Vascular diseases are usually caused by conditions that clog or weaken blood vessels, or damage valves that control the flow of blood in and out of the veins, thus robbing them of vital blood nutrients and oxygen.
Common Vascular Conditions Michael Bruce treatments focus on
Aortic Aneurysm Repair
The second most common site of the development of Aneurysms is the arteries behind the knee.
The most common complication of the Aneurysms is of course rupture and this is associated with a very high mortality rate. Treatment is therefore directed to preventing these Aneurysms from rupture. Almost all of Aortic Aneurysms are picked up incidentally and if smaller than 5cm in diameter are simply observed, periodically having ultrasound examinations to observe their size and check for any change.
If and when the Abdominal Aortic Aneurysm (AAA) reaches 5.5cm in diameter then intervention is required to prevent even the slightest chance of rupture.
Today almost 90% of all Aortic Aneurysms are treated by endovascular stent grafts usually via a 1cm incision in each groin. The stent grafts used to treat the Aneurysms are housed within a tube (sheath) measuring 5-6mms in diameter; they usually pass easily up through the arteries in the groin and pelvis and up into the affected site in the aorta.
Following endovascular treatment the patient goes back to the general vascular ward and is eating within 2-4 hours following treatment. They are usually allowed up the same day and are home within 48 hours.
Post operatively they require long term follow up with ultrasound scans to see that the aneurysmal sac is reducing in size.
If in the unlikely event that the Aneurysms are anatomically unsuitable for treatment via endovascular stent grafts open surgical repair may be required. Patients requiring open surgery usually have an abdominal incision and often require a short stay in intensive care immediately post operatively. They usually require a 7-9 day stay in hospital post operatively. They do not however require continued long term surveillance by ultrasound or CT scanning once the procedure has been performed.
Aneurysms of the peripheral arteries can either be treated with stent grafts or preferably open bypass surgery depending on their length, size and anatomical positions.
Carotid Endarterectomy (CEA)
Surgery: A vertical incision is made on the appropriate side of the neck and the carotid arteries are carefully dissected out. The blood is then “thinned” (anticoagulated) and the blood vessels are clamped. The internal carotid artery is opened and the atheromatous plaque is cored out. The artery is then closed most commonly with a patch of vein taken from the leg. The wound is then closed with invisible sutures. The procedure is usually performed under general anesthesia and all being well post-operatively the patient is usually discharged within 48 hours. The risk of stroke following the procedure is usually reduced from 30% to less than 1%. The risk of stroke in patients who have had a warning stroke or “TIA” and have significant narrowing of their internal carotid artery is in the order of 25-30%. The risk of stroke during the operation for patients with TIA’s is around 1%.
Carotid Stenting: This is an alternative to carotid endarterectomy and is usually done under local anesthetic via a catheter passed up through the femoral artery. It is associated with a slightly higher peri-operative stroke rate compared to carotid endarterectomy and is therefore most commonly used in patients who have had previous neck surgery or radiotherapy to the neck. Occasionally it is used for narrowings situated much higher in the carotid artery. It is occasionally used when patients are not ﬁt enough to have open surgery but open surgery carotid endarterectomy generally remains the primary treatment of choice because of its lower peri-operative stroke rate. All patients having any form of carotid intervention should be on antiplatelet therapy, either aspirin or clopidogrel or both.
It may involve the hands, armpits (axillae), face, scalp and torso, or any combination of the above.
Sweating is a normal physiological response. It is mediated by the sympathetic nervous system. It occurs in times of stress, and also acts to regulate body temperature, for example when we exercise or when the weather is hot. In those with hyperhidrosis, the sweat glands are activated at any time.
This condition, when it affects the hands, and to a lesser extent the axillae, can be treated by interrupting the nerve supply to the sweat glands. This involves dividing or ablating the sympathetic nerves that supply that region.
The procedure referred to as a “Thoracoscopic Sympathectomy” can be accomplished using keyhole surgery. It is performed under general anaesthesia. Two tiny incisions are made in the armpit, and through those incisions a scope a passed into the chest, the sympathetic nerves are easily identified, and ablation of the nerve at the appropriate level will cure the problem. It is generally performed as a day procedure with very little downtime.
