It was discovered that you have a very narrow or blocked artery, typically caused by atherosclerosis (or hardening of the arteries), which has damaged the arteries in your leg(s) and is known as peripheral occlusive arterial disease, as your vascular surgeon has revealed to you. This obstruction causes your blood flow to your leg to get so low that it affects how well it functions, resulting in symptoms like intermittent claudication, which may be quite painful, or placing your foot at danger of amputation due to a condition called critical limb ischaemia.
Based on your medical history, physical examination and imaging investigations, it is very likely that the circulation to your leg will be improved with an operation bypassing the blockage with a graft, so that a new artery for blood flow to your leg is created.
You will usually be admitted to the hospital one or two days before surgery so that there is enough time for the necessary investigations (blood tests, chest x-ray, electrocardiography, echocardiography etc) to be done. Your physician will generally require that 2 units of blood are available for you.
You may need to discontinue any anticoagulant, like Warfarin or Sintrom, or antiplatelet drugs like Clopidogrel (Iscover, Plavix) or Aspirin, for a few days, (if you have been prescribed these before) in order to reduce the risk for bleeding during the operation.
When you are admitted, your medical history will be recorded. Later, your vascular surgeon and the anaesthetist will visit you to explain the procedural details and clarify any doubts you may have. You will need to sign a consent document attesting to your understanding of the necessity for and risks associated with the operation.
Peripheral artery angioplasty/stenting is usually done under local anesthesia , unless the patient is unable to lie still during the procedure ( altered sensorium, severe pain or distress, or pediatric )
For EVAR – Endovascular aneurysm repair, the patient may require general anesthesia as imaging may require control of the patient’s breathing which may not be possible if the patient is awake.
The first part of any operation is the administration of anesthesia which may be regional, general or a combination of the two. Through an IV in your arm, used to provide you with fluids and medications, you may receive the anesthetic, which will put you to sleep within a few seconds. Then, a venous catherer will be inserted in a large vein to give you the fluids required during and after the operation, and an “arterial line” will be used for continuous monitoring of your blood pressure. A urinary catheter will be placed in your bladder to monitor your urine output.
Your vascular surgeon could choose for this more recent surgery, the endovascular repair, rather than the open repair. Endovascular or endoluminal refers to a technique that uses long, thin tubes known as catheters to pass past the wall of your arteries and into their lumen. This kind of procedure may be carried out under regional anaesthesia and is less intrusive.
Endovascular angioplasty with or without stenting is required for blockage to the artery. Once local anesthesia is given, a needle followed by a plastic tube is placed within the artery, and catheters and wires are used to try to cross the blockage. Once successfully crossed with a wire, a cylindrical balloon is introduced across the blockage and gradually inflated to create a passage for blood flow to the leg or body part involved. Occasionally stents may need to be placed is after deflating the balloon, our results are not adequate to maintain blood flow through the treated segment of artery.
For the abdominal vessels (iliac vessels), we prefer placing stents as the long term results are better for stenting than angioplasty alone.
Initially, you may require physiotherapy or assistance by another person. Your physician will advise you to regularly go for short walks and then rest for gradual return to normal activities. You will usually be recommended to take Aspirin or Clopidogrel (Iscover, Plavix) and a statin, as you probably did before the operation.
If any incision gets red, swollen or is leaking, if you develop fever or if the foot of the side of the operation gets cold or numb, you should immediately contact your physician, because a complication may have occurred.
Complications include
- Inability to cross the lesion – 10-20 % , due to hard calcification of the arterial wall.
- Arterial rupture or bleeding
- Dissection or internal separation
- Bruising in the groin
- Pseudoaneurysm or swelling of the artery -at needle insertion site – This may require follow up or open surgery for repair.
These complications of endovascular surgery are uncommon, and if they occur, there are treatment options available for dealing with them.
Overall endovascular surgery is not feasible for all blockages, but when possible, they are less complicated than open surgery with shorter hospital stays and lesser pain. There is also no requirement for skin suturing or suture removal.
Instead of the open repair, your vascular surgeon may consider this newer procedure, the endovascular repair. Endovascular or endoluminal means that the procedure is done through the wall of your arteries inside their lumen using very fine and long tubes, called catheters. This type of operation is less invasive and may be performed under regional anasthesia.
Initially, a small incision is made in each groin area. During the procedure, the vascular team will use x-ray pictures viewed on a screen to guide a tube (made of plastic and metal material), called stented graft or endograft, to the site of the aneurysm. Like the graft in open repair the endograft reinforces the aorta.
Your recovery time after EVAR is shorter than with the open repair and hospital stay may be reduced to 2-3 days. However, this procedure requires follow-up for a long time (probably for your lifetime) with imaging inestigations, currently CT scans, to confirm that it continues to function properly.
Your aneurysm may not be suitable for this procedure, because of its shape, its extent, its relation to the renal arteries etc. While endovascular repair may be a good option for some patients, in other cases open repair may be the best way to cure the problem.
Your vascular surgeon is the only physician qualified to offer all types of treatment for an AAA, and will help you decide the best method of repair in your particular situation.
Plaque accumulation is not stopped by your surgery. If you have undergone an arterial bypass treatment, you should modify your lifestyle to ensure its effectiveness and reduce the possibility of causing more artery damage. If you don’t, you run a higher chance of having a heart attack, a stroke, or developing new circulation issues in your feet.
These changes include:
- Giving up smoking for good
- Daily cardiovascular exercise for 25 to 30 minutes, such as brisk walking
- Preserving your optimal body weight
- Consuming meals low in calories, cholesterol, and animal fat
- Using medicine to manage diabetes, blood pressure, and cholesterol
