In an amputation, a surgeon removes a limb, or part of a limb, that is no longer useful to you and is causing you great pain, or threatens your health because of extensive infection. Most commonly, a surgeon removes your toe, foot, leg, or arm. Vascular surgeons consider amputation a last resort.
Although amputations may be required for other reasons, such as severe injury or the presence of a tumor, the most common reason you may need an amputation is if you have peripheral arterial disease (PAD) due to atherosclerosis (hardening of the arteries). If the blood supply cannot be improved sufficiently or if the tissue is beyond salvage, extensive tissue death may require amputation, especially if you are experiencing severe pain or infection.
Your physician will perform a physical examination to determine whether your limb can be saved or if you need an amputation. He or she will check you for:
- Cool skin near your wound
- Extremely painful skin
- Wound odor
- Infected or non-healing sores or wounds
Your physician will also arrange for tests to see how well blood is reaching your limbs. These tests may include blood pressure tests, duplex ultrasound, and angiography.
If you have any other conditions, such as diabetes, high blood pressure, heart problems, poor kidney function, or infections, your physician will discuss with you how to treat them to get you in the best condition. Your physician will also test your physical strength, balance, and coordination to assess your potential for rehabilitation. If you are going to use an artificial limb, sometimes your physician may arrange for you to be measured for the device before your operation. This way, your artificial limb will be ready as soon as you recover.
Often, however, your physician may advise waiting until your incision is healed adequately before getting your artificial limb. You also may receive counseling before your surgery to help you adapt to the loss of your natural limb.
Your physician will discuss with you whether to reduce or stop any medications that might increase your risk bleeding or other complications. If you have any allergies to anesthesia, pain medications, or antibiotics, you should tell your physician at that time.
The need for Amputation
Most people who require an amputation have PAD, a traumatic injury, or cancer.
PAD is the leading cause of amputation in people age 50 and older, and accounts for up to 90 percent of amputations overall. Normally, surgeons treat advanced PAD through other methods, like controlling infection using antibiotics and draining or removing any infected tissue as well as performing surgery or other procedures to increase the blood flow to the affected area. However, if these treatments do not work, amputation will remove a source of major infection and may be necessary to save your life.
A traumatic injury, such as a car accident or a severe burn, can also destroy blood vessels and cause tissue death. As a result, infection, if not adequately treated, can spread through your body and threaten your life. Your medical team will make every effort to save your limb by surgically replacing or repairing your damaged blood vessels or using donor tissue. However, if these measures do not work, amputation can save your life. Traumatic injuries are the most common reason for amputations in people younger than age 50.
Your physician may recommend amputation if you have a cancerous tumor in your limb. You may also receive chemotherapy, radiation, or other treatments to destroy the cancer cells. Depending upon the particular circumstances, these treatments can shrink the tumor and may increase the effectiveness of your amputation.
If you have other conditions, like diabetes or heart disease, you have a higher risk of complications from an amputation. Having a very serious traumatic injury also increases your risk of complications. Above-the-knee amputations can be associated with more risk than below-the-knee amputations, because people who require above-the-knee amputations are more likely to be in poorer health.
To perform an amputation, your physician must remove your diseased limb but preserves as much healthy skin, blood vessel, and nerve tissue as possible.
Choosing the incision site is important. If your surgeon removes too little tissue, your wound will not heal because unhealthy tissue remains and the circulation at that level may not be sufficient for healing. To determine how much tissue to remove, your physician will check for a pulse at a joint close to the site. He or she will also compare the skin temperatures in the diseased limb with those in a healthy limb, and note places where the skin appears red, since an incision made through reddish skin may be less likely to heal. Your physician will also check that your skin around the proposed incision point still has sensitivity to touch. Finally, after he or she makes the initial incision, your physician may decide that more of your limb needs to be removed if the edges of your skin do not bleed enough to allow them to heal.
Before the procedure begins, your anesthesiologist will either put you to sleep, called a general anesthetic, or numb your body in the region of the amputation, called a regional anesthetic. You will be connected to machines that monitor your heart rate, blood pressure, temperature, and brain function. When the anesthetic has taken effect and you are not able to feel the pain, your surgeon then performs the incision, leaving enough healthy skin to cover your stump for better healing.
Your surgeon may shape the muscles of the leg during the amputation, to make sure that your stump has a comfortable contour for your artificial limb. He/she also divides and protects your nerves, so that they are not exposed and painful. During your surgery, clamps are applied to minimize bleeding when the surgeon divides the healthy major blood vessels. Before finishing your amputation, your surgeon will stitch the vessels, and then release the clamps to ensure that all bleeding points are secure. When your surgeon has completely removed all of the dead tissue, sometimes depending upon the circumstances, he or she may decide to leave the site open (open flap amputation) or to close the flaps (closed amputation). Your surgical care team may place a stocking over your stump to hold drainage tubes and wound dressings, or your limb may be placed in traction, or a splint, depending upon your particular situation.
