Vascular surgery

The Vascular Surgery Department employs doctors who try to identify and treat all diseases relating to the arteries and veins of the entire body, except in the heart and brain.

An overview of the different treatments.

The narrowing or stenosis of the arteries is usually due to atherosclerosis or the hardening of the arteries.

Atherosclerosis is the condition whereby a fatty substance (cholesterol) is deposited against the artery wall. Over time the amount of fat will increase narrowing the diameter of the artery. This fatty substance is called atheromatous plaque in the medical world.
Once this plaque starts to crack a blood clot may form which may clog the entire artery.

(click the photograph for a larger image).

Because the arteries become increasingly narrow the blood flow will be reduced resulting in the following diseases:


Peripheral arterial disease
      

Atherosclerosis may cause a narrowing of the abdominal, iliac or leg arteries. When walking you may experience pain in your calf, thigh or buttock. After a short rest the pain will go away and you can continue to walk. This is known as intermittent claudication.

In case of serious peripheral arterial disease the blood flow to your legs will be reduced to the extent that it becomes impossible to walk. The patient will even experience pain when at ease. In this critical situation the patient will soon start to see chronic wounds appear on the toes, feet or legs. The leg's viability will be compromised and the patient runs a real risk of losing a limb.

Possible treatments:
  • Balloon dilation with insertion of a stent
  • Removal of the atheromatous plaque
  • Bypass
  • Combination of the above treatments

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Narrowing of the carotid arteries       

The carotid arteries supply blood to the brain.
When a clot or a piece of atheromatous plaque breaks free and moves towards a carotid artery leading to the brain the patient suffers an attack.

Examples include: hemiplegia, speech disorders, visual field loss, sudden blindness or blurred vision.

If the claudication is large and lasts for a long time part of the brain may die and the malfunction may become permanent. This is called an infarct.

Possible treatments:

  • Balloon dilatation with insertion of a stent
  • Removal of the atheromatous plaque
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Narrowing of the abdominal and intestinal arteries      

Chronic stomach and intestinal circulation disorders may give rise to abdominal cramps after a meal. The patient will also lose a significant amount of weight as she/he will stop eating out of fear of the ensuing pain.

Possible treatments:

  • Balloon dilation and insertion of a stent
  • Bypass 
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Narrowing of the renal arteries     

Renal circulation disorders are one of the many causes of a reduced renal function or increased blood pressure.

Possible treatments:

  • Balloon dilatation and insertion of a stent
  • Bypass
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Causes of arterial stenosis            

Atherosclerosis has several causes.

A number of causes cannot be prevented: these include ageing, gender (men may already suffer from atherosclerosis from a young age) or congenital predisposition.

By living a healthy life, the number of inducing factors and the incidence of coronary disease may be reduced.

  • Watch your cholesterol.
Our body needs cholesterol, which is generated in our liver. But we also absorb it through food. There is good cholesterol and bad cholesterol. The bad cholesterol will stick to the artery wall causing stenosis.

  • Avoid high blood pressure.

The heart of people with high blood pressure has to pump harder to pump the blood through the body. This may cause serious damage to the artery walls.

  • Stop smoking.

Smoking is bad for your lungs but it may also (among others) give rise to serious cardiovascular diseases. The arteries become narrower due to smoking reducing the blood supply to the heart as a consequence. Smokers have a three times higher risk of having a heart attack than non-smokers.

  • Watch your diet and exercise sufficiently.

Healthy and balanced food and regular exercise will keep your heart young and healthy and will significantly reduce your risk of contracting diabetes. Diabetes will irretrievably damage your artery walls.

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Abnormal dilatation of an artery

When an artery is abnormally dilated this is called an aneurysm.

Each artery in our body can dilate but aneurysms occur most frequently in the abdomen, chest, pelvis, groin and knee arteries.
Initially these aneurysms do not give rise to complaints and usually they are discovered by accident. Some people feel a beating mass in their abdomen, groin or at the back of their knee.

As the aneurysm increases in size the risk of a tear with a life-threatening haemorrhage increases. Usually pain near the shoulder blades, in your chest or back usually indicates a tear.

Blood clots may also break free from the aneurysm which can cause a stenosis of the arteries in the legs.
Very large aneurysms may cause a compression on the surrounding structures, such as the intestine, the urethra, an artery or a nerve.

Possible treatments:

  • Endovascular treatment (endoprosthesis)
  • Traditional open treatment
  • Keyhole surgery (laparoscopy)
  • Combination of the above treatments
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    An aortic dissection is a condition whereby a tear in the inner wall of the aorta causes blood to accumulate between the inner and outer wall of the aorta, as can be seen in this illustration.

    An aortic dissection in the chest or in the abdominal aorta will cause sudden violent back or abdominal pain. An aortic dissection is extremely life-threatening because of the risk of a haemorrhage and the compromised blood supply to the brain, intestines, kidneys and limbs.

    Possible treatments:

    • Endovascular treatment (endoprosthesis)
    • Traditional open treatment
    • Combination of the above treatments

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    Thoracic Outlet Syndrome is a common denominator for diseases involving pressure on a neurovascular bundle in the shoulder area.

    Often people will complain of radiating pain to their neck and the back of their head, limbs falling asleep ('pins and needles'), numbness, loss of force, feeling cold, hands and fingers may swell or have a bluish tinge.

