The aorta is the largest blood vessel in your abdomen.  It carries blood from your heart into the abdomen.  In patients with an abdominal aortic aneurysm, the blood vessel becomes weak and expands like a balloon.  As the blood vessel expands the wall becomes weaker and there is a risk of rupture over time.  However, the risk of rupture is low until the aneurysm becomes larger than 5 cm in a female and 5.5 cm in a male.

Most aortic aneurysms are found incidentally when you have a CT scan or ultrasound for other reasons Sometimes your primary care physician will feel a pulsation in your abdomen and order further testing. Occasionally, they are found when they rupture or cause pain.

If you are found to have a small aortic aneurysm no surgery is required. Your vascular surgeon or primary care physician will follow the size with ultrasound on a regular basis. Generally speaking, an aortic aneurysm is not repaired until it’s largest diameter is 5 cm in a female and 5.5 cm in size in a male. Once the aneurysm reaches this size, your surgeon will do a CT angiogram to better evaluate the aneurysm and plan for repair.

Once your aneurysm reaches the size for repair, you and your vascular surgeon will discuss the options for intervention.  There are two common options:

Standard Open Aortic Aneurysm Repair:

With this type of repair, your surgeon will make a long incision in the middle of your abdomen. The procedure requires a general anesthetic. Once inside your abdomen the surgeon will identify the aneurysm and place clamps above and below the bulge in your blood vessel. The aneurysm is then opened the segment of dilated blood vessel is replaced with a polyester synthetic tube (Dacron)  also known as a graft. Once the graft is in sewn into position, the wall of the old blood vessel is then wrapped around the graft to protect the graft. The abdomen is then closed. You can expect to be in hospital for between 5 and 10 days. It can take between 1 and 3 months for a full recovery. After surgery, your surgeon will see you again in 3 to 6 weeks and repeat a CT scan in one year and five years time.

Endovascular Aortic Aneurysm Repair (Evar):

This is a minimally invasive technique for repairing aortic aneurysms using a stent covered with graft material (endovascular stent graft).  With this type of repair, instead of making a long incision in the abdomen your surgeon will make a small needle hole in the artery of the left and right groin. You will be given either a general anesthetic or spinal anesthetic. Using small catheters with x-rays and a video monitor, your surgeon will evaluate the aneurysm using x-ray dye (angiogram) to make sure the endovascular stent is placed in the correct position. A larger catheter that contains the endovascular stent is then advanced into the aneurysm and the stent is then expanded in normal blood vessel above the aneurysm and below the aneurysm so that blood flows through the stent and not the aneurysm. The aneurysm is now excluded from blood flow, but blood flow to your legs is through the stent.  At the end of the procedure the two needle holes are closed with a small suture device so the artery can heal. Most patients go home the next day. Your surgeon will follow the aneurysm with a CT scan in about 6 months, a year and then will follow it yearly. Not every patient can have this minimally invasive technique. There are certain limitations based upon how your aneurysm looks on your CT scan. You and your surgeon will discuss which option is best for you.
 

Your vascular surgeon has determined that you need angioplasty in an artery of the leg or abdomen. You most likely have peripheral arterial disease (PAD) and have a narrowing or complete blockage in the artery from hardening (atherosclerosis) of the artery. The blockage is usually due to one or a combination of high blood pressure, high cholesterol, smoking, diabetes and older age. Due to these blockages, there is not enough blood flow getting into your leg. The most common reason for needing an angioplasty is a sore (ulcer) on your foot that is not healing, a toe that has turned black or pain in your foot all the time, especially at night. Sometimes angioplasty is done for discomfort in the calves or thigh with walking a certain distance (claudication). Angioplasty is a very common procedure, however, if the blockages are long and severe you may be better off with bypass surgery. Your vascular surgeon will discuss which option is best for you.

Angioplasty and stenting is a minimally invasive endovascular procedure that can be used to fix a severely narrow or completely blocked artery. The procedure is done through a small puncture in the artery at the groin  As a result, a general anesthetic or spinal anesthetic is usually not required.  Local anesthetic with sedation is used. The recovery time is quicker and complications fewer than with standard open bypass surgery. You usually go home later in the day or stay in the hospital overnight.  

Angioplasty and stenting: Once your vascular surgeon obtains access to the artery in the groin through a small puncture, x-ray dye will be given and an angiogram performed to evaluate the blockages. Once it is determined that the blockage can be treated with angioplasty, a small balloon will be advanced to the area and inflated to a high pressure to open up the artery. The balloon is removed and blood can flow freely once again. Often a small wire mesh tube called a stent will be expanded in the artery to make sure the artery does not collapse again. After the procedure you will need to keep your leg straight for between 2 and 4 hours while the puncture site seals. Your vascular surgeon will follow up with you to evaluate the results of the procedure.

A stroke or mini stroke (TIA) can be caused by a narrowing (stenosis) in the neck artery called the carotid artery. The stenosis is usually due to atherosclerosis from one or a combination of high blood pressure, high cholesterol, smoking, diabetes and older age.  In certain situations, surgery to remove the stenosis is performed to prevent a future stroke.