After your surgery, you will stay in the hospital for approximately 5 to 14 days, depending upon your particular situation. Your physician may teach you how to change your wound dressings, or the hospital staff will change them for you. Your physician usually checks the progress of your wound in about 7 to 10 days or as often as necessary. Your physician will also monitor any conditions you have that might slow your healing, such as hardening of the arteries or diabetes. If you need pain medications or antibiotics, your physician will prescribe them. Ideally, your wound should fully heal in about 4 to 8 weeks after your surgery.
If your condition permits, ideally, you will receive physical therapy soon after the procedure. Physical therapy includes gentle stretching for the first 2 or 3 days. Later, you will perform exercises, such as getting in and out of your bed or in and out of your wheelchair. Eventually, you will learn how to bear your weight on your remaining limb.
Depending upon your particular situation, you may also begin to practice with your artificial limb as early as 10 to 14 days after your surgery, but this depends upon your comfort and wound healing progress.
You may experience phantom pain (a sense of feeling pain in your amputated limb) or other emotional concerns, such as grief over the lost limb, after surgery. If this is the case, your physician can recommend counseling or drug therapy, as appropriate.
Complications that occur specifically from amputation include a joint deformity called contracture, a severe bruise called a hematoma, death of the skin flaps (necrosis), wound opening from poor healing, or infection. Your surgeon or physician can treat all of these complications. Rarely, you may need to undergo further surgical treatment or another amputation.
If your wound has healed well and your artificial limb fits you, your amputation should cause you minimal long-term medical concerns. However, if you have PAD, an amputation does not stop plaque from building up in your remaining arteries. To prevent hardening of the arteries from affecting other parts of your body, including your heart, you should consider the following changes:
- Eat more foods low in saturated fat, cholesterol, and calories
- Exercise regularly
- Maintain your ideal body weight
- Avoid smoking
- Discuss with your primary medical doctor starting a statin medication and daily aspirin
You can learn how to adapt to having an artificial limb, including getting regular exercise, with the help of physical therapy. Studies have found that amputees who engage in regular physical exercise feel better about themselves than those who are more sedentary. Also, people who recover from an amputation are more likely to have greater job satisfaction, possibly because of changes in their attitudes regarding life goals.
Angioplasty and Stenting
In an angioplasty, your vascular surgeon inflates a small balloon inside a narrowed blood vessel. The balloon helps to widen your blood vessel and improve blood flow. After widening the vessel with angioplasty, your vascular surgeon sometimes inserts a stent depending upon the circumstances. Stents are tiny mesh tubes that support your artery walls to keep your vessels wide open.
Angioplasty and stenting is usually done through a small incision or puncture or sometimes a small incision in your skin, called the access site. Your vascular surgeon inserts a long, thin tube called a catheter through this access site. Using X-ray guidance, he/she then guides the catheter through your blood vessels to the blocked area. The tip of the catheter carries the angioplasty balloon or stent.
First your surgeon asks you questions about your general health, medical history, and symptoms in addition to conducting a physical exam. Together these are known as a patient history and exam. As part of your history and exam, your physician will ask you if you smoke or have high blood pressure. He or she will also want to know when and how often your symptoms occur, and their location.
Next, your surgeon will order tests to show how much plaque has built up in your arteries. These tests can help determine whether you need an angioplasty or some other form of treatment. The choice of test depends on the blood vessel in question and not all of the tests need to be used for every situation. These tests include:
- Pulse volume recordings (PVRs)
- Duplex ultrasound
- Magnetic resonance angiography (MRA)
- Computed tomography (CT) scan
If these tests show that your arteries are moderately to severely narrowed, your vascular surgeon may also plan a test called angiography. An angiography directly shows your blood vessels on an x-ray and may also provide an opportunity to treat the narrowing with angioplasty at the time of the angiogram. During angiography, your vascular surgeon inserts a long, thin tube called a catheter into an artery in your groin or arm after first making the area numb with a local anesthetic. Using x-ray guidance, your physician then guides the catheter through your blood vessels to the blocked area and injects a dye that allows the arteries to be seen on the x-ray. The dye is later eliminated in your urine after it is filtered out by your kidneys.
Your vascular surgeon will give you the necessary instructions you need to follow before the procedure, such as fasting. Usually, your vascular surgeon will ask you not to eat or drink anything several hours before your procedure. He or she will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications. If you have any allergies to iodine or contrast dye, which is used in angiography, you should tell your vascular surgeon at that time.
Before your procedure, tests may be ordered to check your kidney function as well as your blood’s ability to clot. Your surgeon will order an IV to deliver fluids. Depending upon the circumstances, the angioplasty procedure may sometimes be performed at the time of the initial angiogram or angiography may be performed alone.
Complications resulting from angioplasty and stenting include reactions to the contrast dye, bleeding or weakening of the artery wall, bleeding at the access puncture site in the vessel, re-blocking of the treated artery, and kidney problems. Additionally, blockages can develop in the arteries downstream from the plaque if plaque particles break free during the angioplasty procedure. If severe, these can lead to worsening of the blood flow.
If you have diabetes or kidney disease, you may have a higher risk of complications from the contrast dye, such as kidney failure. In the case of kidney disease, sometimes pre-treatment with fluids may decrease the impact on your kidneys.
