive investigations:
 Vascular Ultrasound:
Uses ultrasound waves to create images of blood vessels and assess blood flow, detecting
blockages, narrowing, or other abnormalities.
 Doppler Ultrasound:
Measures blood flow velocity and direction, identifying potential issues like turbulent flow or restricted
blood supply.
 Duplex Ultrasound:
Combines B-mode imaging and Doppler to provide comprehensive information about vessel
structure and blood flow.
 Ankle-Brachial Index (ABI) test:
Compares blood pressure in the ankles with that in the arms to assess for peripheral artery
disease.
 Magnetic Resonance Angiography (MRA):
Uses magnetic fields and radio waves to create detailed images of blood
vessels, particularly useful for visualizing deep-seated arteries.

4.  Treadmill Exercise Test:
Monitors blood flow during exercise to assess how well the circulatory system
responds to physical activity.
 Pulse Volume Recording (PVR):
Measures blood volume changes in the limbs, indicating blood flow patterns
and potential blockages.
 Photoplethysmography (PPG):
Uses infrared light to assess blood flow near the skin surface, often in
conjunction with ABI.
Invasive investigations:
 Angiography:
Involves injecting a contrast dye into the blood vessels and taking X-ray images to visualize blockages or abnormalities.
 Cardiac Catheterization:
Uses a catheter to access blood vessels and deliver contrast dye for imaging, often combined with
therapeutic procedures.

5. Other assessments:
 Physical Examination:
Healthcare providers may assess for signs like skin changes, pulse
abnormalities, and the presence of bruits (abnormal sounds in blood vessels).
 Blood Tests:
Can help identify risk factors like high cholesterol, diabetes, or chronic
inflammation, which can contribute to vascular disease.
 Laboratory Tests:
May include assessments of vascular function, such as
flow-mediated vasodilation, reactive hyperemia index, and pulse wave velocity.

6. Types of operations
Open Vascular Surgery:
 Traditional Incisions:
Open surgery involves larger incisions to directly access and repair blood vessels. This
approach is often used for complex cases like aneurysm repair or bypass grafting.
 Specialized Instruments:
Surgeons use a variety of clamps, retractors, and sutures to manipulate and
repair blood vessels.
 Bypass Grafts:
In cases of blockages, bypass grafts (often made from synthetic materials or the patient's
own vein) are used to reroute blood flow around the affected area.
Minimally Invasive (Endovascular) Procedures:
 Catheters and Balloons:
Catheters are inserted through small punctures in the skin, allowing surgeons to
navigate through blood vessels. Balloons are used to expand narrowed arteries.

7. Conti…
 Stents:
Metal mesh tubes (stents) are deployed to keep arteries open after balloon angioplasty.
 Atherectomy:
Specialized catheters with rotating blades or suction devices can be used to
remove plaque buildup in arteries.
 Contrast Dye and Imaging:
X-ray and contrast dye help surgeons visualize the blood vessels and
guide the placement of instruments.
 Robotic Surgery:
The DaVinci robot offers enhanced precision and control for minimally invasive

8. Complication:
 Bleeding:
Hemorrhage, or excessive bleeding, is a frequent concern, potentially requiring further
intervention.
 Clotting:
Blood clots (thrombosis) can form in the graft or vessels, leading to blockages and potentially
serious consequences like limb ischemia or stroke.
 Nerve Injury:
Nerve damage during surgery can result in numbness, pain, or weakness.
 Infection:
Infections at the surgical site are a serious risk, potentially jeopardizing the success of the surgery.
 Renal Failure:
Kidney injury or dysfunction can occur, particularly in patients with pre-existing kidney
problems.

