Thoracoscopic Cervical Sympathectomy

Thoracoscopic cervical sympathectomy is often performed to prevent or reduce sweating in your hands and/or your armpits & face.  The aim can also be to improve the circulation in the arm or hand but is also occasionally done to reduce pain in other conditions, where disease of blood vessels is not the primary problem. The procedure involves removal of the sympathetic nerve trunk from the neck and chest.

You need to know the following facts:

  1. After thoracoscopic cervical sympathectomy your hand(s) should feel warmer and dry. This indicates a successful procedure. The armpits should be dry.
  2. One patient in every five having thoracoscopic cervical sympathectomy will experience transient pain in the outer part of the arm. If this happens to you, it will start within the first 10 days and will last from 2 to 6 weeks before disappearing. This is quite normal and is known as post sympathectomy neuralgia. You may have to take pain killers for nighttime comfort.
  3. Thoracoscopic cervical sympathectomy is considered a very safe procedure, with very few problems other than the transient pain mentioned above. Nonetheless, you should know that there is a very small risk - not more than 1 chance in 2000 - that you may experience numbness or weakness in the hand from other nerve damage.  A droopy eyelid and small pupil can also occur as a result of the procedure affecting the nerve supply to the eyelid (1%). Excessive sweating of the lower body will occur and this is known as compensatory sweating and can be quite marked. A stuffy nose may result and this change can be permanent requiring nasal spray for life. The face will feel dry after thoracoscopic cervical sympathectomy and this may be annoying. Failure to improve your condition or failure to remove the part of the nerve can occur and this is called a therapeutic failure and is therefore also a risk. Risk to life is < 0.01%.
  4. For maximum precision and safety thoracoscopic cervical sympathectomy will be performed through the chest with a telescope.  This adds a risk of bleeding or lung damage causing an air leakage. Rarely the chest may have to be cut open for treatment.
  5. Thoracoscopic cervical sympathectomy will be performed in an operating theatre, but there will be no major cut or stitches needed. General anaesthesia is required and some post operative chest pain is common for 2 days. Normally both sides can be performed at one procedure however if technical difficulties occur the opposite side procedure may have to be postponed.

Phenol (Chemical) Sympathectomy

Phenol (Chemical) Sympathectomy is often done to prevent or reduce constriction in the small blood vessels in your legs and feet.  The aim is to improve the circulation in the leg or foot but is also occasionally done to reduce pain in other conditions, where disease of blood vessels is not the primary problem. Excessive sweating is also a reason to have phenol (chemical) sympathectomy performed, as the nerve block stops sweating.

You need to know the following facts:

  1. After phenol (chemical) sympathectomy your leg should feel warmer and dry. This indicates a successful block.
  2. One patient in every five having phenol (chemical) sympathectomy will experience transient pain in the outer part of the thigh or groin. If this happens to you, it will start within the first 10 days and will last from 2 to 6 weeks before disappearing. This is quite normal and is known as post sympathectomy neuralgia.  You may have to take pain killers for nighttime comfort .
  3. Phenol (chemical) sympathectomy is considered a very safe procedure, with very few problems other than the transient pain mentioned above.  Nonetheless, you should know that there is a very small risk - not more than 1 chance in 5,000 - that you may experience numbness or weakness in the legs. If this procedure has been recommended for the treatment of vascular disease, then the benefits of phenol (chemical) sympathectomy, in reducing the likelihood of other problems which might prevent you walking properly, will far outweigh this risk.
  4. For maximum precision and safety in performing the injection, it will be performed with the aid of X-ray pictures to ensure the drug goes in the correct place. The machine used for this gives a much lower dose of radiation than a normal chest X-ray.
  5. For our convenience and your safety, phenol (chemical) sympathectomy will be performed in an operating theatre, but there will be no cut or stitches needed and it is often no more painful than giving a blood sample. Nonetheless, because patients are often nervous, you will be given some sedation. You will therefore have to stay in hospital for 2-4 hours. Afterwards and you must not drive or make any vital decisions for the next 12 hours. You should also be accompanied home by a friend or relative. Any problems should be reported to Dr Milne.

Varicose Vein Surgery

AIM OF VARICOSE VEINS SURGERY

The operation for varicose veins is designed to ligate points of venous valve failure and extract the varicose veins from the leg, by means of multiple small incisions.  The technique is known as "ligation, puncture and extraction".  Sometimes removal of the surface thigh vein or calf vein is required and this is performed by invagination of the vein rather than "stripping”.  This technique allows for minimal trauma and a faster recovery than the old technique of "stripping".  A preoperative ultrasound (duplex scan) is used to identify all the points of valve failure so as few as possible valve leaks are missed at surgery.  At present, varicose veins surgery has resulted in a 90% rate of "cure" for high pressure varicose veins.  Follow up ultrasound and/or injection therapy is sometimes required. Small surface veins are not treated by surgery and they often become more prominent after surgery.

BEFORE VARICOSE VEINS SURGERY

Prior to varicose veins surgery you will be seen by both the Anaesthetist and Mr. Milne.  The anaesthetist will discuss the type of anaesthesia for you and answer any questions regarding same.  It is important that you tell the anaesthetist of any drug therapy or allergies so bring any regular medication with you to hospital.

The surgeon will mark out your legs with red ink at this visit and any further questions about your surgery will be answered.

An Assistant surgeon is employed on all occasions for venous surgery, as it shortens the operation time, thus making the procedure safer.  The assistant will be introduced to you prior to anaesthesia.

SURGERY

When you have your varicose veins surgery, you can expect an incision, approximately one half to three centimetres long, over the site(s) of leaking valves.  These are generally at each groin and less frequently behind the knee.  Some of the incisions for extraction of the varicose veins themselves will be approximately 1/2 to 2 millimetres in length and will be closed by single suture or adhesive tape.  Most extraction sites are small punctures (less than 1 mm) and will not require any suture or closure at all.  Firm compression bandages are applied at completion of varicose veins surgery.  Only minimal blood loss occurs with this surgery so blood transfusion is not a consideration. When varicose veins surgery is complete you will be confined to bed for 4-6 hours with the legs elevated and very firm bandages in place.

AFTER VARICOSE VEINS SURGERY

After varicose veins surgery you can expect some mild stinging discomfort for a few hours, which should be easily controlled by oral analgesia (pain tablets e.g. Paracetamol or Codeine). Tight bandages, causing severe pain or inability to sleep, should be reported to the nursing staff. Sometimes blood thinning injections are used, as a precaution against thrombosis, but most medication is in tablet form only.

Some bleeding may occur through the bandages and should be reported to the nursing staff.

After discharge from hospital any bleeding from wounds can be managed by direct pressure with a tissue for a few minutes. In the rare event of major bleeding elevate the legs vertically and bleeding will immediately cease.

