Please Provide Your Consent We believe it is important to take the time to fully understand the planned procedure, its risks and the recovery process. I will be receiving the following treatment:Choose a treatment type...Carotid EndarterectomyEndovascular Aneurysm Repair (EVAR)Surgical Aneurysm RepairSurgical BypassVaricose Veins Ablation (EVLT)What is carotid endarterectomy (CEA)? Surgery of the carotid artery for prevention of stroke is called "carotid endarterectomy". This is the most intensely studied surgical procedure in the history of modern medicine and there are numerous large-scale studies reported in respected medical journals. There is universal acknowledgement that CEA prevents strokes in carefully selected patients. The operation can be done under general anesthetic or local anesthetic. However, most patients prefer having the procedure done while asleep. An oblique incision is made along the neck and the carotid artery is carefully exposed. The artery is clamped above and below the plaque to allow it to be opened without bleeding. A temporary shunt is inserted to restore blood flow. The plaque causing the blockage is removed ("endarterectomized"). A vein from the ankle or the groin is then harvested and sewn onto the artery as a patch to complete the repair. Occasionally, a synthetic patch or no patch is used. The shunt is removed and the clamps are released to restore blood flow to the brain. A small drain may be left near the artery and the incision is closed. You will be kept in the post-operative recovery room for a few hours of observation and then transferred to your room. The drain is removed the day after surgery. Most patients feel well enough to go home the following morning but usually are discharged on post-operative day two. What are the potential complications of carotid endarterectomy? There is a 4% chance that you may have a stroke or that you may not survive the operation. This risk is lower (2%) if you have never experienced a stroke or mini stroke prior to the surgery. The risk of an injury to one of the nerves in the neck is about 5%. This can result in difficulty swallowing, speaking, or even breathing but the majority of these will recover over time. Some patients may experience bothersome numbness or tingling around the incision or the earlobe but again this should resolve over a few months. There is a 5% chance of developing a hematoma (bleeding) in the neck. Sometimes this requires re-operation to relieve the pressure and to repair the source of bleeding. This complication is more frequently seen in patients taking aspirin or Plavix. Infections occur in <1% of cases. Nevertheless, the vast majority of patients have an uncomplicated post-operative course despite these quoted risks. How long will it take for me to recover? By the time of discharge, most patients are feeling well and only the occasional patient will require a prescription for pain-killers. Within a week, you will be back to normal daily activities. I would recommend that you not drive until there is full range of motion in your neck and the incision in your ankle or groin is no longer uncomfortable (generally about 2 weeks). Are there alternatives to carotid endartectomy? Yes, carotid artery stenting (CAS) is a new procedure that appears promising. The procedure is done through a puncture in the groin. With the assistance of X-rays, a guidewire and a stent are manipulated from the femoral artery in the groin through the blockage of the carotid artery in the neck. A special device is also placed beyond the blockage that catches the debris that becomes dislodged during the procedure. The stent is deployed and the blockage gets pushed outwards and held in place by the radial force of the stent. Some small studies have shown that CAS and CEA have similar results in the short term. However, widespread acceptance of this technique has not occurred because of higher recurrence stenosis rates and because long-term studies have yet to be completed. Until these further studies are reported, CEA remains the standard of care. What is Endovascular Aneurysm Repair (EVAR)? Patients with higher than average risk factors for intra and post operative complications are considered candidates for possible endovascular aneurysm repair. In this technique, a device is inserted into the aorta through the groin. The femoral arteries are either accessed with a puncture or through incisions in the groin. The device is advanced upstream into the aorta under x-ray guidance. The “stent graft” is then deployed or released in the aorta to create strong channel for the blood to flow through taking the pressure of the weakened aortic wall. This approach places less strain on the heart and lungs thus lowering the risk of complications. However, the procedure can only be executed if careful and precise analysis and measurement of critical dimensions of the aneurysm are carried out in advance and if the anatomy is suitable. If there are no good landing zones (areas where the blood vessel walls are parallel) then