Resources / Dr Raghu

Peripheral arteries are the blood vessels that deliver blood to the lower limbs. When the cholesterol accumulates in these blood vessels, the blood flow to the lower limbs gets blocked. Peripheral angioplasty is a minimally invasive procedure. It is done to restore the blood flow by opening the blocked peripheral arteries.

When is peripheral angioplasty performed?

• Peripheral angioplasty is mostly indicated in the treatment of Peripheral Vascular Disease (the circulatory disorder caused by the blocked or narrowed blood vessels outside the heart).
• Peripheral artery disease is the common condition, in which peripheral angioplasty is recommended.

Are there any risks with peripheral angioplasty?

Peripheral angioplasty is associated with the following risks:

• Breathing problems
• Bleeding
• Blood clots
• Infection
• Kidney damage
• Damage to the blood vessel

How to prepare for the procedure?

Before initiating the procedure, a physical examination and imaging tests are done to determine the overall health condition. Additionally, the following steps would help in a successful procedure and quicker recovery:

• Inform the use of current medications, vitamin or mineral supplements.
• Tell the doctor about any underlying disease condition.
• Take the prescribed medicines.
• Notify the doctor if you have any allergies.
• Six to eight hours before the surgery do not eat or drink anything.

What happens during the procedure?

Local anaesthesia is administered in the upper thigh region. Once the anaesthesia sets, an incision is made on the upper thigh to insert the catheter. By using a high-resolution fluoroscopic, the catheter is guided to the blocked artery. When the catheter reaches the obstructed artery, the balloon is inflated to widen the blood vessel. Once the blood flow is restored, a stent is placed to prevent the risk of further blockage. Finally, the incision is closed and covered with a sterilized bandage.

What to expect after the procedure?

You will be placed in a recovery room and the vital parameters would be checked. For at least 3-6 hours, you need to remain still, to prevent bleeding from the incision site. Depending on the patient’s condition, the doctor will decide whether the person requires a hospital stay or not.
Before discharge, you will receive the following instructions:

• Keep the wound clean and dry.
• Do not lift heavyweights.
• Avoid strenuous exercises for at least 24 hours after the procedure.
• Drink plenty of fluids to help flush out the contrast dye from the body.

Care after peripheral angioplasty:

Although peripheral angioplasty clears the blockage, it does not treat the underlying cause of the blockage. So, to prevent the further risk of blockage, the following steps should be taken:

• Maintain a healthy body weight.
• Quit smoking.
• Exercise regularly.
• Take the prescribed medicines to prevent re-narrowing of the blood vessels.
• Manage stress.
• Avoid fatty-foods.
• Have a low-salt and low-fat diet to prevent the risk of fluid retention.

Seek medical attention:

The following symptoms are the warning signs that require immediate medical attention:

• Swelling in limbs
• Chest pain
• Shortness of breath
• Fever associated with chills (over 101oF)
• Weakness
• Dizziness

Critical limb ischemia (CLI) refers to severe compromise of blood flow to alimb (hands or legs) which causes severe limb pain at rest or even loss of limb. It is the most advanced form of peripheral artery disease.

CLI numbers:

• Prevalent in 2% patient over 70 years of age.
• Within 1 year of diagnosis, 40-50% patientshave an amputation and 25% die.

How CLI leads to amputation?

Amputation occurs when there is marked ischemia of the limb owing to reduction of blood flow and increase demand in the limb.

Factors that reduce blood supply:

• Diabetes mellitus
• Severe Renal or Heart failure
• Vasospastic diseases
• Smoking

Factors that increase demand for blood flow:

• Infection (cellulitis)
• Skin breakdown
• Trauma
• Osteomyelitis

 Diagnosis of CLI:

Management plan for critical limb ischemia:

Critical Limb Ischemia Non-Healing Ulcer Rest Pain

MRA, CTA or invasive argiography shows lesion treatable by endovascular approach

• Endovascular revascularization ->Wound care and atherosclerosis risk factor modification
• Lesion treatable by open sugery at acceptable operative risk
  • Surgical revascularization ->Wound care and atherosclerosis risk factor modification
  • Consider primary amputation ->Wound care and atherosclerosis risk factor modification

Carotid arteries are the major blood vessels on each side of the neck that supply blood to the brain, face and neck. These arteries extend from the aorta in the chest to the base of the skull.

Over time, the arteries can harden and cause a build-up of plaque (calcium, cholesterol, and fibrous tissue deposits) on the walls of the arteries. This plaque build-up can narrow and stiffen the arteries. The progressive plaque build-up can reduce the blood flow through the arteries or cause the formation of blood clots. Such narrowed carotid arteries can be treated by using stents.

