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LLUMC - vascular surgery: patient/clinical information
Patient/clinical information
Carotid artery surgery Abdominal aortic aneurysm surgery Thoracoabdominal aortic aneurysm surgery Mesenteric/renal artery reconstruction Lower extremity bypass surgery Varicose veins Hemodialysis access surgery Physical therapy New technology Research programs Endowed funds
Stroke prevention is the primary goal of carotid artery surgery. Symptoms such as a completed stroke or transient ischemic attack ("mini-stroke" or unilateral eye symptoms) may prompt referral to a vascular specialist. We are able to make appropriate surgical decisions based solely on ultrasound examinations done at LLUMC in almost every case, reserving arteriography for occasional use only.
If required, carotid endarterectomy is quite safe in our hands. Stroke risk during surgery ranges from 1 to 2% and this risk has remained stable over the past twenty years. You can expect to be admitted on the day of surgery and then, in all but an occasional case, discharged the following day. There are no skin stitches to remove and there are no activity limitations after surgery. Follow-up ultrasound examination ensures continued perfection at the operative site.
Abdominal aortic aneurysm surgery
Rupture prevention is the primary goal of aortic aneurysm surgery. Abdominal aortic aneurysms are frequently discovered during a radiologic examination for another problem such as chronic low back or vague abdominal pain. AAAs can be surgically treated either with open surgery through a left flank incision or with a minimally invasive technique commonly known as an endovascular procedure or stent-graft. This new procedure allows your aneurysm to be completely treated using two small incisions made over the femoral arteries in the groin. At LLUMC, we offer both surgical approaches and carefully choose the best treatment option depending on aneurysm extent, arterial anatomy and patient wishes.
In either case, the postoperative hospital stay is relatively short (2 to 3 days for stent-graft cases and 3 to 5 for open cases). Activity and diet can be resumed as tolerated. Follow-up CT and ultrasound examinations are required for all endograft cases.
Thoracoabdominal aortic aneurysm surgery
Thoracoabdominal aortic aneurysms involve the aorta in the chest as well as the abdomen. Similar to abdominal aortic aneurysms, rupture prevention is the primary goal of surgery. However, these cases frequently involve important branch vessels that cannot be covered with a stent graft. Therefore, open surgery is required for these extensive aneurysm cases. At Loma Linda University Medical Center we have pioneered a new method for surgical repair of these types of aneurysms that greatly improves patient survival and outcome. Experience has demonstrated encouraging results, and we continue to develop innovative treatment strategies designed to minimize complications associated with this challenging surgical procedure.
Thoracic aneurysm surgery
Aneurysms limited to the thoracic aorta (within the chest region) can be treated with open surgery, or new endovascular stent-grafts. We have developed a program of treating these aneurysms with the best approach based upon specific patient characteristics and risk factors. The newer endovascular approach is providing some excellent results.
Mesenteric/renal artery reconstruction
Reconstruction or bypass of diseased arteries that supply the GI tract or kidneys may be required in some cases. Typically, significant and unintended weight loss (related to mesenteric arteries) or uncontrolled high blood pressure or kidney failure (related to renal arteries) will prompt referral to a vascular specialist. Preoperative arteriography is required in most cases. These cases are generally quite complex; therefore, a trained vascular surgeon is needed to perform this type of reconstructive procedure. At LLUMC, the surgical approach is similar to open aortic aneurysm surgery with a left flank incision so that any or all of the visceral vessels may be reconstructed during one procedure. Postoperative hospital stay is similar to open aneurysm surgery and surgical follow-up can be done with duplex ultrasound in almost all cases.
The treatment of renal artery stenoses has moved toward endovascular approaches with stenting being the first choice. Treatment of combined mesenteric/renal arterial disease is often best addressed with open surgery. Our vascular surgeons have all of these techniques available.