People with blood clotting disorders also may have a higher risk of complications from the procedure. If the plaque deposits in your arteries are especially long, you may have a greater chance of your artery closing up again after angioplasty and stenting.
The physician will usually insert the angioplasty catheter through a small puncture point over an artery in your groin, your wrist, or your elbow. Before the insertion, he or she will clean your skin and shave any hair in the immediate area. This reduces your risk of infection. The physician numbs your skin and then makes a small cut to reach the artery below. Although you may be given some mild sedation, your vascular surgeon will usually want you to stay reasonably alert to follow instructions and describe your sensations during the procedure.
The vascular surgeon then inserts a guide wire or a guide catheter into your artery. Using a type of x-ray that projects moving pictures on a screen, your physician guides the catheter through your blood vessels. Because you have no nerve endings in your arteries, you will not feel the catheters as they move through your body.
Next, your vascular surgeon will insert a balloon catheter over the guide wire or through the guide catheter. The balloon catheter carries a deflated and folded balloon on its tip. The surgeon guides the balloon catheter to the narrowed section of your artery and the balloon is inflated to press the plaque against your artery walls. Usually, this process takes a few minutes.
Your artery may stretch and your blood flow through the artery stops when the balloon is pushing your artery open. This may cause pain. However, the pain should go away when your vascular surgeon deflates the balloon and normal blood flow resumes.
There is a risk that your artery will re-narrow or become blocked again in the future, at the site where the balloon was inflated. This can happen soon after the procedure, or months to years later. Re-narrowing of your artery is called restenosis, and if your artery suddenly becomes blocked again it is called re-occlusion. Restenosis can happen when scar tissue builds up inside your arteries where the balloon compressed your plaque deposits.
After angioplasty, your vascular surgeon will sometimes need to brace the artery open to prevent restenosis and re-occlusion. A stent is a tiny mesh tube that looks like a small spring, and comes in a variety of sizes. He/she guides the stent through your blood vessels to the place where the angioplasty balloon widened your artery. The stent, once deployed, remains in place to support the walls of your artery. Your artery walls grow over the stent, preventing it from moving. Although stents help prop open your arteries, scar tissue can eventually form around stents and cause restenosis.
Once your vascular surgeon finishes angioplasty and stenting, he or she removes all of the catheters from your body. If blood-thinning medications have been used, your physician may leave a short tube, called a sheath, in your artery for a short time until the medications have worn off sufficiently to allow the puncture site to seal over when the sheath is removed.
Eventually, your physician removes the sheath and presses on the puncture area for 15 to 30 minutes to prevent bleeding. Sometimes, instead of pressing, your physician may close the area with a device that places sutures in the artery.
Angioplasty and stenting usually takes between 45 minutes and 3 hours, but sometimes longer depending upon the particular circumstances.
Usually, you will stay in bed for 6 to 24 hours after your angioplasty. During this time, your vascular surgeon and the hospital staff closely monitor you for any complications. If your physician inserted the catheters through an artery in your groin, you may have to hold your leg straight for several hours. Similarly, if your arm was used, then you will need to hold it still to minimize the risk of bleeding.
If you notice any unusual symptoms after your procedure, you should tell your vascular surgeon immediately. These symptoms include leg pain that lingers or gets worse, a fever, shortness of breath, an arm or a leg that turns blue or feels cold, and problems around your access site, such as bleeding, swelling, pain, or numbness.
After you return home, your vascular surgeon will give you instructions about everyday tasks. For example, you should not lift more than about 10 pounds for the first few days after your procedure. You should drink plenty of water for 2 days to help flush the contrast dye out of your body. You can usually shower 24 hours after your procedure, but you should avoid baths for a few days.
Your physician may prescribe aspirin or other medications that thin your blood. These medications will help prevent clots from forming on your stent. Your physician may also ask you to follow an easy exercise program, like walking.
You will be asked to schedule a time to see your physician after the procedure. At this appointment, your physician may check your blood to make sure your medications are at the right dosage. He or she may also take tests to see how blood is flowing through your treated artery.
Serious complications are unusual following angioplasty and stenting but, nevertheless, can occur. Less serious complications include bleeding or bruising where your vascular surgeon inserted the catheters. Sometimes, the hole created by the catheter does not completely close. This can create a false channel of blood flow. Rarely, an abnormal connection can form between an artery and a vein at the place where the catheter was inserted. These problems usually go away. However, if you have any serious symptoms, your vascular surgeon can treat you.
You may have an increased risk for blood clots forming along your stent, especially in the first month after your procedure. To reduce this risk, your physician may prescribe medications that thin your blood.
As more time passes after your angioplasty and stenting, restenosis becomes more likely. However, in some cases, you may need a repeat angioplasty or a bypass surgery if a restenosis develops. Serious, but unusual complications include:
- Reaction to contrast dye
- A clot in the artery that your physician treated
- A torn or weakened blood vessel
- Kidney problems
- Damage to the lining of the artery (called dissection)
- Blockages developing in arteries downstream from the treated artery from particles of the plaque breaking free (called embolization)
Aneurysm Repair: Endovascular vs. Open surgical
Arterial/Venous Thrombolysis or Thrombectomy
Carotid endarterectomy is an operation during which your vascular surgeon removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates a substance called plaque from your artery and can restore blood flow. Carotid endarterectomy is one of the most commonly performed vascular operations, and is a safe and long-lasting treatment performed with the intention of significantly lowering stroke risk.
