MEDICO LEGAL M A G A Z I N E
VASCULAR SURGERY A MEDICO-LEGAL OVERVIEW By Mr Michael Gaunt MA, MD, FRCS. Consultant Vascular Surgeon, Cambridge 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 medicolegal 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
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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
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