What Do Vascular Doctors Do? Conditions & Treatments

Vascular doctors diagnose and treat diseases of the arteries, veins, and lymphatic system throughout the body, excluding the heart and brain (which belong to cardiologists and neurosurgeons, respectively). In practice, that means a single vascular specialist might open a blocked leg artery in the morning, repair a ballooning aorta before lunch, and create dialysis access for a kidney-failure patient in the afternoon. The field blends open surgery, catheter-based procedures done through small punctures, and nonsurgical management like supervised exercise and medication, and the balance among those approaches has shifted dramatically over the past few decades.

How Vascular Doctors Find the Problem

Before any treatment decision, a vascular doctor needs to know where blood flow is compromised and how badly. The workhorse screening tool for leg arteries is the ankle-brachial index, a quick, painless comparison of blood pressure at the ankle and the arm. A structured review of its accuracy found that a low reading is highly specific for detecting significant narrowing in leg arteries, meaning it rarely flags a problem that isn’t there, but its sensitivity varies widely and can be particularly low in older people and those with diabetes.¹ A Cochrane review added nuance: accuracy is best when the blockage sits in the thigh-to-knee vessels, and automated devices may outperform handheld probes used by less experienced operators.²

Beyond the ankle-brachial index, vascular specialists rely on duplex ultrasound (which combines standard imaging with Doppler flow measurements), CT angiography, and MR angiography. For patients whose kidneys cannot tolerate traditional iodine-based contrast dye, carbon dioxide can serve as an alternative contrast agent during procedures because it is not toxic to the kidneys and does not trigger allergic reactions.³ That technique has been used successfully to guide stent placement in kidney arteries in patients with chronic kidney disease, avoiding iodine contrast entirely.⁴

Peripheral Artery Disease

Peripheral artery disease, the gradual buildup of plaque in leg arteries that restricts blood flow, is one of the most common reasons people see a vascular doctor. Symptoms range from leg pain during walking (claudication) to non-healing wounds and gangrene in severe cases. The total number of Medicare claims for peripheral vascular interventions rose by about a third between 2011 and 2017, with vascular surgeons performing roughly half of all procedures and cardiologists and interventional radiologists handling the rest.⁵

Treatment depends on severity. For claudication that limits daily activity but does not threaten the limb, the first-line option is often supervised exercise therapy. In the CLEVER trial, patients with aortoiliac disease who followed a structured exercise program improved their peak walking time by about five minutes over 18 months, which was comparable to the gain from stent placement and far better than medication alone.⁶ A separate trial found that combining a stent procedure with supervised exercise produced even larger walking-distance gains than exercise alone, with the advantage persisting at 12 months.⁷

When the disease is advanced enough to threaten the leg, vascular doctors choose between placing a stent through a catheter and performing a surgical bypass with a vein or synthetic graft. Among patients with diabetes, stent revascularization and bypass surgery showed similar rates of limb amputation and composite outcomes in a study that attempted to control for the many differences between patients who receive each treatment.⁸ That result does not mean the two approaches are interchangeable for every patient; anatomy, the length of the blockage, and the availability of a suitable vein for bypass all influence the decision.

Aortic Aneurysms

An aortic aneurysm is a balloon-like widening of the body’s largest artery. It usually grows silently for years and becomes dangerous when it ruptures. Vascular doctors monitor small aneurysms with periodic imaging and intervene when the risk of rupture outweighs the risk of repair. A 2024 modeling study in the Journal of Vascular Surgery suggested that the optimal repair threshold for a 60-year-old woman of average health was about 6.1 cm, and for a similar man about 6.9 cm, both higher than the thresholds many guidelines currently recommend.⁹ This remains an active area of debate, and individual risk factors like aneurysm growth rate and family history play a role in timing the repair.

When repair is needed, the choice is between traditional open surgery and endovascular aneurysm repair, in which a fabric-lined stent graft is threaded up from the groin. The endovascular approach carries a clear early advantage: a meta-analysis of randomized trials found that the risk of dying within the first six months was substantially lower with the endovascular route. But the long-term picture reverses. Beyond eight years, the risk of aneurysm-related death was significantly higher after endovascular repair, and patients needed reintervention and experienced late rupture more often.¹⁰ A large Medicare-matched study echoed this, finding lower long-term mortality and fewer reinterventions in the open-surgery group.¹¹ In practice, vascular doctors weigh a patient’s age, fitness for major surgery, and expected lifespan before recommending one approach over the other.

