LOWER EXTREMITY ARTERIAL DISEASE
(Poor blood supply to legs and feet)

CRL VASCULAR ASSOCIATES

Lewis V. Owens, M.D., Latham B. Murray, M.D.
Anthony W. Spinelli, M.D., Pradeep Rajagopalan, M.D.

TABLE OF CONTENTS

Introduction
Smoking
High blood pressure
High cholesterol or triglycerides
Diabetes mellitus
Exercise
Drug therapy for patients with arteriosclerosis

•Pletal
•Trental
•Vitamin E
•Aspirin
•Hormone replacement in postmenopausal women.

INTRODUCTION
You have poor blood supply to your legs because of narrowed or obstructed arteries in your thigh or calf. Because this has undoubtedly had an impact on your lifestyle and, because you may need direct intervention on your arteries, perhaps including an arteriogram, an arterial dilatation, or an operation, we have prepared this information on our website. This information is not intended to scare you, rather it is an attempt to educate you about both the adverse as well as the good consequences of treatment options. If you have questions, please call our office and, if our office personnel are unable to answer you satisfactorily, we will be happy to call you back if you will leave us your number.

In over 95% of patients the arterial disease you have is caused by arteriosclerosis or hardening of the arteries. This arteriosclerosis has a number of causes but the major ones are smoking, high blood pressure, high cholesterol and Diabetes Mellitus.

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SMOKING
Smoking is simply the worst thing you can do as far as arterial disease is concerned. It accelerates the progression of arteriosclerosis and causes strokes, heart attacks and, in you if you are or have been a smoker, disease in the arteries to the legs. In addition, of course, smoking is well known to cause lung disease including cancer of the lung. If you are still smoking, please quit immediately as it will slow the progression of your arterial disease as well as markedly help your lung function during and right afterward if you have a dilatation or operation. If you are unable to quit smoking, ask your personal physician for advice about how to quit.

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HIGH BLOOD PRESSURE
High blood pressure or hypertension also accelerates the development of arteriosclerosis. If you have high blood pressure, it is important that this be controlled with diet and medication. You should have your blood pressure checked regularly by your physician (remember high blood pressure itself produces no symptoms so there is no way for you to know whether you have it except by getting it checked regularly, preferably by your personal physician since the blood pressure machines available in drug stores and the like are not highly reliable).

HIGH CHOLESTEROL OR TRIGLYCERIDES
You should have your blood levels of cholesterol and triglycerides checked once a year by your personal physician (a blood test done after you have not eaten for 12 hours). Though no data exist to support the concept that a rigid low cholesterol diet helps someone with a normal blood cholesterol level (see # 3 under WHEN YOU GO HOME below), strong data do exist that suggest that lowering the part of the cholesterol called the low density lipoprotein (LDL) causes regression of arteriosclerosis (that is the arteriosclerotic plaques that are already present can become smaller). Since what you have is arteriosclerosis you should employ every reasonable effort to reduce the progression of arteriosclerosis. This includes careful monitoring of your cholesterol and, if it is elevated, lowering it into the normal range.

If you have an elevated total cholesterol (one that is greater than 200 mg/dl) or an elevated LDL cholesterol (one that is greater than 130 mg/dl), it should be reduced to the normal range by diet or by diet combined with medication. You should see your physician about how to proceed. We believe strongly in patients with vascular disease making sure their cholesterol is in the normal range. Be sure to follow up on this with your personal physician and, if you have questions or doubts, discuss this with us.

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DIABETES MELLITUS
Diabetes mellitus is likewise known to accelerate the development of arteriosclerosis. Careful monitoring and treatment of diabetes by your personal physician can slow the progression of arteriosclerosis as well as many of the other adverse consequences of diabetes.

EXERCISE
Exercise, primarily in the form of walking, is beneficial. If you develop leg cramps, you should continue to try to walk until you cannot walk further. Though this will cause you pain, it will do no damage to your legs and, in fact, will help them. The goal is to increase the blood flow to the legs and thus increase the distance you can walk before the cramps start. Daily walking can make a difference in the distance and pace you are able to walk. For it to make a difference, however, you need to walk daily (in malls in the winter if necessary) and you need to be as aggressive as possible about walking as far as possible each day. However, if you continue smoking the benefit of exercise is compromised. If you develop chest, jaw, left shoulder, or left arm pain while exercising, you should immediately stop and consult your personal physician to see if this type of pain is caused by a heart problem. If you have a dilatation or an operation this may reduce or eliminate the pains you have in your legs when you walk. Nonetheless, after the dilatation or operation you should still try to walk as much as possible. For the first 2-3 weeks after your procedure, you should not try to push yourself too hard, but after that you should try to walk further each day until you increase the distance you can walk without stopping to 1-3 miles each day. If possible you should do this for the rest of your life.

