Health & Disease Info
All You Wanted to Know About ... Infrainguinal 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 Femoropopliteal segment or that portion of the vascular tree below the groin. We have separated disease above the groin and disease below the groin into 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.

What are my Options for Treatment?
There are many options in treating infrainguinal occlusive disease. Not all of which are available in every case. We will list the options generally available here and then make specific recommendations to you based on our best clinical judgment.

I. Endovascular Techniques
This is a broad category of techniques with minimal or no incision. Some techniques can be used percutaneously (making a needle stick into the artery and passing catheters over a guidewire). Other techniques require a small incision to obtain access to the femoral artery. All of them involve doing a procedure from inside of the vessel without making further incisions on the leg. Balloon angioplasty is simply passing a catheter with a balloon on it down to an area of blockage and blowing up the balloon crushing the material inside of the artery out into the arterial wall. All the other techniques are variations on balloon angioplasty. Some involve removal of a small amount of material from the inside of the vessel with or without subsequently angioplasty. Some involve the use of laser energy to reform the channel. All of these techniques are actively undergoing investigation at this time, and unfortunately to the present, at any rate, none of them show any real advantages over simple balloon angioplasty. There are only very few conditions which are amenable to this type of therapy. For the most part, the lesion must be present in one of the larger arteries and most occupy only a small distance in that artery in order to have any significant chance of being successful. Long segment disease and small vessel disease have much lower success rates and are felt to be inappropriate lesions for the use of these techniques.

II. Bypass Techniques
While there are many different operations performed on the legs for bypass of arterial blockage, the basic principle behind bypass remains the same. The graft must be able to be attached to an artery above the blockage which is open and has good "inflow", and there must be a good open vessel below the blockage to provide adequate "outflow" from the graft. The graft is being placed in the leg to replace the blocked artery. However, one must always remember that the graft is an artificial vessel and not the same as the original artery that nature provided you with. Because the bypass graft is not a native vessel, there is a requirement that blood flow through the graft fast enough to prevent it from clotting. Therefore the quality of the outflow system is most important in maintaining patency of the graft. The better the outflow, the better the long term success. There are basically two types of grafts that can be used; namely, the artificial grafts of Dacron or Teflon and vein grafts which are vessels harvested from your body and placed into the arterial circuit as a bypass graft. The best bypass graft is always your own vein, but when a vein is not available, an artificial graft will many times suffice.

AT NO TIME WILL WE EVER RECOMMEND A BYPASS GRAFT TO THE TIBIAL VESSELS FOR THE TREATMENT OF CLAUDICATION ALONE. TIBIAL VESSEL GRAFTING IS A LIMB SALVAGE PROCEDURE ONLY AND HAS NO PLACE IN THE TREATMENT OF CLAUDICATION.

Artifical Grafts
Our current preference is for use of a Gortex graft when an artificial graft is necessary. Gortex is expanded Teflon material which is well incorporated into the body and currently gives as good long term patency rate as any artificial graft available. Gortex is actually our preferred graft if we are grafting into the proximal popliteal artery above the knee. We prefer to use this here simply because the vein is so valuable in the more distal vessels of the leg that we like to preserve the vein for use in these sites rather than use it above the knee. Gortex has approximately the same patency rate (continues to function) in an above knee position as autogenous vein does, which is approximately 70% in three years.

When a vein is not available we frequently use Gortex to approach the popliteal artery just below the knee. This also gives relatively good long term patency although not as good as in the proximal popliteal position. We are quite reluctant to use Gortex grafts when approaching the tibial arteries, the very small arteries in the leg and at the foot. If Gortex is required in this area, we will usually create an AV fistula between an artery and vein in that area prior to attaching the Gortex to it. This provides increased outflow from the graft to provide better flow rates through the graft and hopefully a higher long term patency rate. However, even with creating the AV fistulas in this area, when Gortex is used in a tibial position the patency rate does not exceed 50 to 60% at three years.

Autogenous Vein Graft
As stated above, the autogenous vein graft is the best bypass graft that we have to use. There are many ways that this can be obtained. Our preferred method if a good vein is available is to use an insitu saphenous vein bypass graft using the vein from the inside of your leg and attaching it to the artery in the groin and the artery down below the blockage either at the popliteal level or the tibial level depending on your arteriographic findings. When an insitu graft can not be used, we still prefer using a saphenous vein.

We may use it in either reversed or non-reversed manner. This is really a technical point as far as the performance of the procedure and should not make a significant difference in our discussions. When leg veins are not available veins can be harvested from the arms. These are usually not quite as large as leg veins nor do they have quite the durability that leg veins do, but they do give better results than artificial grafts and are preferred when available. In all areas below the knee a vein graft has a higher long term patency rate than an artificial graft. When the vein is available, grafts can be carried as far distally as the vessels in the foot for salvage of an otherwise threatened limb.

Nonbypass Procedures
Occasionally we are presented with very localized disease either involving a segment not amenable to the endovascular techniques or in an area that is better treated with open endarterectomy. Using this technique the artery is opened and the blockage on the inside of the artery is peeled away leaving the shell of the artery behind. The outer walls of the artery are the strongest support for an artery and is quite strong enough to maintain the circulation without a compromise. Usually when an endarterectomy is performed a patch graft is placed so that narrowing of the vessel will not occur when the vessel is closed. If this procedure is proposed, thorough explanation will be provided to you.

Based on the findings of your arteriogram, we would recommend the following procedure for your consideration.