Aortic Dissection

An aortic dissection is a different kind of emergency: the inner layer of the aortic wall tears, and blood forces its way between the layers, creating a false channel that can block blood flow to organs or rupture. Dissections involving the descending aorta (type B) are the ones most often managed by vascular specialists. Uncomplicated cases may initially be treated with aggressive blood-pressure control alone, but when complications like organ damage or uncontrolled pain arise, endovascular repair with a thoracic stent graft has become the first-line treatment.¹² The stent graft seals the tear, promotes clotting in the false channel, and helps prevent late enlargement of the aorta.¹³

Carotid Artery Disease and Stroke Prevention

The carotid arteries in the neck supply blood to the brain, and plaque buildup there can cause strokes. Vascular doctors have three main procedural options. Carotid endarterectomy, the oldest approach, involves surgically opening the artery and removing the plaque. Transfemoral carotid stenting threads a stent up from the groin. Transcarotid artery revascularization, a newer technique, places a stent through a small incision directly in the neck while temporarily reversing blood flow away from the brain to catch debris.

A large registry-based study found that the short-term rate of stroke or death was lowest for endarterectomy (about 1.7%), followed by transcarotid revascularization (2.0%), and highest for transfemoral stenting (3.7%). By one year, though, endarterectomy and transcarotid revascularization were statistically similar.¹⁴ Longer follow-up in a Medicare population found similar three-year stroke risks for the two procedures in both symptomatic and asymptomatic patients.¹⁵ One single-center study with two-year follow-up did report higher stroke rates after transcarotid revascularization compared with endarterectomy, suggesting the question is not fully settled and center experience may matter.¹⁶

Deep Vein Thrombosis

Blood clots in the deep veins of the legs are usually managed by internists or hematologists with blood thinners. Vascular doctors get involved when the clot is large, especially when it extends into the iliac veins of the pelvis, and when there is concern about long-term damage to the venous valves. Catheter-directed thrombolysis, in which clot-dissolving drugs are delivered directly into the vein through a catheter, can restore flow more effectively than blood thinners alone. In a randomized trial of patients with large clots, about two-thirds of those who received catheter-directed therapy had open veins at six months, compared with roughly a third of those on standard anticoagulation.¹⁷

The hope behind aggressive clot removal is preventing post-thrombotic syndrome, the chronic swelling, pain, and skin changes that can develop after a DVT. But the largest randomized trial on the subject, the ATTRACT trial, found that adding catheter-based thrombolysis to standard anticoagulation did not reduce post-thrombotic syndrome rates and did increase major bleeding.¹⁸ Vascular specialists now tend to reserve catheter-directed therapy for younger patients with the most severe clots, particularly when limb viability is at risk.¹⁹

Varicose Veins and Chronic Venous Insufficiency

Bulging varicose veins are more than a cosmetic concern for many people; they can cause aching, heaviness, skin discoloration, and eventually ulcers. Vascular doctors treat them by shutting down the faulty vein so blood reroutes through healthier ones. The two leading minimally invasive techniques are endovenous laser ablation and radiofrequency ablation, both performed through a small catheter under local anesthesia. Over 12 months, both methods show similar vein closure rates and complication profiles.²⁰ Some studies suggest laser ablation may edge ahead in longer follow-up. One real-world study found lower overall recurrence with laser ablation (about 5% versus 15%) and higher patient satisfaction scores at 12 months.²¹ Return to daily activity after either procedure is fast, typically about one day.²²

Dialysis Access

Patients with kidney failure who need hemodialysis require a reliable connection between an artery and a vein that can handle being punctured repeatedly with large needles. Vascular doctors create two types: arteriovenous fistulas, made by directly connecting a patient’s own artery and vein, and arteriovenous grafts, which use a synthetic tube to bridge the two. Fistulas generally last longer and are associated with better survival in certain groups, including men and patients with diabetes.²³ A cost-effectiveness analysis found that fistulas remained usable for a mean of about 28.5 months compared with 25.5 months for grafts.²⁴

The trade-off is that fistulas take longer to mature before they can be used. In a pilot trial of older adults, the median time to successful use was about 114 days for fistulas versus 75 days for grafts, and early failure rates were similar in both groups.²⁵ For elderly patients or those who need dialysis urgently, a graft can sometimes be the more practical choice despite the slightly shorter lifespan.