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DRUG THERAPY FOR PATIENTS WITH ARTERIOSCLEROSIS

PLETAL
Pletal is a drug whose mechanism of action is unclear but, in several studies, it seems to provide some benefit in increasing the distance patients can walk who have poor blood supply to the legs. It also has some beneficial effect on lipid levels. In most studies the onset of action occurred within a month in many patients with walking distance doubling.

TRENTAL
Trental is a drug that alters the conformability of the red blood cell. The theory is that these red cells can then slip by small obstructed areas and supply more oxygen to the tissues than they normally receive. We have consistently been impressed with the lack of benefit from Trental perceived by our patients. Moreover, when the need to take yet another pill and to pay a lot of money to do so are added to the lack of apparent benefit, we have little enthusiasm for this drug. If you want to try it, we will be happy to give you a prescription, but we see little advantage in taking it.

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VITAMIN E
As those who believe vitamin supplements are beneficial already know, the medical profession is generally poorly informed about the effects and benefits of vitamins. This comes from two beliefs: 1. Americans already receive adequate vitamin intake (there are few cases of overt vitamin deficiency) and 2. Convincing scientific data showing benefit of vitamin supplementation are sparse - primarily because the studies necessary to prove effectiveness require many patients and much money. Nonetheless, there is increased interest in this subject. Much more solid information about vitamin therapy, especially as it relates to cancer and arteriosclerosis (which causes heart and vascular disease) should emerge over the next decade. Antioxidants, such as Vitamin C (water soluble), carotine, and Vitamin E (both fat soluble) have been postulated to inhibit the development of arteriosclerosis. At one point it seemed that Vitamin E was effective in reducing the incidence of arteriosclerosis in the arteries supplying blood flow to the heart (those responsible for heart attacks). Unfortunately, a careful article in the New England Journal of Medicine in late 1999 or early 2000 could find no persuasive evidence that this was so. As a consequence, we no longer recommend Vitamin E. Carotine has been effective in men who smoked but not in non-smokers or women, and Vitamin C was not found to be effective in women or men.

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ASPIRIN
Aspirin has been shown to provide a modest benefit in reducing the incidence of heart attack in men but not women. Aspirin has also shown a very slight beneficial effect in reducing stroke in men. Once again it has shown no benefit in women. The dose of aspirin used in these studies has been between two and four regular aspirin tablets (325mg each) per day. There are experimental data that suggest that lower dose aspirin may be equally effective, though there are no clinical studies to our knowledge that confirm this hypothesis. We recommend that men take one to four buffered aspirin tablets a day. If aspirin bothers them but they can take a baby aspirin (80mg), they probably should take that.

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HORMONE REPLACEMENT IN POSTMENOPAUSAL WOMEN
Estrogen replacement in postmenopausal women is associated with a lower incidence of osteoporosis, a lower incidence of coronary artery disease, a higher incidence of cancer of the uterus, and a slightly higher incidence of breast cancer (but there doesn't seem to be a higher incidence of breast cancer if the total time of taking hormones is less than five years) (See footnotes 1-4). The higher incidence of cancer of the uterus is negated by adding progestins in women who have not had their uterus removed (hysterectomy). Therefore, the trade-off seems to be to accept a slightly higher incidence of breast cancer in exchange for a lower incidence of osteoporosis (bone wasting) and heart disease if you take hormone replacement. Because (by the fact that you have come to specialists in vascular diseases) you probably have at least a moderate amount of arteriosclerosis, it may be to your advantage to try to gain the significant reduction in both heart disease and the incidence of osteoporosis by taking replacement therapy, even though we now know there is a small increased incidence of breast cancer with this approach. This subject, however, is not within our field of expertise and advice will be changing as newer studies of this important topic are published. We recommend, therefore, that you consult your gynecologist and follow his or her advice about replacement therapy.

