What is Peripheral Disease?

Peripheral arterial disease is the result of blocked or narrowed arteries by deposition of plaque.  This can involve any artery in the body, but particularly involves arteries to the lower limbs.  The process gradually blocks off circulation to the limb and in the process causes restriction of blood supply to the muscles of the legs causing a clinical entity called claudication, which means the onset of cramp like pain in the muscles of the legs induced by walking.

If the circulation deteriorates further then pain in the foot, then leg ulcers and even gangrene of toes and foot, which can lead to limb loss.

The cause of this pathology is a build up of atherosclerotic plaque, which progressively hardens the arteries and restricts the blood supply to the legs. 

Risk factors

1.  Smoking

2.  Hypertension

3.  High cholesterol levels

4.  Diabetes

5.  Family history

6.  Advancing age

Arterial Disease assessment

1.  Clinical assessment by history and examination.

2.  Duplex ultrasound scan.

3.  Pressure measurements (occasionally)

4.  CT-angiogram or MRI

5.  Catheter based angiography.

Methods of treatment

1.  Medical therapy to control risk factors.

2.  Active exercise program.

3.  Arterial reconstruction.

     a.  balloon angioplasty and stenting

     b.  bypass surgery

     c.  endarterectomy  (removal of troublesome plaque)

Procedures

Balloon Angioplasty / Stent

When is it applicable?

Balloon angioplasty and stenting is the appropriate treatment when circulation is impaired enough to cause troublesome walking pain, persistent foot pain, ulcers or gangrene, provided the arterial blockage or narrowing can be treated by this technology.  Duplex ultrasound is a very good investigations for making this decision.

What is the procedure?

The patient is usually treated under local anaesthetic with sedation.  A needle puncture is introduced to the appropriate artery then an access sheath is introduced to allow catheter angiogram, which will show the anatomy of the arteries (narrowed or blocked). Then a guide wire is passed through the plaque and a balloon angioplasty catheter passed over the guide wire and inflated to re-establish a channel.  Subsequent angiograms during the procedure will identify any need for a stent and if needed it will be deployed through the same sheath.  Some times the original angiogram shows that the anatomy is not suitable for angioplasty or stenting and therefore, the patient will be considered for other methods of treatment such as bypass. This will usually be at a later date.

Risks

1.  Bleeding (particularly from the puncture site)

2.  Early arterial occlusion.

3.  Late arterial renarrowing or instent blocking.

This can lead to the requirement for a bypass, but this is very uncommon.

Post operative care

The patient is usually discharged from hospital the following day, but sometimes the same day.  Full activities are usually resumed after two days and this includes driving, but sporting activities are best avoided for a week after the procedure.  Post operative  review is important.

Bypass graft

When do we do it?

Bypass is reserved for treatment of more severe peripheral arterial disease causing significant symptoms of claudication, foot pain, ulcers or gangrene. This is usually associated with long occlusion of the leg arteries or in a situation where an attempt at angioplasty and stenting has failed.  Bypass can be combined with angioplasty and stenting of arteries above and below the site of bypass or combined with endarterectomy.

Procedure

This procedure is usually performed under spinal or general anaesthetic.  Bypass graft material is preferably vein from the same leg or prosthetic material, such as Gore-tex or Dacron.  (Sometimes arm vein or contralateral leg vein is used.)

The chosen material is selected and prepared.  The graft is then joined to a healthy artery above the blockage and a healthy artery below the blockage and various leg incisions are made to display these arteries and to aid harvesting of the bypass graft (if vein is to be used). Some times calcified plaque in the groin needs to be removed to facilitate the bypass and some times balloon angioplasty and stenting is required in the calf arteries to improve flow of blood to the muscles and skin in the lower leg and enhance the bypass.

Risks of the procedure

Most patients will experience some swelling of the leg in the early post operative days.  This will get less as time progresses and is controlled with support stockings.

Less common risks

1.  Nerve injury (usually small skin nerves.)

2.  Bleeding

3.  Wound infection

4.  DVT and embolism

5.  Occasionally graft occlusion (4-5%)

Limb loss as a consequence of bypass is a rare complication, but can occur. 

Late complications can include bypass graft occlusion or narrowing and these can be treated often by angioplasty or by revision surgery.

Post operative care

In hospital

Hospital stay is usually 7-10 days.  You will be walking within two days of surgery, with support bandaging or stocking and you will have an ultrasound scan about five days after the procedure.

