John Gonsalves, 62 , diabetic and hypertensive from Goa Velha, found himself with a pulsating swelling in the right groin with pain in his right leg. An evaluation showed the swelling to be an Aneurysm (Ballooning) of the Right External Iliac Artery – the main artery supplying blood to his right leg, with thrombosis or “Block” in its forward course to the leg.
Untreated it would lead to gangrene of his right leg and an amputation above the level of the knee. A horrifying prospect indeed.
The treatment of Peripheral Arterial Occlusive Disease – blockages of the arteries of the limbs or Peripheral Arterial Aneurysmal Disease – ballooning of these arteries , has been either conservative, interventional or surgical. Or a combination of surgical and interventional treatments.
Factors deciding the line of treatment include
- Patient factors related to the blockage – whether long or short-segment,
- His risk-factors like poor general condition and diabetes.
- His or her ability to afford treatments is also a factor in determining the type of treatment in select case.
- Important to a good outcome is also his or her ability to follow appropriate post-treatment care instructions.
The Peripheral Arterial Disease affecting the fish-eating coastal population of India is typical by its generally “long-segment” nature, more so in the diabetic patient.
These patients tend to be better candidates for a bypass procedure as an angioplasty in them needs multiple stents with its associated complications and costs. Angioplasty definitely has a better prospect in Carotid, Renal and Iliac arteries where the length of these occlusions tends to be shorter.
Surgical bypass of arteries in the chest and abdomen with the exception of the heart , needs an artificial tube graft. Surgical bypass in the case of Mr.Gonsalves therefore necessitated an artificial tube graft from the main artery in the abdomen – the aorta, to the groin. However his uncontrolled diabetes and poor general condition coupled with the need for him to be on anti-coagulants -medications to prevent clotting of blood against his background peptic ulcer disease; made him not the ideal candidate for the same.
The patients own leg veins – The Long Saphenous Veins; have traditionally been used for bypassing arterial blockages including those on the heart. But they have not be used in the chest and abdomen as they are unable to stand the high pressures in these locations. They are still not used but by literally stretching the limits, we have been using these veins at the periphery of the chest or abdomen to ensure that these patients are not only relieved of their present problems but also avoid the need of life-long anticoagulation as the patients own vein does not need the same.
No anticoagulation, no chances of the artificial tubes getting infected and no significant after-care. Literally “Place it,, Shut it and Forget it”. All coming at nearly one-third of the cost of a bypass using an artificial graft or an angioplasty.
Mr.Gonsalves had a Femoro-Femoral Crossover Artery Bypass from the left groin artery to the right using his own vein as his left groin artery was normal. The procedure done without a general anesthesia as always with an epidural analgesia. The ballooning in his artery in the abdomen was simply tied. He is doing well three months after his surgery.
Be it for blockages, ballooning or arterial injuries, we have performed “Cross-Over Reversed Saphenous Vein Bypasses” with the patients’ own veins in over two dozen patients with blockages for the lower as well as upper limb arteries over the last three months in Goa.
Making surgical treatment safe, simple and affordable by using acquired skill, experience and knowledge to innovate and devise newer patient-friendly treatments is indeed very satisfying experience.