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SUMMARY OF NON INVASIVE THERAPY FOR ARTERIOSCLEROSIS

WOMEN and MEN

1. No smoking
2. Control of hypertension if present
3. Control of diabetes if present
4. Control of elevated cholesterol if present
5. Daily exercise (primarily walking)
6. May wish to try Pletal
7. Coumadin if appropriate

Probably no need for Trental, Vitamin E supplement or Persantine.

• In addition for WOMEN: Hormone replacement therapy for those who are post menopausal (discuss this recommendation with your gynecologist).
• In addition for MEN: Aspirin one to four pills (325mg each) a day

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RADIOLOGISTS
We will refer you to our invasive radiologists, Dr. Spinelli and Dr Rajagapolan, for your arteriogram. These specialists also perform dilatations, insert stents, and clean out areas of clots with special catheters and medicine when we think you will be benefited by one or more of these maneuvers. Our relationship with these radiologists is one of true collaboration, we all are striving to provide the greatest relief of your symptoms while, at the same time, minimizing your risks.

ARTERIOGRAM
If a dilatation or an operation is planned you will need to have an arteriogram (also called an "angiogram" or "aortogram") in order to localize precisely the location and extent of the arteriosclerosis you have. This is a study in which the radiologist will inject contrast material (a clear fluid that shows up on an x-ray as white) into your aorta or main artery of the abdomen. X-ray pictures will then be taken of your abdomen, pelvis, thighs and legs at the time of the injection. The catheter (or tube delivering the contrast material) is usually inserted through the groin artery, though occasionally it will be inserted through the arm or back . There is some mild discomfort with this but it isn't too painful as the radiologist will usually sedate you with some intravenous medication as well as numb the skin by injection with a local anesthetic before inserting the catheter. At the time of the injection of the contrast material you will probably feel a very warm or even hot burning sensation. It clears completely after 10 to 20 seconds and you should have few if any pains or problems associated with the injection. The catheter is then removed and pressure is applied to the area where you were stuck so as to get the hole to seal. You will then go back to your room. The entire arteriogram usually takes about an hour. Before the arteriogram you will be asked not to eat any solids for 5-8 hours but you should continue to drink fluids, especially water. You don't need to have a full bladder so you can urinate as often as you like but you should have drunk plenty of fluid. This increases the amount of fluid your kidneys filter and reduces any potential kidney damage that might be caused by the arteriogram.

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RISKS OF THE ARTERIOGRAM
The major risk is an allergic reaction to the contrast agent used. These agents almost all have iodine in them so, if you have had a previous reaction to an injection of contrast (for an IVP for instance) or you know you are allergic to iodine, you should let the radiologist know. Other risks include damaging the kidneys with the contrast (this is minimized by drinking large quantities of water prior to the arteriogram) and damage to the artery where the catheter is inserted. If necessary, damage to the artery can usually be fixed by a small groin operation. After the arteriogram you may find that you have swelling or a hard lump in the groin. This is from a small amount of blood that almost invariably leaks out around the catheter during the procedure or out the small hole in the artery immediately after the catheter is removed. This may cause bruising and mild discomfort for a few days but will usually improve without problems. The lump may persist for 1-3 months as it takes time for the blood to be broken down and reabsorbed. This clot, however, is not risky - it is not within a blood vessel so it can't break off and go to your leg or heart. In general, arteriograms are safe and have a major complication rate of 1% or less. The radiologist is the expert in this field and you should be sure to discuss with him or her any concerns or questions you might have.

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DILATATION
If the arteriogram shows that there are one or more arteries that can be dilated so that you can get a satisfactory increase in blood flow to your leg(s) the radiologist will try to do this. If possible it will be done at the same time as the arteriogram though the radiologist may elect to do it at a later time if you have received near the safe limit of contrast material or if a different approach would be easier or safer. Dilatation consists of inserting a flexible wire into your artery and passing it through the tight arterial narrowing. A catheter with a balloon on it is then inserted over the wire and positioned at the level of the tight narrowing. The balloon is then blown up (it is a very rigid hard balloon) and the narrowed area (caused by arteriosclerotic plaque) is compressed to the side. Several areas may be dilated during the same procedure. The advantages of dilatation are that the risks are low (see below), the procedure is not particularly painful, you may get good relief of your symptoms for 1-5 years, and you only need to stay in the hospital for a short time (0-2 days).