As you age, plaque can build up in the walls of your arteries. Cholesterol, calcium, and fibrous tissue make up this plaque. As more plaque builds up, your arteries narrow and stiffen. This process is called atherosclerosis, or hardening of the arteries. Eventually, enough plaque builds up to reduce blood flow through your carotid arteries, or cause irregularities in the normally smooth inner walls of the arteries.
Your carotid arteries are located on each side of your neck and extend from your aorta in your chest to the base of your skull. These important arteries supply blood to your brain. Carotid artery disease is a serious issue because clots can form on the plaque. Plaque or clots can also break loose and travel to the brain. If a clot or plaque blocks the blood flow to your brain sufficiently, it can cause an ischemic stroke, which can cause permanent brain damage, or death, if a large enough area of the brain is affected. If a clot or plaque blocks only a tiny artery in the brain, it may cause a transient ischemic attack (TIA), also known as a mini-stroke. A TIA is often a warning sign that a stroke may occur in the near future, and it should be a signal to seek treatment before a stroke occurs.
Your physician or vascular surgeon will give you the instructions you need to follow before the surgery, such as fasting.
Before your vascular surgeon performs a carotid endarterectomy, he or she may want to determine how much plaque has built up in your arteries. The most common test used for this purpose is duplex ultrasound. Duplex ultrasound uses painless sound waves to show your blood vessels and measure how fast your blood flows. It can also determine the location and degree of narrowing in your carotid artery. Other tests your vascular surgeon may use include:
Having had a stroke in the past increases your chances for complications to a varying degree depending upon its severity, how recently it occurred, and the degree of recovery. Other factors that may increase your chances for problems during a carotid endarterectomy, in addition to those conditions listed above, include:
- The presence of a serious disease, such as severe heart or lung disease
- Plaque your surgeon cannot reach through surgery
- Severe blockage in other blood vessels that supply blood to your brain, such as the carotid artery on the other side
- Having a new blockage at a previous carotid endarterectomy site on the same side (recurrence)
- Cigarette smoking
You may either go to sleep or, alternatively, your surgeon can numb your neck area and keep you awake so you can communicate with the surgeon during the operation. By staying awake, you may help your physician monitor your brain’s reaction to the decreased blood supply. Once you are either asleep or the area around your neck is completely numb, your surgeon will shave the skin on your neck where he or she is going to make an incision, to help prevent infections.
The surgeon then makes the incision on one side of your neck to expose the blocked carotid artery. He/she then temporarily clamps your carotid artery to stop blood from flowing through it. During the procedure, your brain receives blood from the carotid artery on the other side of your neck. Alternatively, your surgeon can insert a shunt to detour the blood around the artery that is being repaired.
After your surgeon clamps your carotid artery, he or she makes an incision directly into the blocked section. Next, your surgeon peels out the plaque deposit by removing the inner lining of the diseased section of your artery containing the plaque. After removing the plaque, your surgeon stitches your artery, removes the clamps or the bypass, and stops any bleeding. He or she then closes your neck incision and the procedure is complete.
Sometimes, a patch is used to widen the artery. The patch material used can be your own vein, usually from the leg, or a variety of synthetic materials depending upon your particular circumstance. The procedure takes about 2 hours to perform but may seem slightly longer depending upon the anesthetic and preparation time.
After surgery, you may stay in the hospital for 1 to 2 days. During this time, your physician will monitor your progress. Initially, during your recovery, you will receive fluid and nutrients through a small, thin tube called an intravenous (IV) catheter. Because the neck incision is so small, you may not feel significant pain.
After you go home, your physician may recommend that you avoid driving and limit physical activities for several weeks. You can usually begin normal activities again several weeks after the operation.
If you notice any change in brain function, severe headaches, or swelling in your neck, you should contact your physician immediately.
You may have complications following any surgical procedure. A stroke is one possible complication following a carotid endarterectomy. This risk is very low, ranging between 1 and 3 percent. Another unusual complication is the re-blockage of the carotid artery, called restenosis, which may occur later, especially if you continue to smoke cigarettes. The chance of developing a restenosis severe enough to require another carotid endarterectomy is usually about 2 to 3 percent.
Temporary nerve injury, leading to hoarseness, difficulty with swallowing, or numbness in your face or tongue, is another uncommon, but possible, complication. This usually clears up in less than 1 month and usually doesn’t require any treatment. However, the chance of any of these unusual complications is much less than the risk of stroke if a significant carotid blockage is not adequately treated.