After discharge from hospital

You will be instructed in an active walking program, which will become more significant about a week after discharge, but it will be about two weeks before you resume normal activities and about six weeks after a full range of activities including strenuous activity.  Driving can be resumed at about four weeks and you will need long term follow up for surveillance of the bypass graft.

Endarterectomy

What is this procedure?

Endarterectomy is a procedure to clear plaque from an artery to re-establish blood flow to the affected limb.  It most commonly applies to the femoral artery in the groin where stenting and bypass are less likely to be suitable.  It can apply to arteries in the abdomen, thigh and behind the knee.  It is a similar procedure to that procedure, which is undertaken with carotid disease.

This procedure is performed under spinal anaesthetic or general anaesthetic.  The artery in the groin is displayed through an incision, which is usually longitudinal in the groin.  The artery is displayed and Heparin is then given to prevent clotting during the clamp time.

Clamps are then applied to the artery.  The artery is opened and cleaned to remove plaque and thrombus and establish flow in the femoral artery and the profunda artery (to the thigh).

The incision in the artery is then repaired usually with a polyurethane patch sutured in place.

Flow is then established and the wound is closed.

Post operative risks

In the immediate circumstance the biggest concern is post operative bleeding, but this is an uncommon complication, which sometimes requires haematoma drainage, but the incidence of this is 1%.

Leg swelling is a common sequel, because of the interruption of lymphatic channels in the groin approach, but settles with support stocking and within three months.  The most common complication is a collection of lymphatic fluid (lymphocele) in the groin, beneath the incision and is sometimes can result in exudation of lymphatic fluid through the wound.  This occurs on 3% of occasions and rarely requires surgical reintervention.

The worse complication is infection and this is also rare.

What can you expect post operatively?

You will be in hospital for about five days until it is clear that the femoral wound is healing satisfactorily.  You will wear a stocking post operatively and you will have low dose anti-coagulants to minimise any risk of deep vein thrombosis.

You will be ambulant on day one after the procedure and after discharge you will be active around the house for a week and then you can start resuming normal range of activities, but it will be four weeks before you are ready for driving a car or returning to work.

Peripheral arterial disease is the result of blocked or narrowed arteries by deposition of plaque.  This can involve any artery in the body, but particularly involves arteries to the lower limbs.  The process gradually blocks off circulation to the limb and in the process causes restriction of blood supply to the muscles of the legs causing a clinical entity called claudication, which means the onset of cramp like pain in the muscles of the legs induced by walking.

If the circulation deteriorates further then pain in the foot, then leg ulcers and even gangrene of toes and foot, which can lead to limb loss.

The cause of this pathology is a build up of atherosclerotic plaque, which progressively hardens the arteries and restricts the blood supply to the legs. 

Risk factors

1.  Smoking

2.  Hypertension

3.  High cholesterol levels

4.  Diabetes

5.  Family history

6.  Advancing age

Arterial Disease assessment

1.  Clinical assessment by history and examination.

2.  Duplex ultrasound scan.

3.  Pressure measurements (occasionally)

4.  CT-angiogram or MRI

5.  Catheter based angiography.

Methods of treatment

1.  Medical therapy to control risk factors.

2.  Active exercise program.

3.  Arterial reconstruction.

     a.  balloon angioplasty and stenting

     b.  bypass surgery

     c.  endarterectomy  (removal of troublesome plaque)

Procedures

Balloon Angioplasty / Stent

When is it applicable?

Balloon angioplasty and stenting is the appropriate treatment when circulation is impaired enough to cause troublesome walking pain, persistent foot pain, ulcers or gangrene, provided the arterial blockage or narrowing can be treated by this technology.  Duplex ultrasound is a very good investigations for making this decision.

What is the procedure?

The patient is usually treated under local anaesthetic with sedation.  A needle puncture is introduced to the appropriate artery then an access sheath is introduced to allow catheter angiogram, which will show the anatomy of the arteries (narrowed or blocked). Then a guide wire is passed through the plaque and a balloon angioplasty catheter passed over the guide wire and inflated to re-establish a channel.  Subsequent angiograms during the procedure will identify any need for a stent and if needed it will be deployed through the same sheath.  Some times the original angiogram shows that the anatomy is not suitable for angioplasty or stenting and therefore, the patient will be considered for other methods of treatment such as bypass. This will usually be at a later date.