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RISKS OF DILATATION
It may not be possible to satisfactorily dilate an area that, on the arteriogram, appeared to be dilatable. In addition the balloon can damage the vessel so that it closes completely or releases arteriosclerotic plaque material down the leg to block other distal (and more inaccessible) arteries. It is also possible for the balloon to rupture the artery and make an emergency operation necessary to control the bleeding. Moreover, dilatation (since the plaque is simply being compressed and not removed or bypassed) tends not to give relief of symptoms for as long as a bypass. Nonetheless it is, as a rule, safe and, on occasion, may give highly satisfactory results for more than 5 years. Repeat dilatations at a later time may be done if necessary and technically possible. In general, dilatation is an excellent temporizing procedure that we advise when it is feasible. The overall major complication rate for the procedure is about 2%. The radiologists do the dilatation and are the experts. You should fully discuss with them the procedure, risks, and alternatives.

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CLOT DISSOLVING
Blood clots for three reasons: 1) sluggish flow, 2) trauma to the blood vessel, or 3) an increased tendency for clotting within the individual. Sometimes an area of particularly tight narrowing within an artery will result in sufficient slowing of blood flow that clot will develop at the level of the narrowing. This clot will then extend backwards up the artery until there is a major branch that allows arterial flow. (The clot will not move to the heart and kill you; this clot is on the arterial side where blood flow is away from the heart; the clot that can kill is found on the venous side where flow is toward the heart.) The consequence of this clot is that you may suddenly experience the onset of pain in your calf or foot when walking (this phenomenon of pain elicited by exercise is called claudication), or you may find that the distance you could walk before developing pain several days earlier has shortened considerably.

If either of these situations has developed (new claudication or sudden worsening of claudication) it may be possible to dissolve the clot and dilate the underlying arterial arteriosclerotic lesion causing the narrowing. Because the clot changes its characteristics over several months, it is usually not possible to dissolve clots that have been present for more than 2-3 months. Accordingly if this clot dissolving approach is to be undertaken, it is important to proceed reasonably promptly after your symptoms have developed or changed. The clot dissolving substance that is generally used is a drug called tissue plasminogen activator (tPA) which is extremely expensive. It is given to you at the time of the arteriogram through the arteriogram catheter with the goal being to deliver the drug directly to the clot within the artery. It is an effective drug and good results are often achieved. When we think efforts at dissolving clot followed by dilatation of a narrowed area within the artery is feasible, we will usually recommend it since the risks are low and it may preserve the patency of an important artery to your leg.

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RISKS OF CLOT DISSOLVING
Some of the complications can be an allergic reaction to the clot dissolving drug, some clot may dissolve but some of the remaining clot can pass further down the artery making the situation worse rather than better, or the drug itself can cause bleeding. Obviously the drug may be ineffective in dissolving the clot or some clot may dissolve, only to reveal extensive arteriosclerotic plaque that would be unresponsive to dilatation. The radiologists administer the clot dissolving drug as well as do the dilatation; they are the experts in this treatment. You should fully discuss with them the procedure, risks, and alternatives.

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LASER
Use of the laser and other "rotor router" devices are now being investigated. We follow this technology closely and have access to many of these devices. At present current NIH effectiveness assessment data suggests that it is still much too early to advocate this approach.. Past experience has likewise been not favorable. The complication rate is high and the longer term success rate is poor. Our treatment goal is to improve the blood supply to your legs at lowest risk to you consistent with getting a good medium to long term result. Newer techniques (such as atherectomy) that allow you to avoid a major operation are highly desirable for us as well as you and we advocate them once their efficacy is demonstrated. Despite early high hopes, laser therapy has failed to achieve the results that currently warrant its use.

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STENTS
Intraluminal stents likewise hold promise in the treatment of short areas of narrowing. These devices, also inserted by radiologists, have now been approved by the FDA for use. In conjunction with the radiologists, we will advocate their use in the appropriate circumstances.

FEMORAL-POPLITEAL OR FEMORAL-TIBIAL BYPASS
THE OPERATIVE PROCEDURE

ANESTHESIA
You will have an anesthesiologist in charge of your anesthesia. He or she will see you before the operation and review with you the risks and approaches that will be employed when you have your anesthesia. You should be sure to ask the anesthesiologist any questions you may have.

