William Purtill, M.D, FACS, RPVI
This is a procedure performed under local anesthesia via the artery in the groin where a wire, then a stent is placed into the narrowed carotid artery in the neck. This is done for patients who have severe Carotid Artery Disease who are not candidates for Carotid Endarterectomy. This procedure is currently FDA approved for patients who have had a small stroke or TIA who are at high risk for surgery. For patients of average risk, the correct data demonstrates a lower risk for Carotid Endarterectomy than Carotid Stenting.
Most cuts or wounds heal in a few days or weeks. A chronic wound is one that has not healed in four weeks. People with wounds that do not heal usually have one or more underlying conditions. The most common of these are Peripheral Arterial Disease, Chronic Venous Insufficiency, and Diabetes with or without neuropathy or people with abnormal pressure areas who are very immobile. Poor nutrition and some medications (steroids, some immunity suppressing drugs, etc.) can also play a significant part in slowing the healing process.
Atherectomy is the removal of an Atheroscleric plaque. One method includes inserting a tiny blade into the artery to cut the plaque away. Another method involves a high speed spinning device that sands away the plaque (it turns it into dust). The principle of this procedure is similar to the Angioplasty/Stent procedure.
An incision is made in the abdomen to replace the weakness in the aorta. This can be done in the middle of the stomach as a vertical incision or it can be done via an incision in the left flank from the incision, the bowels are pushed to the right, the Aneurysm is exposed, a plastic tube sewn into the normal blood vessel above and below the Aneurysm, it allows blood flow to continue to the pelvis and legs. From the left flank incision, the bowels are pushed out of the way, the Aneurysm is exposed and the plastic tube is used to replace the Aneurysm. After the plastic tube has been sewn into place, the old aneurysm is sewn over the tube and the incision is closed. Most patients spend 1 to 2 days in an ICU type area and approximately one week in the hospital. It takes 2 to 3 months to completely recover. Patients are recommended to not lift anything over ten pounds in weight for approximately 6 weeks. Once the patient has recovered from this surgery, they can look forward to a lifetime of no further symptoms from the Aneurysm.
Patent Artery after Stent Insertion
This is the most popular procedure used to treat large Varicose Veins (>5 millimeters). This is done instead of vein stripping. No cut/incision is made in the leg. A needle is inserted into the main vein under the skin called the Saphenous vein. After giving some local anesthesia, a thin wire followed by a laser catheter is then inserted through the Saphenous vein and passed up the groin. Ultimately, the laser is turned on and used to burn the vein from within. The vein then clots, shrivels up and dissolves. This treatment prevents the pooling of blood within this vein that contributes to the development of varicose veins. The varicose veins shrink over 4-6 weeks. The procedure is done in the office with mild sedation only. The patient is advised to take off from work for a few days up to one week.
After bilateral iliac stent insertion (the claudication resolved)
Stenosis resolved after Angioplasty
Stenotic/Narrowed Right Superficial Femoral Artery
Right: Post Stent Insertion, the Internal Carotid Artery is now widely patent.
This is a method to repair an Aneurysm. Small incisions are made in both groins (no stomach/abdominal incisions are made) using x-ray guidance and a system of tubes and wires. The plastic tube used to replace the Aneurysm is positioned inside the Aneurysm (Images of the procedure are shown below). The positioning requires administering intravenous dye. Not all patients are candidates for EVAR as there has to be a normal portion or aorta below the arteries to the kidneys or renal arteries and the arteries in the pelvis or iliac arteries have to be relatively free of disease.
A small operation is performed usually under local anesthesia n the operating room. The procedure is usually done on an outpatient basis. A plastic tube is inserted under the skin between the patient’s own artery and vein. This is done when the veins under the skin are too small for a Fistula. It can be used for dialysis access earlier than a Fistula (10-14 days) as it requires less time to develop. Grafts however, have a higher tendency to clot and stop working, requiring further interventions. This occurs in most AV grafts at between 6 and 12 months and is most commonly caused by the development of scar tissue at the point where the graft and vein are connected. Procedures to de-clot these grafts are done under local anesthesia and not in the operating room. The procedure carries a small risk of bleeding, infection, or decreased blood supply to the hands called steal syndrome. There is also a small risk of infection of the plastic graft and this can require removal of the graft.
