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tically advanced atherosclerotic disease an endarterectomy is a large operation where blood flow is temporarily stopped using clamps the vessel is cut open the plaque removed and then the vessel resealed if an occlusion is too dense or complex a bypass could also be performed where two segments of vessel are bridged by an additional vein or synthetic graft modern endovascular approaches to treating atherosclerosis can include combinations of angioplasty stenting and atherectomy removal of plaque peripheral artery disease pad sometimes peripheral vascular disease pvd is most often a result of atherosclerosis and affects the arteries of the lower extremities those below the aortic bifurcation a hallmark symptom is claudication or progressive pain in a limb associated with activity due to ischemia as the perfusion to a limb diminishes further pain in the foot can occur even at rest and in fact the tissues of the foot can even die there are several systems for staging pad but an often used scale is the revised rutherford classification 88 102 plaque and blood flow can be evaluated using ultrasound ct angiography mr angiography and catheter based angiography to establish anatomic segments of disease the severity of ischemia can be evaluated by correlating symptoms and non invasive physiologic vascular studies including toe pressures tcpo2 and skin perfusion studies certain monitored exercises such as walking regimens have been shown to significantly improve walking distance especially when used consistently for at least six months when medical management fails vascular interventional radiologists can attempt to restore blood flow to extremities using angioplasty and stenting sometimes repeat interventions are required the goal of therapy is to maintain perfusion avoid amputation and preserve the limb structure and function critical limb ischemia cli is a severe variant of pad rutherford 4 and above characterized by rest pain or tissue loss each year this affects just under 1 of the population but develops in approximately 11 of pad patients symptoms develop due to chronic ischemia from vessel plaque burden which builds up over time rest pain is a continuous burning pain in the limb that is aggravated by elevating it and improved by dangling over the bed as the perfusion is so poor that it becomes gravity dependent tissue loss refers to arterial insufficiency ulcers which can progress to frank gangrene arterial ulcers are classically painful and located on the distal aspect of the extremities a diagnosis of cli incurs a higher risk of amputation up to 25 within one year and death up to 25 within one year this is a serious condition that requires multi modality treatment the goal of vascular interventional radiology and others who work in limb salvage is to minimize tissue loss by preserving direct blood flow to the affected limb by treating vessel blockages controlling any infection and optimizing wound care increasingly this can be accomplished with primary endovascular therapies before open surgery is considered acute limb ischaemia ali occurs when blood flow to an extremity is abruptly cut off it occurs most commonly in those with a history of atrial fibrillation or underlying pad pvd unlike chronic ischemia which the body can partially adapt to ali is an emergency that can result in an amputation or even death if not treated in hours it is typically due to an embolus from the heart or a thrombus that develops in a pre existing area of narrowed artery once diagnosed clinically ct or mr angiography may be used to evaluate the cause and extent of disease vascular interventional radiologists may use thrombectomy devices or clot dissolving medications to remove or dissolve the clot surgical options include open thrombectomy and even vascular bypass carotid atherosclerosis involves the major branch arteries that provide blood to the brain carotid artery disease incurs an increased risk of stroke by two different mechanisms either from limiting overall blood flow or more often by showering pieces of plaque or clot deep into the small vessels in the brain either can result in degrees of cerebral ischemia carotid artery disease can be typically addressed with open surgical techniques carotid endarterectomy or though endovascular stenting chronic mesenteric ischemia can produce severe pain with eating and result in food fear and weight loss these vascular disorders can be repaired by endovascular approaches using angioplasty and stenting renal arterial ischemia can contribute to hypertension which can be severe and refractory to medical therapy coronary artery disease involves the arteries supplying blood to heart muscle coronary ischemia results in myocardial infarction also known as a heart attack the coronary arteries were one of the earliest widely accepted applications of angioplasty and stenting developed by cardiology and interventional radiology aortoiliac occlusive disease leriche syndrome is a constellation of symptoms due to significant occlusion of the distal aorta and common iliac arteries most commonly by atherosclerotic disease the classic symptoms include buttock claudication and erectile dysfunction with decreased femoral pulses additional symptoms of critical limb ischemia can be present both surgical and endovascular approaches to revascularization can be considered aneurysm refers to pathologic dilation of an artery to greater than 1 5 times its normal size true vascular aneurysms are due to degenerative processes in the wall of the artery aneurysms can be solitary or multiple and are sometimes found in association with various clinical syndromes including forms of vasculitis or connective tissue diseases aneurysms are typically classified by major shapes either fusiform tubular or saccular eccentric ectasia is another broad term for an enlarged vessel but is not necessarily pathological rupture is a dreaded complication of aneurysms that can lead to extensive difficult to control bleeding aneurysms can also clot or thrombose and rapidly occlude the involved vessel leading to acute distal ischemia aortic aneurysms include thoracic abdominal and thoracoabdominal aneurysms treatment strategies are customized depending on the location size rate of growth and extent of the aneurysm as well as the medical comorbidities of the patient for example an intact small but slowly growing aneurysm may be safely monitored with serial imaging for months or years before elective repair is considered elective endovascular aortic grafting is now routinely attempted when possible endovascular aortic repair evar refers to treatment of an abdominal aortic aneurysm while thoracic endovascular aortic repair tevar is performed on the thoracic aorta a ruptured aneurysm may be taken emergently for open endovascular or combination repair a variety of endovascular grafts are available and each has advantages and disadvantages depending on the characteristics of the aneurysm and patient 103 peripheral aneurysms occur in the arms and legs these can typically be evaluated and monitored with vascular ultrasound ct angiography and mr angiography popliteal aneurysms are associated with distal embolization and are also associated with concurrent contralateral popliteal artery aneurysms and abdominal aortic aneurysms when amenable endovascular treatments for popliteal aneurysms can include endovascular stenting or surgical bypass 104 visceral aneurysms affect