For a femoral-popliteal or femoral-tibial bypass operation, the anesthesiologist may choose a general anesthetic which will consist of putting you to sleep through an IV injection and then keeping you asleep with gasses delivered through a tube in your windpipe (that is put in after you are asleep). Or the anesthesiologist may choose to give you a spinal or epidural anesthetic whereby you will have medicine injected near your spinal cord that will numb up your legs while being heavily sedated. Or the anesthesiologist may choose a combination of these techniques.

The anesthesiologists we use at Martha Jefferson Hospital are excellent. The risks of anesthesia are small, but nonetheless should not be dismissed. One of the great advances in anesthesia over the last 20 years has been the development of oxygen saturation monitors. These are devices that are put on the fingers during the operation and monitor the oxygenation of your blood. This works by shining a light through your finger and detecting color changes if you are not being adequately oxygenated. Alarms go off if your oxygen saturation drops slightly. This gives the anesthesiologist lots of time to make the necessary adjustments and tends to reduce the anesthetic complications due to anesthetic error down to an extremely small number. Anesthesia is an important aspect of your care and you should be sure to ask the anesthesiologist any questions you may have.

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OPERATION
Either a femoral-popliteal or a femoral-tibial is a bypass from your femoral artery in your groin to one of your arteries just above or below your knee. The graft is a vein, usually from the leg being operated upon, or is made of Dacron or Teflon (Gore-tex) and is shaped like a tube. It bypasses the obstructed arteries of the thigh and leg. Though it is a moderately big operation the results are, in general, quite good. Two thirds of these bypasses stay open for a five years; relief of symptoms is usually excellent as long as the graft remains open.

After you have been put to sleep or had your legs and pelvis numbed with an epidural or spinal anesthetic, a tube (Foley catheter) will be inserted into your bladder through your urethra (the tube you urinate through). This will be left in place for 1-2 days after the operation to allow us to measure the amount of urine you produce (a good measure of kidney function and adequate fluid balance).

Rarely you may also wake up with a tube in your windpipe that allows the ventilator to breathe for you. This will prevent you from speaking and may cause you some anxiety (you can communicate by writing - the nurses will provide you with a writing pad). The best approach is to relax as much as possible and we will remove it as soon as breathing tests indicate you can get an adequate amount of oxygen breathing on your own.

This operation is somewhat painful and the incisions will hurt moderately. This pain steadily lessens over the subsequent few days so that by the time you leave the hospital you will be able to control it easily with pain pills. At first, though, you will need narcotic injections and we will order these for you - all you will need to do is ask the nurse for a pain shot. If you aren't getting them frequently enough or getting adequate relief, let us know and we will increase the frequency or amount. You will not become addicted and we are not concerned about it so be sure to take your shots frequently at first. There is no virtue in suffering and the pain shots will allow you to be more active - an important part of recovery. After the first couple of days, however, you should try to reduce the number of pain shots you ask for (you do this - we won't cut you back) since this will reduce the amount of constipation you have.

Normally all of us sigh or take an extra large breath several times a minute. This sighing expands our lungs and prevents tiny areas of collapse called "atelectasis". After your operation you should concentrate on taking deep breaths as often as you can think of it. If you do this fairly frequently, it will improve your lung function. We may also order a blowing instrument (called an incentive spirometer) to help you with this activity.

We will encourage you to get out of bed and start walking quite early. Though you won't like it at first, you will find that it will hasten your recovery and also lessen the likelihood you will develop clots in the veins of your legs. Also, again to reduce the likelihood of clots in the leg veins, you should move your feet and contract the muscles of your calves starting when you wakeup. When you first start to walk be sure to have the nurses help you - you won't be as strong as you think and you certainly don't want to fall and break a bone.

In summary, the things you need to remember to do starting as soon as you wake up from the operation are:

• Breathe deeply fairly frequently. Use the incentive spirometer to aid you in this.
• Move your feet and calves frequently. Try to push yourself to be more and more active as this will prevent clots from developing in your veins.

This recovery period passes relatively quickly and, though you certainly wouldn't want to volunteer for this kind of operation on a frequent basis, it is likely you will find that the anticipation will turn out to have been worse than the actual event. If you have problems, the nurses and we will help as soon and as effectively as we can.