Limb Salvage in Diabetic Foot Disease

Diabetes accelerates artery disease and impairs wound healing, and the combination puts limbs at risk. Vascular doctors play a central role in multidisciplinary limb-salvage teams that also include podiatrists, infectious-disease specialists, wound-care nurses, and plastic surgeons.²⁶ The vascular surgeon’s contribution is restoring blood flow to the foot, either through a bypass or a catheter-based procedure, so that wounds can heal and major amputations can be avoided.

The evidence supports this team-based approach. A systematic review found that establishing dedicated vascular limb-salvage services was consistently associated with lower rates of major amputation.²⁷ One institution saw a roughly 46% drop in below-knee amputations after integrating its surgical teams, with more limb-preserving procedures performed at the midfoot level instead.²⁸

Thoracic Outlet Syndrome

Thoracic outlet syndrome occurs when nerves or blood vessels are compressed in the narrow space between the collarbone and the first rib. The vascular form, while less common than the neurogenic type, can cause artery damage, aneurysm formation, and blood clots in the arm. In a series of 25 patients with vascular thoracic outlet syndrome, all of whom had extra ribs, abnormal soft tissue, or scar tissue causing the compression, vascular surgeons performed rib removal and, where needed, artery reconstruction or clot removal. All reconstructed arteries remained open during follow-up, and patients with arterial compression returned to full activity.²⁹

A broader study of thoracic outlet surgery (including neurogenic cases) found that 90% of patients experienced symptom improvement, with just over half reporting complete relief.³⁰ Physical therapy is almost always tried first, and surgery is reserved for patients who fail conservative treatment or who present with vascular complications that demand prompt intervention.

Visceral Artery Disease and Mesenteric Ischemia

The arteries supplying the intestines can narrow just like leg arteries, and when they do, eating can trigger severe abdominal pain because the gut cannot get enough blood to digest food. This condition, chronic mesenteric ischemia, causes weight loss and fear of eating. Vascular doctors treat it with stents placed through a catheter or, in more complex anatomy, with open surgical bypass. Catheter-based stenting has become the primary treatment for most patients because it provides good long-term results with an acceptable rate of recurrence and avoids major abdominal surgery.³¹ Acute mesenteric ischemia, where blood flow is suddenly cut off, is a surgical emergency that can involve both open and endovascular techniques, and mortality remains high even with prompt treatment.

Pediatric Vascular Anomalies

Children bring a distinct set of vascular problems. Pediatric vascular anomalies fall into two broad categories: tumors like infantile hemangiomas, which are growths of blood-vessel cells that often appear in infancy and tend to shrink on their own, and true malformations of capillaries, veins, lymphatic channels, or arteries that are present at birth and grow with the child. Many hemangiomas need no treatment, but complicated ones may require medication. Vascular malformations, on the other hand, often call for a combination of interventional radiology procedures, surgery, and laser therapy, managed by a multidisciplinary team.³² Distinguishing between the two categories is critical because the treatments are completely different, and misdiagnosis can lead to unnecessary or harmful interventions.

What Happens After a Vascular Procedure

Vascular disease is chronic, and a procedure rarely marks the end of a patient’s relationship with their vascular doctor. Stents can narrow again. Bypass grafts can develop kinks or clots. Endovascular aneurysm repairs need lifelong imaging surveillance to check for leaks around the stent graft, a reality that partly explains why open repair can outperform the endovascular approach over many years. Patients with peripheral artery disease remain at high risk for heart attack and stroke regardless of what was done to their legs, so ongoing management of blood pressure, cholesterol, diabetes, and smoking is part of the vascular doctor’s mandate.

Supervised exercise programs, the same ones used as a first-line therapy for claudication, also serve as rehabilitation after revascularization. The ERASE trial showed that pairing a stent with structured exercise produced larger and more durable walking gains than either treatment alone, reinforcing the idea that a procedure is a complement to lifestyle changes, not a replacement for them. Vascular doctors who integrate long-term medical management and surveillance into their practice tend to deliver better outcomes than those focused purely on the procedural side of the specialty.