Post-Op Information

Peripheral Vascular Disease Surgery

The Risks
While peripheral vascular disease (PVD), otherwise known as peripheral arterial disease (PAD), is generally more troublesome than dangerous, there is a significant group of patients where it causes a lot of trouble. Skin breakdown causes ulceration or lack of blood to the skin and muscles causes severe pain, claudication & rest pain. In this case there is a threat the limbs might die (gangrene). Associated with this the patient will become weak and may fall and injure themselves. The stress may precipitate a cardiac or cerebral event and the patient’s life may be threatened.

The Patients
In many of these cases there are long standing severe blockages of the arteries. Quite commonly there are a number of blockages which were not noticed because the patient was elderly and didn’t walk much. Many patients are minimally symptomatic and not actively investigated. The development of an ulcer or a black toe usually indicates much more than a local problem.

The Operations
After history and examination and imaging studies, which often include angiography, the surgeon may recommend surgery.

It is always major surgery and always comes with a significant risk to the patient’s limb or life. (10-15%) Blocked arteries can be exposed at either end. They may be improved by local clearing out of blockages (endarterectomy). A bypass graft can then be sewn from a reasonable point of inflow to a reasonable point of run-off. Bypasses can be made using the patient’s own veins which are the best material or with synthetic materials (Dacron or Gore-Tex). Dacron or Gore-Tex is favoured in the abdomen, Gore-Tex or vein is favoured in the thigh and generally vein is better for the anything that crosses the knee. Many patients may not have sufficient vein length in their legs and in that case arm vein can be used. Composite grafts with a piece of vein and some plastic component for the patency rate better than the use of plastic alone but worse than the use of vein alone.

The surgery is generally long (2-4 hours), incisions are long. This means fairly deep and prolonged anaesthesia and a significant blood loss and intra-operative cooling of the patient. Associated problems such as cardiac respiratory and renal issues are therefore not surprising.

Following surgery referral to a rehabilitation facility is routine. Some weeks or months later a good recovery can be expected in many patients. Blocked arteries in other areas or other medical issues may then need to be addressed. Ongoing supervision and the possibility of further procedures need to be thought about well in advance for the first operation.

Endovascular Alternatives
When nothing else was available these were extremely beneficial procedures for patients. More lately many of these procedures are being supplanted by endovascular techniques. These are generally safer techniques but sometimes they are less appropriate or less durable. Open vascular surgery is an important part in the management of all vascular surgical patients and should be considered in every case. It remains vitally important in urgent vascular injuries e.g. ruptured abdominal aortic aneurisms, bleeding or occluded femoral artery after angiography, arterial embolism from cardiac rhythm disturbances. The names of some common operations are Aortofemoral bypass, Iliofemoral bypass, Femoropopliteal bypass, Tibial bypass.

Overview Of Pvd Surgery
The final point worth considering with all these bypasses is that it is somewhat like building freeways in Melbourne. If there is no run-off the freeway will clog up. If the graft is running into a very small diseased artery that runs a very short distance then the graft won’t work well or last long. The recent epidemic of diabetes which affects arteries in the calf has meant tibial bypasses may need to be done onto diseased arteries with poor run-off. Not surprisingly long operations can be met with limited results in quite a few patient cases.

Use of this sort of surgery in milder cases of peripheral arterial diseases e.g. pain when you are walking or claudication has generally fallen out of favour. It is uncommon to have a significantly bad result from bypass, but in the context of claudication loss of a limb is a massive disaster. Endovascular procedures are more appropriate for claudicants.