Open Surgical Procedures

Open Surgical Procedures

AV Access procedures

Arteriovenous (AV) Fistula

An arteriovenous fistula is an abnormal connection between an artery and a vein, by-passing certain capillaries. This results in reduced oxygen and nutrient supply to the tissues accessed by those capillaries. Arteriovenous fistulas occur commonly in the legs, but may develop anywhere in the body. Arteriovenous fistulas could be caused by a piercing injury (like a gunshot or a stab wound). They could also be congenital in nature. In patients with end-stage kidney failure, an arteriovenous fistula may be surgically constructed in the forearm for easier dialysis treatment. A series of imaging tests including duplex ultrasound scans, CT scans and MRI scans are used to diagnose arteriovenous fistula. Once diagnosed, it may be treated with ultrasound-guided compression, catheter embolization or surgical intervention.

Arteriovenous (AV) Graft

An arteriovenous graft is a deliberate connection created between an artery and vein by inserting a graft between them. The graft is a small tube made of flexible material that acts as a connecting conduit. The graft functions as an access site for haemodialysis treatment. An arteriovenous fistula is preferable for the access site, but if the walls of the veins are weak, a graft may be preferred. Before the graft is inserted, the blood vessels are mapped using Doppler ultrasound scans. This helps select the right blood vessels for the graft. The insertion of the graft may be performed as an out-patient procedure, depending on the patient’s condition. The AV graft usually heals completely in 2-3 weeks and can be used as a dialysis access site.

Arteriovenous (AV) Graft Repairs

Arteriovenous grafts are inserted to create access-sites for dialysis treatment in patients with end-stage kidney failure. The graft is a flexible tube inserted to connect the two blood vessels. This can get blocked with time and may require a graft repair procedure. The obstruction is usually cleared through a direct puncture into the graft, under x-ray fluoroscopy guidance. The procedure is performed by an interventional radiologist. The entry point and direction of access are carefully chosen based on the individual case. If the patient experiences repeated graft obstructions (restenosis), the doctor may elect to insert a metal mesh cage into the graft to keep the channel open.

Varicose Veins Surgeries

RF Ablation

Varicose veins are enlarged, twisted veins that often appear blue or black. They occur commonly in the feet and legs. They occur when faulty valves in the veins allow blood to flow in the wrong direction or pool in one area. Radiofrequency (RF) ablation is a minimally-invasive procedure to treat varicose veins. The radiofrequency waves produce heat which damages the walls of the varicose vein and trigger the formation of scar tissue. The scar tissue closes up the damaged valve and cuts off the varicose vein. During radiofrequency ablation, a catheter is inserted into the leg through a small skin incision. The radiofrequency waves are fired through the catheter for ablation. The procedure is performed using local anaesthesia or a mild sedative. The patient will be able to walk after the procedure, and recovery is usually quick. The patient will have to wear compression socks after the treatment.

Microwave or Laser Ablation

Laser ablation is one of the methods available to treat varicose veins. Laser ablation uses a laser beam to burn the walls of the varicose vein and trigger scar tissue formation. The scar tissue seals off the bulge of the varicose vein. Laser ablation for varicose veins may be recommended if the patient has red and swollen varicose veins, or if the skin above the varicose veins is inflamed. The side effects of laser ablation include skin burns, nerve damage, pain and infection.

Sclerotherapy

Sclerotherapy is a procedure used to treat varicose veins. During sclerotherapy, a solution is injected into the varicose veins through a very fine needle. The solution damages the walls of the veins and induces scar formation. This seals off the varicose vein and re-routes the blood flow through adjacent, healthier veins. In some cases, multiple sessions may be required to achieve the desired result. It is recommended to use compression socks after the procedure. Sclerotherapy is often performed to improve the appearance of varicose veins and spider veins.

Phlebectomy

A phlebectomy is a surgical procedure to remove varicose veins. There are 2 types of phlebectomy procedures – ambulatory phlebectomy and transilluminated powered phlebectomy. An ambulatory phlebectomy involves removing portions of the varicose veins using hooks inserted into micro-incisions in the skin. A transilluminated powered phlebectomy is performed by inserting specialised, lit tools into a microincision to break up and suction out the pieces. A phlebectomy procedure may be recommended to treat large, protruding varicose veins that are close to the surface of the skin. After surgery, the patient will be advised to wear compression socks for several weeks to stabilise the veins and help them heal. Recovery time depends on the patient’s age, general health and the extent of varicose veins treated.

Peripheral Vascular Disease

Peripheral Artery Bypass Surgery

Peripheral arterial disease is a condition characterised by the narrowing of the arteries that supply blood to the limbs. This is usually caused by the build-up of plaque in the blood vessels, hardening the walls of the arteries. The plaque could accumulate and cause an arterial obstruction. A surgical by-pass re-routes the blood flow around the obstruction, to restore oxygen supply to the affected tissues. Surgical by-pass is recommended to patients who are not good candidates for minimally-invasive approaches such as stenting or a balloon angioplasty. The surgery is performed under general anaesthesia. The surgeon may opt to use an artificial graft or the patient’s own veins to create the by-pass.