    Possible treatments:

    • Physiotherapy
    • First rib resection
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    Raynaud's Phenomenon or Disease relates to attacks whereby the blood flow to the hands and feet (in some cases also the ears and nose) is reduced.

    The hands turn successively white, then blue and when warmed up again, red.
    This phenomenon may occur in case of sudden cold but in some cases it is impossible to identify a clear cause.
    This is commonly known as winter hands and winter feet.

    When the complaints are the consequence of an underlying problem (e.g., a systemic disease) then this is referred to as Raynaud's Phenomenon or Secondary Raynaud.

    Possible treatments:

    • Medication
    • Exceptionally: thorascopic or laparoscopic sympathectomy
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    Varicose veins or varices are abnormal dilations of the superficial veins in the legs.
    The heart pumps blood through the arteries to every part of your body and the blood flows back to the heart through these same arteries.
    There are valves in the arteries in the leg which ensure that the blood does not flow downwards but is pumped up again and returned to the heart.

    If due to circumstances (e.g., standing or sitting for long periods of time) the blood does not flow back to your heart as it should from your legs, there will be more blood in the arteries resulting in engorgement. As a result the pressure in the arteries is increased, the arteries widen and the valves no longer close as they should.

    This in turn means that the blood can no longer be pumped back to the heart as it should, which in turn, results in more engorgement of blood and the further dilation of the arteries. This gradually causes varicose veins.

    1. Normal artery
    2. Valves open and close properly
    3. Muscle
    4. Varicose vein
    5. Muscle
    6. Tensing of amuscle
    7. Valves no longer function properly
    8. Relaxation of the muscle Muscle

    Complaints may include a tired, heavy, fatigued, or restless feeling in your legs.

    Complications that are frequently associated with varicose veins include haemorrhages, clotting, phlebitis, a brown discolouring of one's skin and 'open' legs

      Possible treatments:

      • Medication – compression therapy
      • Sclerotherapy
      • Operative removal – stripping – varicectomy
      • Endovenous radiofrequency ablation or laser treatment
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      Because the deep veins in your legs can become obstructed as a result of blood clots, the return of the blood to the heart may become compromised resulting in a large, swollen and painful leg.

      When a piece of the clot breaks free and circulates through the blood stream travelling to the pulmonary artery this is called a pulmonary embolism. This is a life-threatening situation and the patient may experience chest pain, become short of breath and faint.

      Deep venal thrombosis frequently occurs in bed-ridden patients, cancer patients, in case of dehydration, some coagulation disorders and after surgical procedures involving the bottom limbs. Wearing a cast on the lower leg or long-term immobilisation (during a long-haul flight) may also cause DVT.

      Possible treatments:

      • Administering blood thinners to prevent the clot from becoming bigger
      • Local compression with an elastic bandage or stocking to promote drainage of the leg
      • Pain relief

      If these treatments are insufficient or cannot be administered then in rare cases a filter will be fitted in the abdomen to block any clots which may break free in the legs.

      A short period of hospitalisation is indicated in some cases to start the treatment or to identify the trigger of the thrombosis.
      Follow-up is needed to evaluate the blood thinning: this can be done with subcutaneous injections in the abdomen (short treatment) or using oral medication (long-term treatment).

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      Since 2005 UZ Brussel is home to one of the 22 certified diabetic foot clinics in Belgium.

      UZ Brussel was certified because it was able to prove that it treated a sufficiently high number of patients with serious foot pathologies, that these patients were treated by a multi-disciplinary team and that they had around-the-clock staff for emergencies.

      The vascular surgeon's task in the diabetic foot clinic is to identify arterial insufficiency and to remediate this condition with a surgical procedure.
      Endovascular surgery is preferred (because the results of traditional bypass surgery in the small arteries of the lower limb are not satisfactory).

      Below-the-knee dilations require know-how and equipment, which is more commonly associated with invasive cardiology than with traditional endovascular surgery.

      Although surgical wound care, debridement and amputation can be carried out by most surgeons at UZ Brussel this is the sole responsibility of the vascular surgeon.

      The UZ Brussel diabetic foot clinic takes a very pragmatic multidisciplinary approach (required for the adequate diagnosis and treatment of the diabetic foot): various parties (dialectologist, microbiologist, orthopaedic surgeon, wound care nurse, diabetes educator) have to be consulted every time a therapeutic decision is made.

      In practice this means that consultation and collaboration among doctors is the rule rather than the exception for patients during consultations and in the hospital.

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      Dialysis access refers to all the technical actions taken to establish an entranceway into the patient's bloodstream or the arterial/venal system with the intention of extracting a large volume of blood from the patient for the purpose of dialysis.
      It includes the arteriovenous fistula, the man-made or synthetic graft and the double lumen catheter.

      The aim of the arteriovenous fistula is to exert arterial pressure on the superficial vena in order to enable frequent puncturing and the aspiration of a large volume of blood. To this end the surgeon joins a supplying artery to a draining vein using tissue from the patient's own body (as a result complications such as infection and thrombosis are rare).
      The arteriovenous fistula has to mature for some weeks and even months so that the capacity of the arteries and veins can increase steadily until a sufficiently high flow is achieved.

      In case of emergency dialysis or if there is no suitable vein a man-made graft may be inserted between the artery and vein of the doctor's choice. The subcutaneous part has to be long enough for frequent puncture.

      Failing this, a dialysis catheter may be put in place, with two channels for the simultaneous aspiration and return of the blood to your body with a capacity allowing for sufficient flow.

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