Classical Treatment Methods
The classic “open” vascular surgical methods are the ones that evolved and established the specialty of vascular surgery and are the ones with which all new methods that appear as medicine and technology evolve are basically compared. In general, their application is never wrong or obsolete when the right indication is present, but their scope of application has now been limited and is essentially identical to the scope of contraindications of endoluminal methods. In simpler words, when we cannot apply an endoluminal solution (stent or balloon), open surgery is almost always technically possible, if its risk is reasonable and the patient’s biological reserves allow it.
1. Abdominal Aortic Aneurysm
In the treatment of abdominal aortic aneurysms with the classical method, the first necessary step is to open the abdominal region with an incision along the entire length of its wall. Then, the aneurysm is prepared along its entire length and removed. In its place, a synthetic graft with as many branches as are required to completely block the aneurysmal vessels. It is necessary to monitor the patient postoperatively in an intensive care unit for 1 – 2 days. The total stay in the clinic ranges from 5 – 8 days.
2. Peripheral Occlusive Arteriopathies (PAA)
In ACA, the basic principles of open surgical treatment are the removal of the atherosclerotic plaque that causes the blockage of the arteries (endarterectomy) and/or its bypass (Bypass).
In endarterectomy, the lumen of the vessel is opened lengthwise and the atherosclerotic plaque is removed. The incision in the vessel is closed with a graft – the so-called patch – which is sewn onto the vessel wall.
is Bypass,incisions are made before and after the blockage (usually in the lower extremities, less often in the pelvis) and an elongated graft is placed bypassing the blockage.
The grafts can be autologous(i.e., from the patient himself, such as the great saphenous vein), heterologous (specially processed biological grafts, such as bovine pericardium) and synthetic. Autologous grafts are always used when possible.
In the case of embolism or thrombosis, catheters with a balloon at their tip (fogarty) , which are inserted away from the thrombosis, penetrate it and ultimately "fish" the thrombus and clean the vessel.
These procedures are also performed in the case of obstruction of the abdominal vessels (aorta, iliac arteries) and the method of their restoration technically approaches the classic treatment of abdominal aortic aneurysm with various variations depending on the case.
3. Carotid Disease
In internal carotid stenosis, there are two methods of classical open surgical treatment.
The first is classical endarterectomy with opening the vessel along the length from the common carotid to the internal carotid, removal of the plaque and closure of the incision with a patch (similar to that mentioned in peripheral occlusive arteriopathies).
The second is reverse endarterectomy with a vertical full and wide incision at the base of the internal carotid, removal of the plaque and anastomosis of the internal carotid to the common. Here, the use of a graft is not necessary.
This operation is performed by my team under local anesthesia and the hospital stay ranges from 1 to 2 days.
4. Varicose veins
The classic surgical treatment of varicose veins, which has undergone many evolutionary processes in the last century and specifically since 1907 when Babcock first described it, consists of saphenectomy with stripping of the great or lesser saphenous vein.
In this method, incisions are made in the groin for the great or in the popliteal region for the lesser saphenous vein, as well as at the lowest point of venous insufficiency (which can be from the thigh to the ankle). Through these incisions, the pathological vein and its branches are completely removed (excised).
5. Deep Vein Thrombosis
In patients with recent thrombosis of the iliac or femoral veins, the first-line treatment is pharmaceutical with specific anticoagulant treatment. Sometimes, however, there is an indication for surgical treatment with removal of the clots. This is done with the help of special balloon catheters (fogarty). These are mainly young patients with a serious clinical picture, with the aim of preventing a post-thrombotic syndrome.
Especially when the so-called intense blue painful inflammation (phlegmasia cerulea dolens) , which is a massive and acute thrombosis of all the veins of the lower extremities, surgery is considered urgent due to the increased risk of gangrene and amputation of the limb.
In several cases, open and endoluminal methods are combined (see hybrid surgical methods).