Although a carotid endarterectomy can reduce your risk of stroke by removing the offending plaque, and although the procedure is quite durable, it does not completely stop plaque from building up again in susceptible individuals. To minimize the chance of hardening of the arteries from occurring again, you should consider the following changes:
- Eat foods low in saturated fat, cholesterol, and calories
- Exercise regularly, especially aerobic exercises such as walking
- Maintain your ideal body weight
- Avoid smoking
- Discuss cholesterol lowering medications and antiplatelet therapy with your physician
Carotid artery stenting is a procedure in which your vascular surgeon inserts a slender, metal-mesh tube, called a stent, which expands inside your carotid artery to increase blood flow in areas blocked by plaque.
Hardening of the arteries, also known as atherosclerosis, can cause the build up of plaque. In hardening of the arteries, plaque builds up in the walls of your arteries as you age. As more plaque builds up, your arteries can narrow and stiffen. Eventually, enough plaque may build up to reduce blood flow through your arteries, or cause blood clots or pieces of the plaque to break away and block the arteries in the brain beyond the plaque.
Your carotid arteries are located on each side of your neck and extend from your aorta in your chest to the base of your skull. These arteries supply blood to your brain. You have one main carotid artery on each side, and each of these divides into two major branches, the external and the internal. The external carotid supplies blood to your face and scalp. Your internal carotid artery is more important because it supplies blood to the brain.
When plaque builds up and reduces blood flow in your carotid arteries, you have carotid artery disease. This is a serious issue because clots can form on the plaque and block the blood flow to your brain. If a clot or plaque blocks the blood flow to your brain, it can cause an ischemic stroke, which can cause brain damage or death. Also, if a clot blocks a tiny artery in the brain, it may cause a transient ischemic attack, also known as a mini-stroke.
When your physician wants to treat a blocked carotid artery, he or she may recommend that you have a stent inserted as an alternative to surgical removal of the plaque, known as carotid endarterectomy. During the carotid stenting procedure, your physician inserts a stent into your carotid artery after performing angioplasty. Angioplasty uses a balloon inflated in the narrowed part of the artery to flatten the plaque and open the artery. The stent holds the artery open by holding back the flattened plaque like scaffolding.
Your physician may give you specific instructions to follow before the procedure, such as fasting. You should always inform your physician about any medications that you are taking. In most cases, your physician will instruct you take aspirin and a prescription medication that prevents clots for 3 to 5 days before the procedure. Your physician may also order a duplex ultrasound, a computed tomography (CT) scan, an angiogram, or magnetic resonance imaging (MRI) to evaluate the degree of blockage in your carotid artery.
Factors that may increase your chance for having complications during carotid stenting include:
- High blood pressure
- Allergy to contrast dye
- Hardened (calcified) and long narrowing of the carotid artery
- Sharp bends or other difficult anatomies in the carotid arteries
- Irregular looking plaque
- Significant plaque or atherosclerosis of the aorta near the beginning of the carotid artery
- An age more than 80 years
- Extensive blockages in the arm and leg arteries
Immediately after the procedure, your physician applies pressure to the catheter insertion site in the groin or arm for 15 to 30 minutes to allow it to close and prevent bleeding. Sometimes to close the incision, your physician may use, instead, a closure device or stitches that dissolve.
If your vascular surgeon inserts the catheters and other instruments through your femoral artery, he/she may instruct you to stay in bed for the next several hours to assess for any complications, such as bleeding from the puncture site.
Your surgeon may instruct you not to lift anything more than about 5 to 10 pounds, after you return home, to avoid any pressure on the incision. He/she may also instruct you not to take a bath for a few days (but showers are fine), and to drink plenty of water to help flush the dye out of your system. You will be advised to take blood thinning medications and also be scheduled for periodic follow-up examinations, usually including carotid ultrasound examinations, to monitor the function of your stent over time.
Blockage by a clot or other debris in an artery in your brain, called an embolism, is the most serious complication that can occur after carotid stenting. This blockage can cause a stroke.
Other complications that may cause a stroke include a blood clot forming along the stent or a tear in the artery wall called a dissection. The re-blockage of the carotid artery, called restenosis, is another possible complication. The dye used for the angiogram can sometimes cause damage to the kidneys, especially in people who already have kidney trouble. Bleeding from the puncture site in the groin or arm artery, called a hematoma or a false aneurysm, can also occur, but this is unusual. Bruising and mild tenderness at the puncture site is common, however, and usually resolves with time.
Although carotid stenting opens your artery and keeps blood flowing, it does not stop plaque from building up. To prevent hardening of the arteries from occurring again, you should consider the following changes:
- Eat more foods low in saturated fat, cholesterol, and calories
- Exercise regularly, especially aerobic exercises such as walking
- Maintain your ideal body weight
- Quit smoking
- Follow your physician’s recommendations for medications to control cholesterol and to thin the blood
Dialysis access is an entranceway into your bloodstream that lies beneath your skin and is easy to use. The access is usually in your arm or leg and allows blood to be removed and returned quickly, efficiently, and safely during dialysis or, less commonly, for other procedures requiring frequent access to your circulation.
Dialysis, also called hemodialysis, is the most common treatment for kidney failure. A dialysis machine is an artificial kidney designed to remove impurities from your blood. During dialysis physicians use the dialysis access to circulate your blood through the machine to remove impurities and regulate fluid and chemical balances. The purified blood is then returned to you again through the dialysis access.
