Post Surgery Guidelines

This procedure has become a critical part of stroke prevention strategy. The operation has evolved to a high level of success. Still there are potential problems. Approximately three percent of patients may have a stroke or die as a result of complications. The problem for which carotid endarterectomy is warranted tends to occur in a group of people from 60 years of age and on. Many patients have a history of smoking although not all do. Diabetes is common as is history of heart disease. All of these factors can have a bearing on the potential for complications and the completeness of recovery.

Pre operative considerations:

Stop smoking; continued smoking increases the chance of further vascular disease both in the operated artery as well as other areas. Coughing post operatively is uncomfortable and increases the risk of bleeding and swelling.

• Stop Aspirin and Plavix one week preoperatively to reduce bleeding problems at the time of surgery.
• If you have diabetes, ensure good control by diet and medication.
• Continue to take all blood pressure medications as instructed.
• Plan for your recovery period.

Post operative considerations:

The operation will take approximately 2 hours. Six hours will be spent closely monitoring blood pressure and other factors in the recovery room. Our goal is to have people ready to go home within twenty four hours.

• In 80% of cases this is attainable based on comfort and medical stability. In the other cases, temporary problems with blood pressure, heart rhythm and other factors may lead to a longer stay. These will be further regulated until discharge is considered safe.
• At discharge, there are no sutures in the neck incision to remove unless you have been specifically instructed otherwise. The wound may be left open but a light (Mepore) dressing is suggested for comfort.
• Shaving may be deferred for a few days but can be resumed quickly. Keep in mind, the area between the incision and the chin may be numb for some time so be careful.
• In some cases a piece of vein is harvested from the ankle area to use as a patch for the operated artery. This incision, if present may have surgical clips or sutures that do need to be removed. The ideal time is 7-10 days post operatively and can be done by your family doctor, a home care nurse or your surgeon. It may be wise to make arrangements for this as soon as you get home. As mentioned, this patch is not always needed.
• Be as active as comfort allows. Turning the head and looking up is uncomfortable in the first two weeks but steadily improves.
• Showering and bathing may be resumed after two to three days.
• Do not drive until a complete range of neck movement has been restored and you are no longer taking narcotic containing painkillers.
• Continue to take all preoperative medications unless directed otherwise.
• Continue on one aspirin a day. There is no universal agreement on the best dosage. Some people advocate a baby (81mg) aspirin daily while others suggest an adult (325mg) tablet. My preference is the adult simply because it is inexpensive and it works.
• The chance of recurrence in the operated artery is small (less than 5%). Progression of trouble in the opposite carotid artery can occur more frequently so it is prudent to have a repeat ultrasound arranged at least yearly if not every 6 months.

Endovascular Aneurysm Repair (EVAR) is a technique used to repair Abdominal Aortic Aneurysms. There is a growing interest and ability to treat aneurysms in the Thoracic Aorta with this type of approach as well. A device is inserted into the Aorta through groin incisions. The artery in the groin is large enough in most cases to allow access for the rather large device to be used. The graft material is supported on a metal framework in a tightly compressed tube. Under x-ray guidance it is released internally and secures itself by a spring-like expansion against the normal wall of the blood vessel above and below the aneurysm. When the device is deployed and confirmation that it is secure is obtained by dye injections, the groin arteries are repaired and incisions closed. No entry into the abdomen is needed.

The recovery from this can be much quicker on average than the conventional open surgery. Most people can be discharged between 2-4 days post operatively. Recovery is often much quicker than with conventional surgery. While this all sounds appealing, there are a number of issues that must be considered.

• Grafts are measured to the individual patient and require adequate landing zones below the arteries to the kidney and in the pelvis. In some cases, these landing zones are inadequate so open surgery is still needed.
• The grafts are expensive (average $15,000 per patient) and therefore the health authority limits the number that can be used in a fiscal year.
• The advantages of the EVAR technique are most clear in patients considered High risk.
• Follow up is needed every 6 months with CT scans. This helps to identify patients with an imperfect seal of the aneurysm and directs the need for further intervention if any persistent flow (endoleak) is found.

What is an “endoleak”?

