Health & Disease Info
All You Wanted to Know About ... Aortoiliac Occlusive Disease

This booklet is prepared as a second part to the booklet on lower extremity claudication which you were given on your first visit to our office. From the results of your history and physical examination and the diagnostic tests that have been done thus far, we feel that your primary problem is in the aortoiliac segment (that portion of the vascular tree within the abdomen and above the groin). We have separated disease above the groin and disease below the groin in two separate groups because the surgical procedures involved to correct such lesions are vastly different and clinical decisions are made on much different bases in the two areas. Again, we would remind you that we have not made an attempt to be all inclusive in our consideration of these processes having included only the salient features of the disease process and its treatment. We will be happy to answer any questions that you might have and encourage your active participation in learning as much about the disease process and its treatment as possible.

From your work-up thus far we have identified your problem to be in the area represented below.

What Treatments are Available
There are many options available in the treatment of aortoiliac occlusive disease. We will briefly try to describe them for you.

I - Transluminal Balloon Angioplasty
This is a technique done by the radiologist usually at the time of your original arteriogram. It involves placing a catheter over a guidewire into the area of involvement in the iliac arteries. This catheter is fitted with a balloon which blows up to a specific size and shape and basically crushes the obstructing lesion out against the wall of the vessel. If the radiologist is able to do this technique, you will have to be admitted to the hospital overnight to be sure that bleeding does not occur from the arterial puncture sites since it will be somewhat larger than the standard angiogram catheter used for outpatient studies, and also to be sure that the artery does not clot following the dilatation. This is a very useful technique and when applied appropriately has quite good results. However, the key is appropriate application.

The best lesions to apply this technique are short segment lesions in the area of the common iliac artery. Such lesions when dilated have a long term patency rate of approximately 80%. It is almost as good as we can do with surgical bypass, although balloon dilatation does not require an open operation. It does not work well in the aortic area simply because the vessel is too large and the disease is too extensive. Neither does it work well in the external iliac arteries which do not respond nearly as well to the technique. Long segment lesions (greater than about two inches) also have poor long term results. Occasionally this technique is used in conjunction with urokinase if one iliac artery is found to be completely blocked and the other can be negotiated. By using urokinase any blood clot that is present around the area of blockage can be dissolved, and many times only a short segment of blockage is present which is quite amenable to the balloon dilatation technique. Again, an overnight admission is required if this can be used.

II - Aortoferneral Bypass
This is the standard operation for treatment of aortoiliac occlusive disease. It is the most aggressive operation. It also has the best results for the long term care of this problem. It is done through a long incision extending from the breastbone to the public bone approaching the aorta deep within the abdominal cavity. It also requires two incisions in the groins to approach the femoral arteries at this level. Bypass is done using either a knitted Dacron graft or a Gortex (Teflon) graft both of which have shown excellent long term results with a five year patency rate of approximately 90%. This is the biggest operation that we do for this disease and is a significant insult to your body. However, it is by far the best operation we have to offer, and if your medical condition is felt to be satisfactory, this would be recommended.

III - Aortoiliac Endarterectomy
This also is an operation which has quite good long term results if applied appropriately. It is best used in patients who have localized occlusive disease in the most distal part of the abdominal aorta and the very proximal segments of the common iliac arteries. It is not an operation that works well on extensive disease, so the indications to perform this operation are limited. However, if you are an appropriate candidate, this operation does provide excellent results. The insult to your body is approximately equivalent to that of an aortofemoral bypass.

IV - Iliofemoral Bypass
If you have disease on one side only with a good aorta and proximal common iliac artery segments, but extensive external iliac artery disease, a bypass can be inserted into the common iliac artery and brought down to the femoral artery on that side using a transverse incision in the lower part of the abdomen and actually staying out of the abdominal cavity itself. This is a much less extensive operation and has a couple of inherent hazards. Firstly, there is often occlusive disease present in the proximal iliac artery which is unable to be appreciated by arteriography. Obviously if there is narrowing in this part of the vessel, bypass will not be as effective as if it takes off from a perfectly normal vessel. Secondly, while arteriography may not show it, disease is usually bilateral and many times there is the requirement for a similar procedure to be done on the other side in the not too distant future. If, however, conditions are appropriate, excellent results can be obtained with this operation.