Creating the access portal is a minor surgical procedure. There are two types of portals:
- Fistula: which your vascular surgeon constructs by joining an artery to a vein
- Graft: which is a man-made tube that your vascular surgeon inserts to connect an artery to a vein
For both fistulas and grafts, the connection between your artery and vein increases blood flow through the vein. In response, your vein stretches and becomes strengthened. This allows an even greater amount of blood to pass through the vein and allows your dialysis to proceed efficiently.
You can usually begin using your graft in 2 to 6 weeks, when it is healed sufficiently. Usually fistulas are preferred to grafts because fistulas are constructed using your own tissue, which is more durable and resistant to infection than are grafts. However, if your vein is blocked or too small to use, the graft provides a good alternative.
Before choosing the access site, your surgeon may ask you if you have a history or symptoms of arterial disease affecting the arms or legs. Your vascular surgeon will not place a dialysis access site in an area of the body with reduced circulation. For this reason, your surgeon usually places dialysis access sites in the arms rather than in the legs because atherosclerosis is more common in the legs.
The vascular surgeon will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, your physician will ask you not to eat or drink anything 8 hours before your procedure. Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.
Typically you will have the procedure on an outpatient basis. Most often, you will first be sedated and then your surgeon will numb the area where the fistula or graft will go. In some cases, your anesthesiologist may put you to sleep.
Depending upon the quality of your artery and vein, your surgeon will try to construct the fistula with one incision using the forearm of the arm that you do not use as frequently. For example, if you’re left handed, your physician will place the fistula in your right arm, if possible.
If you cannot receive a fistula because the vein is too small or blocked, your physician may construct a graft using a tube of man-made material. Less commonly, your physician may also choose to use a piece of a vein from your leg or a section of artery and sews the graft to one of your veins and connects the other end to an artery. Your physician may place the graft material straight or form a loop under the skin either in your lower arm, upper arm, or less commonly in your leg.
Expectations after dialysis access
After the operation, you should initially keep the access area raised above your heart to reduce swelling and pain. Your surgeon may recommend an over-the-counter painkiller to relieve pain, if necessary.
- Keep the incision dry for at least 2 days after the procedure and do not soak or scrub the incision until it has healed
- Avoid lifting more than about 15 pounds or other activities that stress or compress the access area
- Report pain, swelling, or bleeding immediately to your physician, especially if these symptoms are becoming worse. Some pain or swelling is common and not worrisome if decreasing, but you should tell your physician if you have bleeding, drainage or a fever higher than 101 degrees Fahrenheit
You may initially feel some coolness or numbness in the hand with the fistula. These sensations usually go away in a few weeks as your circulation compensates for the fistula. However, if these sensations are severe or don’t disappear, tell your physician as soon as possible, because the fistula may be causing too much blood to flow away from your hand, a condition physicians call a “steal.”
You should perform exercises to grow and strengthen your fistula, after the pain from the surgery decreases, to make dialysis faster and easier. Your physician may recommend squeezing a soft object for 4-6 weeks.
Grafts mature more quickly than fistulas depending upon the size of the vein initially. They sometimes can be ready in 2 to 3 weeks, but many physicians recommend waiting about 4 to 6 weeks before using a graft. Grafts are more likely than fistulas to become infected. Grafts usually last about 1 to 2 years, which is less than fistulas. Fistulas can often last up to 3 to 7 years. If you care properly for your graft, however, you can help it last for many years.
Complications with dialysis access include clotting, narrowing, aneurysm formation in the graft or fistula itself; infection, and bleeding.
Protecting the dialysis access is crucial for you. The following tips will help you care for a fistula or a graft:
- Check several times each day to make sure the access is functioning
- Monitor any bleeding after dialysis. If the graft seems to bleed longer than usual from the needle sites, you should notify your dialysis center staff
- Do not carry heavy items with the arm that has the access
- Do not sleep on that arm or wear clothing or jewelry that binds that arm
- Do not let anyone draw blood or measure blood pressure from that arm
- Do not allow injections to be given into the fistula or graft
- Keep the site of the fistula or graft clean
- After dialysis, monitor the access for signs of infection, such as swelling
- Do not use any creams and lotions over the site of the fistula or graft
Peripheral Arterial Bypass Surgery
Radiofrequency Venous Ablation
Surgical bypass treats narrowed arteries by creating a bypass around a section of the artery that is blocked. The arteries are normally smooth and unobstructed on the inside but they can become blocked through a process called atherosclerosis, which means hardening of the arteries. As you age, a sticky substance called plaque can build up in the walls of your arteries. Cholesterol, calcium, and fibrous tissue make up the plaque. As more plaque builds up, your arteries can narrow and stiffen. Eventually, as the process progresses, your blood vessels can no longer supply the oxygen demands of your organs or muscles and symptoms may develop.
During a bypass, the vascular surgeon creates a new pathway for blood flow using a graft. A graft is a portion of one of your veins or a man-made synthetic tube that your surgeon connects above and below a blockage to allow blood to pass around it.
