• Vascutek website

  • Terumo Group website

Ischaemia is the medical term used to describe a deficiency in blood to an area of tissue. This is generally caused by an obstruction of the blood vessels. Chronic means that the condition has persisted for a long time. The most common location for chronic limb ischaemia is in the legs but sometimes it can occur in the arms.

Medical treatment

It is very important to control blood pressure, cholesterol levels and any symptoms of diabetes. This is generally achieved by the use of drugs. Aspirin (or a similar drug) is often used to prevent thrombosis (blood clots). The most effective solution is to stop smoking. Taking regular exercise and gradually increasing the amount of exercise may relieve the symptoms.

Investigations

There is a range of investigations that can be performed to check how healthy your blood vessels are.

  1. Measure the blood pressure in the feet
  2. Exercise tolerance tests (walking on a treadmill until it becomes uncomfortable)
  3. Ultrasound scans
  4. Angiograms (the injection of dye into blood vessels to allow the taking of an x-ray of your arteries)

Depending on the results of your investigations, your doctor will select the best treatment option for you. The options range from lifestyle changes such as stopping smoking and taking more exercise, taking pills to reduce the symptoms, or some form of surgical treatment.

Surgical Treatments

The least invasive surgical treatment is called balloon angioplasty. This is usually performed under local anaesthetic.

What is Balloon Angioplasty?

An angioplasty is a procedure where a balloon is passed into your artery on the end of a tube (catheter) and is inflated to treat a narrowed or blocked artery. This technique means that surgery may be avoided in many cases. For this reason, in most cases, you will be asked to stay overnight. You will usually be asked to start taking aspirin before you are admitted as this makes the blood less sticky. A common dose is half a tablet per day (150mg). If you have an ulcer or are allergic to aspirin, please tell your doctor.

Chronic Limb Ischaemia

The procedure

You may feel the doctor changing and pushing catheters in and out of your groin artery. Although this is occasionally a little uncomfortable, it will not be painful. Sometimes, it will be necessary to insert a special device called a stent to keep the artery open. This is just a small metal cage that expands in your artery to keep the vessel open and allow more blood to flow through.

Afterwards

In some cases Heparin injections (anticoagulation) will be given for 24 hours to prevent the blood clotting at the site of the angioplasty. Rarely, you may require Warfarin tablets to thin the blood for a few months. You will normally be allowed home the following day. If you are given Heparin or Warfarin, this may delay your departure by a few days. You will be seen again in the clinic by your surgeon to assess the success of the angioplasty and to decide if treatments are required.

Are there any side effects?

Some degree of bruising is quite common and this normally disappears in a few days. Serious bleeding is very uncommon. Unfortunately, in about 10% of cases, angioplasty is not successful and other treatments will need to be considered. In addition, even where successful angioplasty has been performed, there is a risk that the area in the artery will narrow down again. After one year, about 20% of arteries will have re-narrowed. In some cases, it may be possible to repeat the angioplasty at that time although in others, this may not be possible. Very rarely, if angioplasty does not work, the circulation may actually worsen. If this is a particular risk in your case, doctor will discuss the risks with you.

Are there any complications?

The risk of complications is estimated to be about 4%. Most complications are caused by excessive bruising, or bleeding from the wound. Sometimes, a blood transfusion may be required. Occasionally, surgery to close the hole made by the needle in the artery is needed. Very rarely, bypass surgery may be needed if the blood clots in the artery. If balloon angioplasty is not possible, surgery may be undertaken.

The most common operation is called a bypass.

1. Why do I need the operation?

Because you have a blockage or narrowing of the arteries supplying your legs, the circulation of blood to your legs is reduced. This becomes particularly noticeable when your muscles require more blood during walking and causes pain. Any further fall in the flow of blood may lead to constant pain with the risks of ulcers or gangrene developing. This operation is to bypass the blocked arteries in the leg so that the blood supply is improved.

2. Before your operation

If you are not already in hospital, you will usually be admitted one or two days before your operation or will be asked to attend a preadmission clinic about a week before your operation in order to allow time for tests required to make sure you are fit for the operation. An x-ray of the arteries (arteriogram) to find out where the blockages are may be performed if it has not already been done.