V - Femorofemoral Bypass
If you are found to have significant disease in one iliac artery but a normal appearing artery on the other side and a good pulse in the other groin, it may be possible to run a graft from one groin to the other. This is able to be done because the normal artery is capable of carrying about five times the normal blood flow and can very easily support the other limb if its iliac artery is blocked. This is about the least aggressive procedure that can be done for aortoiliac occlusive disease but has a lower long term patency rate related to lower flow through the graft and to the above mentioned fact that disease is usually bilateral so that there may be some compromise of the iliac segment that is not appreciated on the donor side. However, reasonable long term patency rates can be expected with this technique.

VI - Axillofemoral Bypass
This is an operation where blood is taken from an artery supplying the arm and brought down to the groin on one side and then run over to the groin on the other side. This operation is done when there is extensive bilateral iliac occlusive disease in a patient who we feel is not a candidate for the aggressive aortofemoral bypass technique. This is certainly capable of relieving the symptoms in your legs, and has a long term patency rate that is quite acceptable.

Preoperative Preparations
Each of the aforementioned procedures with the exception of balloon angioplasty can be quite extensive and several tests will have to be run prior to your admission to the hospital. Since you will have pain following surgery, possibly compromising your breathing ability we may like to check your breathing capacity before you come to the hospital. Arterial blood gases and pulmonary function tests are done in a pulmonary lab and can be done by appointment. An EKG (heart tracing), a chest x-ray, and other blood tests will also be done before admission. We suggest that most people donate some of their own blood for self transfusion at the time of surgery. This is called autologous blood. By doing this you reduce the need for using someone else's blood, and thereby reduce the incidence of transfusion problems such as AIDS, hepatitis, and transfusion reactions. After all, it is your own blood, and you can't catch something new from yourself. Pre hospital testing will be facilitated thru the pre hospital admission services.

The Pre Hospital Day
Before surgery your stomach and intestinal tract needs to be as empty as possible. Therefore, you should take a strong laxative, and you should take only liquids to drink after this. You will be asked to shower with a special soap to help cleanse the skin of bacteria.

Please remember not to eat or drink anything after midnight in preparation for your operation.

The Day of Surgery
You will be admitted the day of surgery thru the Short Stay Unit. An anesthesiologist will see you pre op and an IV will be started to replace fluids from your overnight fast.

You will be asked to remove all your jewelry and any prosthesis that you have such as dentures, contact lenses, etc. Nail polish must be removed. Before going to surgery, you will be given a medication injection to help you relax and make you drowsy. It will also make your mouth dry. An attendant will shave you before taking you into the Operating Room.

The nurse will take you back to the Operating Room where you will meet the people who will be assisting with the procedure. The doctor from anesthesia will then prepare you to go to sleep and you'll be on your way to recovery.

The operation will usually take 3-4 hours of operating time. Of course, the time spent putting you to sleep and waking you up again has to be added to this.

The Intensive Care Unit
Immediately after surgery, you will be taken to the Intensive Care Unit or the Recovery Room. When you wake up you may have a tube in your mouth that goes into your windpipe. This is an endotracheal tube (or ET tube). It may be connected to a respirator, a machine that will help you breathe. Since the tube goes into your windpipe, you will not be able to talk. The ET tube will be removed as soon as you are strong enough and awake enough to breathe on your own, usually in the Recovery Room.

There will also be a smaller tube in your nose that goes into your stomach (a Nasogastric or NG tube). This tube is needed to remove any pressure on your incisions and to keep you from vomiting. This tube will be in for 2 days or so.

There will also be a tube (a Foley catheter) in your bladder. It is very important for us to know how well your kidneys are functioning. Although the catheter will automatically empty your bladder, you may still have the sensation of having to urinate.

