Toronto Endovascular Centre

Peripheral Artery Occlusive Disease (PAD) & Claudication

Treatment Options

Exercise for Claudication

Foot Care

Angioplasty & Stenting

Thrombolytic Therapy

Surgical Bypass

Amputation

Exercise for Claudication

Leg artery disease (peripheral arterial disease or PAD) can cause discomfort or pain when you walk. The pain most often occurs in the calf but can occur in your hips, buttocks, thighs, knees, shins, or upper feet. This is called intermittent claudication.

Claudication is discomfort or pain in your legs that happens when you walk and goes away when you rest. You may not always feel pain; instead you may feel a tightness, heaviness, cramping, or weakness in your legs. Claudication often occurs more quickly if you walk uphill or up a flight of stairs. Over time, you may begin to feel claudication at shorter walking distances.

What can I do to help claudication?

Your physician will give you a specific treatment plan for your PAD, which may include lifestyle changes like quitting smoking and losing weight. Your physician may also recommend a walking program to help improve the blood flow to your legs and decrease the pain you feel in your legs. Walking programs can double or quadruple the distances you can walk without pain.

Your vascular specialist will tailor your walking program to you, but walking programs generally follow similar guidelines. Your walking program will work best if you:

• Walk 3 or more times per week.
• Increase the amount of time that you can walk without reproducing the pain in your legs by gradually walking for longer and longer periods.

You will need to maintain the walking program for 3 to 6 months to gain benefits from it.

Your physician will also tailor your walking program to your specific needs, but typical sessions contain the following elements:

• At first, walk until you feel mild leg pain, often about 3 to 5 minutes after starting.
• Continue walking until the pain becomes moderate to severe (on a scale of 1 to 5, the pain is 3 or more).
• Stop and rest until the pain goes away, usually after a few minutes.
• After the pain goes away, begin walking again.
• Repeat this cycle of exercise and rest for a total of 30 to 35 minutes
• As your program continues, gradually increase the time you walk to a total of 50 minutes to 1 hour.

As you progress in your walking program, you will be able to walk for longer periods of time without pain.

Foot Care

Foot care is important if you have leg artery disease (peripheral arterial disease or PAD). In PAD, the blood vessels in your limbs become blocked because of hardening of the arteries. If you have PAD or diabetes, you must pay special attention to your feet because diabetes makes blood vessels more susceptible to hardening of the arteries and nerve damage called neuropathy. Neuropathy can cause loss of feeling, tingling, and pain in your feet or weakness of your leg. Left untreated, nerve damage can lead to tissue death, known as gangrene, and amputation.

If you have PAD or diabetes, it is important for you to take care of your feet to make sure that they remain healthy. You should monitor your feet regularly and protect them from injuries through proper hygiene and injury prevention. By taking care of your feet, you can avoid serious complications.

What can I do to prevent foot complications?

Your vascular specialist will give you a specific treatment plan depending on your condition. This plan will include instructions about how to take care of your feet. But it will be up to you to make sure that they remain healthy, that you can detect any problems early, and that you seek treatment right away. Some of the ways in which you can keep your feet healthy include:

