Key Words:
Scandinavia , Europe , vascular injury , iatrogenic , endovascular , epidemiology
Introduction
Europe has traditionally had a very strong foundation in vascular surgery—the specialty has its origins on that continent. The first suture of an injured brachial artery was performed by Halliwell as reported by Richard Lambert in a letter to William Hunter in 1759. The principles used in vascular surgery today were introduced by Alexis Carrel, a Frenchman, who moved to the United States after his medical studies in Lyon and who received the Nobel Prize in medicine in 1912. During the first half of the 20th century, Portugal, France, Germany, and the United Kingdom were the leading countries in vascular diagnostics and surgery. Angiography has European origins (Egas Moniz), as well as cardiac imaging (Werner Forssmann) and computerized tomography (CT; Godfrey Hounsfield)—all Nobel Prize laureates as well. The Seldinger technique, which is used today to access vessels for imaging and interventions, comes from Scandinavia (Sven-Ivar Seldinger) ; and the first balloon angioplasty was performed in Europe (Andreas Gruentzig). Initially, vascular surgery was part of thoracic surgery in northern Europe, but in 2005 it was recognized as a separate specialty in Europe.
Europe covers less than a tenth of Earth’s land surface (10 million sq km) with a population of 733 million people in 45 countries. The European Union has 28 member countries and has been a significant organ for peace during the decades it has existed, but the history of Europe is that of strife, conflict, and war. Cultural, religious, ethnic, political, and other differences have prevented any uniform tradition of medicine from being accepted on the continent. Despite a history of war, most of Europe has enjoyed a high standard of living for decades, even centuries, and an element of legal protection of the work force for more than a century. That has meant regulation of traffic, construction, industries, and many other areas of life—meaning that the way of living and the work environment—produces few injuries. An example from a study by Magee et al from Oxford University is telling: 47 vascular injuries requiring operation in 10 years, 11 of them for penetrating injuries, all as a result of stabbing. For more than a decade, there have been no significant armed conflicts in Europe; Sweden has not seen a war in almost 2 centuries. The former northern colonial superpower, the Netherlands, has enjoyed an immensely high standard of living for 5 centuries. It is the Netherlands where science is most generously funded in the world.
For decades, the economic and social development in Northern Europe has been stable; for example, all five Scandinavian countries are among the 20 richest in the world according to the gross domestic product (GDP). The border between Finland and Russia is one with extremes in economic and health-care terms. Russia is very large as a country (300 million inhabitants), but its economy is still only slightly larger than that of Spain with 46 million inhabitants and one-tenth that of the European Union. Even inside Russia, regional differences are significant. Finland’s neighbor to the southeast, Estonia, has joined the European Union and the North Atlantic Treaty Organization (NATO); but it is still struggling somewhat economically, just as are its southern neighbors, Latvia and Lithuania, although the national debt of Estonia is very low compared to most European countries. The overall favorable financial development in Northern Europe has meant easier and more-common adoption of technology in the management of vascular disorders.
As a specialty, vascular surgery has gone through a revolution during the past decade and has become very technology driven. The emergence of endovascular management options within the past decade has caused an immense paradigm shift and has even obscured the borders between angioradiology and vascular surgery. The development has been so rapid that endovascular options in trauma management did not really even exist according to a European review of vascular injuries published in 2002. As a result of the shift, a combination of interventional radiology and surgery in the management of many emergent and elective vascular problems has become everyday practice, especially in wealthier countries with well-equipped hospitals. This change is also reflecting itself in the treatment of vascular injuries, bringing along additional challenges in organizing the care of these patients.
Region-Specific Epidemiology
In contrast to the United States and some other countries with high incidence of penetrating trauma, a significant proportion of vascular injuries in Northern Europe are caused by blunt trauma and, increasingly, by iatrogenic injuries. In a nationwide study from Sweden, the proportion of iatrogenic injuries increased progressively from 57% in 1987-1993 to 79% in 2002-2005 ( Fig. 28-1 ). This was also reflected in the sites of arterial vascular injuries where 63% of the injuries were in the thigh and groin, more often on the right side ( Fig. 28-2 ). Of the noniatrogenic vascular injuries, 45% were caused by blunt trauma ( Fig. 28-1 ), with a high proportion of injuries located in the upper extremity ( Fig. 28-3 ).
Region-Specific Systems of Care
The first civilian trauma centers in Europe were Bergmannshell in Bochum founded in 1890 and the Böhler-Clinic founded in 1925, but it was another 50 years until the first trauma system was established in Germany in 1972. Because of the dominance of blunt trauma, general surgeons with additional specialization in fracture management were mainly responsible for trauma care. Subsequently, two patterns of trauma care evolved in Europe. In countries within the Austro-German surgical tradition, orthopedic-oriented trauma surgeons were trained to manage injuries in almost all body sites, including visceral and vascular injuries. In contrast, in the Mediterranean countries, Baltic States, and most of Western Europe, general and visceral surgeons increasingly took over the management of nonskeletal injuries.
In Northern Europe, and especially in the Nordic countries, the incidence of trauma is low. According to a trauma audit of Finnish hospitals, the annual incidence of severe trauma in 2004 was 19 to 25 per 100,000 inhabitants. In the western part of Norway, the incidence of severely injured patients (Injury Severity Score [ISS] >15) was 30 per 100,000 inhabitants. Considering that achieving the survival benefit of 15% to 20% of a mature trauma system requires about 500 to 600 patients to be seen annually, organizing trauma care with a purely trauma system–based concept as is not a viable option in Northern Europe, with the exception of highly or densely populated countries such as Germany or the Netherlands, or major cities such as London. In countries with large land areas and small populations, regionalization of all emergency surgery services (combining trauma and nontrauma surgical emergency care) seems to be the best option.
Obviously, the regionalization of emergency surgery requires corresponding changes in the training of future surgeons; and adoption of or enforcement of the acute care surgery model currently implemented in the United States is being considered in many Northern European countries. In contrast to expanding a more generalized knowledge and skill sets for emergency surgical care, elective surgery is becoming more and more specialized, almost to the point of one-organ surgery. To successfully combine the requirements of producing high-level and affordable elective and emergency surgical services remains one of the most difficult surgical training challenges for the near future.
Vascular surgery has become a specialty of its own with a centralized European Board Fellowship Examination (ESBQ Vasc or FEBV) in 2005. Centralization of services may be beneficial by bringing larger volumes of patients to a center, which means more experience. It also may mean subspecialization within the specialty. Larger units can afford to have more expensive and yet cost-effective infrastructure. In the case of trauma surgery, it is vascular problems that may call for very urgent management and expertise. In those situations, there may not be time to send a patient to a tertiary hospital, because a life or a limb may be lost in the process.
Who, specifically cares for patients with vascular injuries? According to an informal survey performed by the authors with colleagues from Northern Europe, vascular surgery is an independent surgical specialty in most countries with the exception of some Scandinavian countries and Poland. The majority of vascular injuries are managed by vascular surgeons, except in Germany and The Netherlands where trauma surgeons are responsible for the first-line treatment ( Table 28-1 ).