You will have several IVs and an arterial line in your arms as well as a central line in your neck. These will be used to give you the necessary fluids, nutrients, and medications you need until you can eat again. They are also used to monitor your pulse, blood pressure, and fluid volume status. An EKG monitor will also be evident.

The nurse will be very busy monitoring your progress. In addition to monitoring your pulse, blood pressure, and temperature, she will be checking your pulses in your feet and legs and checking your lab results. She will also ask you to breathe deeply and cough frequently.

Remember, the ICU is a very busy place with many sounds that are new and unusual to you, but very normal for the unit. Please don't let these noises worry you and remember that most of them are coming from the patients around you and they do not really pertain to you.

Recovery
You will be transferred out of the ICU as soon as possible. You will go to another room where your recovery will proceed. We will ask you to get out of bed and move around with assistance at first to be sure that you do not fall. When you are stable on your own, move around as much as possible. This will speed your recovery. All the tubes and lines will be removed as soon as possible. Your diet will be increased as you tolerate it and before you know it, you will be on your way home. The usual length of hospital stay is 4 to 7 days after surgery. After discharge, follow the instructions on the sheet given to you and be sure to call our office at 741-9345 with any questions you may have. It is best to call early in the day, but someone is always available to handle emergency situations.

Information for the Family
Remember that patients usually go to surgery about an hour before they are scheduled so adjust your schedule accordingly. You should take all the patient's belongings with you because he will be going to the Intensive Care Unit after surgery and will not return to the same room.

Please let us know who will be the contact person for the family and where we can contact you after surgery. You may leave the name and telephone number with the nurse to place it on the chart. If you will be in the hospital, please wait in the ICU waiting room. This is just outside the Operating Room and we can talk to you there. ICU visiting hours are varied so talk to the nurses to find out when you should visit.

The ICU can be a frightening place for visitors. Your relative will probably be asleep on your first visit and will be connected to many machines, monitors, tube and bottles. As overwhelming as this may seem, remember it is all normal routine for our patients, so don't be alarmed. Patients usually stay in the ICU for 1 to 3 days before going to a regular nursing unit.

Complications
It is never nice to talk about the bad things that could happen when you have an operation. But, it is necessary that you understand that not always do things go without a hitch. We will not make an attempt to cover all things that can happen, but will list for you the most common problems seen.

Whenever we do any operation for hardening of the arteries, the most common complications are other complications of hardening of the arteries, whether or not they are associated with the surgical procedure. This happens because all the arteries are involved with the disease process and not just the one we are caring for at the moment. Therefore, heart failure, heart attack, stroke, or problems with the circulation in an arm or leg, kidney or bowel are always possibilities. Pneumonia or other lung problems can occur, but are usually preventable if you follow instructions. As with any operation, bleeding problems and infections are also possible. Groin wounds can be a problem, particularly in heavy individuals. Meticulous care needs to be focused here to avoid problems with wound breakdown and infection. There are many other problems that can and have occured, but in a very low frequency. We will discuss the potential complications with you in greater detail if surgery is recommended. Of course, you should feel free to ask us any questions you may have concerning the surgery, its alternatives, and the potential complications.

When You Go Home
Remember you have just had a major operation and your body has a lot of recovering to do. It will take several weeks before you begin to feel really good again. For now you can expect to feel more tired and weaker than you are used to. Your bowels may not move as regularly. Your appetite will not be very good. This is normal and should be expected after this type of surgery. It is also normal not to sleep as well and even to feel somewhat depressed. Remember, the more active you are and the more you force yourself to be active, the faster and smoother your recovery will be.

If you did smoke, we would hope that by now you have stopped. Please don't start again! The circulation restored by your operation could soon be damaged by the continued effects of tobacco. You may drink alcohol if you wish, but remember that your tolerance during convalescence might be much lower than before surgery. One drink may have the same effect now as two or three drinks did before surgery.

It is very important to keep your two week appointment and any subsequent doctor's appointments so that you will have a safer, smoother recovery. In the future we would hope to be able to follow your progress and try to prevent new problems from causing a crisis situation.