The hospital time for varicose veins surgery is in the range of one to three days, depending on comfort.  A change from the bandages to compression stockings of takes place on the second or third day after surgery.  Mr. Milne will see you in hospital and Mr. Milne or the practice nurse will arrange for your bandaging and appointments. Skin closure adhesive tapes and soluble buried sutures are used so no suture removal is required after surgery.

Scars after varicose veins surgery are initially red as they heal.  This redness fades after 6 weeks to 18 months depending on the individual.  The puncture site scars have the appearance of mosquito bites during this time.  Occasionally a thread of fibre is seen at these sites and can be cut off with a nail scissor. The legs are bruised and sometimes lumpy. The thighs may feel bruised, also, and these problems resolve over one to six weeks.  Most thigh discomfort settles after 10 days. Any bruising, swelling or lumps that you feel are alarming contact the office.

If you are prone to small spider veins or burst capillaries then these will often become more numerous.  Follow up treatment is available by means of injection therapy to clear these if required.

There are no restrictions following varicose veins surgery and you may drive, walk or do most chores in the light stockings from 2 days post surgery.  Activity is encouraged and walking is the best activity to look after your body at this time.  When you are not active you will find it more comfortable to put your legs up. Standing, however, does no harm.  The bandages/stockings will control swelling and can be used for extended periods if desired.  One week is the usual time for stockings.  There is no need to elevate your feet in bed after the second post op. Day.

COMPLICATIONS/RISKS

The chances of a complication requiring re-admission to hospital, or delay in discharge, are less than 0.1% or 1 in 1,000.

The special risks are          

    Infection 1:3000 risk

    Thrombosis of the deep veins. 1:2000 chance

Infection is evidenced by a discharge or fever with redness and pain of a wound.

Thrombosis is evidenced by excess pain and/or severe swelling

Minor Risks

Numb patches, bruising, minor infection, inflammation, lumps or solid segments of vein causing discomfort. Disabling pain lasting more than 2 weeks is uncommon and should be reported.

After your varicose veins surgery any complications or difficulties regarding same should be referred immediately to Mr. Milne's office or his call service.  Telephone numbers are on your post-operative instruction sheet.  Any other unrelated medical condition should of course be referred back to your local doctor.

ACCOUNTS

The anaesthetic and surgical bills are currently charged at between A.M.A.  and schedule fee rate. There may be gaps between your rebates from your fund, Medicare and the fee charged.  Advice on “Gap Cover” and total charges can be obtained from this office.  You may also receive an account from the assistant surgeon and anaesthetist which will be mainly covered by your fund and Medicare.  Public hospital access is available for varicose veins surgery but the waiting time is between 6 months and 4 years depending on urgency

Ultrasound Guided Sclerotherapy & Coil Occlusion

AIM

Ultrasound guided sclerotherapy with Coil Occlusion is a further development of standard sclerotherapy (Injection treatment, also known as “Echosclerotherapy”or “Foam Echosclerotherapy”) of lower limb varicose veins. This treatment is designed as an alternative to surgery for varicose veins previously only manageable by operation. The aim is to obliterate defective veins inside the leg that are flowing in the wrong direction.  The ultrasound machine enables us to see defective deeper veins and thus guide the needle used for treatment.  If successful, it results in a decrease in the workload of the remaining vessels in the limb and thus a return to a more normal circulatory status.  Because ultrasound guided injections alone are not very successful for long term clearance of varicose veins, Coil insertion is required for a long lasting result. The largest vein that can be managed by sclerotherapy technology is 4mm in diameter. The largest vein that is treatable by the Coil technology is 12 mm. Generally veins greater than 12 mm in diameter are still best managed by Surgery.

SCLEROTHERAPY

Sclerotherapy was designed many years ago (1930’s) and popularised in the United Kingdom in the 1960's.  The procedure involves injection of a solution (called a sclerosant) into unwanted varicose veins.  The injected veins then go solid and are absorbed by the body.  All injection treatments for varicose veins are based on the principle of damaging the lining of the vein to be obliterated.This results in the collapse of the vein followed by solidification.  The vein traps blood in the centre of the vessel which then thromboses. This makes the vein lumpy after treatment.  The body then dissolves the solid vein by creating inflammation around it.  This process leads to the redness and tenderness experienced with sclerotherapy.  The same process occurs after surgery but inflammation and bruising with injection treatment sometimes takes 6 weeks or more to settle unlike surgery where inflammation settles in 2 weeks. Brown staining can persist for up up to 2 years but mostly fades in 6 months. Sclerotherapy treatment alone is only effective for small veins of less than 4mm diameter. If larger veins are treated by this technique alone, recurrence usually occurs in 12 months with secondary brown staining.

COIL OCCLUSION

To treat larger varicose veins and large valve leakages in the lower limb an additional treatment is sometimes used.  This is known as “coil occlusion”.  For some fifteen years very small stainless steel and Dacron coils have been used to occlude vessels in the body.  They constitute a similar technology to the use of surgical clips in open surgery.  These devices have been used to occlude arteries and veins inside the brain, chest and abdomen for many years.  Their use has been extended to lower limb veins because of the obvious safety of these devices.

Deployment of an occluding coil into a varicose vein extends the effectiveness and durability of ultrasound guided injections and results in a much greater likelihood of long term permanent success.  The use of coils is generally restricted to larger vessels, as small veins respond to injection treatment (sclerotherapy)  alone. This new technology allows for a greater proportion of people with varicose veins to be treated by non surgical means. The majority of persons with recurrent varicose veins can now avoid further surgery and about two thirds of patients with primary varicose veins are suitable for coil occlusion.

SIDE EFFECTS & RISKS OF ULTRASOUND GUIDED SCLEROTHERAPY & COIL OCCLUSION

The concentration of sclerosing agent used for this treatment is higher than for surface veins and therefore the chances of side effects are greater.  The most common side effect is some tingling around the lips or a feeling of faintness. This side effect is in actual fact harmless and wears off extremely rapidly.

The major risks are Ulceration, Infection or Deep vein thrombosis .  An ulcer after ultrasound guided sclerotherapy with coil occlusion is rare but, if this does occur, it can be large and painful requiring hospitalisation and possible skin grafting. The chance of disabling ulceration is one per 500 patient treatment sessions.  People who have had previous ulcers from their varicose veins seem to be predisposed to this complication.

Deep vein thrombosis requires hospital admission for treatment but the risk is less than 11000.   Infection requiring treatment has an incidence of 1500 treatments.  People with ulcers or damaged skin are most likely to suffer this complication and it would require administration of antibiotics.

The use of occlusion coils for larger vessels has dramatically reduced the incidence of side effects from injection treatment. There is also the additional benefit of reducing the total dose of sclerosing Agent as well as reducing the risk of ulceration as a complication.

The risk of coils moving from the original placement site after treatment is considered to be negligible but tangible.