• Check your feet every day: Look for cuts, sores, blisters, redness, warm spots, and swelling all around your feet and ankles and between your toes. If you have trouble seeing the soles of your feet, use a hand mirror or ask someone to check them for you. If you find anything abnormal when examining your feet, call your doctor
• Wash your feet every day: Wash your feet in warm water, but don't soak them because that can dry them out. Make sure the water is not too hot by testing it first with your hand or elbow. Dry your feet thoroughly including between your toes.
• Moisturize your feet to keep the skin soft and smooth: Apply a thin coating of a lotion such as Clean & Moist, Uremol 10 & 20, or Vitamin E ointment with Keri Lotion on your feet every day to keep them smooth and to prevent dryness. Avoid using lotion between your toes because this can cause infections
• Do not treat yourself: If you develop rough skin, corns, or calluses, ask your doctor to treat them, do not treat them yourself.
• Trim your toenails regularly: Use a nail trimmer to keep your toenails neat to avoid irritation of the skin. Cut straight across the nail, avoid cutting the corners of your nails, and smooth any rough spots with an emery board or nail file. If you have trouble trimming your toenails, ask someone to help you. If your toenails become thick, yellowed, or are growing into your toes, call your doctor.
• Always wear shoes and socks: To avoid injuring your feet, always wear socks and shoes even when you're inside. Socks that fit well, have some padding, and are without a seam are best. Remember to check the inside of your shoes to make sure nothing is in them and that the linings are smooth. Also avoid wearing open-toe or open-heel shoes.
• Buy shoes that fit properly: Shoes that don't fit properly can cause blisters and sores. Make sure to have your feet measured every time you buy shoes, and pick shoes that match the shape of your feet. Be sure that your shoes are snug enough so that your feet don't slip in them, but leave enough room for you to wiggle your toes. Buy rounded shoes and preferably low heels.
• Protect feet from heat and cold: Always wear shoes on hot pavement. If your feet are exposed to sunlight, remember to use sunscreen. Avoid sitting or lying with your feet near radiators or space heaters. Do not place heating pads or hot water bottles on your feet. Wear socks to protect your feet from cold. During cold weather, check your feet regularly during cold weather to monitor for frostbite.
• Maintain blood flow to your feet: Wiggle your toes and flex your feet and ankles for 5 minutes 2 to 3 times each day. Remember not to cross your legs for long periods of time. Avoid tight-fitting socks and garters.
• Exercise: Exercise improves circulation as well as overall health. Activities like walking, dancing, swimming, and bicycling are all activities that will improve your overall health but minimize stress to your feet. Be sure to check with your doctor before beginning an exercise program.

Angioplasty & Stenting (Endovascular Treatment)

What is angioplasty and stenting?

In an angioplasty, your physician inflates a small balloon inside a narrowed blood vessel. The balloon helps to widen your blood vessel and restore normal blood flow. After widening the vessel with angioplasty, your physician 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 in your skin, called the access site. Your physician inserts a long, thin tube called a catheter through this access site. Your physician guides the catheter through your blood vessels to the blocked area. The tip of the catheter carries the angioplasty balloon or stent.

Angioplasty most often is used to treat peripheral arterial disease (PAD), which is another name for hardening of the arteries not involving your heart. It can also be used, in some circumstances, to treat narrowed areas in your veins.

Your arteries are normally smooth and unobstructed on the inside, but 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 can narrow and stiffen. This process is called atherosclerosis, or hardening of the arteries. Eventually, enough plaque builds up to reduce blood flow through your arteries.

Depending upon the particular circumstances, your physician may recommend angioplasty as an alternative to bypass surgery, which also treats narrowed arteries. For certain types of blockages, angioplasty has some advantages when compared to bypass surgery. For example, angioplasty does not require a large incision. Because of this, angioplasty patients usually spend less time in the hospital and recover at home faster than bypass surgery patients. Also, your physician can usually perform angioplasty while you are awake, whereas bypass surgery requires general or regional anesthesia. Nevertheless, in some circumstances, bypass surgery may be a better option. Your physician will help you decide what alternative is best for your particular situation.

How do I prepare?

First your physician asks you questions about your general health, medical history, and symptoms. In addition, your physician conducts 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. Your physician will also want to know when your symptoms occur and how often.

Next, your physician will order tests to show how much plaque has built up in your arteries. These tests can help your physician determine whether you need an angioplasty. 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:

• Duplex ultrasound
• Magnetic resonance angiography (MRA)
• Computed tomography (CT) scan

If these tests show that your arteries are moderately to severely narrowed, your physician may also plan a test called conventional angiography that shows your blood vessels on an x ray.

Your physician 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 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. If you have any allergies to contrast dye, which is used in angiography, you should tell your physician at this time. Since the contrast dye may contain iodine, you should also let your physician know if you have allergies to iodine or shellfish.

Immediately before your procedure, your physician may order tests to check your blood's ability to clot and your kidney function, and he or she may insert an IV to deliver fluids. Angiography is usually performed again at the beginning of the angioplasty procedure or sometimes the angioplasty procedure is performed at the time of the initial angiogram.

Am I a candidate for angioplasty and stenting?

You are a candidate for angioplasty and stenting if you have moderate to severe narrowing or blockage in one or more of your blood vessels. Usually, you will also have symptoms of artery disease, such as pain or ulceration, in one of your limbs.

If you have extremely hard plaque deposits, blockages that contain blood clots or a large amount of calcium, extensive or particularly long blockages, or blood vessel spasms that don't go away, you probably are not a good candidate for angioplasty.

Am I at risk for complications during angioplasty and stenting?

