Cardiac & Vascular Surgery Department

Cardiac and vascular surgery is a specialist discipline concerned with the surgical treatment of the heart, the great vessels entering and leaving the heart (aorta, pulmonary artery, vena cava), and the body's peripheral vascular system. It requires a separate specialist training programme of five to six years following medical school.

It is worth clarifying the distinction that causes the most confusion:

• Cardiology is a medical (non-surgical) specialty. Drug treatment of heart disease, interventional procedures such as angiography (stent, balloon), echocardiography, and ECG interpretation all fall within the cardiologist's domain.
• Cardiac and vascular surgery is a surgical specialty. Coronary artery bypass grafting (CABG), heart valve replacement or repair, aortic surgery, and peripheral vascular surgery are the surgeon's domain.

Most patients with heart disease see a cardiologist first: symptoms are assessed, an ECG and echocardiogram are performed, and coronary angiography is arranged if indicated. If that assessment concludes that surgery is needed, the patient is referred to a cardiac and vascular surgeon. The two specialties do not replace one another — they function as two complementary disciplines. Both are active on the second floor of Nis Clinic: our cardiology department handles the medical assessment, and our cardiac and vascular surgery outpatient clinic manages the surgical decision pathway. Cross-specialty consultation can take place on the same day.

The coronary arteries supply blood to the heart. Blockages in these arteries present as chest pain (angina), breathlessness, and reduced exercise tolerance; at an advanced stage they can progress to a heart attack (myocardial infarction). Treatment falls under three broad headings:

• Medical therapy: In patients with stable, single-vessel disease, or where the risk–benefit balance does not favour intervention, medication alone may be sufficient.
• Percutaneous coronary intervention (PCI/stenting): Performed by a cardiologist. In suitable anatomy with single- or double-vessel occlusion, this may be the preferred first-line approach.
• Coronary artery bypass grafting (CABG): The gold standard in three-vessel disease, left main coronary artery involvement, multivessel disease in patients with diabetes, and complex lesions not suitable for PCI.

Where does Nis Clinic come in? Centres routinely performing open-heart surgery in Northern Cyprus are limited in number. The work carried out at our outpatient clinic falls within the following scope:

1. Second opinions regarding the need for surgery following cardiological assessment
2. Routine postoperative review, graft surveillance, and lifestyle management for patients who have previously undergone bypass surgery
3. Preoperative assessment and referral to an appropriate centre for patients in whom surgery is planned
4. Planning of treatment at a partner centre in Türkiye or abroad for non-urgent cases

We are transparent about this scope for a straightforward reason: operating on a patient requiring cardiac surgery in an under-resourced setting is the wrong decision for both the patient and the clinic. The right decision is to involve the right centre at the right time.

The heart has four valves: mitral, tricuspid, aortic, and pulmonary. Over time, these valves can develop stenosis (narrowing) or regurgitation (leakage). Common presentations include:

• Aortic stenosis: Degenerative calcification in older age is the most common cause. The classic triad of breathlessness, syncope, and chest pain is a key warning sign.
• Mitral regurgitation: Rheumatic heart disease, mitral valve prolapse, and ischaemic causes are frequent origins.
• Aortic regurgitation: Bicuspid valve, aortic root dilatation, and rheumatic causes are typical.

Transthoracic echocardiography — and transoesophageal echocardiography when needed — is central to diagnosis. The cardiologist classifies the condition through medical investigations; the cardiac and vascular surgeon determines when operative intervention is required. This timing decision is precise: intervening too early carries unnecessary surgical risk, while intervening too late risks irreversible myocardial damage. International guidelines (ESC/EACTS, ACC/AHA) define clear thresholds based on ejection fraction, valve area, symptom status, and comorbidities.

Our outpatient clinic provides follow-up scheduling, monitoring of operative timing, and referral where indicated for patients with a diagnosis of valve disease. For those in whom valve surgery is decided upon, preoperative preparation and postoperative follow-up are also managed within our department.