Carotid artery stenting (CAS) involves the insertion of a metal-mesh tube, called a stent, at the site of clogged arteries, to expand the lumen of the arteries and increase the blood flow to the brain.

What are the indications and contraindications for CAS?

The indications for CAS include:

• High risk of stroke
• Carotid artery blockage of 70 percent or more
• Intolerance to general anaesthesia for carotid endarterectomy (an open surgery to remove the plaques in carotid arteries and to reduce the risk of stroke)
• Damage to the contralateral vocal cord caused by previous carotid endarterectomy or neck surgery
• Narrowing of carotid artery after previous CEA
• Neck irradiation

The contraindications for CAS are:

• Allergic reaction to intravenous (IV) contrast dye in the past
• Unstable carotid or aortic arch plaque
• A recent stroke in less than 14 days
• Total thrombotic occlusion of carotid artery

What are the complications of CAS?

Here are some complications that may occur during or after CAS:

• An embolism, blockage due to a clot or debris in an artery in the brain, a serious complication which can cause a stroke.
• Formation of a blood clot along the stent or a tear in the artery wall (dissection).
• Restenosis, the blockage of the carotid artery after the procedure.
• Kidney damage, particularly in individuals with kidney problems, caused by the dye used for angiogram.
• Bleeding from the incision site in the arm or groin artery, known as false aneurysm or hematoma (an unusual complication).
• Mild tenderness and bruising at the puncture site, which usually resolves over time.

The factors that increase the chance of complications during CAS include:

• Age > 80 years
• High blood pressure
• Allergy to contrast material
• Sharp bends or other structural abnormalities in the carotid arteries
• Significant atherosclerosis or plaque build-up in or near the carotid artery
• Widespread blockages in the arteries in the legs and arms
• Poor kidney function

How to prepare for CAS?

When planning for the procedure, inform your doctor about:

• All the medicines that you take, including over-the-counter medicines, blood thinners, herbs, supplements, etc.
• Habits like smoking; your doctor may help you quit smoking
• Any changes in your health, like a fever
• Are or may be pregnant
• Allergies to medicines such as iodine, anaesthesia, or contrast dyes
• Any pacemakers that you have
• Any other medical condition that you have

Some tests may be performed before the procedure, including:

• Blood tests, to check for infection and anaemia
• A chest X-ray, to view the heart and lungs
• An electrocardiogram (ECG), to assess the heart rhythm
• Ultrasound of the neck, to assess the carotid artery
• Computed Tomography (CT) angiogram of the blood vessels in the neck and head

Your healthcare team may give you some instructions to prepare for the procedure, which may include:

• You may be asked to stop some medicines, such as blood thinners, a few days before the procedure
• Ask your doctor which medicines you can take on the day of the procedure, and which medicines you should stop taking.
• Do not eat or drink after midnight, the night before CAS.
• Make sure you have an adult to drive you home on the day of the procedure

What happens during CAS?

Although the exact steps of the procedure may vary, a typical CAS may go like this:

• An intravenous (IV) line will be put in the arm before the procedure. Sedation will be given through this IV line to help you relax and sleep.
• Local anaesthesia is injected near the groin region.
• A small incision is made in the blood vessel in the groin region.
• A thin, flexible tube called catheter, with a balloon at its tip is inserted into this incision.
• The catheter is threaded through the blood vessel into the carotid artery.
• X-ray images may be used to guide the catheter to reach the blocked region in the carotid artery.
• The balloon is inflated and deflated several times inside the narrow part of the carotid artery.
• A compressed stent is then inserted using the catheter to reach the affected area.
• Once the stent is at the precise location, it is released. The stent expands to fit the artery.
• The balloon catheter may be used to expand the stent further.
• The balloon is deflated, and the catheter is removed.

What happens after the procedure?

After the procedure, you will be moved to the recovery room. Your vitals, like your breathing and heart rate, will be monitored. Pain medicines will be given if needed. You may have to lie down, without bending your legs for few hours to prevent bleeding from the incision site.

You can go home on the same day of the procedure, but some patients may have to stay in the hospital for the night. You should ask a family member or a friend to drive you home.

After leaving the hospital, you may have some pain or a bruise near the incision site. You may be given certain over-the-counter pain medicines, drugs to prevent blood clot formation or spasm of the blood vessels; your healthcare provider will instruct you the dose and when you should take these medicines. Rest well and avoid strenuous exercise for the next 24 hours at least.