the graft will not seal properly and the procedure will fail. If the aneurysm anatomy is appropriate then the stent graft can result in lower risks, shorter hospital stay and quicker recovery. One other aspect of EVAR is that the patient should have a CT scan of the Aorta every 6 months to ensure the repair is stable. This is required due to the small possibility of the seal failing and the graft no longer providing protection. Approximately 10% of patients will have some persistent flow in the aneurysm sac. If this persists over a year and particularly if the aneurysm enlarges, further interventions to eliminate the leak may need to be attempted (usually through the groin). In approximately 1% of cases the graft may fail completely in the long term and require a complete open operation to deal with the situation. The preparation for surgery is identical to open surgery in case there is a need to convert to the open procedure although this is a very rare event. Length of stay in the absence of any complications varies between 1-3 days based on type of incision and the patient’s overall health. Follow up in the office is necessary at 4-6 weeks postoperatively and as mentioned CT scan should be arranged every 6 months. Please see section on post operative guidelines for EVAR and the video available on this website. Aneurysm Surgery Surgery involves a general anesthetic and an incision on your abdomen. The aorta is clamped above and below the abdominal aortic aneurysm (AAA). The aneurysm is then replaced with synthetic graft material. Blood transfusions are required in about 30% of cases. Post-op hospitalization is about one week and complete recovery takes up to 6 weeks. Possible complications include heart attacks, stroke, kidney failure, gangrene of your colon, impotence in men, blood clots in the arteries or veins of the legs. Nevertheless, the majority of patients do well and the operative mortality is less than 4%. About Surgical Limb Bypass As people age, plaque made up of cholesterol and other fats (lipids), calcium, and fibrous scar tissue can accumulate on the inside walls of their arteries. Plaque deposits can enlarge, causing arteries to narrow and stiffen, a process called atherosclerosis or hardening of the arteries. This narrowing decreases blood flow and can result in insufficient oxygen levels in body tissue, known as ischemia. A small piece of loose plaque or a blood clot that lodges in a narrowed artery, called an arterial embolism, can also disrupt blood flow and cause ischemia. Ischemia that results from narrowed or blocked arteries in the leg can cause pain in the feet and toes, skin ulcerations, and in extreme situations, numbness and muscle weakness. When the arteries that supply blood to a person's heart or brain become blocked and ischemia results, it can cause a heart attack or a stroke. To prevent these consequences, the physician may perform surgical bypass to reroute blood and improve blood flow around the blocked portion of an artery. During surgical bypass, doctors make a new connection between arteries using a graft vessel, which is made from a portion of a person's own vein or a synthetic fabric tube. The graft vessel creates a detour, allowing blood to bypass any blockage. Physicians most commonly perform bypasses in the legs. Surgical bypass for leg artery disease typically involves rerouting blood from the femoral artery in the thigh to another artery in the thigh, knee, lower leg, or foot. Other arteries involved in surgical bypass may include: The aorta; The subclavian artery in the shoulder; The vertebral arteries in the spine; The iliac arteries, which are located in the pelvis; and The renal (kidney) arteries. When is the Procedure Suggested? Physicians first attempt to treat atherosclerotic artery disease by prescribing lifestyle changes, such as regular exercise, changes in diet, and control of risk factors such as smoking. Certain medications can also help prevent atherosclerosis from worsening. However, surgery may be indicated if atherosclerosis progresses and does not respond to lifestyle changes or medication. For example, it may be needed to address severe leg artery disease, the complications of which include: Claudication (leg discomfort caused by compromised circulation); and Critical limb ischemia (blood flow prevents tissues from getting enough oxygen, resulting in pain, sores, or even loss of limb). Pre-Treatment Guidelines Before performing surgery, the physician determines the presence of risk factors, such as smoking, and listens to the patient describe symptoms. He or she also may order tests to assess the extent and exact location of any blockages, including: Ankle/brachial index (compares the blood pressure in a person's arms to the blood pressure in the legs). Blood cholesterol; Contrast arteriography, also called angiography (injecting a contrast dye into the arteries and then taking x rays); Duplex ultrasound; and Magnetic resonance angiography (MRA); What to Expect Generally, before a bypass, the vascular surgeon