Loss of a coil during the actual procedure, however, would require removal of the coil by X-Ray control through a catheter in the vein. Surgery to remove an incorrectly placed coil should rarely be required and would consist only of a tiny incision under local anaesthetic.

TREATMENT

What you need to know

There are no special requirements beforehand except that you should wear warm clothes loose enough to go over the legs after the application of bandages. Warmth is helpful in dilating the veins so over dress or walk briskly before your visit.

Ultrasound guided sclerotherapy with coil occlusion itself is usually not uncomfortable with only the needle insertion causing discomfort during administration of Local Anaesthetic.

Usually a fine tube is threaded into the vein to deliver the coil and sclerosant. You may be able to feel the tip of the catheter moving inside the leg but this is not a painful sensation.

Once the coils have been placed the sclerosant is introduced and you will feel some stinging in the surface varicose veins as they vanish. Several additional needle insertions are usually required to obliterate remaining veins on the surface.

After coil insertion, with injection of sclerosant, cotton wool balls and adhesive tape are applied at the injection sites.  You will then be placed in compression bandages. These cover the cotton wool balls and compress the treated veins. You should leave these bandages intact for at least 8-12 hours.

After treatment you should walk at least two to five hundred metres to help circulate blood through the deeper veins of the limb. This should be repeated a few times over the next few hours.

Bandages Following application of compression bandages you will be given instructions as to exactly how long to wear them.  Normally you will wear the compression bandages until the following morning.  You must remove the bandages and then shower and remove the cotton wool balls and adhesive tape from the limb. (Removal of the cotton wool and adhesive tape is essential within 12-24 hours to prevent skin blisters).   Following the shower you should re-apply the bandages to compress the legs (not the thighs) for a further few days.  This period may be shorter and you will be advised accordingly. The purpose of the bandages is to try and compress the vein walls together so that there is very little trapped blood.  Without compression the veins tend to be big and bulky when solidified and thus they take longer to absorb. Sometimes the thigh bandages tend to unravel rapidly in which case they can be left off but bandages below the knee should be reapplied.

AFTER ULTRASOUND GUIDED SCLEOTHERAPY WITH COIL OCCLUSUION

There will be some tendency for the ankles or legs to swell.  Any dramatic increase in swelling should be reported to Mr. Milne.  An unusual degree of pain following Ultrasound guided sclerotherapy with coil occlusion should also be reported.  There is no limitation on your activity following treatment and you should carry on all your normal sporting and work related activities.  Discomfort usually settles with analgesia such as Panadeine.

In the weeks following ultrasound guided sclerotherapy with coil occlusion swelling of the ankles will settle, if it has occurred at all.  You will feel some hard lumpy areas where the veins have solidified and these become tender as the absorption process gets under way.  The veins will become red and inflamed as part of the absorption process and simple anti inflammatory agents such as Aspirin, Nurofen, or Naprogesic may be used.

When the veins are completely absorbed (usually within six months) there may be some brown staining left on the surface of the skin.  This goes away slowly with time sometimes as long as 2 years.  The coils are impalpable and are not visible.  The veins will disappear as completely as they would with injection treatment alone.

THE SCLEROSANT

Over the past ten years several agents have been used as sclerosants The agent that is currently the most satisfactory is known as "Aethoxysklerol" or its generic name "Polidocanol".  This agent is a surfactant, which means that it has a soap like action, which leaches the fat from the wall of the vein, resulting in the vein collapsing and going solid.  Pregnancy and breast feeding are the only contraindication for sclerotherapy with this agent .

Possible side effects are as follows

Anaphylaxis

This is an extreme life threatening allergic reaction. It is extremely rare, however it has been reported once overseas but not in Australia.

Local Skin Ulcers

These are very rare and tend to be very small and heal rapidly.  Occasionally excision of an ulcer with suturing may be necessary and this is usually done in the office under local anaesthetic.

Deep Vein Thrombosis

This is rare if the correct dosage is followed and the injection is associated with compression bandaging and mobilisation. Current risk 1750 treatments.

THE COILS

The devices commonly called “coils” are made either of stainless steel and polyester or platinum and polyester.  The devices used for this treatment are T.G.A. approved for use in Australia and have a long documented history of safe deployment.  Like surgical clips they are fully inert after implantation.

There is a very small risk of infection (less than 1 in 1000) with these devices. Infection would require removal of the coil, normally under local anaesthetic.

After ultrasound guided sclerotherapy with coil occlusion, the coils are visible on plain x-ray and appear very much like surgical clips commonly used for abdominal surgery.  They will not trigger a metal detection device such as those commonly used at airports. They are MRI Compatible for MRI scanning. These coils, once implanted, are completely inert with less than 110,000 rejection rate.

Any difficulties with ultrasound guided sclerotherapy with coil occlusion should be reported immediately by phone to this practice, not your local doctor.  The result of your treatment, and/or significant complications, must be reviewed by Mr Milne before you can be discharged to your referring medical officer.

TREATMENT COMPARISON
  Hospital time Procedure time Anaesthetic Discomfort
Surgery 1-2 days 1-2 hrs General/Spinal 2-3 weeks
Coils 1-2 hrs 20-40 mins Local 6-12 weeks

Safety of the two treatments is similar with risks of deep vein clot (less than 1750 treatments).

Discolouration, with brown staining, can occur with either surgery or coil treatment and fades in 6 weeks to 2 years.  Mostly fading takes place within 6 months but, injected veins take longer to fade than surgically removed veins.

Post procedure visits are at 2-6 weeks then 6 months after treatment.

“Top up” treatment (sclerotherapy) in the office is available at these visits if required for left over superficial veins.

Permanence

Surgery is normally 95% effective in removing large veins for 10 years.

Ultrasound guided sclerotherapy with coil occlusion appears reliable at 5 years. Small surface veins occur with time after either treatment and can be managed with sclerotherapy in the office. Recurrence of  varicose veins in the calf is not uncommon with either treatment and is managed by injections.

COSTS

Out of pocket costs can be substantial if you have no Private Health Cover so please enquire re same prior to treatment. Quotes are issued by this office for your treatment.  Substantial gaps between your fund rebate and the fee charged may occur and is defined with your quote. Rebates vary between Health Funds so your out of pocket cost is fund dependant

Sclerotherapy (Injection Treatment)

AIM

Ultrasound guided sclerotherapy with Coil Occlusion is a further development of standard sclerotherapy (Injection treatment, also known as “Echosclerotherapy”or “Foam Echosclerotherapy”) of lower limb varicose veins. This treatment is designed as an alternative to surgery for varicose veins previously only manageable by operation. The aim is to obliterate defective veins inside the leg that are flowing in the wrong direction.  The ultrasound machine enables us to see defective deeper veins and thus guide the needle used for treatment.  If successful, it results in a decrease in the workload of the remaining vessels in the limb and thus a return to a more normal circulatory status.  Because ultrasound guided injections alone are not very successful for long term clearance of varicose veins, Coil insertion is required for a long lasting result. The largest vein that can be managed by sclerotherapy technology is 4mm in diameter. The largest vein that is treatable by the Coil technology is 12 mm. Generally veins greater than 12 mm in diameter are still best managed by Surgery.

