Vascular Surgery in 60 Seconds

Vascular Surgery in 60 Seconds – Transcript

Hi, my name is Dr. Andrew Choong, and I’m a vascular surgeon in Singapore. This is Vascular Surgery in 60 Seconds.

Vascular surgeons are circulation doctors — we’re blood vessel surgeons. We operate on all parts of the body outside of the heart and outside of the brain.

We look after:

• The arterial blood supply that carries blood from the heart

• The venous blood supply that returns blood to the heart

Our work includes:

• Stroke prevention

• Treating aortic aneurysms and aortic dissections

• Managing deep vein thromboses (DVT) and varicose veins

• Providing dialysis access

• Non-healing wounds

• Preventing amputations

Am I a cardiologist? No. But just like a cardiologist, I use stents, balloons and wires to perform angioplasty.

Am I a heart surgeon? No. But I also perform bypasses in the neck, chest, abdomen, and legs when required.

👉 Please like, subscribe, and follow me to find out more

Aortic Dissection Awareness Day 2025

Aortic Dissection Awareness Day (19 September): Why Awareness Saves Lives

Today, 19th September, was Aortic Dissection Awareness Day. I was honoured to deliver a continuing medical education talk to fellow specialists, family medicine doctors and general practitioners from IHH Singapore, comprising of healthcare professionals from Mount Elizabeth Hospital, Mount Elizabeth Novena Hospital, Gleneagles Hospital, Parkway East Hospital and Parkway Shenton primary care medical group.

Aortic dissection is a time-critical emergency that can mimic heart attack, stroke, abdominal emergencies or back pain. Delays in diagnosis cost lives, yet prompt CT scanning and expert treatment dramatically improve survival. To support public and professional awareness, I delivered this short talk on Aortic Dissection Awareness Day 2024. Below is the video and full transcript, edited for clarity. If you or a loved one develops sudden, severe chest, back, neck, or abdominal pain, Think Aorta! and seek urgent medical attention.

For appointments or more information about personalised, aortic care in Singapore, visit drandrewchoong.com/links. For more information about aortic aneurysm treatment and vascular surgery, please explore the information pages.

Transcript (edited for grammar and readability)

Aortic Dissection Awareness Day – Public Talk (2024)
Speaker: Dr Andrew Choong, Vascular, Endovascular & Aortic Surgeon, Asian Aortic & Vascular Centre (AAVC), Singapore

Opening

Good afternoon, everyone. Thank you for joining us and for taking time out of your lunch to attend this public awareness talk. Today, 19 September, is Aortic Dissection Awareness Day.

My name is Andrew Choong. I’m a vascular, endovascular, and aortic surgeon at the Asian Aortic & Vascular Centre here in Singapore. We’re streaming this session live for the first time and also recording it so you can watch it later.

A big thank-you to Medtronic, our technical team, and the AAVC operations team for making this possible.

Why awareness matters

Many people are unfamiliar with aortic dissection, and even fewer know that 19 September is Aortic Dissection Awareness Day. Events like this are designed to heighten public awareness, improve understanding, and—most importantly—improve outcomes for patients.

You can also find me on social platforms (Facebook, Instagram, X/Twitter) if you’d like to follow future updates.

A few well-known cases

There have been high-profile deaths from aortic dissection. Richard Holbrooke, President Obama’s special envoy to Afghanistan, died after delayed surgery. Perhaps more widely known is actor John Ritter, whose diagnosis was also delayed. Following his death, his family founded the John Ritter Foundation, a major patient-advocacy group promoting awareness and research into aortic disease. I’ll refer to “Ritter Rules” later.

Key facts

From the John Ritter Foundation and other sources:

• Aortic dissections are preventable in many cases.

• Early detection and treatment prevent premature deaths.

• In the United States, roughly 20,000 people suffer an aortic dissection each year.

• Up to 50% may die—an unacceptably high figure for any condition.

• Survival can reach ~80% with prompt diagnosis and appropriate treatment.

What is the aorta?

The aorta is the body’s largest blood vessel. It starts at the heart, curves (the aortic arch), descends through the chest and abdomen, and supplies blood to every organ. It’s the main “pipe” moving roughly five litres of blood per minute.

What is an aortic dissection?