After a stroke or mini stroke your physician may order a CT scan or ultrasound to find out if there is a severe narrowing of the carotid artery. Sometimes, a stenosis is found incidentally when you have an ultrasound of the neck for other reasons, even though you may never have had a stroke.
 

The majority of carotid stenoses do not require surgery. Your physician will encourage you to stop smoking if you smoke and may start you on medications to reduce your future risk of stroke. If you have had a stroke or mini stroke and your carotid stenosis is severe your vascular surgeon may recommend surgery as there can be a benefit to prevent future stroke. If you have not had a stroke but have a severe carotid stenosis, there may also be benefit for surgery. You and your surgeon will have a discussion and decide whether you benefit from surgery.

In the majority of cases a severe carotid stenosis is fixed by a procedure called a carotid endarterectomy. In Winnipeg, the procedure is usually done with a general anesthetic. Your vascular surgeon will make an incision in the neck to expose the carotid artery.  The arteries will be clamped to prevent bleeding. There is usually enough blood flow from the other side of the body to take over while the artery is clamped, but some surgeons use a small plastic tube to maintain blood flow. The surgeon will then make an incision in the diseased artery and directly remove the narrowing. Usually, a small patch is sewn to the edges of the artery to keep the artery open and prevent a new narrowing from forming. Before closing the incision your surgeon may decide to leave a small tube in the neck to prevent neck swelling after surgery. This tube will be removed the next day. You will be monitored in the hospital overnight and most patients are able to go home the next day. Your surgeon will see you again in 3 to 6 weeks and order an ultrasound in one years time.

Your vascular surgeon has determined that you need bypass surgery in the leg. You most likely have peripheral arterial disease (PAD) and have a narrowing or complete blockage in the artery of the leg from hardening (atherosclerosis) of the arteries. The blockage is usually due to one or a combination of high blood pressure, high cholesterol, smoking, diabetes and older age. Due to these blockages, there is not enough blood flow getting into your leg. The most common reason for needing bypass surgery is a sore (ulcer) on your foot that is not healing, a toe that has turned black or pain in your foot all the time, especially at night. Sometimes surgery is done for discomfort in the calves or thigh with walking a certain distance (claudication). There are lots of options to treat this problem, but when the blockages are long or severe you may be best served with leg bypass surgery.

The procedure is performed in the operating room. You will have either a general anesthetic or a spinal anesthetic. Most commonly, your vascular surgeon will use the long vein in your leg and this will become your new artery. You do not need this vein as other veins in the leg will take over. A long incision is made on the inside of your leg and the vein is found. The surgeon will also expose a good artery above the blockage and a second artery below the blockage. The vein will be used to bypass around the blockage. The vascular surgeon will then clamp the arteries and sew the vein to the good artery above and the good artery below the blockages. The vein is now carrying arterial blood around the blockage and should improve circulation to your lower leg.  You are usually in hospital anywhere from 1 to 5 days. The incision is long and it does take 4 to 6 weeks before the incision is completely healed.

Varicose veins occur when the veins below the skin surface of the leg dilate and become swollen with too much blood.  The most common reason for varicose veins to develop is damage to the valves of the veins in the leg. In healthy veins these valves make sure blood from your leg is directed towards the heart. In varicose veins the valves do not work properly and allow some blood to flow back down the leg and then the veins swell and become varicose. The dilated veins are what you see on your leg. The underlying cause of varicose veins is unknown. Risk factors may include a family history of varicose veins, female sex, obesity and pregnancy. You also may not have any of these risk factors.

A lot of people with varicose veins do not have any symptoms, but some people do. The most common symptoms are swelling, itching and burning in the legs. There can be throbbing, discomfort and fatigue in the legs as well. Over time, some patients develop brown discolored skin near the ankle. Less commonly, you may develop a rash or a sore in the lower leg.

Most varicose veins can be managed conservatively without surgery. Your vascular surgeon or primary care physician may suggest wearing a compression stocking. The stocking will make your legs feel better and will prevent your veins from worsening. If you have symptoms that are bothersome and compression is not satisfactory, your vascular surgeon will usually order a special ultrasound to evaluate the veins of the leg to confirm that the valves are not working properly. Your vascular surgeon will then discuss the options with you.  

The options for intervention for large varicose veins include a standard saphenous vein stripping operation, or less invasive techniques such as endovenous laser therapy and radiofrequency ablation. These procedures either remove the damaged vein or shrink it using heat.  Currently, Manitoba Health insurance will cover a saphenous vein stripping operation. If you wish to pursue less invasive techniques you will have to seek a private clinic.
 

The procedure is done as day surgery. You will be given a general anesthetic or spinal anesthetic. Your vascular surgeon will make small incisions in the groin and at the knee. The main damaged vein is identified then tied off with sutures. A device will be inserted into the damaged vein and an instrument used to pull out the damaged vein. Often at the same time, small incisions will be made over other bulging veins in the leg and removed with a small hook. At the end of the procedure your leg will be wrapped in either a tensor bandage or a compression stocking. You can take off the initial tensor wrap in 48 hours, but you will need to wear a compression stocking for the first 4 to 6 weeks after surgery. You will want to elevate your legs when you are sitting or lying down to prevent swelling. We encourage you to walk as much as you can after the procedure. Your surgeon will review you again in about 6 weeks time.