SCLEROTHERAPY

Sclerotherapy was designed many years ago (1930’s) and popularised in the United Kingdom in the 1960's.  The procedure involves injection of a solution (called a sclerosant) into unwanted varicose veins.  The injected veins then go solid and are absorbed by the body.  All injection treatments for varicose veins are based on the principle of damaging the lining of the vein to be obliterated.This results in the collapse of the vein followed by solidification.  The vein traps blood in the centre of the vessel which then thromboses. This makes the vein lumpy after treatment.  The body then dissolves the solid vein by creating inflammation around it.  This process leads to the redness and tenderness experienced with sclerotherapy.  The same process occurs after surgery but inflammation and bruising with injection treatment sometimes takes 6 weeks or more to settle unlike surgery where inflammation settles in 2 weeks. Brown staining can persist for up up to 2 years but mostly fades in 6 months. Sclerotherapy treatment alone is only effective for small veins of less than 4mm diameter. If larger veins are treated by this technique alone, recurrence usually occurs in 12 months with secondary brown staining.

COIL OCCLUSION

To treat larger varicose veins and large valve leakages in the lower limb an additional treatment is sometimes used.  This is known as “coil occlusion”.  For some fifteen years very small stainless steel and Dacron coils have been used to occlude vessels in the body.  They constitute a similar technology to the use of surgical clips in open surgery.  These devices have been used to occlude arteries and veins inside the brain, chest and abdomen for many years.  Their use has been extended to lower limb veins because of the obvious safety of these devices.

Deployment of an occluding coil into a varicose vein extends the effectiveness and durability of ultrasound guided injections and results in a much greater likelihood of long term permanent success.  The use of coils is generally restricted to larger vessels, as small veins respond to injection treatment (sclerotherapy)  alone. This new technology allows for a greater proportion of people with varicose veins to be treated by non surgical means. The majority of persons with recurrent varicose veins can now avoid further surgery and about two thirds of patients with primary varicose veins are suitable for coil occlusion.

SIDE EFFECTS & RISKS OF ULTRASOUND GUIDED SCLEROTHERAPY & COIL OCCLUSION

The concentration of sclerosing agent used for this treatment is higher than for surface veins and therefore the chances of side effects are greater.  The most common side effect is some tingling around the lips or a feeling of faintness. This side effect is in actual fact harmless and wears off extremely rapidly.

The major risks are Ulceration, Infection or Deep vein thrombosis .  An ulcer after ultrasound guided sclerotherapy with coil occlusion is rare but, if this does occur, it can be large and painful requiring hospitalisation and possible skin grafting. The chance of disabling ulceration is one per 500 patient treatment sessions.  People who have had previous ulcers from their varicose veins seem to be predisposed to this complication.

Deep vein thrombosis requires hospital admission for treatment but the risk is less than 11000.   Infection requiring treatment has an incidence of 1500 treatments.  People with ulcers or damaged skin are most likely to suffer this complication and it would require administration of antibiotics.

The use of occlusion coils for larger vessels has dramatically reduced the incidence of side effects from injection treatment. There is also the additional benefit of reducing the total dose of sclerosing Agent as well as reducing the risk of ulceration as a complication.

The risk of coils moving from the original placement site after treatment is considered to be negligible but tangible.

Loss of a coil during the actual procedure, however, would require removal of the coil by X-Ray control through a catheter in the vein. Surgery to remove an incorrectly placed coil should rarely be required and would consist only of a tiny incision under local anaesthetic.

TREATMENT

What you need to know

There are no special requirements beforehand except that you should wear warm clothes loose enough to go over the legs after the application of bandages. Warmth is helpful in dilating the veins so over dress or walk briskly before your visit.

Ultrasound guided sclerotherapy with coil occlusion itself is usually not uncomfortable with only the needle insertion causing discomfort during administration of Local Anaesthetic.

Usually a fine tube is threaded into the vein to deliver the coil and sclerosant. You may be able to feel the tip of the catheter moving inside the leg but this is not a painful sensation.

Once the coils have been placed the sclerosant is introduced and you will feel some stinging in the surface varicose veins as they vanish. Several additional needle insertions are usually required to obliterate remaining veins on the surface.

After coil insertion, with injection of sclerosant, cotton wool balls and adhesive tape are applied at the injection sites.  You will then be placed in compression bandages. These cover the cotton wool balls and compress the treated veins. You should leave these bandages intact for at least 8-12 hours.

After treatment you should walk at least two to five hundred metres to help circulate blood through the deeper veins of the limb. This should be repeated a few times over the next few hours.

Bandages Following application of compression bandages you will be given instructions as to exactly how long to wear them.  Normally you will wear the compression bandages until the following morning.  You must remove the bandages and then shower and remove the cotton wool balls and adhesive tape from the limb. (Removal of the cotton wool and adhesive tape is essential within 12-24 hours to prevent skin blisters).   Following the shower you should re-apply the bandages to compress the legs (not the thighs) for a further few days.  This period may be shorter and you will be advised accordingly. The purpose of the bandages is to try and compress the vein walls together so that there is very little trapped blood.  Without compression the veins tend to be big and bulky when solidified and thus they take longer to absorb. Sometimes the thigh bandages tend to unravel rapidly in which case they can be left off but bandages below the knee should be reapplied.

AFTER ULTRASOUND GUIDED SCLEOTHERAPY WITH COIL OCCLUSUION

There will be some tendency for the ankles or legs to swell.  Any dramatic increase in swelling should be reported to Mr. Milne.  An unusual degree of pain following Ultrasound guided sclerotherapy with coil occlusion should also be reported.  There is no limitation on your activity following treatment and you should carry on all your normal sporting and work related activities.  Discomfort usually settles with analgesia such as Panadeine.

In the weeks following ultrasound guided sclerotherapy with coil occlusion swelling of the ankles will settle, if it has occurred at all.  You will feel some hard lumpy areas where the veins have solidified and these become tender as the absorption process gets under way.  The veins will become red and inflamed as part of the absorption process and simple anti inflammatory agents such as Aspirin, Nurofen, or Naprogesic may be used.

When the veins are completely absorbed (usually within six months) there may be some brown staining left on the surface of the skin.  This goes away slowly with time sometimes as long as 2 years.  The coils are impalpable and are not visible.  The veins will disappear as completely as they would with injection treatment alone.