9. Conti…
 Anastomotic aneurysms:
Bulges or weakening at the connection point of a graft or vessel can lead to complications and may require
further surgery.
 Aortoenteric fistula:
A rare but life-threatening complication where a connection develops between the aorta and the digestive
tract.
 Graft failure:
The implanted graft may not function properly, potentially leading to blockages or other issues.
 End-organ ischemia:
Reduced blood flow to organs can cause damage or dysfunction.
 Reaction to Anesthesia:
Adverse reactions to anesthesia can occur, though they are generally uncommon.
 Delayed Healing:
Incisions or wounds may take longer to heal, especially if blood flow is compromised.
 Deep Vein Thrombosis (DVT):
Blood clots in deep veins, often in the legs, can be a postoperative complication.
 Pulmonary Embolism:
A clot from a DVT can travel to the lungs, causing a potentially serious blockage

10. i. ischemia Of Lower Limb: Arterial
Stenosis:
 Etiology
• Atherosclerosis (most common)
• Thrombosis over stenosis
• Embolism (rare in chronic ischemia)
• Iatrogenic or traumatic causes
Clinical Evaluation
Symptoms: Claudication, rest pain, non-healing ulcers, gangrene
Signs: Diminished/absent pulses, cool extremity, skin changes
 Assessment Tools:
• Ankle-Brachial Index (ABI)
• Duplex Doppler ultrasound
• CT/MR Angiography
• Digital Subtraction Angiography (DSA)
Surgical Indications
 Critical limb ischemia (CLI)
 Failed conservative or endovascular
treatment
 Severe lifestyle-limiting claudication
 Tissue loss (ulcers/gangrene)

11. Surgical interventions:
 Endovascular First Approach:
 Balloon angioplasty ± stenting
 Suitable for short, focal stenoses
 Open Surgical Revascularization:
 Bypass Grafting:
 Femoral-popliteal bypass (most common)
 Aorto-bifemoral bypass (for aortoiliac disease)
 Graft material: Autologous vein (preferred), PTFE/Dacron
 Endarterectomy:
Localized plaque excision
 Hybrid Procedures:
Combination of open and endovascular techniques

12. Postoperative Considerations
 Antiplatelet therapy
 Graft surveillance (duplex scan)
 Risk factor modification (smoking, diabetes, statins)
 Amputation in non-salvageable limbs

13. Arterial occlusion vs arterial stenosis:
Feature Arterial Stenosis Arterial Occlusion
Onset Gradual, chronic Sudden (acute) or chronic
Symptoms Intermittent claudication
Acute ischemia (6 Ps) or
critical limb ischemia
Collateral Flow Usually present
Poor in acute, variable in
chronic
Surgical Urgency Elective or semi-elective Emergency (acute occlusion)
Common Surgery Angioplasty, stenting, bypass
Thrombectomy,
embolectomy, bypass
Goal
Improve flow, relieve
symptoms
Restore urgent blood flow
Prognosis Good with treatment
Poor if delayed, risk of limb
loss

14. ii. Gangrene
Gangrene is death with putrefaction of macroscopic tissue, typically affecting:
 Distal limbs (toes, feet)
 Appendix
 Loop of small intestine
 Occasionally: gallbladder, pancreas, testis
Etiology – Common Surgical Causes
1. Arterial Obstruction:
• Thrombosis of atherosclerotic artery
• Embolism (e.g., from heart in atrial fibrillation)

15. Conti…
2. Inflammatory & Vasospastic Disorders:
• Arteritis with neuropathy (e.g., diabetes)
• Buerger’s disease
• Raynaud’s disease (arterial shutdown)
3. Iatrogenic & Toxic Causes:
• Intra-arterial injections of thiopentone, cytotoxic drugs
• Ergotism (drug-induced vasospasm)

16. 4. Infective:
Boils & Carbuncles (local spread)
 Gas Gangrene (Clostridium perfringens)
 Fournier’s Gangrene (necrotizing fasciitis of the
perineum)
3. Traumatic Causes
a. Direct Trauma:
 Crush injuries
 Pressure sores
 Constriction groove in strangulated bowel
 b. Indirect Trauma:
 Vascular injury distant from site
➤ e.g., pressure on popliteal artery from a
fractured femur
4. Physical Causes
 Burns & Scalds
 Frostbite
 Chemical injuries
 Irradiation
 Electrical burns