the vessels that supply the solid organs similar to other aneurysms treatment depends on several factors including size location shape and growth endovascular treatments for visceral aneurysms can usually be performed with less morbidity when compared to open surgical techniques 105 intracranial aneurysms arise in the arterial supply of the brain endovascular approaches to treatment include stenting and coiling and are preferable in most cases since clipping and resection require a surgical craniotomy rupture of intracranial aneurysms can have devastating clinical effects for further discussion refer to the neuro interventional radiology section pseudoaneurysm is when there is not all three layers surrounding the artery these structures can technically be considered a type of contained bleed they are most often due to focal damage to a blood vessel which could be the result of trauma infection or inflammation splenic artery pseudoaneurysms for example may develop as a result of pancreatitis in some cases pseudoaneurysms of the femoral and radial arterials can be a complication of arterial access for endovascular procedures depending on the size and location of the pseudoaneurysm it may be treatable with minimally invasive interventional radiology methods though some particularly the infected ones may require open surgery dissection refers to a tear in the inner layer of the arterial wall blood pumps into this defect and dissects its way between the layers in the wall of an artery creating a false channel separate from the true arterial lumen dissections can develop due to trauma spontaneously due to high blood pressure and native vascular disease or in some cases as a complication of prior surgical or endovascular treatment when an arterial dissection expands it can restrict normal flow through the affected artery or potentially block the origin of a branch vessel this can compromise distal perfusion in either case when acute and symptomatic this is an emergency that requires prompt treatment however as medical imaging has improved chronic asymptomatic dissections have also been discovered and in some cases these may be safely managed with blood pressure control follow up imaging and proper counseling for the warning signs of potential ischemia dissections can occur in any artery and are named for their vessel of origin aortic dissections can be further classified and treated depending on whether they involve the thoracic aorta the abdominal aorta or both classic pain related to acute aortic dissections is described as tearing or ripping and possibly radiating to a patient s back acute aortic dissection can be difficult to diagnose but is more common than aortic aneurysm rupture thoracic aortic dissections are further characterized with the stanford classification 106 type a dissections involve the root and ascending aorta these require prompt treatment which currently is mostly surgical in nature type b dissections begin in the distal aortic arch beyond the left subclavian artery origin and may often be addressed with pain medication and blood pressure control if the type b aortic dissection results in poor circulation to the intestines kidneys or legs it often requires urgent endovascular repair with endografts and or fenestrations if a type b aortic dissection has ruptured or has features that indicate impending rupture they are urgently repaired too takayasu arteritis angiography dissections can also arise in virtually any other artery carotid artery dissection for example places patients at increased risk for stroke and may extend further into the blood vessels within the brain vertebral artery dissection are less common but also dangerous for similar reasons mesenteric artery dissection may limit the blood supply to the intestines renal artery dissections can decrease blood flow to the kidneys and contribute to hypertension 107 peripheral arterial dissections can be found elsewhere in the arms and legs these dissections can occur primarily due to focal traumas underlying vascular disease or as an extension of a larger complex aortic dissection that tears further into these smaller branches treatment of dissections depends on several factors including the location extent how long it has been developing acute or chronic and whether it is limiting perfusion surgical approaches to dissections can include reconstructing the aorta surgical bypass and surgical fenestration like other arterial disorders endovascular approaches to dissection such as stent grafting 108 and percutaneous fenestration 109 can be utilized either primarily or in combination with surgery depending on the complexity of the dissection penetrating aortic ulcer pau is an advanced focal form of atherosclerosis most often encountered in the aorta 110 it starts as a small plaque in the inner most layer of the aorta called the intima but the inflammatory process ulcerates and penetrates through this layer into the media while pau is considered a distinct entity many think this is a precursor lesion to dissection or aneurysm citation needed along with intramural hematoma aneurysm and dissection pau is recognized as one of several acute aortic syndromes a spectrum of related conditions correlated to potential aortic rupture they thus have a high potential morbidity and mortality and should at least be followed closely acute or active bleeding can occur throughout the human body due to a variety of causes interventional radiologists can address bleeding with embolization usually with small plastic particles glues or coils traumatic rupture of a blood vessel for example may be addressed this way if a patient is at risk of fatal bleeding this has revolutionized medicine and interventional radiologists commonly treat refractory nose bleeds excessive coughing of blood intestinal bleeding post pregnancy bleeding spontaneous intra abdominal on intra thoracic bleeding bleeding related to trauma and post surgical bleeding in some instances where severe bleeding is anticipated such as in complex surgery or the excision of a highly vascular tumor interventional radiologists may embolize certain target blood vessels prior to the operation to prevent major blood loss transplant organs rely on healthy blood supply to survive in some instances the arteries that feed a transplant may narrow typically where the donor vessel is sewn to the recipient interventional radiologists evaluate the blood supply of these patient s and may use balloons or stents to open narrowed vessels and keep the transplant organ functional venous disease edit this section does not cite any sources please help improve this section by adding citations to reliable sources unsourced material may be challenged and removed december 2023 learn how and when to remove this message the veins of the human body are responsible for returning de oxygenated blood back to the heart like a rock rolling down a hill blood flows from the highest pressure the blood in the aorta to the lower venous pressure the blood in the vena cava as it empties back to the heart unlike arteries veins are thin walled and distensible allowing them to accommodate large volumes of blood without significant changes in pressure in fact the venous system is so low pressure that veins have valves to keep blood from flowing backward the motion of the human body helps pump blood through the veins squeezing leg muscles while walking for instance helps push venous blood back up to the heart against the pull o...