THE SCLEROSANT

Over the past ten years several agents have been used as sclerosants The agent that is currently the most satisfactory is known as "Aethoxysklerol" or its generic name "Polidocanol".  This agent is a surfactant, which means that it has a soap like action, which leaches the fat from the wall of the vein, resulting in the vein collapsing and going solid.  Pregnancy and breast feeding are the only contraindication for sclerotherapy with this agent .

Possible side effects are as follows

Anaphylaxis

This is an extreme life threatening allergic reaction. It is extremely rare, however it has been reported once overseas but not in Australia.

Local Skin Ulcers

These are very rare and tend to be very small and heal rapidly.  Occasionally excision of an ulcer with suturing may be necessary and this is usually done in the office under local anaesthetic.

Deep Vein Thrombosis

This is rare if the correct dosage is followed and the injection is associated with compression bandaging and mobilisation. Current risk 1750 treatments.

THE COILS

The devices commonly called “coils” are made either of stainless steel and polyester or platinum and polyester.  The devices used for this treatment are T.G.A. approved for use in Australia and have a long documented history of safe deployment.  Like surgical clips they are fully inert after implantation.

There is a very small risk of infection (less than 1 in 1000) with these devices. Infection would require removal of the coil, normally under local anaesthetic.

After ultrasound guided sclerotherapy with coil occlusion, the coils are visible on plain x-ray and appear very much like surgical clips commonly used for abdominal surgery.  They will not trigger a metal detection device such as those commonly used at airports. They are MRI Compatible for MRI scanning. These coils, once implanted, are completely inert with less than 110,000 rejection rate.

Any difficulties with ultrasound guided sclerotherapy with coil occlusion should be reported immediately by phone to this practice, not your local doctor.  The result of your treatment, and/or significant complications, must be reviewed by Mr Milne before you can be discharged to your referring medical officer.

TREATMENT COMPARISON
  Hospital time Procedure time Anaesthetic Discomfort
Surgery 1-2 days 1-2 hrs General/Spinal 2-3 weeks
Coils 1-2 hrs 20-40 mins Local 6-12 weeks

Safety of the two treatments is similar with risks of deep vein clot (less than 1750 treatments).

Discolouration, with brown staining, can occur with either surgery or coil treatment and fades in 6 weeks to 2 years.  Mostly fading takes place within 6 months but, injected veins take longer to fade than surgically removed veins.

Post procedure visits are at 2-6 weeks then 6 months after treatment.

“Top up” treatment (sclerotherapy) in the office is available at these visits if required for left over superficial veins.

Permanence

Surgery is normally 95% effective in removing large veins for 10 years.

Ultrasound guided sclerotherapy with coil occlusion appears reliable at 5 years. Small surface veins occur with time after either treatment and can be managed with sclerotherapy in the office. Recurrence of  varicose veins in the calf is not uncommon with either treatment and is managed by injections.

COSTS

Out of pocket costs can be substantial if you have no Private Health Cover so please enquire re same prior to treatment. Quotes are issued by this office for your treatment.  Substantial gaps between your fund rebate and the fee charged may occur and is defined with your quote. Rebates vary between Health Funds so your out of pocket cost is fund dependant

Conventional (Open) Aortic Aneurysm Repair

You have been booked for admission to hospital for repair of the main artery within the abdomen of your body. This may be in the form of a bypass for blockage or, repair of an arterial weakening known as an "aneurysm". You will be admitted to hospital the night before the Conventional Aortic Aneurysm Repair unless there is any special medical condition requiring earlier treatment.

BEFORE CONVENTIONAL AORTIC ANEURYSM REPAIR

Mr. Milne and the Anaesthetist will see you the night before Conventional Aortic Aneurysm Repair to discuss the operative procedure and the anaesthesia involved. An Assistant surgeon will be introduced to you prior to the start of your operation on the day of surgery. Blood tests will be performed before Conventional Aortic Aneurysm Repair to check kidney function, blood chemistry and blood crossmatching. An electrocardiograph will be performed. Blood transfusion may be required although pre-operative blood banking by yourself can be undertaken if you are fit. Your own blood will then be used during your operation. If you have any objection to a blood transfusion please contact this office.

You should bring all your normal medications with you to hospital. Report any allergies to drugs or previous difficulties to the Anaesthetist.

THE OPERATION

Conventional Aortic Aneurysm Repair involves a large incision in the middle of the abdomen. Additional incisions may be made at the groin of each lower limb. General anaesthesia is required for Conventional Aortic Aneurysm Repair. A tube (catheter) will be inserted into the bladder at the operation and will remain in place for two days post operatively. Tubes will be placed in the neck and arms called intravenous catheters. These will be used for replacing fluids and feeding you.

Abdominal surgery is quite painful and the favoured form of pain relief is by means of an epidural catheter. This is similar to the epidural catheter used during childbirth to provide pain relief during labour. Your Anaesthetist will discuss with you the means of post-operative pain control using this catheter.

AFTER CONVENTIONAL AORTIC ANEURYSM REPAIR

For the first two post-operative days you will require close monitoring and will be admitted to a Special Nursing Area. After surgery on the abdomen for bypass of the main artery the intestines (small bowel) cease to function for a few days. During this period you will be supported by intravenous administration of fluids. From three to five days after Conventional Aortic Aneurysm Repair your bowel will commence to function again and you will be able to start eating and drinking. The urinary catheter, intravenous feeding requirements and epidural catheter requirements have usually ceased on day five after surgery and you may then resume normal mobility. Expected hospital time for Conventional Aortic Aneurysm Repair is between five and ten days.

After surgery you will be visited by a Physiotherapist on a daily or twice daily basis who will give you instructions on the correct breathing techniques to avoid acquiring infection of the lungs or collapse of the lungs which can prolong your hospital stay.

On your discharge from hospital you will be able to walk normally. You will be able to shower and wash down the area of the operation site with soap and water and pat dry gently. Unusual events in the form of chest pain, abdominal pain, difficulties with function of the lower limbs should be reported to Mr. Milne promptly. In the event of any chest pain, which is disabling, this should be reported without delay.

During the post operative recovery period you will feel quite tired and note a substantial reduction in appetite for approximately six weeks. After this period there is usually a rapid return of normal appetite but you can expect a weight loss of approximately 5Kg-7Kg in the weeks following Conventional Aortic Aneurysm Repair.

After your operative procedure any complications or difficulties regarding the operation should be referred immediately to Mr. Milne's office or his call service. Telephone numbers are on your post-operative instruction sheet. Any other unrelated medical condition should of course be referred back to your local doctor.

EXERCISE AFTER CONVENTIONAL AORTIC ANEURYSM REPAIR

Walking is the best form of activity after Conventional Aortic Aneurysm Repair. It is recommended that you do not drive a motor car for 10 days following your operation and that heavy lifting of items over 10Kg in weight should be avoided for approximately four weeks.