17. Sign:
1. Dead Tissue Characteristics
 Dry: Wrinkled, hard, brown/black
 Wet/Infected: Soft, boggy
2. Separation by Demarcation
a. Initial Zone:
 Hyperemia & hyperesthesia between viable and dead tissue
b. Granulation Tissue:
 Forms at the interface of living and dead parts
c. Line of Demarcation:
 Ulceration clearly separates gangrenous tissue from healthy area

18. Surrounding Tissue
 Tenderness often present proximal to line of demarcation
4. Signs in Gangrenous Area
- No arterial pulsation
- No venous return
- No capillary refill
- No sensation
- No warmth
- No function

19. TREATMENT: Management of Gangrene
A. Conservative Treatment:
- Treat underlying conditions: Cardiac
failure, AF, anemia
- Nutritious diet & control of diabetes
- Analgesics: Prefer non-opioids
- Keep affected part absolutely dry
- Protect pressure points (e.g., heels,
malleoli)
B. Surgical Treatment
 Minor Surgical Toilet
- Lift crusts, remove desiccated skin to aid demarcation,
drain pus, relieve pain
 Amputation
- Distal (limb-saving) for hands/feet
- Salvage depends on adequate blood supply or potential
to improve perfusion
C. Major (Life-saving) Amputation
o Indicated for:
- Badly crushed limb
- Rapidly spreading symptomatic gangrene
- Gas gangrene (clostridial infection)

20. Amputation and its types
•Surgical removal of a limb or part of a limb due to
trauma, infection, ischemia, or malignancy
Indications:
o Severe trauma
o Peripheral arterial disease (critical limb ischemia)
o Infection (e.g., gangrene, osteomyelitis)
o Malignancy
o Congenital deformities

21. Types:
Level Description Common Indications
Partial foot
Removal of toes or part of the
foot
Localized infection, ulcers
Below-Knee (Transtibial)
Amputation below the knee
joint
Most common for vascular
disease
Above-Knee (Transfemoral)
Amputation above the knee
joint
Extensive disease or trauma
Syme's Amputation
Ankle disarticulation
preserving heel pad
Trauma, infection
Hip disarticulation
Removal of entire leg at the
hip joint
Extensive trauma or
malignancy

23. iii. Abdominal Aortic Aneurysm (AAA)
•Localized dilation of the abdominal aorta >1.5 times normal diameter (usually >3 cm)
Epidemiology:
Common in men >65 years, smokers, and those with atherosclerosis
Risk Factors:
•Age
•Male sex
•Smoking
•Hypertension
•Family history
•Atherosclerosis
Pathophysiology:
Degeneration of the aortic wall’s media layer → weakening → dilation and possible rupture
Clinical Presentation:
Mostly asymptomatic, found incidentally
If symptomatic: abdominal/back pain, pulsatile abdominal mass

24. Diagnosis: of AAA:
Abdominal ultrasound (screening and initial diagnosis)
CT angiography (preoperative planning)
•Management:
Small AAAs (<5.5 cm): Surveillance with ultrasound every 6–12 months
Large AAAs (>5.5 cm) or symptomatic: Elective surgical repair
•Open repair or Endovascular Aneurysm Repair (EVAR)
•Complications:
Rupture → severe abdominal/back pain, hypotension, shock (life-threatening)
Thrombosis/embolism
Compression of adjacent structures
•Screening Recommendation:
One-time ultrasound screening for men aged 65–75 with smoking history.

25. iv. Arteriovenous fitula: (AVF)
Abnormal direct connection between an artery and a vein, bypassing the capillary bed
Types:
•Congenital
•Acquired: Trauma, surgery, or iatrogenic (e.g., dialysis access)
Clinical Features:
•Pulsatile mass
•Bruit and thrill on palpation
•Limb swelling or ischemia distal to the fistula
•High-output cardiac failure in large AVFs
Diagnostic Tools:
•Doppler ultrasound (gold standard)
•CT/MR angiography
Management:
• Small/asymptomatic: Observation
• Symptomatic or large AVF: Surgical ligation or endovascular repair
 Special Note:
AVFs are deliberately created for hemodialysis access in chronic kidney disease patients.

