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The speciality of vascular surgery is concerned with the diagnosis, assessment and treatment of all conditions of the arteries, veins and lymphatics affecting every part of the body apart from the heart (cardiology/cardiac surgery) and the brain (neurology/neurosurgery).
Vascular surgery is a high risk speciality for medico-legal claims primarily because when problems occur within the vascular system they do so quickly and with severe limb and life-threatening complications. For the purposes of description, it is convenient to divide vascular conditions into arterial, venous and lymphatic.
Arterial Conditions
In general, arteries carry blood high in oxygen (except the pulmonary arteries) and nutrients under high pressure to every organ and area of the body. If the arterial supply is disrupted ischaemia occurs and the affected organ will malfunction or even die. Disruption can be caused by the arteries blocking off slowly, as in atherosclerosis, or quickly due to thrombosis, embolism or a combination of the two. Alternatively, arteries can gradually weaken and burst e.g. aneurysms, causing haemorrhage and ischaemia, or be damaged during trauma, medical interventions or accidents.
The aorta is the major artery originating from the heart which runs through the chest and abdomen. All other arteries take their blood supply from the aorta so conditions affecting this large vessel tend to have very serious consequences.
Dissection of the aorta is a condition where a breach occurs in the innermost lining of the aorta allowing high pressure blood to enter into the wall and split the layers of the artery apart. Delayed diagnosis and treatment can result in the dissection extending the full length of the aorta and blocking off important arteries originating from the aorta. Consequences of this include spinal cord ischaemia resulting in paraplegia (lower body paralysis) and resulting in the patient being wheelchair bound with loss of bladder and bowel control. Other complications include renal failure requiring dialysis, ischaemic bowel and ischaemic legs which can lead to amputation and a combination of factors ultimately leading to death. Aortic dissection can occur across the age range due to a variety of causes and can be associated with particularly long term complications. Early diagnosis and aggressive lowering of the blood pressure can avoid these complications but diagnosis can be difficult and can be easily missed.
Abdominal aortic aneurysm (AAA) is another serious condition where the wall of the aorta weakens and dilates to several times its normal size. Eventually the AAA can burst with a mortality rate approaching 90%. In contrast, detected and treated early the elective mortality rate for repair is less than 5%, therefore, failure to diagnose has serious effects on life expectancy and is a common cause of claims.
Atherosclerosis (hardening of the arteries) is a very common disease in western societies as a result of lifestyle, diabetes and smoking and can affect any artery in the body. Atherosclerosis of the coronary arteries causes angina and heart attacks while that of the carotid arteries in the neck and the cerebral arteries is a common cause of strokes. Atherosclerosis affecting the arteries of the legs causes conditions ranging from intermittent claudication to gangrene and whilst the prevalence of smoking is in decline, arterial disease due to obesity, type II Diabetes and old age is on the rise.
Classically, symptoms in the legs progress, as more arteries block off, from pain in the legs when walking (claudication) to pain in the feet at night, to pain in the feet all the time, to non-healing ulcers and gangrene. Interventions to improve the blood supply range from balloon angioplasty to open up narrowed and blocked arteries to bypass surgery. Diagnostic difficulties arise because patients can progress directly from claudication to gangrene without passing through the other stages. This can occur in patients who are poorly mobile due to other conditions e.g. arthritis, who never walk enough to experience symptoms of claudication. Alternatively, diabetics patients with peripheral neuropathy may never experience pain in their feet. Therefore, delayed diagnosis can result in amputation and permanent disability. Alternatively, medical negligence claims can arise from complications or failures of interventions such as angioplasty or surgery.
Vasospastic disorders occur when arteries go into spasm in response to cold. Abnormal vasospasm in response to cold is termed Raynaud’s phenomenon. Commonly, this affects the fingers and toes but can also affect other extremities including nose and ear-lobes. Typically, one or more fingers turn deathly white on exposure to cold and then turn blue and bright red on rewarming. Primary Raynaud’s disease has no underlying cause and typically starts in early adult life. The symptoms are mild, never progress to gangrene and can usually be controlled by conservative measures. Secondary Raynaud’s syndrome has an underlying cause and often starts in middle age, increases in severity over time and can result in loss of fingers due to gangrene. Severe Raynaud’s occurring for the first time in later life can be a sign of a serious underlying condition such as an autoimmune connective tissue disorder or even cancer. In such cases investigations to exclude underlying causes are required and failure to recognise this can be a source of litigation.
Hand Arm Vibration Syndrome (HAVS) is a secondary cause of Raynaud’s commonly caused by prolonged and excessive exposure to vibratory tools at work. The condition used to be called vibration white finger until it was recognised that vibration may also cause neuropathic and/or musculoskeletal complications independent of the Raynaud’s. As with all syndromes, diagnosis depends on identifying a combination of positive factors and exclusion of alternative causes. Severity is graded according to the Stockholm Workshop Scale but there is a wide range of medical opinion in milder cases as to what constitutes the condition.
A vascular surgeon can provide advice and an opinion on a wide range of arterial conditions, just a few of which have been described here.
In the next issue, the conditions associated with the venuous and lymphatic systems will be explored from a medico-legal perspective.
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