This is an open surgical procedure where an incision is made at the groin and at the ankle or knee. A device (The Stripper) is passed inside the main subcutaneous vein called the Saphenous vein. The vein is then pulled out under the skin. The leg is then wrapped to prevent leg swelling or bleeding. This is sometimes done in conjunction with excision of the varicose veins (Stab Avulsion or Phlebectomy) and results in resolution of the varicose veins. This procedure is done in the operating room and requires a general or spinal anesthetic.
A small Varicose Vein (2-4 millimeters) in injected with a solution that causes the vein to clot. A tiny needle containing the solution is injected into the vein. The vein is then compressed, clots and resolves. The procedure is done in the office and because the needle is tiny no anesthesia is necessary. It is recommended that compression stockings be work afterwards for four weeks. No time off of work is necessary. Vigorous exercise should be avoided for one week.
Stenosis in Fistula
This is a schematic of open AAA repair. The aneurysm is opened and the clot is removed, the graft is sewn in and the aneurysm is wrapped around the graft to keep it away from the bowel.
A small operation is performed usually under local anesthesia in the operating room. The procedure is usually done on an outpatient basis. The patient’s artery and vein are connected directly. It requires a good quality vein under the skin and good quality artery. The blood goes directly into the vein, the vein enlarges and its wall thickens. Once the vein has enlarged and thickened (matured) needles for the dialysis machine are inserted directly into the vein. Maturation can take from 6 weeks to several months. A Fistula once mature can last for many years and thus it is regarded as the best long-term access for dialysis. The procedure carries a small risk of bleeding, infection, or decreased blood supply to the hands called steal syndrome.
Varicose Veins are dilated or swollen veins that are usually in the leg. They appear as bulged and twisted veins under the skin. They are more common in women (25% of all women). They can be hereditary. Varicose Veins are caused by poor function of valves on the inside of vein walls. Blood then flows in the wrong direction or refluxes and causes bulging of smaller veins causing them to become Varicose Veins. Varicose veins can cause an aching or discomfort in the legs. Rarely, they can become tender or clot and very rarely they may bleed. They are also rarely the underlying cause of chronic leg swelling (Chronic Venous Insufficiency) and even ulcers or wounds. Treatment options are leg elevation, pain medications, compression stockings, sclerotherapy or injections, Laser Vein Ablation or Vein Stripping.
Also known as Peripheral Arterial Disease (PAD) is the narrowing of arteries that results in poor circulation blood flow to your arms and legs. When you walk or exercise, your leg muscles do not get enough blood and you could experience painful cramping. This condition is caused when a blockage occurs in the arteries which carry blood, rich in oxygen and nutrients, from the heart to the rest of the body.
Angioplasty is usually done without an incision under local anesthesia where a balloon is inserted into the narrowed portion of the blood vessel to treat Peripheral Vascular Disease. The balloon is inflated and the plaque that has narrowed the artery is pushed aside widening the artery to its normal size. The procedure may be in an angiograph suite or in the operating room. It is usually done with sedation and local anesthesia. Contrast dye is also administered during this procedure. A stent which is a mesh like tube or scaffold is used to reinforce an area that is treated with angioplasty and further forces the plaque that narrows an artery up against the wall of the artery. Some stents are treated with drugs. These drugs prevent re-narrowing the area treated with a stent. They have been found in studies to have a significant effect upon this re-scarring in the coronary arteries, however, to date they have not been shown to benefit patients with stenosis in the peripheral circulation.
Post Carotid Endarterectomy
These are moderately tight elastic stockings that are used for patients with Varicose Veins, Chronic Venous Insufficiency, Lymphedema, etc. Compression Stockings are designed to be tighter at the ankle than at the knee and thus push blood towards the heart. They come in a range of pressures: 8-15, 16-20, 20-30, and 30-40 millimeters of mercury. They come in different lengths: knee high, thigh high and pantyhose. They also come in a range of colors. Many patients do not tolerate them in the summer, however in the last several years they have become sheerer for women and look like dress socks for men.