27. Burger's disease
(Thromboangiitis Obliterans)
Non-atherosclerotic, segmental inflammatory disease-causing
occlusion of small and medium-sized arteries and veins,
primarily in the limbs
 Epidemiology:
• Mostly young male smokers (20–40 years)
• Strongly associated with tobacco use
o Pathophysiology:
- Inflammation and thrombosis → vessel occlusion → -
ischemia and tissue damage
 Clinical Features:
 Ischemic pain in hands/feet (rest pain, claudication)
 Digital ulcers, gangrene
 Superficial thrombophlebitis
 Cold sensitivity (Raynaud’s-like symptoms)
Diagnosis:
•Clinical + exclusion of atherosclerosis and
autoimmune diseases
Management:
•Absolute smoking cessation (only effective
treatment)
•Vasodilators, analgesics
•Surgical: amputation if severe

29. Rayaud’s disease and syndromes
Episodic vasospasm of small arteries and arterioles
causing color changes in digits (fingers/toes)
Types:
•Raynaud’s Disease (Primary):
Idiopathic, no underlying cause
•Raynaud’s Phenomenon (Secondary):
Due to underlying diseases (e.g., scleroderma, lupus,
arterial occlusion)
•Clinical Features:
Triphasic color changes:
1.White (ischemia)
2.Blue (deoxygenation)
3.Red (reperfusion)
- Triggered by cold or stress
- Usually symmetric, affects fingers/toes
 Diagnosis:
• Clinical history
• Nailfold capillaroscopy (abnormal in
secondary)
• Exclude secondary causes with
autoimmune tests
 Management:
 Avoid cold exposure, stress reduction
 Calcium channel blockers (e.g.,
nifedipine)
 Treat underlying disease in secondary form

30. Varicose veins
Dilated, tortuous superficial veins caused by valve incompetence and venous reflux, commonly in lower limbs.
Epidemiology:
•More common in women
•Prevalence increases with age
•Risk factors: pregnancy, obesity, prolonged standing, family history
Pathophysiology:
•Valve failure → retrograde blood flow → venous hypertension
•Vein wall weakening → dilation and tortuosity
Clinical Features:
•Visible bulging veins, mainly on legs
•Aching, heaviness, cramps, swelling
•Skin changes: pigmentation, eczema
•Complications: thrombophlebitis, bleeding, ulcers

31. Diagnosis & Management of Varicose
Veins
 Diagnosis:
- Clinical exam: visible dilated veins, Trendelenburg test
 Duplex Doppler ultrasound: confirms reflux, assesses deep and superficial veins
 Classification:
 Primary: valve incompetence of superficial veins
 Secondary: due to deep vein thrombosis or obstruction
 Management:
 Conservative:
 Leg elevation
 Compression stockings
 Lifestyle modifications (weight loss, avoid prolonged standing)
 Medical: venoactive drugs (limited evidence)

32. Surgical/Procedural:
 Endo venous laser therapy (EVLT)
 Radiofrequency ablation (RFA)
 Vein stripping and ligation
 Foam sclerotherapy
Complications to monitor:
•Venous ulcers
•Bleeding
•Superficial thrombophlebitis

33. Superficial and deep venous thrombosis:
a. Superficial Venous Thrombosis (SVT)
Thrombosis in superficial veins, commonly the
great or small saphenous vein
 Causes:
 Varicose veins
 Trauma or IV catheter
 Hypercoagulable states (less common)
 Clinical Features:
 Localized pain and tenderness along vein
 Redness, warmth, swelling over superficial
vein
 Palpable, cord-like vein
•Complications:
•Usually mild
•Risk of extension into deep venous system
•Diagnosis:
•Clinical examination
•Duplex ultrasound to confirm and rule out DVT
•Treatment:
•NSAIDs for pain
•Compression stockings
•Anticoagulation if extensive or near deep veins

