Vascular Surgery

Ospedale San Raffaele

key figures 

CLINICAL SERVICES:

  • Aortic and iliac pathology
  • Supra-aortic trunks pathology
  • Lower limb arterial pathology
  • Visceral vessels pathology
  • Venous pathology

PROCEDURES PERFORMED PER YEAR:

  • 2.500 admissions
  • 2.100 vascular and endovascular procedures
  • 20.000 ultrasound examinations
  • 10.000 standard and advanced medications
  • 9.000 outpatient consultations

Major vascular pathologies develop in the arterial circulation, which brings the blood filled with oxygen and nutrients to the cells. These diseases affect, in particular, the population aged 50 and over. The most serious consequences of these diseases can cause thrombosis, stroke, limb ischemia and internal bleeding (rupture of aneurysm) with sometimes disabling or lethal outcomes.

The Vascular Surgery Unit is highly specialised in the treatment of all vascular pathologies. It carries out more than 2.500 admissions with over 2.100 vascular and endovascular surgical procedures every year (10% are of urgent character), particularly on the abdominal and thoracic aorta, on the carotid arteries, on arteries in general and on the veins of the lower limbs region. It carries out over 20.000 ultrasound examinations, 10.000 standard and advanced medications programmes and 9.000 outpatient consultations per year, both for the first diagnosis of vascular disease, and for the follow up of patients who’ve previously had vascular procedures.
 
For the diseases of arterial pathology highlighted below, the treatments currently in use are: direct surgical treatment (open), endovascular surgical treatment, and mixed (hybrid) surgical treatment. Disorders of the venous circulation, on the other hand, normally have milder consequences than those of arterial pathologies, but affect a very large population and in advanced stages can be extremely disabling.  The Unit provides a complete range of treatments for such pathologies as well.


treatmentS

Aortic and iliac pathology

The Unit is highly specialized in the treatment of aortic and iliac pathologies such as aneurisms and occlusive diseases. In the case of aneurisms there are three types of treatments depending on which aorta is affected. The surgical treatment is carried out by replacing the affected aorta with a synthetic prosthesis. The endovascular treatment, on the other hand, can only be performed in selected cases, when the anatomy allows the stable and safe positioning of a prosthesis inside the affected aorta (endoprosthesis), through the femoral, iliac, thoracic arteries or the abdominal aorta. There is also the possibility of a hybrid treatment, a method in which the combination of surgical treatment with an endovascular treatment allows to deal with even the most complex cases of aortic disease.

For the stenosis and occlusive pathologies there are also a range of treatments offered in the Unit. The medical treatment consists of a therapy with antiplatelet agents that prevent the platelets from binding to atherosclerotic plaques, aggravating the disease. It also includes the use of blood-diluting drugs that make the blood more fluid and able to flow more easily inside the diseased vessels, as well as vasodilatory drugs that increase peripheral vascularization. Correction of individual patient risk factors, abstention from smoking and correct physical activity are essential. The results from the medical therapy can be good in the early stages of the disease.

Surgical treatment on the other hand is implemented by replacing (bypass) the occluded artery tract with a synthetic prosthesis (Dacron, PTFE) or by clearing the artery through the removal, from the inside, of the atherosclerotic plaques (endarterectomy). Endovascular treatment can also be performed in cases of segmental stenosis with a percutaneous approach. Arteriography is also performed whereby the arteries are dilated at the points where they are stenotic (restricted), possibly by implanting one or more stents (metal mesh tubes).

Main Pathologies Treated:

  • Aneurysm of the thoracic aorta
  • Aneurysm of the thoracoabdominal aorta
  • Acute and chronic dissections of the thoracoabdominal aorta
  • Aneurysm of the abdominal aorta
  • Aortoiliac occlusive disease
  • Aneurysm of the aortic arch
  • Arcuate ligament syndrome
  • Aortic and iliac stenosis and occlusions

Top Procedures:

  • Endovascular Treatments
  • Hybrid Treatments
  • Surgical Treatments
  • Laparoscopic Treatments

Supra-aortic trunks pathology

The Vascular Surgery Unit is broadly experienced in supra aortic-trunks pathologies, and offers both, an open treatment as well as endovascular procedures.