3. Coming into hospital

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also note down your personal details in your nursing records. Prior to surgery you will undergo a number of investigations, if these have not been performed previously, including a heart tracing, a chest x-ray and blood tests. You will be visited by the surgeon who will be performing your operation and also the doctor who will give you the anaesthetic. If you have any questions regarding the operation please ask the doctors.

4. The operation

You will be taken initially to a reception area in the theatre suite, then to the anaesthetic room where you will be given your anaesthetic, and from there into the operating theatre. You will either be put to sleep (a general anaesthetic) or you will have a tube inserted into your back through which pain killers can be given to numb the lower half of your body (epidural). Sometimes, you will have this as well as the general anaesthetic to provide pain relief after your surgery. While you are asleep, a tube may be inserted into your bladder to drain your urine, and into a vein in your arm or neck (or both) for blood pressure measurements and administration of fluid following surgery. You will have a cut in the groin and one somewhere lower down your leg depending on which blood vessel is being bypassed. You may need a number of cuts, or a long cut all the way down the leg, these are used to harvest your leg vein. The bypass will usually be performed using your own leg vein (don’t worry - you can manage without it) but an artificial bypass tube, made of plastic, may be used instead. The wounds are often closed with a stitch under the skin that dissolves by itself.

5. After the operation

After your operation, you will be given fluids by a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth. The nurses and doctors will try to keep you free of pain by giving pain killers by injection, via a tube in your back, or by a machine that you are able to control yourself by pressing a button. As the days pass and you improve, the various tubes will be removed and you will become gradually more mobile until you are fit enough to go home. You will be visited by the physiotherapist before and after your operation to help you with your breathing, to prevent you developing a chest infection and to aid your ability to walk.

6. Going home

If dissolvable stitches have been used, these do not need to be removed. If your stitches or clips are the type that need removing, and this is not done while you are still in hospital, the practice or district nurse will remove them and check your wound. You will feel tired for many weeks after the operation but this should gradually improve as time goes by. Regular exercise such as a short walk, combined with rest, is recommended for the first few weeks following surgery with a gradual return to your normal activity.

Driving: You will be safe to drive when you are able to perform an emergency stop. This will normally be at least 4 weeks after surgery, but if in doubt, check with your own doctor.

Bathing: Once your wound is dry, you may bathe or shower as normal.

Work: You should be able to return to work within 1-3 months following your operation. If in doubt please ask your doctor.

You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin, an alternative drug may be prescribed.

7. Complications

A bypass procedure is a major operation and may place a strain on your heart, lungs and kidneys. It is unusual to die after this sort of surgery, but this is a risk and can occur in about 5% of patients, usually because of pre-existing problems with the heart or lungs. There is also a similar risk of problems with heart, lung and kidney function that may delay your recovery and prolong your hospital stay. You should discuss this with your surgeon and anaesthetist as they will be concerned to minimise the risk of surgery. Sometimes these operations have to be done urgently, but if not, you may be asked to see another specialist before surgery to optimise your health before the operation.

The main complication involving the graft is blood clotting within the graft causing it to block, and if this occurs, it will usually be necessary to perform another operation to clear the graft. If your leg is in danger because of its poor blood supply prior to surgery, there is a risk of amputation if the graft becomes blocked. Slight discomfort and twinges of pain in your wound is normal for several weeks following surgery, but wounds sometimes become infected and these can usually be successfully treated with antibiotics. Also the wound in your groin can fill with a fluid called lymph that may discharge between the stitches but this usually settles down with time.

You may have patches of numbness around the wound or lower down the leg which is due to cutting small nerves to the skin. This can be permanent but usually gets better within a few months. It is also common for the foot to swell due to the improved blood supply. Elevation of the leg when sitting helps the fluid to disperse.

8. What can I do to help myself?

If you were previously a smoker you must make a sincere and determined effort to stop completely. Continued smoking will cause further damage to your arteries and your graft is more likely to stop working. General health measures such as reducing weight, a low fat diet and regular exercise are also important. If you develop sudden pain or numbness in the leg which does not get better within a few hours then contact the hospital immediately.

Endarterectomy Procedure

Occasionally an endarterectomy (surgical removal of the blockage) is performed. This operation involves surgical removal of obstructing plaque through an opening in the artery.

1. Why do I need the operation?

An endarterectomy is used instead of bypass surgery in certain situations. It is indicated for shorter blockages where bypass is not needed. This operation is often carried out in the groin to improve blood supply to the leg. If more extensive disease is encountered, it is sometimes possible to open up long segments of blocked arteries with an endarterectomy. Some surgeons will prefer to move to a bypass in this situation.