Femoral Popliteal Bypass

Femoral popliteal bypass surgery is performed to treat a blockage in the femoral artery, which supplies blood to the legs. The obstruction is typically caused by the accumulation of plaque on the walls of the artery, also known as atherosclerosis. Femoral popliteal bypass is an open procedure, performed under general anaesthesia. During the procedure, the surgeon accesses the femoral artery through a large incision in the thigh. A vein is harvested from another part of the leg (known as an autograft) and grafted to form the by-pass for blood to flow around the obstruction. An artificial graft may also be used instead of an auto-graft. The patient must follow recovery procedures for 2-3 months after the surgery.

Femoral Tibial Bypass

Femoral tibial bypass surgery, also known as infra-popliteal bypass, is a procedure to treat peripheral artery disease of the lower leg, comprising the calf, ankle and foot. It is an open surgical procedure, performed under general anaesthesia. The surgeon grafts an alternate route for blood to flow around the obstruction. The graft used may be a piece of vein harvested from elsewhere on the patient’s leg, or an artificial, flexible tube made of synthetic materials. The type of graft is chosen based on the individual patient’s condition.

Stroke Prevention Surgery

Carotid Endarterectomy

Carotid endarterectomy is a surgical procedure to treat carotid artery disease. The carotid artery is the primary blood vessel that carries oxygen to the brain. Carotid artery disease causes a narrowing or obstruction in the carotid artery, depriving the brain of oxygen. This is dangerous and requires immediate medical attention. A carotid endarterectomy is an open surgical procedure, during which the surgeon accesses the carotid artery through a neck incision and removes the plaque build-up inside. The artery is then repaired with stitches or a graft patch. In some cases, the surgeon may opt to use a different technique called eversion carotid endarterectomy. This technique involves creating an incision in the carotid artery and turning it inside out for easier removal of plaque. Once all the plaque is removed, the artery is returned to its original position and repaired with stitches or patch grafts.

Carotid Angioplasty and Stent Placement

Carotid artery disease causes a narrowing or obstruction of the carotid artery which supplies blood to the brain. Carotid artery disease can cause a stroke. To treat or prevent a stroke or oxygen deprivation to the brain, the doctor may recommend a carotid angioplasty with an optional stent placement. The angioplasty is a minimally-invasive procedure, in which a balloon catheter is inserted into a micro-incision in the neck and guided to the plaque build-up. The procedure is performed under X-ray fluoroscopy guidance, with the use of a contrast dye. The contrast dye is injected through the catheter, and helps visualise the obstruction better on the X-ray. The balloon is inflated at the site of the obstruction to expand the artery, and a stent is placed to hold the walls open.

Others

Carotid Body Tumour Removal

Carotid body tumours, also known as chemodectoma or paraganglioma, are abnormal tissue growths on the carotid arteries on either side of the neck. Carotid arteries supply blood to the brain. The tumour may not cause any symptoms but can be felt on the side of the neck. The tumour can press on the nerves and blood vessels in the neck and cause complications if it grows very large. Carotid body tumours may be treated with a minimally-invasive or open surgical techniques. The blood flow to the tumour may be reduced or cut off by a procedure called a transcatheter embolization. This is a minimally-invasive procedure, in which embolizing chemicals are injected into the tumour through a catheter. The chemical reduces the blood supply to the tumour and causes it to shrink. For small carotid body tumours, this may be sufficient. Larger tumours will be surgically removed after transcatheter embolization. The embolization reduces the chances of bleeding out during the surgical procedure.

Thoracic Outlet Procedures

The thoracic outlet is a ring formed by the top ribs, just beneath the collar bone. Nerves, arteries and veins pass through the thoracic outlet to supply blood to various parts of the upper body. Thoracic outlet syndrome occurs when the nerves and blood vessels are compressed by the ribs of the thoracic outlet, causing pain. Thoracic outlet syndrome may be caused by physical trauma (like a car accident or a fall), a congenital abnormality or pregnancy. In many cases, the condition can be treated with medication and physical therapy; however, if these are ineffective, surgical correction is performed. The surgeon will perform a thoracic outlet decompression to relieve pressure on the nerves and blood vessels. The thoracic outlet may be accessed through an incision above the collar bone (supra-clavicular approach), below the collar bone (infra-clavicular approach) or through the chest (trans-axillary approach), depending on the individual case.

Covid and Thrombosis

Embolectomy and Thrombectomy procedures

Embolectomy is a surgical procedure for the removal of an embolus, a blood clot or foreign body that has moved through the blood vessels and become lodged in the blood vessels. A thrombectomy is a surgical procedure for the removal of blood clots. Patients with Covid-19 have an increased risk of developing blood clots and emboli as a complication. Blood clots and emboli can cut off blood supply to tissues and cause serious complications. The removal of blood clots and emboli may be performed using minimally-invasive or open surgical techniques. Minimally-invasive removal involves the use of a balloon catheter to clear the obstruction. This technique is preferred compared to the open surgical approach, as it has a shorter recovery time. However, in some cases, especially emergencies, an open surgical approach is preferred so the surgeon has direct visual access of the embolus or blood clot. A large incision is made in the leg, directly above the blood clot through the muscle, and the obstruction is removed.

Other Procedures
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