Complications to angioplasty and stenting include reactions to the contrast dye, bleeding or weakening of the artery wall, 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 you have diabetes or kidney disease, you may have a higher risk of complications from the contrast dye. In the case of kidney disease, sometimes pre-treatment with medications or 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.

What happens during angioplasty and stenting?

Your 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. This reduces your risk of infection. Your physician numbs your skin and then makes a small cut to reach the artery below. Although you may be given some mild sedation, your physician will usually want you to stay reasonably alert to follow instructions and describe your sensations during the procedure.

Your physician 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 physician 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. Your physician guides the balloon catheter to the narrowed section of your artery. He or she partially inflates the balloon by sending fluid through the balloon catheter.

Your physician watches the x ray screen for signs of a pinch in the balloon. Then, your physician will inflate the balloon more, until the pinch caused by your artery flattens out. When the balloon is full, your physician may deflate and re-inflate it repeatedly to press the plaque against your artery walls. Usually, this process takes a few minutes. Sometimes, if you have a severe blockage, your physician may need to inflate and deflate the balloon longer.

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, any pain will go away when your physician deflates the balloon and normal blood flow resumes. Make sure to tell your physician if you experience any symptoms during angioplasty.

There is a risk that your artery will re-narrow or become blocked again 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 physician will sometimes need to use a stent 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. To place a stent, your physician removes the angioplasty balloon catheter and inserts a new catheter. On this catheter, a closed stent surrounds a deflated balloon. Your physician guides the stent through your blood vessels to the place where the angioplasty balloon widened your artery. Your physician inflates the balloon inside of the stent. This expands the stent. Your physician then deflates and removes the balloon. The stent 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.

A new type of stent is coated with drugs. These drugs help prevent scar tissue from forming inside a stent. Studies have shown that these new stents are more likely to prevent restenosis than ordinary, non-coated stents.

Once your physician 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.

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 looks like a tiny cork or he or she may give you stitches that will dissolve.

Angioplasty and stenting usually takes between 45 minutes and 1.5 hours, but sometimes longer depending upon the particular circumstances.

What can I expect after angioplasty and stenting?

Usually, you will stay in bed for 6 hours after your angioplasty. During this time, your physician 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.

If you notice any unusual symptoms after your procedure, you should tell your physician 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 physician 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 will 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.

Are there any complications?

Serious complications are unusual following angioplasty and stenting but, nevertheless, can occur.

Less serious complications include bleeding or bruising where your physician 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 physician 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. Stents, especially drug-coated stents, may reduce this risk. However, in some cases, you may need a repeat angioplasty or a bypass surgery.

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
• Blockages developing in arteries downstream from the treated artery from particles of the plaque breaking free (called cholesterol embolization).

Thromblytic Therapy

What is thrombolytic therapy?

Thrombolytic therapy is a treatment used to break up dangerous clots inside your blood vessels. To perform this treatment, your physician injects clot-dissolving medications into a blood vessel. In some cases, the medications flow through your bloodstream to the clot. In other cases, your physician guides a long, thin tube called a catheter through your blood vessels to the area of the clot. Depending on the circumstances, the tip of the catheter may carry special attachments that break up clots. The catheter then delivers medications or mechanically breaks up the clot.

Thrombolytic therapy commonly is used to treat an ischemic stroke, which is another name for a clot in blood vessel in your brain. It can also be used to treat clots in:

• A lung artery, called a pulmonary embolism
• The deep veins of your leg, called deep vein thrombosis (DVT)
• Your heart, which may cause a heart attack
• An artery elsewhere in your body, such as in an arm or leg artery; or
• A bypass graft or dialysis catheter that has become blocked

Your blood is normally a liquid that travels smoothly through your arteries and veins. Sometimes, however, blood components, called platelets, can form clumps and other blood components can cause the blood to gel. This process is called clotting or, more technically, coagulation. This is a normal process that protects you from excessive bleeding from even a minor injury. However, in certain circumstances blood clots can build up inside a blood vessel and block blood flow. At other times, pieces of these clots can break off, travel through your bloodstream, lodge in a blood vessel somewhere else in your body and obstruct normal blood flow. Blood clots in your heart or lungs, for example, can starve the organ and be life threatening.

Depending upon the situation, your physician may decide to provide thrombolytic therapy, also called thrombolysis, as an emergency treatment or as a scheduled procedure to dissolve the blood clots. For example, you may receive emergency thrombolysis if you are having a stroke. If you have DVT, your physician may schedule thrombolytic therapy for you.