In cases of steno-obstructive pathologies of the carotid or the subclavian arteries the formation of atheromatous plaques in the affected artery causes narrowing that prevents blood from flowing freely and supplying the brain in correct quantities. This can lead to ischemic shocks if its left without treatment. In many cases, this pathology runs without symptoms until the cerebral ischemic event. It is therefore of fundamental importance to include their assessment in the cardiovascular screening programs, especially in subjects with one or more risk factors.

There are different types of treatments for this pathology. The medical therapy is implemented to prevent the progression and symptoms of non-serious stenosis (antiplatelet agents).

Meanwhile, the surgical treatment is implemented, proven suitable by years of experience, and consists in the removal of atheromatous plaque directly through an incision of the artery, under locoregional anaesthesia. The endovascular treatment is performed only in selected cases, it is in fact the treatment of choice only in patients who, for technical reasons or related to the general conditions, cannot undergo the surgical treatment option. The Unit specialises in the treatment of the carotid artery stenosis, as well as the management of thoracic outlet syndrome and other steno-occlusive pathology of the subclavian artery. The pathology of supra-aortic trunks including atheromatous stenosis of the carotid arteries, kinking of the internal carotid artery, stenosis of vertebral and subclavian arteries, carotid body tumours is also treated by a highly-trained team of specialists.

Main Pathologies Treated:

  • Thoracic outlet syndrome
  • Steno-occlusive pathology of the subclavian artery
  • Carotid artery stenosis
  • Supra-aortic trunks pathology including:
    • Atheromatous stenosis of the carotid arteries
    • Kinking of the internal carotid artery
    • Stenosis of vertebral and subclavian arteries
    • Carotid body tumours

Top Procedures:

  • Surgical Treatment
    • Carotid endarterectomy
  • Endovascular Treatment
    • Carotid artery stenting

Lower limb arterial pathology

Steno-obstructive pathology of the lower limbs consists of the formation of atherosclerotic plaques in the femoral-popliteal segment that cause a lack of blood circulation in the lower limbs, especially under stress. There are different types of treatment for this pathology. The medical treatment consists of a therapy with antiplatelet agents that prevent platelets from binding to atherosclerotic plaques, aggravating the disease. Blood-borne drugs are also given to the patient to make the blood more fluid and able to flow more easily into the affected vessels.  In addition, vasodilatory drugs can be prescribed that increase peripheral vascularization. Correction of individual patient risk factors is essential such as, abstention from smoking and correct physical activity. The results from this kind of therapy can be good in the early stages of the disease.

Surgical treatment is implemented by replacing (bypass) the occluded artery with a synthetic or biological prosthesis. In some cases, it is only possible to clean the arteries (endarterectomy), removing atherosclerotic plaques from the inside. Meanwhile, an endovascular treatment is also offered but can only be implemented in cases of segmental and non-occlusive stenosis. The treatment is percutaneous, and an arteriography is performed whereby the arteries are dilated at the points where they are stenotic (restricted), possibly by implanting one or more stents.

Main Pathologies Treated:

  • Occlusive disease of the arteries of the lower limbs
  • Aneurysm of the arteries of the lower limbs
  • Chronic limb ischemia secondary
  • Femoral artery occlusions
  • Critical limb ischemia pain

Top Procedures:

  • Surgical Treatment
  • Endovascular Treatment
  • Hybrid Treatment
  • Balloon angioplasty
  • Neuromodulation
  • Stenting
  • Femoral-popliteal bypass implantation

Visceral vessels pathology

The visceral artery can be damaged and affected by occlusions and atherosclerosis. The Unit is specialised in the treatment of such pathologies and provides different types of treatment for mesenteric ischemia. The disease progresses slowly but can be life threatening if left untreated. In the cases of non-serious vascular disease, the medical therapy is sufficient and can prevent worsening of the patient’s condition and decrease the risk. A surgical treatment is recommended in the more progressed cases. The vascular surgery Unit’s team is highly specialized in laparoscopic and minimally invasive methods of opening the affected vessels, including angioplasty, stenting and drug coated balloons positioning. In addition, the Unit can also provide open surgery treatment with the use of the most innovative equipment available. The Unit works in a multidisciplinary manner to develop a comprehensive and personalised therapy plan for every patient. The Unit also treats patients with ‘nutcracker syndrome’ and provides endovascular treatment of aneurysms of the visceral vessels.