RISKS OF CONVENTIONAL AORTIC ANEURYSM REPAIR

If surgery runs according to plan you have a 95% expectation of an uncomplicated recovery as described. During the post operative phase however the following complications may occur -

Heart Attack (Coronary Thrombosis, Myocardial Infarction)
Pneumonia or other respiratory difficulties.
Infection - either of the lungs or wound - rarely occurs but constitutes a risk of Conventional Aortic Aneurysm Repair.
Potency - sexual potency may decrease depending on surgery.
The risk of death, stroke, paralysis or loss of legs associated with Conventional Aortic Aneurysm Repair is less than 2%.

ACCOUNTS

Fees are between the government and AMA schedule. There will be a gap between you

Intraluminal Aortic Aneurysm Repair

The aim of an Intraluminal Aortic Aneurysm Repair is to repair the main artery within the abdomen of your body. The materials used are already approved but the mechanism of use is new (15 years). Many of the prostheses (implants) used are still subject to trial conditions and require follow up and mandatory reporting.

Coventional aortic aneurysm repair (surgical replacement of the main artery) has been practiced reliably since the early 1960’s with decreasing risks and improved outcome for patients. Conventional surgery however still imposes significant strain and risk on patients undergoing surgery. “Minimally Invasive” surgery (Intraluminal Aortic Aneurysm Repair) has developed from a desire to decrease these risks and stresses. The newer technology repair involves less blood loss than the older repair and a shorter hospital stay, on average 2.5 days instead of 7-10 days. There is still a period of feeling unwell after Intraluminal Aortic Aneurysm Repair, which lasts approximately 7 to 6 weeks days, but this is not as dramatic as the post-operative course of conventional repair of aneurysms. Mortality is now < 1% versus 5% for conventional repair.

DURABILITY OF INTRALUMINAL AORTIC ANEURYSM REPAIR

At present the follow up of Intraluminal Aortic Aneurysm Repairs shows it to be effective for a period of 10 years but there are no patients with a follow up with a period of 14 years as the technology has not yet been in use for this time. Patients accepting the newer technique must accept more frequent follow up. Computer scanning is required at six, twelve and twenty four months after Intraluminal Aortic Aneurysm Repair. Further scans may be required even after this period. Normally, after Conventional Aortic Aneurysm Repair, follow up can be at every 2-5 years but the new technology requires annual visits.

BEFORE INTRALUMINAL AORTIC ANEURYSM REPAIR

Mr. Milne and the Anaesthetist will see you before Intraluminal Aortic Aneurysm Repair to discuss the operative procedure and the anaesthesia involved. An assistant surgeon will be introduced to you prior to the start of your operation on the day of surgery. Pathology tests will be performed. You should inform your surgeon before Intraluminal Aortic Aneurysm Repair of any regular medication you take and bring all your medications with you to hospital.

THE OPERATION

An incision is made in both groins for Intraluminal Aortic Aneurysm Repair. They are approximately 3cm long and do not give too much discomfort after the operation. A bladder catheter is sometimes required but you stand out of bed to void within 2 hours. You can normally shower after two days and resume normal eating and drinking within a few hours of Intraluminal Aortic Aneurysm Repair.

Leg Artery Bypass Surgery

This advice sheet is to inform the patient about what to expect when undertaking a bypass operation on the lower limb. You will be admitted to hospital prior to surgery to allow for anaesthetic assessment and pre-operative blood and other tests. Blood is held in case of blood transfusion requirements. Preoperative donation of your own blood can be arranged if required. If you have any objection to receiving blood products or blood transfusions please notify Mr. Milne promptly. You should inform your surgeon before Leg Artery Bypass Surgery of any regular medication you take and bring all your medications with you to hospital. You should also inform him of any previous difficulties with anaesthesia or surgery. He should know of any allergies to drugs and this information should also be made available to the Anaesthetist.

BEFORE LEG ARTERY BYPASS SURGERY

Mr Milne and the Anaesthetist will see you before Leg Artery Bypass Surgery to discuss the operative procedure and the anaesthesia involved. An assistant surgeon will be introduced to you prior to the start of your operation on the day of surgery.

THE OPERATION

Arterial bypass of the lower limb involves two or more incisions on the limb.
The incision(s) will usually be at the groin and in the region of the knee. Leg Artery Bypass Surgery lasts from 1 to 4 hours and may be performed under general or local anaesthesia. The new artery in your limb may be made of your own vein or a synthetic (plastic) artery. (Any artificial artery will be supplied by the hospital or surgeon.)

AFTER LEG ARTERY BYPASS SURGERY

Your leg will be bandaged and placed on a pillow. You should not get out of bed for the first 24 hours but may stand if supported by a nurse. Because of the discomfort following the surgery you will be confined mostly to bed for between two to four days.

The hospital time following Leg Artery Bypass Surgery will be in the region of two to ten days; 95% of patients can expect to have a hospitalisation period within this range. The anaesthetist will discuss with you methods of pain control at the pre-operative consultation. Any difficulties in passing urine after Leg Artery Bypass Surgery may require management by means of insertion of a tube into the bladder (catheter).

After surgery you will be mobilised initially by getting you out of bed, commencing walking just to the toilet and then progressively longer distances. When you are confident about walking without assistance you will be able to go home from hospital unaided.

Swelling is a common post-operative problem but if it is marked, inconvenient or painful it should be reported. You will be able to walk outside the home after discharge from hospital but you should refrain from driving a motor vehicle for 7 to 14 days.

After 2 days you may shower normally and wash the surgical site gently with soap and water and pat dry gently.

It is not unusual for some of the fluid which accumulates in the leg after Leg Artery Bypass Surgery, to escape from the area of the incisions. When this happens a clear straw coloured discharge can be noted. Any marked pain in the wound, reddening or discharge of yellow material with a consistency of cream should be reported to this office. Any unusual changes or sudden deterioration in limb function, comfort or performance, or a sudden onset of coldness or pain should be reported immediately.

After Leg Artery Bypass Surgery any complications or difficulties regarding the operation should be referred immediately to Mr. Milne's office or his call service. Telephone numbers are on this information sheet. Any other unrelated medical condition should of course be referred back to your local doctor.

RISKS OF LEG ARTERY BYPASS SURGERY

There is a 98% chance that the post-operative phase and surgical phase of your Leg Artery Bypass Surgery will be as planned. There is a 2% complication rate for arterial surgery in the lower limb and the following complications are the most common ones experienced -

Heart Attack (Coronary Thrombosis, Myocardial Infarction) can cause death or disability.
Wound Infection causing swelling, pain and fever.
Thrombosis of the veins of the leg or of the arterial bypass graft leading to failure of the reconstruction. This may endanger the leg and limb loss (amputation) in extreme cases may result.
Bleeding (haemorrhage) after Leg Artery Bypass Surgery or secondary to infection.