Lower extremity bypass surgery
Exercise-induced leg pain, non-healing ulceration, nighttime foot pain, gangrene or diabetic foot problems may require bypass surgery to cure or ameliorate the disease process. Treatment of these chronic lower extremity problems is complex. Often this requires care well beyond that of just an open surgical procedure and less invasive, endovascular treatment may be a viable option in selected cases. At LLUMC, we make every effort possible to save the affected foot/extremity. Preoperative arteriography will help to "map out" diseased arteries and bypass target sites for foot salvage. In these cases, closely supervised postoperative care is paramount to success. Aggressive postoperative wound care and physical therapy are a mainstay of this comprehensive treatment strategy.
A full range of services for treatment of varicose veins and other manifestations of chronic venous insufficiency (severe skin changes and venous ulceration) is provided through members of our vascular surgery division and our clinical nursing staff. Surgical procedures for venous problems are outpatient and are generally well tolerated. A cosmetically appealing result is achieved by use of minimally invasive surgical techniques. In addition, injection therapy (sclerotherapy) for spider veins and some small varicose veins can provide effective non-surgical therapy for this form of venous disease.
Painful varicose veins are removed with very small stab incisions and a microhook and the saphenous vein is "closed" instead of stripped out. The VNUS Closure procedure uses an endovenous catheter to obliterate (i.e. close) the saphenous vein as a treatment for primary chronic venous insufficiency secondary to valvular incompetence. The technique employs radio frequency at the catheter tip to heat the vein, causing the vein to collapse and occlude as the catheter is slowly withdrawn. This procedure offers several distinct advantages over even the newer vein stripping surgical procedure. Patients feel very little discomfort during or after the procedure, and recovery time is significantly less than that experienced with traditional vein stripping. Our patients who have received the Closure procedure often return to normal activity within a couple of days.
We are committed to providing excellent and timely treatment of patients in need of hemodialysis access. Kidney failure is the usual reason for referral to a vascular specialist. If possible, we first create a native AV fistula by making a small incision in the wrist or elbow crease to surgically connect an artery to an adjacent vein. The vein eventually matures (dilates and thickens) so that it can be used for dialysis access. Otherwise, a synthetic graft tunneled just under the skin is used for access. This involves surgical placement of the graft in the forearm (usually), arm or occasionally in the thigh. Either way, you will be able to go home the same day of surgery. After surgery, you will continue to be primarily followed by your kidney doctor, reserving visits to the vascular surgery clinic for brief checkups or graft revisions.
Patients with vascular disease may become symptomatic while performing everyday activities (such as vacuuming, shopping, or climbing stairs) as well as during exercise. Treatment for lower extremity vascular disease at Loma Linda University Medical Center includes a comprehensive evaluation by a physical therapist who has a special interest in patients with vascular problems. Muscle strength, joint/extremity range of motion, functional ability and quality of life are just a few of the many variables that are evaluated in our outpatient clinic. A structured walking program is prescribed for each patient with exertional lower extremity pain (claudication) and is designed with unique patient goals in mind. Lower extremity bypass surgery is often delayed or becomes unnecessary as a result of a supervised exercise program. If needed, physical therapy following bypass surgery helps to speed recovery and decrease postoperative discomfort.
Members of the vascular surgery division work closely with other disciplines in the medical center to develop and apply new technologies for the treatment of vascular diseases. These include all endovascular technology such as endovascular repair of aortic aneurysms, thoracic aneurysms, carotid artery angioplasty/stenting and aortoiliac stent deployment. We have pioneered a new technique for repair of thoracoabdominal aortic aneurysms and were one of the first centers to begin video-assisted subfascial perforator vein ligation for the treatment of complex venous disease. The exciting areas in vascular surgery continue to expand daily and members of the division are committed to staying on the cutting edge.
The division of vascular surgery has a very active clinical research program. Recent research efforts have focused on patient outcome analysis, comparison of traditional open surgery to less invasive endovascular surgery, prospective management of diabetic foot problems and critical analysis of complex aortic reconstruction and aneurysm repair procedures.
The Wilden Family Chair in vascular surgery
Mrs. Naomi Wilden, benefactor