Call your doctor immediately if you have:

• Severe pain or swelling at the incision site that is progressing
• Blood or fluid leakages from the incision site
• Fever
• Redness or warmth at the incision site
• Chest pain

What measures do I take to stay healthy after CAS?

CAS opens the artery and ensures good blood supply to the brain. But this procedure does not stop building-up of plaque in the arteries. Therefore, to preventing hardening of the arteries, plaque formation and clogging of the arteries, take the following measures:

• Eat foods containing low calories, cholesterol, and saturated fat.
• Exercise regularly, particularly aerobic exercises like walking.
• Maintain an ideal body weight.
• Quit smoking.

Varicose vein is one of the most common venous disease in the legs, affecting 1 out of every 5 adults.

Varicose veins are twisted, swollen veins, which usually appear in the lower legs, but can affect any part of the body. This condition occurs when the valves that direct the blood flow in the veins are weak or damaged, resulting in the decreased blood flow to the heart, and subsequent backing up of blood within the veins, leading to the enlargement of the veins.

How are varicose veins presented in patients?

Varicose veins may be painful for some individuals; they are usually presented as:

• Dark purple or blue coloured veins
• Twisted, bulged, cord-like veins
• Heaviness or aching in the legs
• Muscle cramping, burning, swelling or throbbing in the legs
• Pain gets worse after sitting or standing for a long time
• Itchiness around the veins
• Discoloration of the skin around the veins

How to diagnose Varicose Veins?

Following a physical examination, the doctor may prescribe the following tests to diagnose varicose veins:

• An ultrasound is a non-invasive test, which is performed to check the flow of the blood.
• A venogram involves releasing a special dye into the veins and then taking an X-ray, which provides an overview of the blood flow.

What are the treatment options for varicose veins?

Varicose veins can be treated by certain medications, lifestyle changes and surgical procedures.

The lifestyle changes include:

• Maintaining a healthy body weight
• Exercising regularly to improve blood circulation
• Avoiding standing for prolonged periods of time
• Elevating or raising the legs while sleeping

Using compression socks or stockings can also help treat varicose veins.

Surgical procedures:

Surgery is opted when lifestyle changes are not effective in managing the symptoms of varicose veins. Most surgical procedures, including vein ligation and vein stripping, involve cutting and removing the affected part of the veins.

The other procedures performed to treat Varicose Veins include:

Endovenous ablation therapy, in which radiofrequency or heat radiation is used to block off the vein.

Sclerotherapy, wherein a chemical foam or liquid is injected into the vein that blocks the larger vein.

Microsclerotherapy, wherein a chemical foam or liquid is injected into the block of the smaller veins.

Laser therapy, in which Light Frequency Radiation is used to unblock the blocked vein.

Endoscopic Vein Surgery, in which a small lighted scope is inserted into the vein to block the vein, through a small incision.

What happens before the procedure?

Inform your healthcare provider about:

• Onset and severity of pain and numbness (if any)
• If you have any medical conditions
• Any allergies or intolerances to certain medicines
• Whether you are pregnant or think you may be pregnant
• If you are breastfeeding
• Medicines or supplements that you are taking including, blood thinners, over-the-counter medicines (aspirin or ibuprofen), herbs or vitamins
• If you smoke or drink alcohol on a regular basis

Ask the doctor about:

• What procedure would be best for your case
• The possible outcomes of the treatment

Your healthcare team may give you guidelines for when to stop eating and drinking before the procedure. You may be asked to stop taking aspirin or other blood thinning agents at least one week before the procedure.

What happens during radiofrequency ablation?

Radiofrequency ablation is a procedure which uses radio waves to create heat and block the damaged vein.

The following are the steps involved in radiofrequency ablation procedure:

• You will be asked to lie down on a hospital bed.
• Imaging techniques like ultrasound will be used to guide the procedure.
• The leg to be treated will be injected with a numbing medicine.
• Once the leg is numb, a small hole is made in the vein using a needle.
• The catheter is inserted into the vein.
• When the catheter reaches the right position, it is slowly pulled backwards.
• The catheter emits radio waves, and the vein is closed due to the heat generated.
• Also, the other side branches may be removed or tied.
• Then the catheter is removed, and pressure is applied to the insertion site to stop the bleeding.

The procedure takes about 45 to 60 minutes. You can go home on the same day.

What happens after the procedure?

You may experience pain, swelling, bruising, soreness and change in the colour of the treated area. Individuals treated for vein ligation and stripping may experience severe pain, infection, scarring and blood clots after the procedure. Seek immediate medical attention/care if the condition worsens.

