Overview

Peripheral arterial disease refers to disease affecting the arteries. This commonly affects the arteries in the legs and causes narrowing (stenosis). The reduced blood flow to the feet can manifest as a range of symptoms from: pain in the calves when exercising (claudication), pain at rest, ulceration or gangrene.

Arterial disease of the peripheries is commonly associated with risk factors such as smoking, diabetes, hypertension and high cholesterol. It is often also associated with heart disease, kidney disease and stroke.

Treatment Options. 

It is essential to manage the medical risk factors aggressively. This includes measures such as stopping smoking, treating high cholesterol and blood pressure and using blood thinning agents.

Surgical options include open surgery and minimally invasive endovascular procedures. Open surgery may include procedures such as bypass operations where a bypass conduit such as a vein is used to bypass the arterial blockage. Endovascular procedures include the use of minimally invasive techniques such as wires, balloons and stents in order to reopen the narrow or blocked artery.

 Other considerations. 

Different alternatives may be appropriate in differing circumstances depending on the underlying health of the patient as well as the technical aspects required for the surgery.

Overview

Aneurysms represent areas of weakening of the arterial wall. The weakness results in a ballooning of the vessel which can be prone to rupture or to blockage (thrombosis). Aneurysms can occur in any artery but often may involve the abdominal or thoracic aorta or the popliteal vessels (at the knee). There is sometimes a family history associated with aneurysmal disease.

Aneurysms that are symptomatic, reach a certain size for have a certain shape may warrant treatment.

Treatment Options

Multiple options are often available for treatment of certain aneurysms.

Open surgery will often involve exposure of the aneurysm followed by resection of the diseased artery and rejoining the blood vessel with a graft of some form (either autogenous or prosthetic).

Endovascular options involve access to the vessel through a minimally invasive technique followed by relining the aneurysm with a stent graft. For smaller aneurysms where it is non-essential to maintain blood flow it may be possible to simply block off the vessel with coils.

Other Considerations

Aneurysms that do not as yet require treatment will often require some form of surveillance with regular imaging. Aneurysms that have undergone treatment may also likewise require ongoing surveillance to ensure there is no recurrence of the problem.

Overview

The carotid arteries are responsible for the primary blood flow to the brain. They can sometimes develop areas of narrowing (stenosis) because of atherosclerotic disease. In some cases, this may cause strokes due to becoming occluded or throwing small bits of plaque into the brain.

In instances where the narrowing is considered high risk or has already caused a stroke event there may be valued in performing an intervention to improve the narrowing in the carotid artery.

Treatment Options

Carotid endarterectomy is an open operation which involves exposure of the carotid vessel. The area of diseased plaque is removed, and the vessel repaired with a prosthetic patch. The purpose of the patch his to prevent subsequent narrowing in the artery.

Carotid stenting is an alternative procedure where the area of narrowing is treated with a stent to restore the patency of the vessel.

Other Considerations

It is important to note that carotid intervention is designed to reduce the risk of future stroke events. In the situation where a patient has already had a stroke event it will not change or aid in the neurological recovery.

Overview

Diabetes is an increasingly common disease process. It is known to accelerate the atherosclerotic process which can affect the vessels to the lower leg. In addition to this diabetes can attack the nerves of the lower leg leading to reduced sensation. The combination of effects on the arteries and the nerves increases the propensity to develop foot ulceration and gangrene.

Treatment Options

Options to improve the blood flow to the foot are often considered vital as part of the management of diabetic foot disease. This can include both open surgery and endovascular techniques.

Continuing care of the diabetic foot is essential with appropriate podiatry, footwear and dressings as required.

Other Considerations

Diabetic patients are likewise at high risk of other cardiovascular problems. This includes a increased risk of heart disease, renal disease and stroke.

Overview

Leg veins are blood vessels that channel blood from the feet back to the heart. They do this through the presence of valves which ensure one-way flow. When the venous valves fail then blood can leak in a backwards direction (reflux). This becomes associated with areas of dilated veins which represent varicosities.

Varicose veins are exceedingly common in the general population and their presentation can be variable. Most patients will simply have cosmetic concerns regarding their appearance. However, patients can develop symptoms such as discomfort, pain and leg swelling. More complicated varicose veins can lead to bleeding, clotting (thrombosis) and chronic leg ulcers.

Treatment Options

Traditionally, open surgery has been performed for varicose veins involving stripping of the vein through the thigh as well is avulsions.

Newer techniques involve minimally invasive (endovenous) vein treatments. This includes the use of such devices such as laser, radiofrequency ablation, cyanoacrylate glue and sclerotherapy to treat the varicose vein disease without the need to perform open surgery.

Other Considerations

Varicose veins can be treated both in public hospitals, private hospitals and private outpatient settings. Talk to your surgeon regarding each of these possible options.

