Sunday, June 24, 2007

Vascular Surgery

Vascular Surgery
Week 1


I have been shadowing Dr. Vouyouka in the department of vascular surgery. Vascular surgery is a general term that describes interventions on arteries and veins throughout the body excluding the heart and the brain. In general, vascular problems arise from two causes: aneurysms or occlusions of vessels. Aneurysms are localized dilations of blood vessels that may be caused by disease or a weakening of the blood vessel wall, while occlusions are blockages in vessels that may restrict blood flow. These conditions may be problematic for a patient because of the risk of rupture and/or ischemia.

For vascular problems in the lower extremities, patients may present with pain in the legs known as claudication. This pain may be mild or severe, occur during walking or while resting, and could be caused by ischemia. Untreated severe vascular problems may lead to a loss of sensation of the lower extremities and gangrene requiring amputation.

The Operating Room

The OR is not like what I expected! It’s very busy and there are a lot of personnel in the room from the surgeons and nurses to anesthesiologists. It also seems very primitive in some regards (Are staples, rubber bands, and triple knots really the state-of-the-art for wound closures?) and advanced in others (angiogram imaging technology).

One procedure I saw was an angiogram. This involves threading a catheter through the vasculature to a site of interest. Contrast dye is used in conjunction with fluoroscopy to visualize the vascular tree to looks for stenosis or occlusions. This is a really interesting procedure because the surgeons use a two-dimensional image as a roadmap for a three-dimensional procedure. They told me that “You get the hang of it; it’s like learning any other procedure”, but I’m still skeptical!

I also saw a balloon angioplasty of a leg vessel. This procedure also uses a catheter placed at a site of stenosis. A balloon is inflated at the site to help open the vessel to improve blood flow. These procedures are often now done by vascular surgeons, but were traditionally aspects of the job of interventional radiologists. In any case, the technology available to the surgeon is pretty amazing.

The Clinics

I also saw patients at the clinics in Weill Medical and at Lincoln hospital in the Bronx. This was really interesting because each person presents with their symptoms and it was up to the surgeon to try to figure out what was wrong. Often the patients had pain in their legs, and the surgeon can get a pretty good idea of where the problem areas in the vasculature are based on where it hurts. The vasculature system is a lot like plumbing—a blockage will cause problems downstream. Treatments might first be having a duplex, or an ultrasound of a suspected problem area. The next step might be an angiogram to better visualize the circulation. Surgery might be needed if there are extensive occlusions or an aneurysm present. I really like the clinic because each person had something different going on and you get a good sense of the “human” side of patient care.

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