The success rates are very high, and the overwhelming majority of patients do exceedingly well. There are however potential adverse reactions, which you need to be aware of. The most important is rebound sweating or compensatory hyperhidrosis. This involves increased sweating involving the torso, which occurs in response to the sympathectomy. It occurs commonly in 30% of patients, but is usually very mild and not troublesome. However in 2%, it can severe, and it is often difficult to predict who might develop this. There is a very small risk (one in 1000) of Horner’s syndrome, which can result in a droopy eyelid. As the procedure is performed in the chest, discomfort in the chest is common, but invariably settles within a week.
Overall, the high success rate and low rate of complications make this a most satisfying procedure for those patients with severe hyperhidrosis.
Peripheral Arterial Disease
Narrowing (stenoses) or complete blockages (occlusions) are often responsible for pain in the calf muscles that develops with walking (claudication) and if more severe can cause ulceration and even focal gangrene.
Treatment of these narrowings or blockages are preferably undertaken by endovascular means using balloons and stents which are inserted usually through the artery in the groin (femoral artery) under local anaesthetic. It is often possible for the patient then to go home on the same day of the procedure or at the latest following morning.
If however the blockages are quite long and beyond the scope of the lesser invasive endovascular treatment then open surgery usually consisting of bypass grafting is required. The patients own (long saphenous) vein is most often used as the conduit to take blood from the artery (usual the femoral) above the blockage to the artery (usually popliteal) above or below the knee to overcome the blockage. Thankfully the vein we most often use lies in the line above the arteries that need to be treated.
If a suitable length vein is not available we often use synthetic veins to bypass the blocked artery.
The length of stay following bypass surgery is variable but patients are usually home or at rehab within 5-7 days.
Bypass grafts may also be required in situations of acute blockages of arteries, trauma and blocked peripheral artery aneurysms.
Radiofrequency / Laser Ablation of varicose veins
This procedure is designed to avoid the need for open surgery of varicose veins in appropriate cases. The procedure is normally performed in the consulting suites under local anaesthetic. There is no need for significant sedation or general anaesthesia. Very often sclerotherapy (injecting) the smaller varicose tributaries is undertaken at the same time.
With the patient comfortable on the examination couch the course of the offending vein is mapped using Doppler ultrasound. Once the leg is suitably prepared a small catheter is placed inside the saphenous vein in the region of the knee. The radiofrequency or laser probe is then passed through this fine catheter and advanced up to the groin under ultrasound control. As both the laser and radiofrequency ablater generate a lot of heat dilute local anaesthesia is infiltrated along the course of the vein to be treated to cool and anaesthetise the area. It also has the secondary function of compressing the vein wall against the probe.
The probe is then activated which causes a thermal injury to the long or short saphenous vein as it is slowly withdrawn. This injury causes the vein to shut down effectively eliminating it from the circulation. When this part of the procedure has been completed some sclerotherapy of smaller veins may be undertaken. At the conclusion of the procedure an elastic stocking is applied to the leg. This stocking is to be worn continuously for 5 days and nights and then for the following 2 weeks, being applied in the morning and removed in the evening.
Following the procedure there are no real restrictions and the patient is encouraged to be as active as possible.
Simple analgesia is usually all that is required to control any post operative pain if it occurs.
A follow up ultrasound scan is performed at the 1 week mark and the patient is usually reviewed following the ultrasound scan. Any further varicose tributaries that require treatment can be sclerosed any time after that.
The procedure is very safe and effective and is associated with a very low complication rate and a very low risk of DVT. This risk is less than 1%.
The sclerosant injected, most commonly aethoxysclerol, is highly effective in blocking off (occluding) these smaller veins causing them to eventually disappear.
A very fine needle is used to inject this sclerosant into the unwanted veins and following the treatment a stocking is applied to the treated leg. The stocking remains on unchanged for 5 days and nights and then is worn for a further 2 weeks, applying it in the morning and removing it in the evening. There are no other restrictions and patients are encouraged to continue their normal activities including exercise. There are no restrictions in regard to driving a car.
Potential side effects:
- Minor discomfort is sometimes experienced and best treated with a non steroidal anti-inflammatory tablets such as Nurofen.
- The occluded vein may be tender to palpation for sometime and it will feel “lumpy” to touch.
- Pigmentation overlying the site of the injected vein is a common occurrence and usually resolves spontaneously over a period of 6 months. If it persists, a topical application or the use of laser treatment can be employed to eradicate the staining.
- Skin damage is an uncommon occurrence and in the unlikely event that it occurs, it is usually self limiting and heals spontaneously.
- DVT is extremely unlikely in the treatment of superficial veins.
- Allergic reactions are also extremely rare.