The Hospitalization
Most patients for distal bypasses are admitted to the hospital the day before surgery so that thorough preparation can be achieved. We will ask you to shower using an antibiotic soap to prepare your skin and cleanse it of as many bacteria as possible. The nurse or respiratory therapist will instruct you on coughing and deep breathing exercises that you will be asked to do after surgery. If an open wound is present on your leg, whirlpool may be obtained to keep the wound as clean as possible prior to surgery. The evening before your operation an IV will be started. You will be able to get out of bed and walk around, but the IV will remain in until after your surgery. In this way we will be able to give you fluids directly into the vein so that you are not dehydrated at the time of your surgery. Someone from anesthesia will come in to see you the afternoon or evening prior to surgery to discuss anesthetic considerations with you. This person will be able to tell you when your surgery is scheduled to take place. Please remember not to eat or drink anything after midnight in preparation for your surgery.

The Day of Surgery
You will be asked to remove all your jewelry and 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. You may be given your morning oral medications with a small sip of water if the anesthesiologist feels that this is appropriate. You will be taken on a litter to the holding room where 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 and administer either a general or regional anesthetic depending on what you have decided in your discussions with the anesthesia department. After surgery you will be taken to the recovery room where you will stay until you are awake enough and can move your extremities well enough to be taken to your room. When you first wake up you may have an endotracheal tube in your mouth that goes into your windpipe. This will be used during your surgery to help you breathe. While it is in place you will not be able to talk. When you are awake and can breath by yourself the tube will be removed, and an oxygen mask applied. The nurse will ask you to breath deeply and cough frequently as you were instructed to do before surgery.

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. This catheter is usually removed in one to two days. The IV may stay in your arm for several days but will be removed as soon as possible after surgery. The nurse will take frequent blood pressures and check your pulses either by feeling them or by listening to them with a doppler probe. She will also check your dressings. You will also need to be aware of how your legs feel so that you can report any changes to the nurse. The day of surgery and that evening, you will have to remain in bed.

The following morning the dressings will be removed, and you will be allowed to get up. It is normal for you to feel light headed the first time you get out of bed. Please do not try to do this yourself. Please wait until someone is there to help you. It is normal for your leg to be swollen and warmer than usual. The swelling will gradually decrease over the next several days, but some swelling may remain for up to six months.

You are encouraged to walk as much as possible. The more you get out of bed and move around the faster you will recover. Many times we will arrange for you to go to the physical therapy department for gait training and for help in learning to use a walker or crutches if you have significant pain in your leg. The length of your hospitalization is really determined by you and your medical problems. We do want to be sure, however, that you are able to get out of bed and walk around and will not be confined to a chair a home. We want you to be active as much as possible. Remember, the more active you are, the more you use your muscles, the better the flow through the graft and the better chance of long term patency.

When You Go Home
Remember, you 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. Now you can expect to feel more tired and weaker than you used to be. We do want you to continue doing as you were in the hospital; walk as much as possible, eat and sleep as much as you want, but try to resume your normal daily activities and be as active as possible at home. Our only restriction is to ask that you do not bend your knee at an acute angle and keep it that way. This would restrict flow throughway the graft and may cause it to clot. We would prefer that you do not drive a car at least until after we see you for your return appointment.

You may, however, ride in a car and get around as much as you feel you can tolerate. You may go up and down stairs. Your appetite may not be as good as usual and your bowels may not move regularly. 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 that 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 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 as two or three drinks did before surgery. You may shower using your regular soap on your incisions. Be aware how your feet and legs feel after surgery, and if you notice any change in circulation to your feet such as persistent numbness, tingling, pain, coldness, or discoloration, please call us right away. It is very important to keep your two week appointment and any subsequently doctor 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.

Information for the Family
Remember that the patients usually go to the operating room an hour or so before they are scheduled for surgery. Family members should adjust their schedules accordingly if they want to visit before the operation. Surgery will usually take several hours. We encourage family members to wait by the telephone at home, and we will be happy to give you a call as soon as we are finished. If you want to wait in the hospital, we will be glad to come out and talk to you in the intensive care lounge on the second floor outside of the OR suite. The patient will then be going to the recovery room and will be there for several hours. You will be able to see him again on his return to the room.

Complications
Problems associated with your anesthetic will be discussed with you by your anesthesiologist.

It is never nice to talk about the bad things that could happen when your 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 the 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. Leg wounds many times will leak a clear yellow fluid (Lymph) for a while. This is not unusual. The wounds, however, should not become red and the fluid should not become cloudy. If this happens, you need to let us know as soon as possible.

The most undesirable problem to arise can be the failure of the reconstruction. If the graft fails, the leg usually reverts to the same condition it was in before the surgery. But, if there is clot that extends into the outflow system, it can become worse. While this is an uncommon problem, it can and does occasionally happen, and you must be aware of it.

There are many other minor problems that can and have occurred, but in a very low frequency. We'll be happy to discuss them with you in greater detail if surgery is recommended. Of course, you should feel free to ask us any questions you have concerning the surgery, it's alternatives, and the potential complications.

Call Us If:

1. Your wound becomes red, sore or swollen.
2. You develop a fever in excess of 101.
3. You develop new symptoms of numbness, tingling, pain, or weakness in the operated extremity.
4. Increased shortness of breath.

Should any problems arise, please call our office as early in the day as possible. Our office is open from 8:00 am to 4:30 pm daily. Most problems can be handled in office, but if you call early, our nurses have a better chance of contacting your own surgeon for advice. Of course, if there is an emergency, one of us will be available at all times through our answering service.

Some Final Words in Summary

1. The best diet is low fat and low cholesterol; eaten in moderate quantity.
2. Follow a regular walking exercise program
3. Take 1 aspirin per day (unless otherwise instructed)
4. Don't smoke! (unless you want us to acquire even more experience in limb salvage vascular reconstruction than we already have)