2. Before your operation

If you are not already in hospital, you will usually be admitted one or two days before your operation or will be asked to attend a pre-admission clinic about a week before your operation in order to allow time for tests required to make sure you are fit for the operation. An x-ray of the arteries (arteriogram) to find out where the blockages are may be performed if it has not already been done.

3. Coming into hospital

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also note down your personal details in your nursing records. Prior to surgery, you will undergo a number of investigations, if these have not been performed previously, including a heart tracing, a chest x-ray and blood tests. You will be visited by the surgeon who will be performing your operation and also the doctor who will give you the anaesthetic. If you have any questions regarding the operation, please ask the doctor.

4. The operation

Endarterectomy is the name given to an operation designed to remove the blockage from within the artery rather than placing a bypass around it. Short blockages may be treated through a small cut. Once the blockage is removed, the opening is closed using a patch made of either vein or synthetic material.

Chronic Limb Ischaemia

Longer blockages may be treated by cutting the artery open along its length (open procedure) or through a cut at each end (semi-closed procedure). The plaque (blockage) is removed using a dissector. The artery is usually closed with a patch made of either vein or synthetic material. You will be in hospital for about a week or a bit longer.

Chronic Limb Ischaemia

5. After the operation

Your care will be conducted in the same way as described for bypass above. Patients having a small cut will recover more quickly and probably go home within 5 days. For more extensive operations, your stay in hospital will be similar to that after bypass surgery.

6. Going home

If dissolvable stitches have been used, these do not need to be removed. If your stitches or clips are the type that need removing, and this is not done while you are still in hospital, the practice or district nurse will remove them and check your wound. You will feel tired for many weeks after the operation but this should gradually improve as time goes by. Regular exercise such as a short walk combined with rest, is recommended for the first few weeks following surgery, followed by a gradual return to your normal activity.

Driving: You will be safe to drive when you are able to perform an emergency stop. This will normally be at least 4 weeks after surgery, but if in doubt check with your own doctor.

Bathing: Once your wound is dry you may bathe or shower as normal.

Work: You should be able to return to work within 1-3 months following your operation. If in doubt please ask your doctor. You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin, an alternative drug may be prescribed.

7. Complications

An endarterectomy is a major operation and may place a strain on your heart, lungs and kidneys. It is unusual to die after this sort of surgery, but this is a risk and can occur in about 5% of patients, usually because of pre-existing

problems with the heart or lungs. There is also a similar risk of problems with heart, lung and kidney function that may delay your recovery and prolong your hospital stay. You should discuss this with your surgeon and anaesthetist as they will be concerned to minimise the risk of surgery. Sometimes, these operations have to be done urgently, but if not, you may be asked to see another specialist before surgery to optimise your health before the operation. The main complication directly related to the endarterectomy is clotting of the artery at the site of surgery. If this occurs, it will usually be necessary to perform another operation to reopen the artery. If your leg is in danger because of its poor blood supply prior to surgery, there is a risk of you ending up with an amputation if the graft becomes blocked. Slight discomfort and twinges of pain in your wound is normal for several weeks following surgery, but wounds sometimes become infected and these can usually be successfully treated with antibiotics. Also the wound in your groin can fill with a fluid called lymph that may discharge between the stitches but this usually settles down with time. You may have patches of numbness around the wound or lower down the leg which is due to cutting small nerves to the skin. This can be permanent but usually gets better within a few months. It is also common for the foot to swell due to the improved blood supply. Elevation of the leg when sitting helps the fluid to disperse.

8. What can I do to help myself?

You cannot do anything to relieve the actual narrowing. However, you can improve your general health by taking regular exercise, stopping smoking and reducing the fat in your diet. These actions will help slow down the hardening of the arteries which caused the problem in the first place, and may avoid the need for further treatment in the future.

This information was produced as a service to medicine by VASCUTEK, a TERUMO Company

Contact Vascutek

VASCUTEK, a TERUMO Company
Registered Office:
Newmains Avenue
Inchinnan
Renfrewshire PA4 9RR
Scotland UK

General Enquiries
This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel: 00 44 141 812 5555
Fax: 00 44 141 812 7170


© 2011 Vascutek Ltd. a Terumo Company