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COMPLICATIONS OF FEMORAL-POPLITEAL OR FEMORAL-TIBIAL BYPASS

The major risk associated with entering a hospital or having any procedure performed, no matter how minor, is death; this unassailable fact must always be kept in mind. The major risks of femoral-popliteal or femoral-tibial bypass (the operation described in this handout) are death, stroke, heart attack, bleeding, loss of one or both legs, hepatitis, infection either of the graft or throughout your body, worsening of the blood supply to the legs and clots forming in the legs and possibly going to the lungs.

Death is usually caused by a heart attack in the postoperative period but can be caused by many other factors as well. The risk of death within 30 days of the operation is 2-3%. Stroke, bleeding, blood transfusion complications, infection, impairment of blood supply to the legs are unusual after this operation but all can and, on occasion, do occur. Clots can form in the legs and cause leg problems later or can break off, go to your lungs, and interfere with your ability to breathe.

You will almost certainly develop swelling of the ankle and calf on the side that is operated upon. This isn't a complication so much as it is a routine result of this operation. Though this swelling will persist for 3-6 months after the operation, it only minimally interferes with your activity and it almost always resolves. Be patient.

This is a short but by no means comprehensive review of some of the complications that can occur. If you have any questions or want a more detailed explanation of any of these complications, please make sure you discuss it with us before you enter the hospital. We will certainly try to avoid or minimize the likelihood of operative complications. Nonetheless this operation is not now, and never will be, risk free. You should feel very comfortable with your understanding - not only of the benefits, but also of the risks.

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BLOOD TRANSFUSIONS
You may need blood during or after this operation, though it is rare. We will try to lose as little as possible. The risk of transmitting hepatitis or AIDS virus is exceedingly small as our blood supply is carefully checked and monitored. Nonetheless, you may want to donate blood in advance or have family members contribute specifically to you. The methods for this are complex and may not be successful. Our own view is that the blood supply is adequately safe and these other methods are probably not necessary. If, however, you would like more information or would like to explore your or your family's donating blood please ask our office personnel to help you got the appropriate information (the way to achieve this varies from hospital to hospital).

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BLOOD THINNERS - COUMADIN
Blood thinners or, more precisely, anticoagulants, are sometimes used in an attempt to prolong the time that a bypass remains open or patent. There aren't strong data to support the use of anticoagulants for this purpose; nonetheless all bypass grafts, especially ones made out of prosthetic materials such as Gore-tex or Dacron, have an inherent propensity to clot. Accordingly, we will often recommend the use of moderate anticoagulation to try to counteract this clotting tendency. The drug used for this comes in a pill form and is called Coumadin. The blood test used to monitor effectiveness of the anticoagulation produced by Coumadin is the Prothrombin Time or Pro Time or PT (all the same test).

Once you go home from the hospital, if you are taking Coumadin, you will need to assume the major responsibility for monitoring your prothrombin time (PT) to make sure that you stay in the appropriate range. Prothrombin times are reported in seconds and as an Iternational Normalized Ratio (INR). The normal time for most people is 10 to 12 seconds. With Coumadin therapy we want to aim for an International Normalized Ratio (INR) of between 2 and 3. You'll need to get a prothrombin test done once a week for 3 or 4 weeks until we and you are sure that the dose you are taking is a correct dose. Dosages of Coumadin can range anywhere form 2.5 mg to 10 mg a day with a wide variation among people. Once your standard dose is established, you should maintain your dietary habits as well as take all of the medicines that your physician has prescribed for you. If you start other medicines or change your diet in any substantial way, you should again repeat your prothrombin time within a week or so because Coumadin can cross react with so many different substances that it's always safe to make sure you are not creeping up or creeping down. If you have an INR of 2-3 (the rate we aim for), there is about a 2% per year or less major complication rate of bleeding. Despite its relative safety, however, you should be aware that Coumadin itself is a formidable drug with potential serious consequences and one should not be on anticoagulation therapy cavalierly.

After the first 3 or 4 weeks of getting weekly prothrombin time checks you can switch to every 2 weeks for a couple of times and then every 3 - 4 weeks for the remainder of your time taking the Coumadin. We will assist you in arranging this service with your primary physician. You should not assume that, because you have not heard what your Protime results are that they are acceptable. Lots of communication errors can occur and we think it is always safest if you make sure that you have called your doctor's office two to three days after each blood test to confirm that your prothrombin time or INR is in the appropriate range. We will be happy to communicate with your physician regarding our thoughts about the appropriate range if that information is desired.

