Vascular Surgery Explained: From Diabetic Foot Care to Endovascular Tech

[music] Welcome to vascular insights. I am Dr. Joel, general surgeon from Manipal Hospital Whitefield. And today I'm joined with Dr. Navein Rajendra who is a vascular surgeon from Manipal Hospital Whitefield. We are honored to have him today as a respectable surgeon who is highly involved in the treatment and the diagnosis of various arterial and venus disorders. In this episode, we'll be discussing about uh the basics of vascular surgery and how vascular surgery is evolved and how vascular surgery is being used in the modern day medicine in the treatment of various diseases. We welcome you Dr. Naven to our podcast this morning. >> Thank you Dr. Joy for a very nice introduction. So let's begin the podcast. >> A lot of people who are listening to this podcast are not very well verssed in the specialty of vascular surgery. Could you please briefly explain to us what is vascular surgery and what does a vascular surgeon do? >> Vascular surgery is a specialty that deals with blood vessels of the body apart from the brain and heart. The main goal of a vascular surgeon is to restore normal blood flow in an occluded or a blocked vessel or uh to improve the overall vascular health of our patients. >> So what are the diseases that you usually encounter with sir? basic diseases or the most common diseases that we encounter as vascular surgeons are peripheral arterial disease. Peripheral arterial disease um is nothing but blockages in the arteries where patients uh have pain in the legs while walking, gangrine or any ulcers that do not heal for a long time. And um we treat venus conditions like varicose veins where the patients have grossly or hugely dilated veins in the legs. Um swelling in the legs and also patients with deep vein thrombosis where patients have clots in the legs. Then we also treat arteriovenenous mal forations where the vascular network or the vascular channels in the body they become dilated and they coil within themselves and it usually presents as a swelling. Then we treat uh diialysis uh axis issues and also uh creation of new diialysis axis. We treat uh stroke patients with uh who have carroted occlusions with carroted endaties or carroted stentings. So there is a huge or a wide variety of cases that we handle. Dr. Joy, >> there are certain specialties like cardiology and uh cardiothoracic surgery. Uh how would you say that the vascular surgery is different from these certain specialties? >> That's a very good question. So there are various fields or specialtities which deal with similar vessels. So cardiologists are the doctors who deal with the vessels of the heart and overall the heart health of the heart. So basically they treat the heart conditions with tablets and also they do a lot of catheter based interventions in the heart. Cardiothoracic surgeon deals with diseases of the chest wall. basically they do open surgeries of the heart and the major vessels which is which are within the chest and also they deal with the lungs. So and vascular surgeons u we uh specialists deal with all the blood vessels apart from the brain and [snorts] heart like all the arteries which supply all the organs and also the veins which take blood back to the heart. So with variety of treatment modalities like medicines, we give medications, we also do interventions like the catheter based interventions, thrombolyis and also we do open surgeries based on what the patient requires. >> Why is vascular surgery becoming uh more and more important as the days go by? >> That's a very uh nice question Dr. Joy. So the burden of vascular diseases have been increasing over the past two or three decades. That's probably because the longevity or the patients are living for a longer time then the incidences of diabetes, hypertension, smoking and other sedentary lifestyles have worsened the prevalence of the disease. that is um the number of patients indulging in all these things and also patients who are suffering from the co-orbidities have increased so much so that the incidence of vascular surgery is rising especially uh in in country like ours uh where the um incidence of diabetes is skyrocketing or going so high it's just like an epidemic where patients are suffering with huge ulcer and diabetic foot tissues. So patients are ending up with lot of amputations and lot of um what do you say poor quality of life. So early vascular intervention and diagnosing their condition plays a very huge and very important role in such patients. >> You're absolutely right sir as we see a lot of patients in India they come to us in a later stage when the disease is progressed for us to adequately treat the patient. What are the most common misconceptions about vascular surgery do you think that people have right now? >> Yeah, there are a lot of misconceptions among people. Um the most common being they think that vascular surgeons treat only varicose veins. No, that's not true. Uh vascular surgeon treats a variety of problems even arteries, veins, lymphatics, blocks in your arteries, varicose veins is just a part of it. And um the other misconception is uh when a patient comes with diabetic foot ulcers they the common misconception is that they feel they always lose their toe or they lose their limb. That's that's also not true. So early intervention early treatment can