Risks

1.  Bleeding (particularly from the puncture site)

2.  Early arterial occlusion.

3.  Late arterial renarrowing or instent blocking.

This can lead to the requirement for a bypass, but this is very uncommon.

Post operative care

The patient is usually discharged from hospital the following day, but sometimes the same day.  Full activities are usually resumed after two days and this includes driving, but sporting activities are best avoided for a week after the procedure.  Post operative  review is important.

Bypass Graft

When do we do it?

Bypass is reserved for treatment of more severe peripheral arterial disease causing significant symptoms of claudication, foot pain, ulcers or gangrene. This is usually associated with long occlusion of the leg arteries or in a situation where an attempt at angioplasty and stenting has failed.  Bypass can be combined with angioplasty and stenting of arteries above and below the site of bypass or combined with endarterectomy.

Procedure

This procedure is usually performed under spinal or general anaesthetic.  Bypass graft material is preferably vein from the same leg or prosthetic material, such as Gore-tex or Dacron.  (Sometimes arm vein or contralateral leg vein is used.)

The chosen material is selected and prepared.  The graft is then joined to a healthy artery above the blockage and a healthy artery below the blockage and various leg incisions are made to display these arteries and to aid harvesting of the bypass graft (if vein is to be used). Some times calcified plaque in the groin needs to be removed to facilitate the bypass and some times balloon angioplasty and stenting is required in the calf arteries to improve flow of blood to the muscles and skin in the lower leg and enhance the bypass.

Risks of the procedure

Most patients will experience some swelling of the leg in the early post operative days.  This will get less as time progresses and is controlled with support stockings.

Less common risks

1.  Nerve injury (usually small skin nerves.)

2.  Bleeding

3.  Wound infection

4.  DVT and embolism

5.  Occasionally graft occlusion (4-5%)

Limb loss as a consequence of bypass is a rare complication, but can occur. 

Late complications can include bypass graft occlusion or narrowing and these can be treated often by angioplasty or by revision surgery.

Post operative care

In hospital

Hospital stay is usually 7-10 days.  You will be walking within two days of surgery, with support bandaging or stocking and you will have an ultrasound scan about five days after the procedure.

After discharge from hospital

You will be instructed in an active walking program, which will become more significant about a week after discharge, but it will be about two weeks before you resume normal activities and about six weeks after a full range of activities including strenuous activity.  Driving can be resumed at about four weeks and you will need long term follow up for surveillance of the bypass graft.

Endarterectomy

What is the procedure?

Endarterectomy is a procedure to clear plaque from an artery to re-establish blood flow to the affected limb.  It most commonly applies to the femoral artery in the groin where stenting and bypass are less likely to be suitable.  It can apply to arteries in the abdomen, thigh and behind the knee.  It is a similar procedure to that procedure, which is undertaken with carotid disease.

This procedure is performed under spinal anaesthetic or general anaesthetic.  The artery in the groin is displayed through an incision, which is usually longitudinal in the groin.  The artery is displayed and Heparin is then given to prevent clotting during the clamp time.

Clamps are then applied to the artery.  The artery is opened and cleaned to remove plaque and thrombus and establish flow in the femoral artery and the profunda artery (to the thigh).

The incision in the artery is then repaired usually with a polyurethane patch sutured in place.

Flow is then established and the wound is closed.

Post operative risks

In the immediate circumstance the biggest concern is post operative bleeding, but this is an uncommon complication, which sometimes requires haematoma drainage, but the incidence of this is 1%.

Leg swelling is a common sequel, because of the interruption of lymphatic channels in the groin approach, but settles with support stocking and within three months.  The most common complication is a collection of lymphatic fluid (lymphocele) in the groin, beneath the incision and is sometimes can result in exudation of lymphatic fluid through the wound.  This occurs on 3% of occasions and rarely requires surgical reintervention.

The worse complication is infection and this is also rare.

What can you expect post operatively?

You will be in hospital for about five days until it is clear that the femoral wound is healing satisfactorily.  You will wear a stocking post operatively and you will have low dose anti-coagulants to minimise any risk of deep vein thrombosis.

You will be ambulant on day one after the procedure and after discharge you will be active around the house for a week and then you can start resuming normal range of activities, but it will be four weeks before you are ready for driving a car or returning to work.