An endoleak represents blood flow inside the aneurysm but around the graft. This may represent flow from small side branches of the Aorta or in less common circumstances, loss of the seal at the top or bottom of the graft. If this situation occurs, a procedure will be arranged where one of our radiologists will carry out angiography by puncturing the groin and/or arm artery to gain access to the area of the leak and attempt to seal it with small coils or other materials (embolization). The majority of these interventions are successful in eliminating the problem. There is a need for an overnight stay for observation. Complications are not common

Possible complications in the hospital include but are not limited to:

• Fever, elevated white blood cell count treated with anti inflammatory medication. Lasts 2-7 days
• Damage to a leg artery with loss of blood supply requiring further reconstruction (rare)
• Bleeding due to damage to an abdominal or pelvic blood vessel (rare).

Possible complications after discharge from the hospital:

• Swelling or fluid drainage from the wound: increases risk of serious wound infection. Surgeon needs to be made aware. Meticulous wound care and antibiotics needed
• Swelling of the legs: Incisions in the groin often interrupt lymphatic channels and can result in some swelling of the leg(s). This is usually resolved within 6 weeks.
• Infection: Always serious and needs to be aggressively treated and monitored by surgeon and his colleagues. This is a rare complication
• False aneurysm: occurs late, usually years after the initial operation and requires reoperation in the groin where most of these occur.

Life long follow up is needed to ensure the best control of the aneurysm. Make certain that there is a follow up visit and CAT scan scheduled every six months.

• Post operatively the operated leg will be wrapped in tensor bandages with a bulky absorbent dressing in place. The tensors should be kept in place, adjusted as necessary (because they tend to slip down the leg). The padding and tensors are to minimize the bruising that occurs after the veins are removed. The tensor is used for the first week, until the sutures are removed from the leg.
• The leg should be kept dry for the first three to four days. If necessary a shower can be taken and a useful trick to keep the wounds and dressings from getting soaked, is to place the leg in a large garbage bag, secured at the groin by tape. Keep the shower brief.
• Walking is encouraged. Sitting and standing still cause blood to pool in the leg and will aggravate swelling and pain. Try to elevate the leg as much as possible when you are not walking. At approximately one week the sutures from the lower incisions can be removed. The groin is usually closed with an absorbent suture or staples. The bruising that appears quickly on the leg post operation starts to fade by the end of the first week and is usually gone by the end of the second.
• Resumption of unrestricted activity, showering, bathing etc occurs usually at the end of the second week. The scars are initially thick and firm, red in colour. As time (months) pass, they become pale and flat with no significant difference from the surrounding tissue texture.
• The vast majority of patients find the scars to be far less obvious and visible than the veins they have had removed. The leg will usually feel less heavy and ache less at the end of the day. Aesthetically, the results are excellent in uncomplicated cases. In patients with advanced skin changes (pigmentation, scarring, previous surgery or sclerotherapy) and extensive deep venous reflux, results are variable and should be discussed with the surgeon.

Any person who has varicose veins, even if they have been treated surgically, should be advised to use a good quality compression stocking. These devices prevent the engorgement of the veins and retard the progression of the problem. Symptomatic relief is achieved in most cases as the leg does not feel as heavy or aching at the end of the day. The stockings that are most appropriate for the degree of venous disease will be prescribed by the surgeon. Even people with a good outcome following surgery are advised to at least use a non prescription strength, quality compression stocking.

The majority of patients having these procedures are operated on for limb salvage. The preferred graft material is one’s own vein, usually from the same leg. If the long Saphenous vein has been previously removed or is unusable, vein may be harvested from another site. The opposite leg or arm veins may be used. In a small minority of patients, a synthetic material (PTFE) may be used. Vein is the preferred conduit because it performs better in the long run.

Dissection of the groin area disrupts lymphatic channels at least temporarily. This is aggravated by the change in blood flow both into and out of the leg. It is therefore very common, almost expected, that the operated leg will swell to a variable extent. The swelling itself is not painful. It will persist up to six weeks when it starts to subside. As comfort improves walking is encouraged. The walking should be as natural as possible and include a full range of motion for the operated leg. It may be desirable to arrange for a walker or cane for the first month particularly if there are other factors such as arthritis, or unhealed wounds that may make weight bearing uncomfortable. The worst position for someone recovering from lower limb bypass is sitting with hips and knees flexed. The sitting position encourages swelling and delays wound healing. Patients with arterial disease should not feel compelled to elevate their leg. Having the leg at the same level as the heart (supine) when sleeping or resting is adequate. Walking is encouraged. When not walking one should sit in a slightly slouched position. Gentle curves of the torso and limbs rather than sharp angles! The use of a walker is encouraged to assist in resumption of normal walking mechanics. This activates the calf muscles which are important in pushing blood and fluid back up to the heart.