definitely save their toes save their limbs and they can have a really great quality of life. And another common misconception is vascular surgeons remove our toes when we go with gangrine. No, that's not the case. After restoring the blood supply, we can limit the amputation. So we can limit remove as less as possible so that they can really have a good quality of life and they can live a really what do you say a healthy life. As you were saying, so you're trying to do surgeries to limit the amount of um damage and amount of um tissue that we are going to remove in surgeries. Can you please tell us a few of the emergency procedures that you've performed? Sir, >> the most common vascular surgery emergencies that we encounter acute limb eskemia where there is sudden cut off of blood supply to the limbs due to blockage. Um so it's a very important surgery which has to be done probably within 6 hours of presentation or within 6 hours of occurrence of symptoms because beyond 6 hours the patient loses his limb. Then uh we encounter a lot of vascular trauma where patients meet with a road traffic accident or workplace injury where there's fractures of bone vascular injury. Um so these patients again restoration of blood supply is really very important. Then we also encounter a lot of uh ruptured iotic aneurysms. So they uh these patients um generally come with sudden pain, sudden episodes of back pain. This is one of the most common thing we encounter and also we encounter lot of AV access complications like bleeding, sudden block of AV fistulas which need to be intervened. Then we also encounter lot of diabetic foot absesses or necroizing fascitis which has to be uh debrided or um cleaned as early as possible to prevent the patient from developing sepsis. Then also we encounter acute mentric eskemia that is uh the blood supply which supplies the bubble or the intestines gets blocked due to different reasons uh which can again lead lead to a very catastrophic situation. So we encounter such patients um then bleeding from any problems like any different surgery uh where where they encounter any vascular injury we need to be at that point and probably repair the vessels as early as possible. And the key here is early recognition. Early recognition and prompt rapid treatment. If you do not treat it early in such emergency situations, it's going to be really bad. It's going to be a catastrophic situation for the patient where they might really have poor quality of life then they might even lose their limbs. Losing limbs is like almost losing a life. So it's very important to be fast. >> Exactly. So as you treat all these emergency cases, I'm sure there are also a few elective cases that patients can present with where you can provide a proper and adequate treatment. Could you please tell us a few of the cases which are elective >> after the emergencies? Now emergencies is probably about 10 to 20% of our practice. 80 to 90% by and large we do a lot of elective surgeries. The most commonly done elective surgeries are definitely varicose vein surgeries like the endovvenous laser therapy, radio frequency ablation, stripping aulions. So these are the treatment surgeries for varicose veins. Then we do a lot of angoplasties, stenting, bypasses for a peripheral arterial disease where there's an occlusion of the arteries of the leg or anywhere else in the body. [snorts] We do a lot of iotic aneurysm surgeries. We do endovvascular aneurysm repair, open aneurysm repair. We also do a lot of diialysis axis that is AV fusulas, AV grafts, then perm cats, chronic mentric eskeeia where the blood supply to the bowel or the intestine is cut off. So there we need to do a lot of stentings. Uh we also encounter lot of uh DVTs which is which generally come as an emergency or a semi-emergency. So such patients we do we do catheter directedto thrombolyis we do venus tentings. Um in such patients we also get lot of venus mal forations or arter venus mal formations uh where we have we do a array of treatments like sclerotherapies emolization even surgical excision um so the list goes on and on Dr. Joy. >> So could you please elaborate on the role of a vascular surgeon treating a diabetic foot and the wound care post surgeries for a diabetic foot? Diabetic foot management is one of the most important step in today's vascular surgery practice. So early detection and treatment of vascular foot ulcers can uh really improve the quality of life for our patients. So diabetic foot ulcers is not just a wound. So there are a lot of things which are happening in a patient with diabetic foot ulcers. So these ulcers may have deficiencies in blood vessels because diabetes generally involves all the arteries of the limb. There could be nerve damage or neuropathy. There could also be a lot of infection which could be hidden which is not detected at the time right from soft tissue that is the skin and subcutinous tissue and also the bone infections. So it's very much important to address all these issues. So a vascular surgeon is really the right person who could sort out most of these issues like improving the vascularity by either doing an angoplasty or by doing a bypass cleaning up the wound like debridements thorough wash um and also treating the neuropathy with adequate medicines and also deformity corrections uh which could prevent from recurrence of ulcers. So it's