How do I prepare?

First your physician will ask questions about your general health, medical history, and symptoms. In addition, your physician will conduct a physical examination. Together these are known as a patient history and exam. As part of your history and exam, your physician will ask you to list any medications, including vitamins or dietary supplements, you take. Your physician will also want to know when your symptoms occur and how often.

Next, your physician will order tests to make sure that you are able to receive thrombolysis safely. For example, he or she will check to see if your blood is clotting properly and that other factors, such as the mineral salts in your blood, are normal. The tests you will receive depend on which blood vessel is blocked and your medical condition. For example, your physician may order an echocardiogram test to find out whether there is a blood clot in your heart or an electrocardiogram (ECG) to evaluate your heart rhythm.

Your physician will give you the necessary instructions you need to follow before the thrombolysis procedure, such as fasting. Usually, your physician will ask you not to eat or drink anything 12 hours before your procedure. Your physician will also discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.

You will usually undergo a test called angiography either before or as part of thrombolytic therapy. Angiography creates a picture of your blood vessels (called an angoigram), and uses a dye, called contrast, which is eventually flushed out through your kidneys. If you have kidney trouble, or if you have had a test that uses contrast before and had an allergic reaction to the contrast, you should tell your vascular surgeon.

Am I a candidate for thrombolytic therapy?

You may be a candidate for thrombolytic therapy if you have symptoms of a stroke, heart attack, pulmonary embolism, DVT, or a clot in an artery or bypass graft in a limb. These symptoms may include:

• Chest pain
• Numbness or tingling on one side of the body
• Blurred vision in one eye
• Slurred speech
• Sudden weakness
• Severe swelling of an arm or leg; or
• Pain, numbness, or coldness in a limb

If you have a life-threatening clot, your physician will attempt to establish thrombolytic therapy as soon as possible after symptoms begin, preferably within 1 to 2 hours.

If you have severe high blood pressure, active bleeding or severe blood loss, a stroke from bleeding in the brain (called hemorrhagic stroke), severe liver disease, or have recently had surgery you probably are not a good candidate for thrombolytic therapy.

Am I at risk for complications during thrombolytic therapy?

If you have diabetes or kidney disease, you may have a higher risk of complications from the contrast agents used in the angiogram. If you have kidney disease, sometimes your physician can treat you with medications or fluids before you receive contrast, to protect your kidneys and minimize the risk.

People with blood clotting disorders also may have a higher risk of complications from thrombolysis. Other factors that may increase the risk for complications include:

• History of internal bleeding
• Pregnancy
• Endocarditis, an infection in the lining of the heart
• Advanced age
• Poorly controlled hypertension; or
• Diabetic retinopathy, a problem in the eyes that results from diabetes

What happens during thrombolytic therapy?

In some hospitals, physicians perform thrombolytic therapy in the intensive care unit, but in others thrombolysis may be performed in nursing units familiar with the treatment and potential complications. In either circumstance, your physicians and nurses will carefully watch your vital signs and be prepared for an emergency during the procedure, such as bleeding. Initially, you will lie on an x-ray table, and machines will monitor your vital signs.

Thrombolytic drugs can be delivered in two ways: through a short catheter inserted in a vein (called an intravenous, or IV, catheter), or through a long catheter that is guided to the clot through your arteries or veins. In emergencies, Physicians often choose the IV method because it is quick and safe to perform outside of a hospital. If your physician chooses to guide the catheter directly to the clot, the end of the catheter may be placed in the vessels leading to your brain, lung, heart, arm, or leg depending upon the location of the clot.

To deliver the thrombolytic therapy, your physician will make a small puncture over an artery or vein in your groin, your wrist, or your elbow. This place is called the access site. Before inserting the catheter through this puncture, he or she will clean your skin and shave any hair. This reduces your risk of infection. Your physician then will numb your skin with a local anesthetic and then sometimes makes a small cut or puncture to reach the blood vessel below. Although you may be given some mild sedation, you will usually stay awake during the procedure.

Next, your physician will usually inject contrast through the catheter to map your blood vessels with angiography and to locate the clot. You may feel a warm sensation during the injection, which is normal. As the contrast flows through your blood vessels, x-rays are taken. The x-rays do not pass through the contrast, so pictures of your blood vessels appear on a screen. An indication of the clot location will appear as well.