Wound care:

The surgical wound can discharge some clear, yellowish fluid as it heals. Absorbent dressings are used until this ceases. This usually stops by a week. The wound should be kept dry and bathing and showering should be avoided during this phase. Once the wounds are dry showering is permitted. Surgical clips or sutures are removed at 8-10 days. This may be done by home care nurses, family doctor or the surgeon depending on the individual situation. For patients travelling from outside of Victoria, it makes sense to have them removed by a local individual. Coverage with a dressing is advised for comfort. The dressing can be changed as needed but if it is clean and intact it may be left in place for several days. The easiest dressing material to work with for long incisions is “Mepore” and is available through most large pharmacies.

If an open wound exists, either as a non healing area of the incision, an open ulcer or tissue loss that predated the operation, then wound care becomes more involved and critical. The open ulcer or wound will heal more quickly with a moist surface than a dry scabby one. Dressings should be selected that will keep the surface of the wound from becoming dry and coagulated.  They can be changed every three to five days.

Some useful products are:

• Duoderm liquefies as it absorbs fluid from the wound and looks like pus. It also has an odour. It leads many to conclude there is an infection when in reality there is none. This is a very valuable dressing and is widely available. Despite its above features, it is very useful.
• Intrasite is more useful for small deep wound on non-flat surfaces. It can be covered by a membrane dressing or a Mepore dressing. At the time of dressing change, the wound should be liberally rinsed. If it is part of the surgical wound a sterile saline bottle may be obtained from a pharmacy. If it is a chronic ulcer simple tap water in a bath is adequate. Wound care materials should be carefully bagged and disposed of. Towels should be kept separate from other family members and hands should be washed frequently. If there is any contaminated or infected material from the wound it is wise to employ these principles to avoid transmitting infection to other household members.
• For superficial open wounds a petroleum based product such as Polysporin or Neosporin applied liberally twice daily will usually suffice

If a wound has a large amount of open surface or has a large volume of fluid discharge a VAC dressing (vacuum assisted closure) is often applied. This can be managed at home and will be discussed as needed. Home care or community clinics can handle the necessary dressing changes and maintenance while the wound heals (often over a period two to three weeks). This latter situation is not common. 

Mobility after major surgery may be compromised. This is particularly true if there were limits preoperatively. The weakness that comes with the surgery in the first 6 weeks may make basic functions difficult. It is wise to ensure that there are adequate food supplies in the house during the recovery. A family member or friend may be needed to provide transportation for shopping or to do the shopping for you for the first week or two. Meal preparation can be arduous in the first couple of weeks if one is not feeling strong enough and appetite is fragile. For these reasons it is wise to make plans to have prepared meals available if there is no other person to do the cooking for the patient. Social assistance may need to be arranged through your local health authority (Meals on Wheels, home help for laundry, cleaning etc.). If one is a caregiver, special considerations may be needed to deal with the other person’s care during one’s own convalescence.

Resumption of driving should be considered only when the individual can move comfortably with no restriction and is off narcotic pain killers. This will often take up to 4 weeks. It is wise to be cautious in this regard.

Walking is encouraged early. More vigorous activity will require 6 weeks. This includes recreational activities such as golf. Even though you may feel tired, it is helpful to walk and be active early on. Gradual increase in activity can be undertaken as one feels more comfortable. No special exercises are needed. Once the abdominal wound is completely healed, more vigorous activity can be taken up. Whether work related or recreational, remember to increase gradually. The recovery period causes some de-conditioning. Trying to resume activities too quickly can result in injuries.

Due to the loss of tone in the abdominal muscles immediately post operatively, people will commonly complain of more back pain as they place more strain on the back to compensate. This can be avoided in many cases. Attention to strengthening the abdominal muscles preoperatively helps. Sitting is a major strain on the back. Walking is helpful but as mentioned above may be limited. Use of a walker may help and is strongly advised for the first few weeks. When tired, lying down relaxes the back. Place a small pillow under the knees to take pressure off the back. Do not hesitate to do this several times a day in the first few weeks.

Bowel and bladder function should not be permanently affected by the surgery but may be temporarily a bit erratic. Mild laxatives in the form of stool softeners (fiber based laxatives) may be needed in the first few weeks. A multiple vitamin with Iron is also advised.