Main Pathologies Treated:

  • Occlusive and aneurysmal pathology of the visceral arteries including:
    • Celiac trunk
    • Superior mesenteric artery
    • Renal arteries
  • Abdominal venous disease including
    • Pelvic and inferior vena cava syndromes
    • Nutcracker syndrome
  • Chronic mesenteric ischemia
  • Visceral arteries stenosis/occlusions

Top Procedures:

  • Endovascular Treatment
  • Surgical Treatment
  • Positioning and removal of cava filters
  • Laparoscopic Treatments

Venous pathology

Chronic venous insufficiency of the lower limbs and its manifestations (varicose veins and telangiectasias) represent one of the most frequent pathologies in industrialized countries. For the diagnosis, a specialised visit with a vascular surgeon is carried out and, if necessary, a venous ecocolordoppler examination of the lower limbs is made. This is a non-invasive examination that allows to analyse the superficial venous circulation, to evaluate the continence of the valves and to identify the veins with "insufficiency". It also makes it possible to verify that the deep venous circulation has no occlusions: a determining condition for deciding whether or not to carry out the removal of the superficial circulation of the saphenous veins. There are different types of treatments. The medical treatment consists of the application of gradual compression stockings and elastic bandages that help partially compensate for venous insufficiency, and the use of vasotonic drugs that tonify the venous wall.

Outpatient treatment is offered whereby spider veins are treated on an outpatient basis with sclerosing injections or through the use of radiofrequency. In the first case a liquid is injected that causes the fibrosis of the vessel and its subsequent closure. Radiofrequency therapy uses a different physical medium (heat) to achieve the same effect of closing the capillary. Both therapies, being practiced on very small vessels and in limited areas, do not create problems and have no particular consequences.

Surgical Treatment entails the complete removal of the vessel and is performed only for the large and small saphenous varicose and involves the surgical procedure called saphenectomy. The saphenectomy remains the classic and most used intervention. Its success depends on both, the experience gained in years of surgical practice, and the fact that the initial technique has been constantly updated with the introduction of new materials and new types of anaesthesia. Postoperative recovery is rapid, generally four or five days of moderate rest are enough, and the long-term results, even from an aesthetic point of view, are excellent. The removal of small varicose veins that do not affect the small or large saphenous is called phlebectomy and can also be performed under local anaesthesia. Having less vein does not create any problem for the patient's legs because, when the indication is correct, the deep venous circulation and, in part, the cutaneous circulation can effectively drain even the normally vascularized zones of the saphenous veins.

Endovascular occlusion with radiofrequency is also available at the Unit. It is a new therapeutic option for the treatment of saphenous and collateral insufficiency. It is used for the treatment of small and large saphenous varicose, collateral and small capillaries, but only in selected cases, after careful evaluation of the ecocolordoppler examination. The surgeon punctures the saphenous vein at the knee and introduces a radiofrequency probe. The probe advances under ultrasound guidance and, reaches the tract of the vessel to be treated, emitting energy in the form of heat that denatures the proteins of collagen and allows the obliteration of the vein. The intervention is less invasive and can be performed under local anaesthesia.

Last but not least, an endoluminal treatment with sclerosing substances is also performed. Sclerotherapy is the injection of a mixture of air and sclerosant fluid within the varicosities constricted to the area, generating the fibrosis and eventual obliteration of the vein.

Main Pathologies Treated:

  • Varicose saphenous veins
  • Chronically occluded deep veins

Top Procedures:

  • Minimally invasive radiofrequency ablation
  • Minimally invasive surgical treatment
  • Recanalization
  • Stenting
  • Saphenectomy
  • Endoluminal Treatment
  • Sclerotherapy

 

NOTABLE ADVANCED TECHNOLOGICAL EQUIPMENT

  • Endovascular grafts custom-made on specific patients' anatomy
  • High-quality cath-lab and two portably angiographic units for minimally invasive endovascular procedures