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For the vascular-surgical treatment of cerebrovascular insufficiency, prior staging is essential. In stage I only the 80-89% asymptomatic stenosis should be operated on. Using this approach, the stroke risk decreases significantly in comparison with conservative treatment. Stage II disease is the domain of vascular surgery. In stage II a and b, an operation makes sense only exceptionally in the noncomatose patient and within the first 6 hours following the event. Prior to disobliteration of stage IV stenoses, CT and MRI findings need to be considered. In the presence of a contralateral high-grade stenosis of the internal carotid, surgery is recommended here too. The classical method is carotid disobliteration with patchplasty. Possible alternativeas are eversion endarterectomy and carotid bifurcation-plasty.

Chronic venous insufficiency affects more than 50% of the German population. Major factors involved in its development are age, family disposition, female sex and an occupation involving much standing. Together with the clinical presentation, Doppler and duplex ultrasonography in particular enable a reliable pre-operative diagnosis, and deep venous thrombosis can also be definitively excluded. Indications for surgical treatment are in particular varicosis of the greater and lesser saphenous vein and perforating vein insufficiency. Commonly used procedures are crossectomy, restrictive stripping of pathological vein segments, resection of varicose side branches, and the endoscopic discission of perforating veins. Recent developments are deep-freezing and extraction of the vein and endovenous laser treatment (EVLT), requiring only tiny incisions. In most cases, these interventions can be performed on an outpatient basis.

To accomplish hemodialysis in the patient requiring regular dialysis, a well-made shunt establishing a permanent access to the vascular system is essential. This involves making a connection between a vein and an artery, either directly or via a plastic prosthesis. A classic example is the Cimino shunt, a subcutaneous shunt between the cephalic vein and the radial artery, which today can usually be carried out under plexus anesthesia. It is important to establish the indication for a shunt in good time and to optimally prepare the patient, e.g. by vein training. In cooperation with the nephrologist, the vascular status of the patient, and prior diseases such as peripheral occlusive arterial disease or diabetes mellitus, must be established. A fully functional shunt is essential for the patient with terminal kidney failure to be able to lead a civilized life of the long-term.

Intermittent claudication or rest pain are typical symptoms of peripheral arterial occlusive disease (PAOD) affecting the lower limbs. The pain is localized one level below that of the occlusion. Initial investigations should determine skin temperature and color, pulse status, stenotic sounds and Doppler occlusive pressures. If intermittent claudication is present, angiography of the pelvis and legs then follows. Treatment is stage-dependent: while in stages I and IIa conservative treatment such as cessation of smoking, administration of acetylsalicylic acid and walking training suffices, stages IIb and higher require invasive measures extending from PTA to amputation of gangrenous parts of the limb.

The thoracic outlet syndrome and the entrapment syndrome involving the popliteal artery are two major examples of arterial compression syndrome. Since not only the arteries, but also the entire neurovascular bundle is compressed, the initial symptoms are often neurological: paresthesias, tingling, numbness, etc., in particular when certain movements are carried out. In such a case, bilateral blood pressure measurements, provocative tests and Doppler (duplex) examination are indicated. A point that is, perhaps, less well-known is the fact that compression can lead to serious vascular lesions ranging from post-stenotic aneurysms to complete thrombotic occlusion and peripheral emboli. When the diagnosis has been confirmed, early surgery is indicated.

The diagnosis of an infrarenal aortic aneurysm mandates not only regular ultrasonographic monitoring, but also careful instruction of the patient about an emergency, that is, symptoms associated with rupture, and how to react. If ultrasound reveals a clear increase in the size of the aneurysm, or if a diameter of 5 cm is reached, the indication for surgery is established. Two options are then available: implantation of an aortic stent, which has the advantage of being a minimally invasive procedure, or open prosthesis implantation. However, the benefits and risks of both options must be carefully weighed up, since the patients are often elderly and have cardiopulmonary problems. Postoperative surveillance of the patient comprises three- to six-monthly follow-up with ultrasound or CT scan.

Acute limb ischemia is a vascular-surgical emergency requiring immediate referral to a hospital provided with all the necessary therapeutic facilities. Essential initial measures are protection of the limb against continued cooling, management of pain, and bolus administration of heparin. For the physician providing further care, not only an accurate history, but, ideally, also the results of earlier investigations such as ECG, abdominal US or Doppler studies, provide useful information. In patients who have not undergone prior surgery vascular-surgical management, that is, embolectomy with a balloon catheter, is the treatment of choice. Furthermore, the patient requires continuing care after discharge; here, wound management and the supervision of anticoagulation measures that might be needed are important tasks for the general practitioner.

Based on two patients suffering from chronic visceral ischemia, the anatomic and pathophysiologic principles prior to surgery are discussed. Antegrade revascularization is supposed to be better hemodynamically. Complete revascularization of multiple arteries seems to be theoretically superior to one-vessel procedures. Within the bypass procedures the aortic-celiac-mesenteric patch bypass could be an excellent surgical possibility combining antegrade with simultaneous revascularization of celiac and superior mesenteric artery.