Vascular surgery

Vascular surgery for congenital vascular diseases is rare and often associated with other complementary techniques.

According to Loose, 6 different surgical procedures have been established:

• Reconstructive operations
• Operations to reduce hemodynamic activity
• Surgery to eliminate the vascular defect
• A combined therapy
• Unconventional therapy methods (e.g., vascular denudation by dissection or ligation of side branches) and
• Multidisciplinary treatments

Typical vascular reconstructive surgery, such as those performed in peripheral arterial occlusive disease or aneurysms, is rarely indicated for congenital vascular diseases. As shown by the choice of the above-mentioned tactics in the context of 1,892 cases at 4 European centers, the rate of reconstructive procedures (6.3%) was as low as that for reduction of hemodynamic activity (2.8%).

It is difficult to choose the right timing to perform surgery.

• If vascular surgery is performed too early, the procedure may be too invasive, or even unnecessary.
• If the operation is too late, the treatment may be performed also too late.

The optimal period for vascular surgery therapy in children, e.g., when the musculoskeletal system is involved, is considered to be between the 3rd and 7th year because at this stage abnormal growth (e.g., leg length discrepancy) can still be compensated for.

Reconstructive surgery is only considered for large, dysplastic vessels.

Examples are localized aneurysmal dilatations of arteries and veins.

The choice of vascular graft material is extremely important:

Alloplastic materials have the disadvantage of lower patency rates over the long term and the problem of an increased risk of infection, especially in the case of repeat procedures and procedures with poor soft tissue coverage. On the other hand, the stability of these materials is very high.

In comparison, degenerative or aneurysmal changes are possible in the long run with autologous graft materials.

Operations to reduce hemodynamics (arterial and/or venous) are primarily non-curative.

Sufficient primary healing without recurrency is possible with small, very localized processes in rare cases. In most cases, these interventions are performed over a longer period of time or in combination with other procedures (e.g., additional sclerotherapy or embolization).

In arteriovenous malformations, the technique of dissecting the vessels with ligation of fistula branches has not proven to be effective, as identical reperfusion of the arteriovenous malformation often develops via collateral connections.

It is important to note that, in resection procedures with occlusion of arterial or venous connections or feeders, no vessels should be interrupted that would have to serve as access vessels for later endovascular techniques.
This must be taken into account during planning.

Nowadays, resection of vascular malformations is performed only after or in combination with endovascular techniques.

Venous malformations with venous hypertension can be treated surgically in the case of thick, dysplastic venous trunks and refluxing perforators by the suture ligature or ligation of these veins.

Venous malformations often have very thin walls that easily tear during preparation and suturing. This makes surgery technically difficult. There is a risk of increased blood loss, especially if the venous malformation has a sponge-like morphology and a large volume.

If the malformation is located at the limbs, preventive measures against blood loss are indicated, e.g., the application of a tourniquet or so-called bloodless surgery.

Vascular surgery techniques may have advantages over treatments with radiation exposure, depending on the location of the malformation. For example, vascular surgical resection is often preferable to multiple sclerotherapy sessions for extensive malformations of the testis because of the lack of radiation exposure.

In summary, vascular surgical therapy for vascular malformations is only necessary in a small percentage of cases.

Surgical procedures supplement endovascular therapy, if necessary, or create access routes for endovascular techniques.