Overview

Venous thrombosis refers to clotting within the deep or superficial veins. Deep venous thrombosis (DVT) represents a possible life-threatening problem as it may cause pulmonary embolus (PE). Superficial venous thrombosis (also called superficial venous thrombophlebitis) on the other hand may often be associated with varicose veins.

There are a large range of reasons why veins may develop clots and comprehensive assessment is often necessary.

Treatment Options

In certain patients with DVT there may be a feasible benefit in using catheter directed thrombolysis and thrombectomy. This involves the use for very strong blood thinners which can break down clot or devices that can mechanically remove clot. These options are not appropriate for all patients and careful selection criteria apply.

In superficial thrombophlebitis it may be appropriate to consider treatment of the underlying problem especially if it is due to varicose veins. This would feasibly reduce the likelihood of having recurrent clots in the underlying diseased veins.

Other Considerations

Most venous thrombosis patients will not require intervention. The mainstay of treatment is anticoagulation and assessment of the underlying cause.

For patients where treatment is an option, there will often be greater success with earlier treatment (two weeks).

Overview

Leg swelling and discomfort can have many causes. Both venous and lymphatic conditions where there is a reduction of blockage to flow can lead to swelling. Accurate assessment with appropriate imaging modalities is essential in forming the diagnosis.

Treatment Options

Certain venous conditions may respond to treatment. Major veins that are narrowed or blocked may respond to stents or other treatments. Varicose veins contribute to leg swelling may see an improvement once treated. Lymphatic disorders may be amenable to surgery by lymphatic surgical specialists.

Other Considerations

Treatment for venous disease and leg swelling requires a coordinated approach of which the key is often compression. A review by a vascular surgeon is recommended to ensure the appropriate medical grade compression therapy is prescribed.

Overview

Venous ulcers are the most common cause for chronic leg ulcers. Leg ulcers can represent a very debilitating condition which requires continuing wound care and management. Conditions that affect the deep or surface veins may give rise to venous ulcers. Other conditions such as reduced mobility, chronic leg swelling, heart and kidney disease may also give rise to ulcers which may mimic a venous cause.

Treatment Options

Management of ulcers can be very complex. Appropriate wound care is very important.  Compression management may be required. In some cases surgical debridement of the wound in the operating theatre is necessary.

In some instances there may be a underlying pathology which affects the veins which may be amenable to treatment. Extensive investigation of the function of the deep and surface veins is necessary. Referral to a vascular surgeon is encouraged.

Other Considerations

Chronic leg ulcers can be very difficult to manage and may often require a multidisciplinary approach. Whilst a number may be managed through a private clinic in some cases referral to a specialist outpatient wound clinic and a referring hospital may be appropriate.

Overview

For certain patients with end-stage renal failure, renal replacement therapy is required through haemodialysis. Access is required by providing an AV fistula which allows the insertion of the haemodialysis needles. Blood is subsequently moved through the dialysis circuit.

The AV fistula is a connection that is created between an artery and vein which subsequently allows the vein to grow to provide a reasonable target for insertion of the needles.

Treatment Options

An autogenous AV fistula here is one where the connection between the artery and the vein is created using the patient’s own blood vessels. This avoids any foreign material which has a higher risk of infection and failure.

Fistulas are commonly created in the forearms but in some cases may be created elsewhere. Appropriate assessment by a vascular surgeon and with focused ultrasound will allow the creation of the most appropriate access circuit.

Other Considerations

In some patients creation of a straightforward AV fistula in the forearms is not feasible. More creative options may be required in this circumstance.

AV fistulas often require continuing management to ensure they continue to function well. In some cases this will warrant surveillance imaging and assessment. A proportion of patients may require further intervention following the initial creation of the access.

Overview

Some patients may require other forms of central vascular access. Examples of such conditions include: the need for temporary renal replacement therapy, chemotherapy, plasmapheresis, failed peripheral access.

Treatment Options

Central lines are often used to access the central veins within the chest. This allows the infusion of certain substances which are not able to be administered through more peripheral lines.

There are a range of differing central line options depending on what the requirements for access are.

Other Considerations

Central lines may not always be possible especially in view of situations where the central veins have become blocked or occluded. Likewise, Central lines may also impose a risk of infection or blockage.

Overview

Renal transplantation refers to a process whereby a donor kidney (cadaveric or living donor) is implanted into a recipient with end-stage renal failure. It represents an alternative to dialysis therapy.

Treatment Options

Typically the donor kidney is implanted into the pelvis of the recipient. The renal artery is connected to the external iliac artery. The renal vein is connected to the external iliac vein. The donor here it is connected to the dome of the bladder.

Other Considerations

Renal transplantation is a complex process and will require extensive consultation. In the first instance, discussion and assessment should be made with the patient’s treating renal physician.