Once your physician locates the clot, depending on the particular circumstances, he or she may inject the thrombolytic drugs through an IV catheter. More commonly, your physician will guide a longer catheter through your blood vessels to the vicinity of the clot and then inject the drugs near it. Because you have no nerve endings in your blood vessels, you will not feel the catheters as they move through your body.

Currently, the most common thrombolytic agents (“clot-busting" drugs) are:

• Streptokinase
• Urokinase; and
• Tissue plasminogen activator (t-PA)

Other drugs include recombinant, or genetically engineered, t-PA (a newer version of t-PA) and TNK (Tenecteplase.)

Your physician will periodically monitor the x-ray screen to see the clot breaking up. However, depending on the size and location of the clot, the drugs your physician chooses, and other factors, this process can take several hours. Sometimes, if you have a severe blockage, the treatment could last for several days. Once the clot has been dissolved or if it cannot be dissolved further, your physician will stop the medication. When the tests used to monitor your blood's coagulation ability are in a satisfactory range, your physician will then remove the IV or catheter, and press on the access site for 10 to 20 minutes to stop any bleeding. During the process, and for several hours afterwards, your physician will ask you to remain still to minimize the risk of bleeding from the access site.

The technique for mechanical thrombectomy is similar, except that small devices are attached to the catheter tip remove the clot or even break it up physically. These devices include a suction cup, a rotating device, and a high-speed fluid jet. Mechanical thrombectomy can work faster than thrombolytic drugs in some cases, and in favorable circumstances the procedure may take as little as 30 minutes. You physician will advise you if you are a good candidate for mechanical thrombectomy.

What can I expect after thrombolytic therapy?

Usually, you will stay in bed as you recover from thrombolytic therapy. During this time, your physician and the hospital staff closely watch you for any complications. You may receive fluids, antibiotics, or painkillers. If your physician inserted the catheter through an artery in your arm or leg, you may have to hold the limb straight for several hours. Once any bleeding from the access site stops, and your vital signs are normal, you may be discharged. Often, however, you will require further hospitalization for treatment of the underlying reason for the clot, or for adjustment of anticoagulation doses if needed to prevent clots from reforming.

If you notice any unusual symptoms after or during your procedure, you should tell your physician immediately. These symptoms may include:

• Arm or leg pain that lingers or gets worse
• A fever
• Shortness of breath
• An arm or a leg that turns blue, develops swelling or feels cold; or
• Problems around your access site, such as bleeding, swelling, pain, or numbness

Before your discharge, your physician will give you instructions about everyday tasks to follow after you return home. 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.

During your recovery, you may experience nausea, vomiting, or coughing. You should tell your physician if any nausea, back pain or lightheadedness lingers, because these symptoms could mean you have internal bleeding.

If you received thrombolytic therapy in an emergency, you may receive additional care for your condition. For example, if you had a stroke, your physician may prescribe medications, a special diet, or physical therapy. If you had a heart attack, your physician may need to examine your heart to see if any other arteries are blocked. If you had an blocked bypass graft, you may need further treatment or anticoagulation to keep the bypass open.

Are there any complications?

Complications are not unusual with thrombolytic therapy, which is why it should be carried out under close supervision. However, your physician can manage most of them, including:

• Bleeding in the access site or elsewhere
• Low blood pressure; or
• Allergy to thrombolytic drugs

Bleeding in the brain leading to stroke, can also occur, but it is rare and affects fewer than 1 in 100 patients.

Thrombolytic therapy is not always successful. In up to 25 percent of patients, the treatment is unable to break up the clot. This is especially true if the clot has been established for a long time. In another 12 out of every 100 patients, the clot or blockage will re-form in the blood vessel, especially if an underlying reason for the clot to form in the first place is not found and treated.

Surgical Bypass

What is surgical bypass?

Surgical bypass treats your narrowed arteries by creating a bypass around a section of the artery that is blocked. Your 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, your 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.

You may be familiar with bypass surgery on heart arteries, but vascular surgeons also 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. Surgeons also use bypass to treat arm artery disease.

How do I prepare?

First your 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, your physician orders tests to locate the blockage and choose 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
• Conventional 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 arm or leg artery disease, your physician may order segmental blood pressures 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.

Am I a candidate for bypass surgery?