Vascular surgeons use bypasses to treat peripheral arterial disease (PAD). Surgeons use bypasses most commonly to treat leg artery disease, which is hardening of the arteries in the leg and to also treat arm artery disease.
First the physician asks you questions about your general health, medical history, and symptoms. In addition, your physician conducts a physical exam and may order a blood test to determine your cholesterol levels. Together, the questions and examination are known as a patient history and exam. Your physician will also want to know when your symptoms occur and how often.
Next, the physician orders tests to locate the blockage and chooses the best places to connect the graft. These tests include:
- Duplex ultrasound, which is a non-invasive test that uses high-frequency sound waves to measure real-time blood flow and detect blockages or other abnormalities in the structure of your arteries
- Magnetic resonance angiography (MRA), which uses magnetic fields and radio waves to show blockages inside your arteries
- Angiography, which produces x-ray pictures of the blood vessels in your legs using a contrast dye that is injected to highlight your arteries
If you have arterial disease affecting the arms or legs, your physician may order segmental blood pressures or pulse volume recording to determine the narrowing of the arteries in your arm or leg. If you have had a heart attack in the past, or if you have chest pain, your physician might recommend a stress test or, possibly, a heart catherization.
Your physician or vascular surgeon will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, your physician will ask you not to eat or drink anything 8 hours before your procedure. Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.
Factors that increase your chances of complications include:
- High blood pressure
- High cholesterol
- Coronary artery disease
- Chronic obstructive pulmonary disease, such as emphysema
- Poor kidney function
During the procedure
For an arm or leg bypass, your vascular surgeon usually first selects and removes the vein that will serve as the bypass graft for your artery. Your vascular surgeon usually uses your great saphenous vein (GSV) for the graft, if it is suitable. Your GSV runs under your skin between your foot and your groin. Sometimes your surgeon may need to use another vein or a synthetic fabric artery for the graft.
To reach the bypass site in your blocked artery, your surgeon makes an incision in your skin over the artery. Once your surgeon exposes the artery, he or she evaluates the pulse in the healthy part of the artery. By checking the pulse, your surgeon makes sure that the artery provides enough blood flow to supply the bypass.
Your surgeon next opens the artery below the part that is blocked. This is where he or she will connect one end of the graft. Your surgeon sews the graft into your artery with permanent stitches. Next your surgeon routes the other end of the graft between your muscles and tendons to a site above the blockage. In the same way, the surgeon then opens the artery and, at this location, stitches the graft onto this end of the artery. Your surgeon checks the bypass for correct alignment and leakage.
During the procedure, your vascular surgeon may perform an arteriogram or duplex ultrasound examination in the operating room to check the bypass for any problems. When the surgery is complete, your surgeon closes all of the incisions. After the procedure, your surgeon may order a duplex ultrasound or other non-invasive tests, such as pulse volume recordings, to make sure the bypass is functioning properly.
Expectations after surgical bypass
Your hospital stay may range from about 3 to 10 days. After you leave the hospital, your surgeon will remove staples or stitches from the incisions, usually about 7 to 14 days after your operation. You may need assistance from a visiting nurse, home health aide, or physical therapist when you first go home or to a rehabilitation facility.
If you develop fevers, a cold painful arm or leg, or if your incision area becomes extremely red, swells, or begins draining, you should contact your physician immediately. If you have PAD, your physician or surgeon may recommend that you take an anti-platelet medication, such as aspirin, which can help prevent blood clots.
Complications from bypass surgery are possible, but not usual. Some less serious complications from bypass surgery may include swelling or inflammation at the incision site. Others, such as blockage of the bypass, bleeding from the incision or infection, are potentially more serious. Your vascular surgeon will discuss the important risks and benefits with you and answer your questions.
Surgical bypass does not stop plaque build up. If you have bypass surgery, you should make changes in your lifestyle to preserve the success of your bypass graft. You should consider changes that will help lower your blood pressure and decrease the chances that plaque will affect your graft or other arteries. These changes include:
- Regular use of aspirin, statin (cholesterol lowering) medications
- Eating foods low in fat, cholesterol, and calories
- Maintaining your ideal body weight
- Exercising aerobically, such as brisk walking, for 20 to 30 minutes at least 5 times each week
- Quitting smoking
Surgical Aneurysm Repair
In surgical aneurysm repair, your vascular surgeon repairs or removes an aneurysm through an incision in your skin. An aneurysm is an enlarged and weakened section of an artery. An aneurysm is a serious health concern, because as it increases in size, it can rupture. Besides rupturing, aneurysms carry another risk. Blood clots can form in an aneurysm and block blood flow to parts of your body.
Fortunately, aneurysms can be repaired safely. It is also fortunate that more than one method to repair aneurysms is available. These include surgical, sometimes called “open” aneurysm repair, and endovascular, sometimes called “stent graft” aneurysm repair. The best method to repair each aneurysm depends upon several factors, including the location and shape of the aneurysm as well as the condition of the patient.