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WHEN YOU GO HOME:

1. You should resume all the medications you were taking before the operation unless your personal physician has changed them.
2. You should not drive until you are completely confident of your stamina and your ability to suddenly put the brakes on should an emergency arise. This usually take 2-4 weeks.
3. You can resume your normal diet. You may notice that you lost a few pounds during your hospitalization. If you are overweight you might want to use this opportunity to reach the weight you want by being more moderate in your intake and reducing the fats in your diet. More fish, poultry, vegetables and unsaturated fats; less butter, cheese, pork, eggs, cream etc. A prudent diet is best. A rigid low fat diet, though probably somewhat beneficial, is difficult to comply with, probably doesn't make a great deal of difference unless started earlier in life and isn't worth the inevitable marital discord, "Now, remember honey, the doctor said you shouldn't have that scrambled egg". "GRRR". [Back]
4. You should not smoke again. Ever. Not even a little. Not at all. If you cannot comply with this, ask your doctor for his or her suggestions or we will refer you to someone who will try to help you.
5. You may drink alcohol in moderation.
6. You may take showers and get your incisions wet - you don't need to wear bandages over your incisions. Avoid baths and soaking your incisions until the staples are removed because the wounds can get macerated.
7. You should walk daily and should slowly increase the distance you walk each day.
8. You should see your personal physician within two weeks after you leave the hospital. Bring all your medicines to him or her so they can be checked to make sure you are taking the medicines the way your personal physician wants you to.
9. Return to our office within two weeks and we will take any remaining skin sutures or staples out, check you over, and answer any questions you might have.
10. You may resume sexual relations when you feel strong enough. Be aware, however, you may find your desires and abilities diminished for some time.
11. Because arteriosclerosis is a progressive disease, you should return to us at least once a year for repeat vascular evaluation. You should also be sure to return promptly if your symptoms suddenly change (for instance if you notice that you can only walk a block before your leg cramps develop, whereas the week before you could walk three blocks). This change in symptoms could reflect recent clotting of an artery or bypass. We can usually dissolve this clot if we are able to give you the clot dissolving medicine relatively promptly; whereas the obstruction will be permanent if the clot is allowed to remain undissolved for very long.

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A WARNING
This operation is a big one. Patients are understandably focused on two aspects: "Will I die and will I have a major complication"? After the operation when they realize they are doing well, they are obviously pleased and become reasonably happy when they see substantial improvement each day after the operation. After about three weeks, however, they stop noticing daily improvement and observe that they are still weak, fatigue easily and require daily naps. Frequently, patients then become depressed and irritable - not so nice to be around. This depression will last 3-6 weeks but improves when the patient realizes that he or she is still improving week to week. Recovery from the operation to the point you can get about is relatively quick but complete recovery to the point where you feel as well or perhaps even better than you did before the operation may take 3-6 months. Be patient and continue to try to walk further each day.

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BEFORE YOU ARE ADMITTED TO THE HOSPITAL
You should call or see your personal physician. We would like him or her to thoroughly evaluate you to make sure you are in optimal condition to have an operation. Ideally, we would like you to have a complete physical examination and blood tests.

In addition, We would like your physician to send you to a cardiologist to make sure your heart is in reasonable shape. The cardiologist will check your blood pressure, perform an EKG and perhaps do other tests to detect unsuspected heart disease (arteriosclerosis is a systemic disease and in addition to causing problems in your aorta in your abdomen, it can also cause problems in the arteries supplying your heart). Though you may view this additional testing as inconvenient or unnecessary, in the unlikely event you have a problem postoperatively, it is reassuring to know that both your personal physician and a cardiologist have recently examined you and are quite familiar with your overall condition.

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BILLING
Our charges for the operation include the admission evaluation, the operation, the in hospital postoperative care, and the postoperative visits over the 2-3 months after the operation. You should check with our office personnel for the amount you will be charged and the extent to which your insurance will cover it. You will also receive other related bills - the hospital, radiologists and anesthesiologists all will have separate bills. Be sure to check with our office regarding any questions you have about what your financial obligation is.

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REFERENCES
1. Belchetz, PE. Hormonal treatment of postmenopausal women. N Engl J Med, 1994; 330:1062-71.
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