selects the blood vessel graft that will connect the arteries. The most effective grafts for leg or arm bypasses are veins from a person's own body. The physician performing leg bypass surgery frequently chooses the great saphenous vein, the largest vein in the body, which runs between the foot and the groin. However, arteries made from synthetic fabrics may be used to bypass large arteries in the chest and abdomen. To access the parts of the arteries that will be connected by the bypass, the physician makes incisions in the skin and muscle above the arteries. Next, the physician cuts into the wall of the diseased artery below the plaque blockage (known as arteriotomy). At this site (known as anastomosis), the physician attaches one end of the graft vessel with permanent sutures. The other end of the graft vessel is then routed through muscles, tendons, and other anatomy to a healthy artery, known as the inflow site. The physician sutures (sews) the inflow end of the graft to the wall of the healthy, inflow artery in the same manner. The surgeon ensures that the bypass vessel is aligned correctly, so it will not kink, and checks for any signs of leakage. In some cases, the physician performs a completion arteriography to confirm the success of the procedure. Post Procedure Guidelines and Care Following the procedure, a person may stay in the hospital for 3 to 10 days, depending on how complicated the surgery. Many people who undergo surgical bypass need care from a visiting nurse, home health aide, or physical therapist immediately following discharge. After discharge, it can take 5 weeks to 3 months to fully recover from surgery. Read more about what to expect post surgery. Possible Complications Surgical complications during bypass surgery vary depending upon which arteries are involved in the bypass and on a person's age and physical condition. Minor complications include swelling and infections at incision sites. The risk for serious complications, such as a heart attack or stroke, is less than 2 percent. After the bypass is complete, the physician predicts the graft vessel's patency, or the estimated time during which the bypass is expected to remain widely open and functioning properly. Grafts usually remain functional for 10 years or more. However, the patency period of a bypass graft can be shortened by factors including: Diabetes mellitus; High blood pressure; Atherosclerosis; The length and diameter of the bypass graft; and Infection or aneurysm of the blood vessel graft. Lifestyle Adjustment People who have undergone surgical bypass must visit their physician's office each year for an examination to make sure that the bypass graft remains patent. People with bypass grafts should alter their lifestyles to help ensure the long-term success of the procedure. It is important to remember that surgical bypass does not reverse atherosclerosis. It only restores circulation to body tissues and reduces symptoms, such as claudication and leg ulcers. Changes that help lower blood cholesterol levels and may lower the risk of atherosclerotic disease include: Eating foods low in fat, cholesterol and calories; Exercising aerobically, such as brisk walking, for 20 to 30 minutes, five times a week; Losing weight; and Quitting smoking. What is EVLT (Endovenous Laser Treatment)? Laser energy seals the abnormal vein as the catheter is withdrawn preventing "reflux" of blood. EVLT is used as a minimaly invasive surgery in the treatment of Varicose Veins. In laser ablation, a guidewire and the catheter sheath are long and are advanced to the end of the vein (such as the junction of the GSV and the femoral vein.) The physician removes the guidewire and inserts a laser fiber through the catheter sheath so that it protrudes slightly beyond the sheath. The fiber and sheath are pulled back slightly so that the laser does not protrude into the femoral vein. Local anesthesia is injected along the length of the vein that is being treated. Using ultrasound for guidance, the physician ensures that the laser is properly placed at the end of the vein to be treated. He or she manually compresses the leg above the vein to help the walls of the vein come in contact with the laser. The physician activates the laser and then pulls it and the catheter sheath back a tiny distance. The physician repeats this sequence until the entire length of the diseased vein is treated with laser pulses. The laser fiber and the catheter sheath are removed, pressure is applied to the incision for a few minutes to stop any bleeding, and the procedure is complete. Occasionally, the patient may experience brief pain if the radiofrequency catheter or laser heats tissue near a nerve. This pain disappears once the physician retracts the catheter away from the nerve. The procedure takes about 60 minutes and may relieve symptoms immediately. Once you have read the respective document please fill out this form.Name* First Last Email* Enter Email Confirm Email PhoneUpon reading the provided documentation:* I provide my informed consent.