it's it's a big uh topic by itself probably that we can really have a separate talk on. Um so but uh it's very crucial and vascular surgeon plays a very very important role in management of diabetic foot ulcers. >> Would you like to explain to us how vascular surgery has evolved in the past few decades? >> The specialty has evolved um leaps and bounds. It's gone to you can say the next level. Um so earlier probably two or three decades back most of the treatments were open surgeries where patients had to be admitted for a week with big cuts on the body. Now with the evolution of vascular surgery most of it is like is become endovvascular. So everything happens through a puncture hole or a needle hole and uh and catheter uh catheterss are navigated within the arteries uh through these small puncture holes and we open the blocks. We do different interventions with these uh catheter basian uh techniques and we um and the patients are really happy because they have to stay to in the hospital for only a day or two um and uh they can resume their activities uh immediately after surgery. Um it's um I can say it's evolving and it's evolved to a really great extent and it's really there's a lot of future which I can see ahead. >> Would you like to talk a little bit more about endovvascular surgery as you were saying? Sir, >> endovvascular surgeries are minimally invasive surgeries where patients do not have any major cuts. So we usually take an axis through a needle with a small sheath which is as slightly bigger than the needle. [snorts] uh we generally do them from the groin or from the from the elbow or from the wrist. So through this small sheath we take our catheterss the wires and we remove the blocks using balloons. We also use stances we can do a lot of catheter based interventions like thrombolyis. So uh this is all done under the fluoroscopy guidance. So there's not much of blood loss and patients are really comfortable. The most commonly done endovvascular surgeries uh are peripheral angoplasties, stentings. Uh we do thrombolyis, we do venus tentings, we insert IVC filters, um we um do emolizations for malf forations, we do uh aneurysm, iotic aneurysm treatment by doing endovvascular aneurysm repair. We also treat thoracic um descending thoracic iota arch of iota aneurysms uh using again endovvascular anurism repair. The surgeries are increasing day by day with newer modalities, newer therapies and newer um hardwares that are available which were not available probably a decade ago. So definitely it's the way looking forward. >> Uh when do you choose endovvascular approaches over open approaches? When do we choose endovvascular surgeries? So it depends on various factors actually. Patients age, anatomy, then co-orbidities, availabilities of hardware, then the extent of disease. So these are the major factors that decide whether we do an endovvascular surgery or open surgery. Generally I would say a young patient who is very fit for surgery who has very unfavorable or unsuitable anatomy we would do open surgery still but otherwise by and large most of the surgeries have become endovvascular at the moment. >> What are the newer technologies that are available in the field of vascular surgery? Sir >> let me put it simple vascular surgery is evolving day by day. So the technologies are evolving too. U we earlier had plain balloons. Now we have drug quoted balloons. We have drug coated stances. Uh we have various atherctomy devices. Atherctomy devices just core off the calcium or the plaque. So we have uh lot of vascular mimetic stents that is the stent behaves like a vessel. Then we have newer emol embleization agents. uh we have better IVC filters. We have newer uh devices like uh branched endographs, penetrated endographs for treatment of iotic anurisms. AI modulated or sequenced CTS. We have fusion CTS where we overlap a CT scan with our um catlab imaging. We have 3D imaging. um literally in every field or every subsp specialty of vascular surgery we have newer technologies coming across. It's really a advantage which patients take and it life is more easier for them and also for the surgeon and this is the reason why uh the subject or the field or the specialtity is just evolving and becoming more and more uh popular. >> Thank you sir. It was a very enlightening discussion that we had about the introduction based on vascular surgery. Uh before closing, is there like a single message that you would like the listeners to take away from this whole topic of discussion? Thank you Dr. Joel. Um so I would like to conclude by telling that um vascular health is really very crucial. Please safeguard your vascular health. Keep your arteries and veins safe. any problems like difficulty in walking, any small wounds or any ulcers, any skin discoloration in your leg or hands, please visit a vascular surgeon. It has to be addressed as early as possible. The earlier you visit, the faster the treatment, the earlier the recovery and always safeguard your legs, your fingers and toes. I would like to say or conclude by telling um save your limbs, you can save your lives, you can save the world. Thank you. >> Thank you. Uh that was a very elaborate and illuminating talk sir. This further sets the stage for us to progress and get into the other various topics regarding vascular surgery. Thank you so much for your time sir. >> [music]