A large intravenous catheter or cannula like device is inserted directly into the vein or through a tunnel under the skin into the vein. There are two basic types with multiple brand names. The simpler type can be done at the patients’ bedside with local anesthesia and involves inserting a large catheter through the skin directly into a large vein in the neck, upper chest or groin. It must be removed in approximately seven to ten days to prevent infection and a new access is thus then required. The other type of catheter is called a “perm-cath” as it is meant to be permanent- it rarely is. It is inserted via a small surgical procedure. The patient is given local anesthesia and sedation. A large catheter is inserted into the vein in the neck. However, it is then tunneled under the skin. This tunneling under the skin allows the catheter to be left in place for a longer period of time than the temporary catheter. These catheters also have a risk of becoming infected and they thus are not recommended as the ideal long-term method to facilitate hemodialysis. A catheter is easier to insert than the creation of a fistula or a graft, however, these catheter have a tendency to become infected and also they block off or clot. The procedure also carries a small risk of injury to the blood vessel and a small risk of collapse of the lung.
This is when a large blood vessel (Aorta) that supplies blood to the abdomen, pelvis and legs become abnormally large or balloons outward. Abdominal Aortic Aneurysm repair is indicated for patients who have large Abdominal Aortic Aneurysm. That means that the Aneurysm is greater than 5 or 5.5 cm in diameter. Measurement can be performed by ultrasound or CT scan.
Kidney or Renal Failure occurs when the kidneys stop filtering the blood of toxins and excess water build up. When untreated it is fatal. Dialysis is the treatment for this condition. This is a treatment for kidney failure where toxins from the blood are removed. There are two basic techniques, one is hemodialysis, where a machine is hooked up to the patients blood vessel; the other is peritoneal dialysis where a catheter is inserted into the patient's stomach cavity followed by exchange of different fluids to remove the impurities. Hemodialysis may be performed through a fistula, a graft or a catheter.
This is a surgical procedure where the plaque that has built up on the inside of the carotid artery in the neck is removed. The procedure is done to prevent strokes. This procedure can be done in patients who have buildup of the plaque within the artery with no symptoms or patients who have suffered a small stroke, mini-stroke or TIA. An incision is made in the neck, the artery is exposed, clamps are then placed to stop the blood supply. A Shunt is frequently placed thereafter to keep the blood flowing to the brain. The plaque is then removed, the artery is re-closed and the shunt is removed. The procedure carries a small risk of a stroke, however the risk is less than the risk of not having any procedure performed in patients who have a severe Carotid Artery Stenosis. The procedure takes approximately two hours and patients spend 1 to 2 days in the hospital.
This is a condition where the blood pools in the veins in the legs due to poor function of the valves within the veins. It can result in discomfort or pain, leg swelling, skin color changes, hardening of the skin or breakdown of the skin resulting in ulcers. It can occur in patients that have had a previous blood clot or DVT. Patients who are significantly obese are also at risk of developing this. It is diagnosed with a Doppler Ultrasound. Treatment includes compression stockings, moisturizers to treat/prevent dry and cracked skin, treatment of any varicose veins if present as outlined above, treatment of wounds as outlined in the wounds segment, vein bypass or venous valve repair are rarely performed. Angioplasty/stenting of occluded or narrowed pelvic (iliac) veins is also very occasionally needed.
Left: Angiogram of Internal Carotid Stenosis
Severe bilateral common and external iliac artery stenoses (the patient had severe claudication
This is a condition where the main artery in the neck that supplies blood to the brain is narrowed by atherosclerotic plaque. This is the buildup of fatty substance on the inside of the artery. This can sometimes contain calcium and clotted blood. A buildup of this causes the narrowing and portions of these to break off. It can result in a stroke by blocking off the blood supply to a part of the brain. The plaque is caused by the same condition that cause coronary artery disease and peripheral arterial disease. This can be caused by smoking, high blood pressure, high cholesterol, diabetes, etc. The condition can be mild, moderate or severe. If severe, it may require treatment such as: Carotid Endarterectomy or Carotid Angioplasty and Stent. The condition can be diagnosed with a Carotid Ultrasound, a CT Angiogram, MRA or Angiogram.
Dilated Mature AV Fistula