An aortic dissection is a medical and surgical emergency. A tear develops in the inner lining of the aorta (intima), allowing blood to split the wall layers (intima–media–adventitia). This can weaken the wall and lead to rupture.

Different mechanisms can initiate the problem (a small intimal tear, a penetrating ulcer, plaque rupture), but the result is the same—blood tracks within the wall, separates layers, and compromises blood flow.

Why presentations vary (the “great mimicker”)

Because the aorta supplies the entire body, a dissection can affect any branch:

• Coronaries → heart attack/sudden death

• Carotids → stroke

• Arm arteries → sudden painful, cold hand

• Visceral arteries (gut, kidneys, liver) → severe abdominal pain

• Leg arteries → painful, cold legs

This is why dissections are often misdiagnosed. They can look like a heart attack, stroke, kidney stone, perforated bowel—almost anything. Hence the nickname: “the great mimicker.”

How serious is it?

• About 20% suffer instant rupture and death.

• If you reach an appropriate facility quickly, survival can be ~75–80%.

• Delay kills: each hour without correct diagnosis/treatment reduces survival.

Typical survival estimates (illustrative):

• 0–2 hours: ~75–80% with prompt care

• 2–6 hours: ~65%

• 7–12 hours: ~60%

• >24 hours without correct management: ~50% mortality

Why diagnosis is delayed

A CT scan of the chest/abdomen is the definitive test. Delays happen because symptoms mimic other conditions, patients are triaged to the wrong pathway, or early tests (ECG, bloods, X-ray) appear non-specific.

This is why awareness campaigns emphasise a simple message:

Unexplained, severe pain? Think Aorta. Get a CT.

Common symptom locations: neck, back, chest, abdomen—often described as sudden, tearing or ripping pain unlike anything experienced before.

Risk factors include: hypertension, certain genetic conditions (e.g., Marfan syndrome, Ehlers–Danlos), bicuspid aortic valve, smoking, age, and male sex.

Ritter Rules (key takeaways)

• Aortic dissection is a medical emergency.

• Mortality increases ~1% per hour with delays in diagnosis/repair.

• Seek immediate emergency care for sudden, severe pain in the chest, back, abdomen, or neck—especially if it’s tearing/ripping/migratory or feels “very wrong.”

• CT angiography confirms the diagnosis.

Types of dissection (briefly)

• Type A: starts in the ascending aorta; usually requires open surgery.

• Type B: starts in the descending aorta; often managed with endovascular stent-graft repair (my subspecialty), depending on complications.

How we treat dissections (endovascular overview)

There’s typically an entry tear. By placing a stent-graft (delivered through the leg via keyhole access), we seal the entry, redirect flow into the true lumen, and allow the aorta to remodel. Modern stent-grafts are made from durable fabric supported by nitinol (a nickel-titanium alloy).

Aneurysms and dissection

A dissection weakens the aortic wall, which can later balloon into an aneurysm.
Treatment options:

• Open repair: replace the diseased segment with a surgical graft.

• Endovascular repair (EVAR/TEVAR): stent-graft lined from within; often with a “trouser-leg” bifurcated device in the abdomen.

Key reminders

• Unexplained severe pain? Think Aorta.

• Aortic dissection is an emergency and often fatal if missed.

• CT scanning is the definitive diagnostic tool.

• Vascular/aortic surgeons are available across Singapore in both public and private sectors.

For appointments or information: drandrewchoong.com/links.

Q&A (selected)

Q: How long does a stent last?
A: The goal is for the stent-graft to last the patient’s natural life. Over decades, the native aorta (not the stent itself) may degenerate further, occasionally requiring additional interventions.

Q: How many stents are usually needed?
A: It depends on extent and anatomy. Many dissections need one to two components; complex aneurysms may need three to five components.

Q: Why does dissection happen?
A: Genetics (e.g., Marfan, Ehlers–Danlos), population differences, and especially uncontrolled high blood pressure. Other cardiovascular risks—smoking, age, male sex, cholesterol—also contribute.

Q: When is an aortic root replacement (“Bentall procedure”) needed?
A: If a dissection involves the aortic root, compromising the coronary arteries or aortic valve, open surgery may replace the root, valve, and reimplant the coronaries.