After the procedure:

• Take oral anti-coagulants for 3 months
• Wear grade 2 elastic leg stockings for 3 months
• Reduce weight

Long-term measures:

• Use compression stockings throughout the day to squeeze the leg, thereby easing the blood flow through the veins and the muscles of the leg.
• Elevate the feet while sleeping, which ensures a free back flow of the blood to the heart.

Call your healthcare provider if:

• Fever of 100.4°F (38°C) or higher
• Trouble breathing or chest pain
• Signs of infection at the catheter insertion site, including redness, warmth, inflammation, increasing pain, bad-smelling discharge or bleeding
• Numbness or tingling in the leg
• Severe pain or inflammation

How to prevent the recurrence of varicose veins?

Individuals above fifty years of age are at an increased risk of recurrence of varicose veins within five years of having surgery. However, following a low-salt diet helps to prevent swelling and water retention in the limbs.

After the procedure, you may be asked to restrict doing strenuous activities. But prolonged inactivity may cause the formation of clots and pain. Therefore, following a regular exercise plan, as suggested by your doctor, helps to regain normalcy in the limbs and prevent recurrence of the varicose veins.

Inferior vena cava (IVC) is the large vein in your abdomen that carries deoxygenated blood from the lower part of the body back to the heart. This vein branches out throughout the body to transport deoxygenated blood to the heart

Deep vein thrombosis (DVT) is a serious medical condition where blood clots are formed in the deep vein of the thigh or lower leg. This causes pain, swelling, and tenderness in the leg. The clot formed can break free, travel to the lung and stick to a vessel in the lung. This can lead to a blockage in the vessel, called pulmonary embolism, which can cause severe shortness of breath and sudden death. An IVC filter placement is one option to prevent pulmonary embolism.

Inferior vena cava (IVC) filter placement involves insertion of a filter into the IVC through a small incision made in the neck or groin. An IVC filter is a small, metal device shaped like the spokes of an umbrella. When the filter is placed in the IVC, the filter catches the blood clots and prevent them from reaching the lungs.

Indications for IVC filter placement

IVC filter placement is considered when anticoagulants (blood thinners) cannot be used to prevent the formation of blood clots.

The following conditions are indicative of IVC filter placement:

• You have or had DVT or pulmonary embolism
• Anticoagulants-associated bleeding
• Severe platelet problems or shortages
• Recurrence of blood clots while on anticoagulants
• Recent or current major bleeding that cannot be treated
• Bleeding in your head
• A need for surgery in the near future
• Multiple broken bones

The risks of IVC filter placement procedure:

IVC filter placement is usually a safe procedure. Sometimes, the following problems may occur during the procedure:

• Filter blocks the inferior vena cava, leading to swelling of the leg
• Failure of the filter sooner or later
• Filter moves or travels to the heart or lungs
• Damage to the vein (rare) or other structures/organs
• Bleeding
• Infection
• Allergic reactions to medicines or dyes
• A pool of blood (hematoma) around the site where a flexible tube is inserted (catheter insertion site).

What happens before the procedure?

When planning for the procedure, inform your doctor about:

• Any blood disorders or other medical conditions you have.
• The medicines or supplements you are taking, such as over-the-counter drugs, vitamins, herbs, creams, or eye drops.
• Any allergies, including iodine allergy.
• Problems associated with anaesthetic medicines you or family members have or had.
• The surgeries you have undergone.
• If you are or may be pregnant.

Preparations for the procedure:

1. Staying hydrated:

Your healthcare provider may instruct about hydration before the procedure:

• Up to 2 hours before the procedure- you may drink clear liquids, such as water, clear fruit juice, black coffee, and plain tea.
  

2. Eating and drinking restrictions:

Your healthcare provider may give some guidelines related to eating and drinking, such as:

• 8 hours before the procedure – stop eating heavy meals or foods such as meat, fried foods, or fatty foods.
• 6 hours before the procedure – stop eating light meals or foods, such as toast or cereal.
• 6 hours before the procedure – stop drinking milk or drinks that contain milk.
• 2 hours before the procedure – stop drinking clear liquids.

3. Medicines:

Ask your health care provider about:

• Changing or stopping your regular medicines, especially diabetes medicines or blood thinners.
• Taking medicines such as aspirin and ibuprofen, as these can thin your blood. Do not take these medicines before your procedure if your health care provider instructs you not to.
• Taking any antibiotic medicine to help prevent infection.