If you have symptoms of atherosclerosis, you may be a candidate for bypass surgery. Symptoms can range from pain in the arms or legs during activity, called intermittent claudication, to the development of non-healing ulcers or gangrene (tissue death) in more severe cases. You may be a candidate for bypass surgery even if you are not eligible for angioplasty and stenting.

Am I at risk for complications during procedure?

Factors that increase your chances of complications include:

• High blood pressure
• Obesity
• High cholesterol
• Coronary artery disease
• Chronic obstructive pulmonary disease, such as emphysema
• Poor kidney function
• Diabetes
• Smoking

What happens during surgical bypass?

Your specific surgical procedure depends on your symptoms, your overall physical condition, and how much plaque has built up in your arteries. Your surgeon, with the help of your anesthesiologist, may use either general or regional (epidural or spinal) anesthesia for 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.

What can I expect 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.

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 antiplatelet medication, such as aspirin, which can help prevent blood clots.

Are there any complications?

Complications from bypass surgery are possible, but not usual. No procedure is risk-free, but you will experience a minimum number of complications if you select a well-trained vascular surgeon who specializes in the type of bypass surgery that your symptoms indicate. Some complications from bypass surgery are less serious and 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.

What can I do to stay healthy?

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:

• 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

Amputation

What is amputation?

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. Physicians consider amputation a last resort.

The most common reason you may need an amputation is if you have peripheral arterial disease (PAD) due to atherosclerosis (hardening of the arteries). In PAD, the blood vessels in your limbs become damaged because of hardening of the arteries or diabetes. Your body's cells depend on a constant supply of oxygen and nutrients from your blood. If your blood vessels are unable to deliver blood and oxygen to your fingers or toes, the cells and tissues die and are vulnerable to infection. Extensive tissue death may require amputation.

How do I prepare?

Your physician will perform a physical examination to decide whether you need an amputation. He or she will check you for:

• Fever
• Cool skin near your wound
• Extremely painful skin
• Wound odor
• Infected or non-healing sores or wounds

Your physician will also order tests to see how well blood is reaching your limbs. These tests include angiography, duplex ultrasound, and blood pressure tests.

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. Your physician will also test your physical strength, balance, and coordination. If you are going to use an artificial limb, your physician may measure you for the device before your operation. This way, your artificial limb will be ready as soon as you recover. You 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 this time.

When do I need 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 draining any infected tissue or performing surgery. 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 destroy blood vessels and cause tissue death. As a result, infection 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 cancerous tumors in your limbs. You may also receive chemotherapy, radiation, or other treatments to destroy cancer cells. These treatments can shrink the tumor and increase the effectiveness of your amputation.

Am I at risk for complications during 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 riskier than below-the-knee amputations, because people who receive above-the-knee amputations are more likely to be in poor health.

What happens during amputation?

To perform an amputation, your physician must remove your diseased limb but preserve 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. 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 cut, 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 put you to sleep or numb your body below the spine. You will be connected to machines that monitor your heart rate, blood pressure, temperature, and brain function. Your surgeon then cuts into your skin, leaving enough healthy skin to cover your stump for better healing.

When your surgeon then cuts through the muscles, he or she may either sew them to the bone, or shape them, to make sure that your stump has a comfortable contour for your artificial limb. Your surgeon 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.

If you have a traumatic injury your surgeon will remove the crushed bone. Your surgeon then will smooth the uneven areas of your bone to prevent pain once you receive your artificial limb. If necessary, your surgical team may then install temporary drains that will drain your blood and other fluids.

When your surgeon has completely removed all of the dead tissue, he or she may decide to leave the site open (open flap amputation) or to close the flaps (closed amputation). In an open flap amputation, your skin remains drawn back from the amputation site for 10 to 14 days so your surgical care team can clean off of any questionable or infected tissue. Once the stump tissue is clean and free of infection, the skin flaps are sewn together to close the wound. In a closed amputation, the wound is sewn shut immediately. A closed amputation is usually done if your surgeon is reasonably certain that the chance of infection is small.

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.

What can I expect after amputation?

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. 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 your surgery. 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.

Are there any complications?

You may have complications following any surgical procedure. 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, or infection. Your surgeon or physician can treat all of these complications. Rarely, you may need to undergo further surgical treatment or another amputation.

What can I do to stay healthy?

If your wound has healed well and your artificial limb fits you, your amputation should cause you no long-term medical concerns. However, if you have PAD, amputation does not stop plaque from building up. 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

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, probably because of changes in their attitudes regarding life goals.

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