Either bleeding or thrombosis involving your procedure would involve further surgery in the operating room to control.

WARNING

Smoking increases the risk of surgery and is associated with a much higher risk of failure of the bypass. You are expected to cease smoking if you are a current smoker.

ACCOUNTS

Fees are between the government and AMA schedule. There may be a gap between your Medicare and private fund rebates although “Gap Cover” applies with some funds. Accounts will also be received by you for anaesthetist, and the assistant surgeon. Quotes are available at this office for the surgeon.

Carotid Stenting

This constitutes the the "ballooning open" of the neck artery through a puncture normally in the groin artery. The major aim of Carotid Stenting is to prevent stroke and or blindness by unblocking the neck artery and thus allowing blood to flow unimpeded to the brain.

BEFORE CAROTID STENTING

You will be admitted to hospital before Carotid Stenting and an Anaesthetist will consult with you regarding sedation. You can ask questions regarding risks of surgery and anaesthesia at this visit. No blood transfusion is required for Carotid Stenting however blood testing may be undertaken to check body function and a Cardiograph is done.

THE PROCEDURE

Carotid Stenting will last approximately 1-1/2 hours. At completion of the procedure you will have a dressing on the groin puncture and there should be minimal discomfort. Carotid Stenting is usually performed under local anaesthesia although general anaesthetic techniques are sometimes used.

RISKS OF CAROTID STENTING

Stroke: Although Carotid Stenting is designed to prevent stroke there is a small chance of a stroke occurring during the operation, or in the immediate period after your operation (48Hrs). The chance of this happening with your Carotid Stenting is less than 0.3%.
Heart Attack: The second most major risk associated with Carotid Stenting is one of heart attack and this risk is approximately 0.3%.
Death: Heart attack or stroke during Carotid Stenting is the most common cause of death after surgery and this combined risk is less than 0.6%.

AFTER CAROTID STENTING

Your post-operative recovery should be rapid and discharge home from hospital can be expected between one and two days after your Carotid Stenting. Following the operation you will be able to get out of bed and move about on the day of surgery. Aspirin is essential as a daily dose of 100-300 mg. after Carotid Stenting to keep the blood less sticky as well as another tablet for 6weeks. Over the next 10 days the groin puncture will be lumpy and tender. Any untoward symptoms such as weaknes or numbness in an arm or leg, vision or speech disturbance, should be reported to Mr. Milne immediately. Other general medical problems (coughs and colds) should, of course, be referred direct to your local doctor.

EXERCISE FOLLOWING CAROTID STENTING

After your discharge from hospital you may resume most normal activities but heavy exercise should be avoided for approximately seven days after your Carotid Stenting. You may drive a motor vehicle two days following discharge from hospital unless you have any untoward symptoms.

EFFECTIVENESS OF CAROTID STENTING

Recurrence of the problem of blockage occurs in 3% of patients in the first 18 months after Carotid Stenting. Ultrasound scanning is therefore performed at 6, 12 and 18 month intervals after your operation to detect any abnormal healing. If no narrowing is present after this time then further narrowing from artery hardening is unlikely over the next ten years. Surveillance of the un-operated artery on the other side of the neck artery is advisable and is done by your local doctor or by this practice. If re-narrowing does occur in the first year it is usually managed by balloon treatment.

DISADVANTAGES OF BALLOON/STENT TREATMENT

There is no long term follow up of the new technology of Carotid Angioplasty and Stenting as yet so it may not be as permanent as surgery for neck artery disease. Although the procedure is now nearly as safe as surgery there is a higher chance of artery blockage and stroke in the first 12 months than after surgery. Surgical management remains the “Gold Standard” of treatment although Carotid Angioplasty and Stenting is getting close to equal efficacy.

Carotid Endarterectomy versus Carotid Stenting

This discussion is regarding the current status of Carotid Stenting
and Carotid Surgery.

In recent years the advent of special equipment has made Carotid Angioplasty and Stenting a reasonably safe alternative to surgery of the neck artery.

Carotid Angioplasty and Stenting to prevent sroke is currently under investigation but concerns remain regarding efficacy in the long term. At present ethical standards decree that Stenting for narrow neck arteries be only performed to prevent stroke in those
patients who are having warning strokes. Neck artery narrowing that is causing no symptoms should only be managed surgically. This is because no long term outcome has been documented for stent procedures. The ongoing trials of stent and surgery will answer this concern in the next five years.

Carotid stenting shortens hospital stay by half a day but overall is a more expensive procedure than surgery. Carotid endarterectomy remains the gold standard for Carotid artery narrowing.

COMPARISONSURGERYSTENT
Immediate Stroke Risk
of
Procedure
<1%
2%
Risk
of
Heart Attack
0.5% 0.5%
0.5%
0.5%
Scar
Linear neck scar
Groin Puncure
Numbness
Under chin
None
Nerve Injury
1%
None
Efficacy
Normal artery
Artery Still a Little
Narrow
Stroke Prevention
at
1 year
99%
90% or
less
Stroke Prevention
at
5 Years
98%
Unknown


© PETER Y. MILNE
F.R.A.C.S., F.R.C.S., (ENG), F.A.C.S.
VASCULAR SURGEON

 

Carotid Endarterectomy

You have been booked for admission to hospital for an operation known as "Carotid Endarterectomy". A Carotid Endarterectomy constitutes the "re-boring" of the neck artery through an incision approximately 10-15cm long on the side of the neck. The major aim of this procedure is to prevent stroke and or blindness by unblocking the neck artery and thus allowing blood to flow unimpeded to the brain.

BEFORE THE CAROTID ENDARTERECTOMY

You will be admitted to hospital before the Carotid Endarterectomy and the Anaesthetist and the Surgeon will visit you to discuss the procedure accordingly. You can ask questions regarding risks of the operation and anaesthesia at this visit. No blood transfusion is required for Carotid Endarterectomy, however blood testing will be undertaken to check body function and a Cardiograph is done.

THE OPERATION

The Carotid Endarterectomy will last approximately 1-1/2 hours. At completion of the operation you will have a dressing on or a bandage around the neck and there should be minimal discomfort. Carotid endarterectomy is usually performed under general anaesthesia although local anaesthetic techniques are sometimes used.

RISKS OF CAROTID ENDARTERECTOMY

Stroke: Although Carotid Endarterectomy is designed to prevent stroke, there is a small chance of a stroke occurring during the operation, or in the immediate period after your operation (48Hrs). The chance of this happening with your Carotid Endarterectomy is less than 0.3%.
Heart Attack: The second most major risk associated with Carotid Endarterectomy is one of heart attack, and this risk is approximately 0.3%.
Death: Heart attack or stroke during the Carotid Endarterectomy is the most common cause of death after surgery, and this combined risk is less than 0.6%.
Nerve Injury: Damage to the voice, tongue or swallowing nerves during the Carotid Endarterectomy can occur in less than 0.5% of cases. Numbness of the neck and earlobe is normal after the operation.