General instructions:

• Ask your health care provider how your surgical site will be marked or identified.
• You may have blood tests to tell how well your kidneys and liver are working. They can also show how fast your blood is clotting.
• You may be asked to shower with a germ-killing soap.
• Ensure that you have someone take you home from the hospital or clinic.
• If you will be going home right after the procedure, plan to have someone with you for 24 hours.
• Do not use any products containing nicotine or tobacco, such as cigarettes and e-cigarettes. If you need help quitting, ask your health care provider.

What happens during the procedure?

Before heading to the procedure, to lower the risk of infection, your healthcare team will:

• Wash or sanitize their hands
• Wash your skin with soap
• Remove hair from the surgical area
• Insert an IV tube into one of your veins

You will be given one or more of the following:

• A medicine to help you relax (sedative)
• A medicine to numb the area (local anaesthetic)

Once the anaesthesia sets in, the steps below may be followed:

• A small cut (incision) will be given in the neck or groin region to access the IVC.
• A flexible tube (catheter) will be inserted in the incision.
• Contrast dye may be injected into the IVC to help guide the catheter reach the precise vein.
• X-rays may be used to make sure that the catheter is in the correct position.
• The filter will be inserted into the vein through the catheter and it will be positioned at the correct location in the IVC.
• The catheter will be removed.
• Pressure will be applied to the insertion site to stop bleeding.
• A bandage (dressing) may be applied over the catheter insertion site.
• Your IV tube will be taken out.

The procedure may vary among health care providers and hospitals.

What happens after the procedure?

Your blood pressure, heart rate, breathing rate, and blood oxygen level will be monitored until the medicines you were given have worn off.

Your insertion site will be monitored for the first few hours for any signs of bleeding.

Do not drive for 24 hours if you were given a sedative.

Call your provider immediately if you have:

• Numbness or coldness in one of your limbs
• Bleeding that won’t stop with pressure
• Severe pain or swelling at the incision site
• Fluid leakage from the incision site
• Redness or warmth at the incision site
• Fever
• Severe headache or nausea
• Chest pain

Patent Ductus Arteriosus (PDA) is a congenital heart condition in which the opening between the pulmonary artery and the aorta, persists after its normal closure time. The ductus arteriosus is a small connection between the two major blood vessels in the fetal heart, and it naturally closes shortly after birth. When it fails to close, it’s called patent ductus arteriosu

A PDA may allow the oxygenated blood to mix with the deoxygenated blood, compromising the heart and lung function.

What are the treatment options for PDA?

• The treatment options depend on the age of the person.
• In a premature baby, the PDA may close with time, as the baby grows. Some babies may need medications such as indomethacin, to facilitate closure. Surgery may be needed if the duct fails to close.
• In full-term babies, a small defect can be monitored, as it may close with time. Large defects may need to be closed surgically.
• Surgical closures can be achieved through open-heart surgery and percutaneous catheterization.

What is Device Closure for Patent Ductus Arteriosus (PDA)?

The larger PDA results in increased workload of heart, and also carries a risk of bacterial infection. PDA can be closed by inserting a device through the blood vessel in groin, a non-surgical method called percutaneous transcatheter approach.

Who is eligible for this treatment?

This method is considered only if the child is

• Older than 6 months
• At least 22 pounds
• With defects that are not too large

Considerations in adults include:

• The device closure is considered as long as the elevated pressure in the lungs is not irreversibly elevated
• If the lung pressure is already very high, it is carefully measured along with lung resistance to determine the safety the procedure.

What are the risks associated with the procedure?

PDA closure is a low risk procedure, but the common risks include:

• Rupture of the blood vessel or the heart wall
• Complications during positioning the device
• Leakage through the closure device

What happens during the procedure?

• In case of adults, a sedative might be given to relax them, and a local anesthetic is given to numb the site of catheter introduction.
• Children are administered general anesthesia during the procedure.
• A catheter is inserted into the blood vessel in the groin. It is then moved up to the heart into the PDA.
• The pressure, oxygen saturation and the size of opening in the heart is measured.
• A closure device is threaded through the catheter and placed onto the PDA.
• Once the device is in place, it is pushed out of the catheter to implant it over the opening.

What care should be taken post-procedure?

• After implantation, the catheter is removed, and the incision is closed.
• The procedure usually takes between 1 and 3 hours.
• You might need to have an X-ray after the procedure to ensure the implant is at the right position.
• An echocardiogram may be recommended after six months to ensure that the PDA is properly closed.
• Antibiotics might be prescribed to prevent endocarditis.
• The child may need to come for regular follow-ups to ensure that the device closure is effective.