Peripheral artery disease (PAD) is an occlusive process affecting the peripheral vessels, most commonly those supplying the legs. The most typical symptom is intermittent claudication: cramp-like pain in the calf, thigh, or buttock that develops after walking a certain distance and resolves with rest. At an advanced stage, rest pain, non-healing wounds, and, rarely, limb loss may occur.

Risk factors overlap substantially with those for cardiovascular disease in general: smoking, diabetes, hypertension, hyperlipidaemia, family history, and older age. When PAD is diagnosed, simultaneous coronary and cerebrovascular assessment is standard practice — these vascular systems are not independent.

Investigations at the diagnostic stage include:

• Ankle–brachial index (ABI): Simple, non-invasive screening. Normal range: 0.9–1.4.
• Colour Doppler ultrasonography: Localisation and severity of occlusion.
• CT angiography / MR angiography: The gold standard for surgical or endovascular planning.

Treatment depends on disease stage. In mild-to-moderate PAD, smoking cessation, supervised walking exercise, antiplatelet therapy, and statin treatment are the core steps. In advanced cases, endovascular intervention (balloon, stent) or bypass surgery becomes relevant. Our outpatient clinic carries out staging of PAD, lifestyle planning, and referral for patients requiring surgery.

Varicose veins are a common vascular problem: some form of venous insufficiency is seen in approximately one third of adult women and approximately one fifth of adult men. Three main clinical presentations exist:

• Telangiectasia (spider veins): Under 1 mm, red-to-purple capillary networks. Generally a cosmetic concern.
• Reticular veins: 1–3 mm, blue-green, deeper superficial veins.
• Varicose veins: Over 3 mm, raised, tortuous veins. May be symptomatic (heaviness, evening swelling, cramp).

Diagnostic pathway: Clinical examination combined with colour Doppler ultrasonography. Doppler identifies which vein (great saphenous, small saphenous, perforator) is refluxing and the severity of reflux. A treatment plan cannot be formulated without this information — treating superficial varicosities without first addressing great saphenous vein reflux substantially increases the recurrence rate.

Treatment options:

• Superficial capillary/spider veins: Sclerotherapy (foam/liquid injection) and Nd:YAG 1064 nm laser are appropriate. These procedures are performed on the first floor of our clinic in the aesthetics department, as detailed on our laser varicose vein page.
• Great saphenous / small saphenous vein reflux: Endovenous laser ablation (EVLA), radiofrequency ablation (RFA), or conventional stripping surgery. These fall within the domain of vascular surgery.
• Varicose tributaries / branch veins: Sclerotherapy or mini-phlebectomy.

Our outpatient clinic provides Doppler assessment, formulation of the treatment plan, and referral of appropriate patients to the correct treatment pathway. Aesthetically focused superficial treatment is available on our first floor; cases requiring advanced venous surgery are managed through the referral pathway.

Treatment of a patient with cardiac or vascular disease is not the work of a single specialty. A typical patient journey proceeds as follows:

1. Symptom stage: Chest pain, breathlessness, palpitations, leg pain, or visible varicose veins. The patient may first attend their GP or general internal medicine outpatient clinic.
2. Cardiology assessment: In our cardiology department, an ECG, echocardiogram, exercise tolerance test, and Holter monitor (where indicated) are performed. Medical treatment is initiated.
3. Surgical decision required: When the cardiologist considers surgery, the patient is referred to the cardiac and vascular surgery outpatient clinic.
4. Preoperative assessment: Risk scoring (EuroSCORE II, STS), management of comorbidities, anaesthetic consultation.
5. Surgery: Selection of the appropriate centre and team. The referral pathway is activated for major procedures not performed at Nis Clinic.
6. Postoperative follow-up: Reviews at one week, one month, three months, and at six-monthly intervals thereafter continue at our outpatient clinic.

This sequence does not follow exactly the same pattern for every patient; steps may be skipped or reordered according to urgency, patient preference, and clinical presentation. What matters is the capacity of both specialties to produce a concurrent opinion. The layout of Nis Clinic's second floor, with cardiology and cardiac-vascular surgery outpatient clinics side by side, facilitates this concurrent assessment.