34. b. Deep Venous Thrombosis (DVT)
Thrombosis in deep veins of lower limb (e.g.,
femoral, popliteal)
 Causes:
 Prolonged immobilization or surgery
 Malignancy
 Pregnancy
 Hypercoagulable disorders
 Clinical Features:
 Limb swelling, pain, warmth, erythema
 Positive Homan’s sign (less specific)
 Complications:
 Pulmonary embolism (life-threatening)
 Post-thrombotic syndrome (chronic swelling,
pain)
 Diagnosis:
 Duplex ultrasound (gold standard)
 D-dimer blood test (supportive)
 Treatment:
 Anticoagulation (heparin, warfarin, DOACs)
 Compression therapy
 Thrombolysis or thrombectomy in severe cases

35. Venous hemorrhage
Bleeding from a damaged vein, typically slower flow than arterial bleeding due to lower pressure
Causes:
•Trauma (blunt or penetrating)
•Surgical injury
•Venous rupture in varicose veins or venous malformations
•Characteristics:
•Dark red blood (deoxygenated)
•Steady, slow flow
•Easier to control than arterial bleeding but can still cause significant blood loss
Management:
•Direct pressure and elevation
•Tourniquet (if needed)
•Surgical repair or ligation
•Venous thrombosis prevention after injury
Complications:
•Hematoma formation
•Risk of deep vein thrombosis (DVT)
•Air embolism (rare, from large venous injuries)

36. Lymph edema
•Chronic swelling caused by impaired lymphatic drainage,
leading to accumulation of protein-rich lymphatic fluid in
interstitial tissues
Types:
•Primary: congenital or hereditary lymphatic malformations
•Secondary:
due to lymphatic damage (surgery, radiation,
infection, malignancy)
•Clinical Features:
Progressive, non-pitting swelling (especially in
limbs)
- Skin thickening and fibrosis (elephantiasis in severe cases)
- Recurrent infections (cellulitis, lymphangitis)
Positive Stemmer’s sign (inability to pinch skin on toes/fingers)
•Diagnosis:
Clinical examination
Lymphoscintigraphy (gold standard imaging)
Ultrasound to exclude other causes
 Management:
 Compression therapy (bandages,
stockings)
 Manual lymphatic drainage
(physiotherapy)
 Skin care and infection prevention
 Surgical options in refractory cases

37. Lymphadenitis and lymphomas
 A. Lymphadenitis
Inflammation and enlargement of lymph
nodes due to infection
 Causes:
 Bacterial (e.g., Staph, Strep)
 Viral (e.g., EBV, CMV)
 Mycobacterial (e.g., TB)
 Fungal or parasitic infections
 Clinical Features:
 Painful, tender, swollen lymph nodes
 Overlying skin redness and warmth
 Systemic signs: fever, malaise
o Diagnosis:
 Clinical exam
 Blood tests (CBC, cultures)
 Imaging if abscess suspected
 Fine-needle aspiration or biopsy if unclear
•Treatment:
 Antibiotics for bacterial causes
 Supportive care for viral infections
 Drainage if abscess forms

38. Lymphomas
Malignant tumors of lymphoid tissue (lymph nodes, spleen, bone marrow)
 Types:
 Hodgkin lymphoma (HL): Characterized by Reed-Sternberg cells
 Non-Hodgkin lymphoma (NHL): Diverse group of lymphoid malignancies
 Clinical Features:
 Painless, firm lymphadenopathy
 symptoms: fever, night sweats, weight loss
 Possible splenomegaly, hepatomegaly
o Diagnosis:
•Lymph node biopsy (definitive)
•Imaging (CT, PET) for staging
•Bone marrow biopsy if indicated
o Treatment:
•Chemotherapy ± radiotherapy
•Targeted therapies and immunotherapy in some cases