The majority of patients with hardening of the arteries in the legs do not require surgery (see intermittent claudication). Most patients have a degree of disability which is manageable by adjustments in lifestyle. Treating vascular risk factors reduces the risk of further problems due to atherosclerosis.
Hardening of the arteries in the legs only leads to serious problems in a small number of patients. However, if hardening of the arteries progresses, then there may be a risk of amputation.
Arterial bypass surgery is indicated in patients with a threatened leg likely to require amputation if left untreated (critical limb ischaemia). It can also be considered in patients with very severe disabling claudication. Arterial bypass surgery can save the leg or reverse severe disability. The benefits of bypass surgery in patients with life style limiting claudication are more controversial. Many surgeons will advise against such surgery in these circumstances as surgery may precipitate problems as well as solve them.
Arterial bypass surgery is not minor surgery. Operations are frequently prolonged, complex and carry significant risks. A decision to proceed with an operation to improve the blood supply to a leg needs to be taken in a careful and considered way. It will be the right option for many patients. In other patients an amputation may be more appropriate. In some very sick patients nearing the end of their lives the compassionate option may be to avoid any type of treatment and to allow the patient to die peacefully.
Rest pain - this is a severe, continuous pain felt in the toes and foot. Some patients find that they only experience this pain at night. This is because during the day when the leg is down, gravity can assist the flow of blood. When the leg is elevated at night this gravity assistance disappears. Many patients find that dangling the foot over the edge of the bed can help to ease the pain. The pain is often very severe, and patients will sleep in a chair to avoid the discomfort of elevating the leg.
Gangrene - if the blood supply deteriorates to a stage where insufficient blood is available to keep the tissues alive then gangrene can develop, as shown (below right) in the 2nd toe (previous big toe amputation). This means that the tissue has died and turns black. If the tissues remain dry (mummified) then sometimes a toe can autoamputate and drop off without surgery. If it becomes wet (infected) then surgery is frequently required.
Ulceration and loss of tissue - sometimes frank gangrene does not develop but the tissues can ulcerate. In this situation the superficial tissues die and are shed leaving an ulcer crater which will not heal because the blood supply is so poor. This is shown in the picture (below left) in which an ulcer has developed on the outside of the foot due to a poor blood supply. Severe disabling claudication - some patients experience none of the above symptoms but they can develop claudication symptoms after a few steps and managing a normal life becomes virtually impossible.
What to Expect While You're There ?
You may encounter the following procedures and equipment during your stay :-
- Taking Vital Signs: These include your temperature, blood pressure, pulse (counting your heartbeats), and respirations (counting your breaths). A stethoscope is used to listen to your heart and lungs. Your blood pressure is taken by wrapping a cuff around your arm.
- Blood Tests: You may need blood taken for tests. It can be drawn from a vein in your hand or from the bend in your elbow. Several samples may be needed.
- Chest X-ray: The doctor will examine this picture of your lungs and heart to make sure you can withstand the stress of surgery.
- Heart Monitor: (Also called an electrocardiogram [e-LEK-tro-KAR-di-o-gram] or EKG). Typically, three to five sticky pads are placed on different parts of your body. Each pad has a wire that is hooked to a TV-type screen or to a small portable box (telemetry unit) that shows a tracing of each heartbeat.
- IV:A tube placed in your vein for giving medicine or liquids. It will be capped or have tubing connected to it.
- Pulse Oximeter: With a little clip connected to your ear, finger, or toe, this machine measures the oxygen in your blood.
- Arterial Doppler: Your doctor will order this painless test to determine how much blood is flowing through the artery. During the test, medical personnel listen to the flow of blood with a small machine placed on the skin over the artery.
- CVP Line:A CVP line, also called a central line, is an IV tube inserted in a large blood vessel near your collarbone, in your neck, or in your groin. To make insertion easier, the head of your bed may be lowered to help the blood vessel fill up and expand. The skin at the insertion site will be numbed to reduce any pain. Once in place, the line can be used to give medicines and measure the activity of your heart.
- Swan-Ganz: This is another type of IV tube that may be inserted in a vein near your collarbone or in your neck. The tube is then guided through the inside of your heart and into your lungs. One part of this tube is hooked to a monitor that measures pressure within the heart and lungs. Another part may be used to give medicine.
- Cardiac Outputs: These tests check the heart's pumping capacity. First, an IV liquid is pushed into your Swan-Ganz line very quickly. Then sensors in the line measure how long it takes the heart to push the liquid out into your system.
- Arterial Line: This tube, also called an "art line" or an "A-line," is inserted into an artery, usually in the wrist or groin. The line is attached to liquid-filled tubing to keep it from clogging up. It can be used to measure your blood pressure or to draw blood for tests.
- Anesthesia: You'll need a pain-killer during the operation. For this type of surgery, the following options are available:
- Spinal Anesthesia:This type of anesthesia requires an in the spine. You will be awake during surgery but will be numb below the waist. Feeling will return in about 2 hours.
- Epidural Anesthesia: For this type, a tiny tube is positioned near the spine, allowing administration of additional medication during the operation. You will be awake during surgery but will be numb below the waist. Feeling will return to your legs when the anesthesia wears off.
- General Anesthesia: This alternative puts you completely to sleep throughout the operation. The anesthetic is given either as a liquid in your IV or as a gas through a face mask or endotracheal (END-o-TRA-kee-ull) tube placed in your mouth and throat.
During Surgery :
The doctor will make at least 2 incisions in your leg, one along the inner thigh, the other along the inside of your knee. If the saphenous vein is being used as the bypass, you'll need a third incision along the inside of the calf. At the end of the operation, all three incisions will be closed with stitches or staples. The surgery generally takes 1 to 3 hours.
Call Your Doctor If ...
- New numbness or tingling develops in the foot or leg below the surgery site.
- Any of the incisions become swollen and red, or you see any pus. These are signs of infection.
- The stitches or staples come apart.
- A bandage becomes soaked with blood.
- You develop a fever.
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