Although aneurysms can involve other arteries, most aneurysms occur in your aorta, which is the largest artery in your body. It runs from your heart through your chest and abdomen. An aneurysm that occurs in your abdomen is called an abdominal aortic aneurysm, or AAA. An aneurysm that occurs in your chest is called a thoracic aortic aneurysm, or TAA. Aneurysms also occur in the arteries located in your thigh, knee, spleen, liver, kidneys, or stomach. AAA is the most common type of aneurysm.
When an aneurysm causes symptoms or grows to a size that it can threaten your health, your physician might recommend surgical aneurysm repair. A vascular surgeon performs this procedure, while you are under anesthesia, by making an incision in your body to reach the aneurysm. In some cases, depending upon the type and location of the aneurysm, your surgeon may repair your artery using tissues from your body or synthetic fabric patches or tubes called grafts. Less commonly, your surgeon may use clips or clamps to stop blood from flowing into your aneurysm.
First, the physician obtains a medical history by asking you questions about your general health and symptoms. The physician will also want to know if and when your symptoms occur and how often. In addition, the physician conducts a physical exam. Together these are known as a patient history and exam. As part of your physical exam, your physician will gently feel the aneurysm through skin over the suspected aneurysm and listen to your arteries through a stethoscope.
Next, the physician may order some tests to measure the size of the aneurysm and determine its location. Although not all the tests may be required for each patient, they usually include:
- Duplex ultrasound
- Computed tomography (CT) scan
- Magnetic resonance angiography (MRA)
Your physician or vascular surgeon will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, the physician will ask you not to eat or drink anything at least 8 hours before your procedure. Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.
Serious health problems, which may be more likely in some individuals especially if they are very elderly, may increase the chances of having complications during aneurysm surgery. If your general health is good, however, your age alone is not a reason to avoid necessary aneurysm repair. Other factors that may increase your chances of complications include:
- Congestive heart failure
- Cardiopulmonary obstructive disease (COPD), in which airflow through your lungs is decreased
- A previous heart attack, which may indicate coronary artery disease (CAD)
- Recurring chest pain, called angina pectoris, which may also indicate CAD
These risk factors should be evaluated and treated by your physician before elective aneurysm repair to lessen your chances of complications associated with aneurysm repair.
You will be given anesthesia to eliminate pain during your aneurysm operation and your vascular surgeon will make an incision in your skin and muscle over the aneurysm. For AAA, for example, your surgeon will work through your abdominal wall. If your aneurysm is in your knee, your surgeon will operate in your leg.
Once your surgeon exposes the aneurysm site, he or she will clamp the artery above the aneurysm to stop blood from flowing through the area. Your surgeon next opens the aneurysm and removes the clotted blood and plaque deposits.
Usually, depending upon the location of the aneurysm, your surgeon will not completely remove your aneurysm. Instead, he or she may cut through the wall of the weakened artery and open it. He or she may then insert a graft that is the same size and shape of your healthy artery. Your surgeon will attach one end of this graft by sewing it to the healthy artery just above where the aneurysm begins and sewing the other end to your normal artery below the end of the aneurysm.
In some cases, if the aneurysm involves a smaller artery in your leg or other location, your surgeon may remove the aneurysm and replace it with a piece of a vein from your leg. For aneurysms involving larger arteries, such as your aorta, a man-made graft is necessary because your vein would not be large enough for this location.
After your surgery, depending on the location of your incision and your general health, you may need to stay in the hospital for about 7 to 10 days until you are recovered enough to go home. Again, depending upon the location of your incision and your general health, you may require intensive care until you recover sufficiently.
Your physician or vascular surgeon will give you the special instructions you need to follow after the surgery, such as not lifting anything more than 10 to 15 pounds, until your incision heals adequately.
Periodically, depending upon its location, your physician may schedule you for an imaging study to make sure that your aneurysm is not redeveloping and that the graft, patch, or clips are functioning correctly.
You may have complications following any major surgical procedure. Less serious complications that you may experience following aneurysm surgery include swelling, respiratory or urinary infections, or infections at the incision site. More serious complications that you may experience include:
- Heart problems
- Breathing problems
- Kidney problems
- Colon problems
Paralysis in the lower half of the body is very rare following abdominal AAA surgery but can occur more commonly following extensive thoracic aortic aneurysm operations. Surgery for AAA can sometimes lead to scar formation that can interfere with the nerves that control the flow of semen into the penis as well as its erection. If you are a man, and if you have normal sexual function before the procedure, you might experience retrograde ejaculation or possibly difficulty with erection after the operation. Retrograde ejaculation means that the semen travels up into your bladder instead of coming out your penis, but it does come out later when you urinate.
These complications are relatively unusual after elective aneurysm AAA surgery but more frequent after emergency AAA repair and must be balanced against the risk of not treating the aneurysm.
To help maximize the long-term benefits of aneurysm surgery, you may have to change some of your lifestyle habits. Recommended changes include:
- Eating foods lower in fat, cholesterol, and calories
- Exercising aerobically, such as walking briskly, for 20 to 30 minutes 5 times each week
- Quitting smoking
- Maintaining your ideal body weight.
Varicose Vein Excision
Venoplasty and Stenting