Surgical Procedures for CLI

• • The surgical options for CLI is balloon angioplasty, arterial by-pass grafting or amputation
  • The latter being the only option where tissue death - gangrene - has actually occurred or due to complications relating to by-pass graft surgery
  • Of course, up to the point of surgery it is necessary to try and alleviate as much pain as possible so expect patients to be on analgesia
  • Because the basis of this pathology is atherosclerosis you would also expect a patient to be on drugs such as statins to lower LDL cholesterol and limit atheroma development, and anti-platelets to reduce the risk of thrombus formation secondary to either change in blood flow patterns (haemodynamic) or in the instance of plaque rupture
• • Don’t forget that whilst CLI is most usually a chronic condition, which progresses insidiously increasing rest pain, ulceration and necrosis secondary to progressive atheroma enlargement, an atheroma can spontaneously rupture at any time triggering a thrombus resulting in a sudden total vessel occlusion
  • This event represents a medical emergency and requires prompt reperfusion to prevent infarction / cell death or as we say in particular in reference to the lower limbs; gangrene
  • Prompt reperfusion usually by either balloon angioplasty or rapid bypass grafting – could save the leg
  • Alternatively doing nothing would quickly within hours produce significant tissue necrosis necessitating amputation
• NICE guidelines for management of CLI:

  • continued lifestyle modification
  • analgesia
  • angioplasty +/- stent
  • bypass grafting
  • amputation
  • cardiovascular drugs
• Surgery for arterial insufficiency:

  • angioplasty and bygrafts mays be offered to pts with intermittent claudication only where there is significant functional and quality of life impairments
  • surgery must be offered to those with critical limb ischaemia
• When you need to remove focal localised atheromas - you may use:

  • directional or laser atherectomy
  • balloon angioplasty +/- stent insertion
  • ie percutaneous transluminal angioplasty = a peripheral percutaneous coronary intervention (PCI)
• Surgery & atherosclerotic Peripheral Artery Disease:

  • where there are multiple atheromas - may use:
  • by-pass grafts
  • aim:
  • ideal graft below groin = autologous vein e.g. inverted saphenous vein
  • ideal graft above the groin - a synthetic polymer e.g. PTFE or darcon +/- eluting substance e.g. heparin bonded to inner surfaces via (commonly) saphenous vein

  
• By-pass grafts:

  • usually has an immediate effect - pts symptoms of intermittent claudication was relieved
  • but new or even healthy recycled vessels will become disease over time by the same factors which caused the initial plaques
  • for long term health vessels, behavioural change must occur
  • plus medication e.g. statins and antihypertensives and antihyperglycemic medication, anti-platelets
• Post-graft Physio:

  • mobilisation
  • advice / exercise programme based on walking, strength and flexibility
  • discharge
  • surgical review
  • behaviour modification
• Vascular surgery rehabilitation:

  • pts may come to surgery unaware, so it is vital the receive advice, support, education and access to services to promote lifestyle modification
  • to:
  • decrease disease progression
  • decrease risk of amputation
  • decrease risk of any other cardiovascular event (e.g. angina, AMI)
  • decrease chance of premature death caused by CVD
• • evidence shows that supervised exercise programmes post-by-pass result in significant improvements in walking distance and quality of life compared to home exercises alone
• • for some with intermittent claudication or critical limb ischaemia, the vascular surgery is successful ie amputation is prevented and health related quality of life is improved
  • but that isnt the case for everyone