AFTER CAROTID ENDARTERECTOMY

Your post-operative recovery should be rapid and discharge home from hospital can be expected between one and four days after your Carotid Endarterectomy. Following the procedure you will be able to get out of bed and move about on the day after surgery. The neck wound following Carotid Endarterectomy is not terribly uncomfortable and does not require strong painkillers, so tablets should be quite adequate for pain control. Aspirin is essential as a daily dose of 100-300 mg. after the operation to keep the blood less sticky. Over the next 10 days the neck incision will be lumpy and tender.

Fading of the neck scar may take between six weeks and six months. Massage of the scar is recommended and should be commenced some two weeks after your Carotid Endarterectomy and continue for 6 weeks. Face creams or other moisturisers can be used as a lubricant when massaging the scar. You will notice numbness in front of the scar, this is a normal phenomenon and harmless. Hoarseness of the voice, tongue weakness or lip weakness can occur but these are rarely permanent.

Any untoward symptoms such as weakness or numbness in an arm or leg, vision or speech disturbance, should be reported to Mr. Milne immediately. Other general medical problems (coughs and colds) should, of course, be referred direct to your local doctor.

EXERCISE AFTER CAROTID ENDARTERECTOMY

After your discharge from hospital you may resume most normal activities, but heavy exercise should be avoided for approximately seven days after your Carotid Endarterectomy. You may drive a motor vehicle two days following discharge from hospital unless you have any untoward symptoms.

EFFECTIVENESS OF CAROTID ENDARTERECTOMY

Recurrence of the problem of blockage occurs in 3% of patients in the first 18 months after Carotid Endarterectomy. Ultrasound scanning is therefore performed at 6, 12 and 18 month intervals after your procedure to detect any abnormal healing. If no narrowing is present after this time then further narrowing from artery hardening is unlikely over the next ten years. Surveillance of the un-operated artery on the other side of the neck artery is advisable and is done by your local doctor or by this practice. If re-narrowing does occur in the first year it is usually managed by balloon treatment.

Balloon Angioplasty

Hardening of the arteries that causes narrowing is usually the result of a build up over a long period of time of fatty deposits, mainly consisting of cholesterol. With time bits of calcium (bone), old blood and other material collect within these areas of narrowing. The appearance of the artery, once it has undergone these changes, is rather like that of a rusty pipe. Unlike a water pipe however, the artery is an elastic pipe and does actually still stretch. Because of this ability of the artery to stretch, balloon dilatation (balloon angioplasty) is used as a means of treating the problem.

Balloon angioplasty is usually used to treat hardening of the arteries in the lower limbs where narrowing restricts blood flow in the limb thus producing pain in the muscles of the leg when walking. Severe narrowing or blocks may even result in the leg becomes cold, painful or even starts to die (gangrene). The aim of balloon angioplasty is to re-open the artery to allow the flow of blood to be restored. Balloon angioplasty requires an initial angiogram followed by balloon treatment as appropriate. The angiogram is performed by an insertion of a needle into the groin artery and this is followed by the threading of a fine tube up the needle into the artery. Dye is then injected to make the artery show up on the x-ray screen.

Once the area of narrowing has been defined, a balloon is then threaded through the needle in a collapsed state. It is then inflated within the narrow segment of artery to stretch it open. The balloon is then deflated and withdrawn through the needle. A further angiogram is done to check that the result is satisfactory. The needle is then withdrawn from the artery and pressure applied to the puncture site in the groin to prevent bleeding.

On occasions the artery being treated may also require stenting. This refers to the placement of a wire mesh tube inside the artery to keep it open after treatment. These devices are mostly used for the arteries above the groin.

PROCEDURE

Balloon angioplasty itself is normally done in the Vascular Laboratory under local anaesthetic (sedation is available if you feel nervous.) You may request no sedation or a general anaesthetic from the doctor before the procedure if you wish. Any excess pain should be reported to the doctor performing the angioplasty. Following the completion of the angioplasty, pressure in the groin is required to seal the artery where the needle was inserted. This is often uncomfortable but not excessively painful. You are then required to lie flat for some hours after the procedure to ensure that there is no further bleeding from where the puncture was performed in the artery. Once the seal has been confirmed you can then sit up, move about. You may go home or stay in hospital overnight at completion of the angioplasty - whichever is appropriate.

RISKS

The angioplasty itself may cause problems by dislodging some of the hardening of the artery, or there may be difficulties associated with the angiogram dye (used to make the artery show up on the x-ray) and this can result in danger to the foot or an allergic response.

The local risks of balloon angioplasty are rupture or thrombosis of the artery. This may often require further treatment by means of clot dissolving medicine, or else an operation may be required to repair the damage. This happens in approximately 1 in 200 procedures. Rarely complications that are disastrous occur and the limb may be in danger of amputation from lack of blood supply. The risk of amputation is 1 in 5,000 procedures and loss of life less than 1 in 10,000. Bruising (haematoma formation) may occur around the needle puncture site and can produce some uncomfortable swelling and/or bruising on occasions. Mostly however, the puncture site is not troublesome. Any excessive discomfort or bleeding at the needle puncture site should be
reported to Mr. Milne immediately.

SMOKING

Tobbacco consumption after balloon angioplasty is a 'sure fire' recipe for re-occlusion or reblockage. It is therefore imperative that you cease smoking prior to and then following a balloon angioplasty if you expect to get a good result.

DURABILITY

Most balloon angioplasties result in a considerable period of improvement.
The most common problem after balloon angioplasty is re-narrowing which occurs in about 5% of people in the following weeks. More often people return with further trouble some years later and this is due to narrowing of the artery, generally at another site. This problem can also be treated by balloon angioplasty.

Your balloon angioplastyis performed by Mr. Milne or a nominated interventional radiologist. Mr Milne is always on standby should any problem occur after balloon angioplasty. Any difficult or complicated procedures are often performed by Mr. Milne and a radiologist in conjunction.

STENTING

Most balloon angioplasties result in a good result in the leg arteries but sometimes a metal “stent” is required to keep the vessel open or stabilise the lumen of the artery. Abdominal arteries are nearly always stented at the time of balloon angioplasty as this results in better long term improvement. The stents are made of stainless steel or steel alloys and are inert. They are not subject to rejection and will not show on metal detectors. MRI scanning may find the stents distort the images so mention this if you require this type of scan in the future. Infection of a stent is very rare but does constitute a risk of the procedure.

Melbourne Vascular Surgery Unit
Cabrini Medical Centre - Suite 5, 183 Wattletree Road
Malvern VIC 3144
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Phone: (03) 9509-9055  Fax: (03) 9576-1391
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