Q: Should we screen regularly?
A: Screening won’t usually catch an acute dissection, which strikes suddenly. However, a one-time abdominal aortic aneurysm ultrasound is sensible for men ≥55 or anyone at increased risk. It’s simple and non-invasive.

Q: Can we treat a dissection with medication alone?
A: Selected patients—usually uncomplicated Type B—can be managed with aggressive blood-pressure control and close specialist surveillance. The approach must be individualised by an aortic team.

Q: Do blood thinners (e.g., daily aspirin) increase dissection risk?
A: They don’t cause dissection but can worsen bleeding if one occurs. This is why misdiagnosis (e.g., treating presumed stroke/MI with strong blood thinners) can be dangerous in undetected dissection.

Q: What symptoms suggest an aneurysm?
A: Sometimes pain or a pulsatile abdominal lump. Classic teaching: a man in his mid-60s with sudden severe back/abdominal pain—exclude an aortic cause. The aorta runs along the spine; irritation there often presents as back pain.

Final note: If you experience sudden, severe, unexplained pain—especially in the chest, back, neck, or abdomen—Think Aorta and seek emergency care.
For consultations or referrals: drandrewchoong.com/links.

President Trump’s Chronic Venous Insufficiency

Earlier this year, on the 18th of July 2025, White House Press Secretary, Caroline Leavitt, announced to the world that President Donald Trump had chronic venous insufficiency. I react to the press briefing, decode the medical jargon, and give my take on the diagnosis.

As I have shared on my research philosophy, evidence-based care is central to vascular decision making. For more information please take a look at my Varicose Veins and Deep Vein Thrombosis patient information page. You can find out more about me here. If you have leg swelling, varicose veins or a suspected venous issue, please book a consultation.

This is the transcript of the video:

Dr Andrew: Hi, my name's Dr. Andrew, and I'm a vascular surgeon based in Singapore. Earlier this year, on the 18th of July 2025, White House Press Secretary, Caroline Leavitt, announced to the world that President Donald Trump had chronic venous insufficiency. I react to the press briefing, decode the medical jargon, and give my take on the diagnosis.

Caroline Leavitt: On another note, I know that many in the media have been speculating about, uh, bruising on the president's hands and also swelling in the president's legs. So in the effort of transparency, the president wanted me to share a note from his physician with all of you today. In recent weeks, President Trump noted mild swelling in his lower legs.

Dr Andrew: There are a huge number of different causes of leg swelling, some serious, some not so serious. Let's listen and see what the White House medical unit did to investigate President Trump's lower limb swelling.

Caroline Leavitt: In keeping with routine medical care and out of an abundance of caution, this concern was thoroughly evaluated by the White House medical unit. The president underwent a comprehensive examination, including diagnostic vascular studies.

Dr Andrew: Diagnostic vascular studies are normally non-invasive ultrasound scans. They serve 2 purposes. They look at the structure and the anatomy of the blood vessels, but they can also look at the blood flow as well.

Caroline Leavitt: Bilateral lower extremity ven- venous doppler ultrasounds were performed.

Dr Andrew: Bilateral lower extremity venous doppler ultrasound is a bit of a mouthful, but what it's really referring to is doing diagnostic vascular scans of both of his legs, specifically looking at the venous system, the system that returns blood to the heart from his legs. And this is an ultrasound scan, which, again, as I said, looks at structure, looks at anatomy, and looks at blood flow.

Caroline Leavitt: And revealed chronic venous insufficiency, a benign and common condition.

Dr Andrew: So this is probably the first point of contention. The diagnosis of chronic venous insufficiency has been made, and I will talk about that later. It is an incredibly common condition, but to call it benign without context probably needs a little bit more explanation, and I hope to be able to offer that to you later on in this video.

Caroline Leavitt: Particularly in individuals over the age of 70. Importantly, there was no evidence of deep vein thrombosis or arterial disease.

Dr Andrew: There's a few things to unpack here. Chronic venous insufficiency is indeed more common in those over 70. But what Caroline Leavitt also said was that President Trump did not have any deep vein thromboses or arterial disease. Starting with the last one first, the body essentially has 2 circulation systems. It has the arterial system, and it has the venous system. The arterial system comes direct from the heart. The heart is like a big pump, pumping the blood around the body. The venous system is a slightly more passive system, which relies on movement in the legs to drive the blood back towards the heart. In the legs, in particular, there are also a series of one-way valves that it relies upon.

Caroline Leavitt: Laboratory testing included a complete blood count, comprehensive metabolic panel, coagulation profile, D-dimer, B-type natriuretic peptide, and cardiac biomarkers. All results were within normal limits. An echocardiogram was also performed and confirmed normal cardiac structure and function. No signs of heart failure, renal impairment, or systemic illness were identified.

Dr Andrew: Earlier on in the video, when I spoke about potentially serious and less serious causes of leg swelling, Caroline Leavitt here is detailing what the White House medical team has done to ensure that it is not a serious cause of leg swelling. So they've excluded heart failure as a potential issue, they've excluded renal failure or kidney failure as a potential issue, and they've also done a generic set of blood tests to further investigate President Trump's condition. However, 2 blood tests that Caroline Leavitt mentioned are not generic and, um, are worthy of discussion.

D-dimer is a protein fragment that is found in the body and increases in level as blood clots are broken down. So, interestingly, if your D-dimer is normal or 0, then it is highly unlikely that you have a significant blood clot, either a deep vein thrombosis or a pulmonary embolus in your body. However, if it is high, it doesn't necessarily mean that you have a significant blood clot, but obviously the risk is there, and I would suggest you need other modalities to investigate your condition further. One of the analogies that may work for you is the crumbs on the floor analogy. If you do find crumbs on the floor, then it is highly possible that there might have been a cake and somebody was eating it and spilt crumbs on the floor. If, however, you find no crumbs on the floor, then the likelihood of somebody walking round eating a cake is low. Look, it's a bit tenuous. I get it. But it's probably one of the better ways that I've heard describing the value of D-dimer in these situations.

The other blood test that Caroline Leavitt mentions is B-type natriuretic peptide. This is a hormone that's released by the heart, and essentially, it rises in response to heart damage. It is an indicator of heart failure and is best thought of as a bit of a distress signal. The higher the BNP, the higher the potential for heart failure. It's important to note that President Trump had a normal D-dimer and a normal BNP, so he does not have a serious blood clot and he does not have heart failure. But it's interesting because both of these investigations were mentioned, um, and they're worth discussing.

Caroline Leavitt: Additionally, recent photos of the president have shown minor bruising on the back of his hand. This is consistent with minor soft tissue irritation from frequent hand-shaking and the use of aspirin, which is taken as part of a standard cardiovascular prevention regimen. This is a well-known and benign side effect of aspirin therapy, and the president remains in excellent health.

Dr Andrew: Aspirin works by making your blood a little bit less sticky. It affects one of the components of blood called platelets. And so as a result, people who take long-term anti-platelet agents, aspirin is one, clopidogrel is another common one, also known as Plavix, then yes, they are slightly more prone to bruises. As for whether this is caused by repeated hand-shaking, that's not for me to say, but if you are on aspirin or you are on clopidogrel or an anti-platelet agent, then yes, you are definitely more prone to bruising.

So back to the topic of chronic venous insufficiency. As I said earlier, there are 2 main systems of circulation in the body, the arterial system that takes pumped blood from the heart round the body, and then the venous system which returns blood to the body. Now when the system, the venous system is affected, it is insufficient. And if it happens over a long time, then i- it's chronic. And that's really all chronic venous insufficiency is. It is the venous system not working as well as it normally does. Now this can present with minor lower limb swelling. It can present as varicose veins, but, and this is the point I was trying to make earlier, it can also present as really severe non-healing ulcers and discoloration of the leg, particularly around the ankle bone on the inside of the leg. That's why I said there should be a caveat when they said that chronic venous insufficiency is benign. Most of the time, sure, it is, but it is a spectrum of disease and venous disease can be serious and can be associated with significant morbidity.

So if you're concerned, go and find your local vascular specialist or your local vascular surgeon, go and have your own, um, diagnostic vascular studies, and in our clinic that would be a bilateral lower limb venous reflux scan. Um, that would be a duplex scan, which is doppler and ultrasound. So we look at the blood flow and we look at the structure and the anatomy of the veins in your leg.

I really hope you enjoyed this. Please leave comments below. Tell me if you have any questions and I'll do my best to answer them. Tell me if there are any other topics that you might want me to cover and, um, like, subscribe, and I'll see you on the next one. Thanks very much.