Dr Ponosh and Ponosh Vascular provides a comprehensive diagnostic and treatment management solution to all vascular disorders.
Utilizing up to date and cutting edge, evidence based management, Mr Ponosh will tailor your treatment for the very best outcome through conservative medical therapies, minimally invasive endovascular (keyhole) treatments or open surgical operations.
Please see below for information sheets relating to some some commonly treated conditions and therapies.
Ponosh Vascular provides the very latest, up to date and comprehensive diagnostic and management service of all vascular conditions. Utilizing the optimal conservative medical therapies, minimally invasive endovascular techniques and contemporary surgical options, we specialise in:
Peripheral Arterial Disease (PAD) is a condition where the arteries become narrowed or blocked by fatty deposits called atherosclerosis, more commonly known as “hardening of the arteries”.
Whilst this can occur in many arteries in you body, significant problems may arise when this narrowing occurs in the arteries of your leg. To learn more about Peripheral Arterial Disease click here.
An angiogram is a procedure to visualize the flow through your arteries. Whilst Mr Ponosh will organize ultrasounds, CT or MRI scans to assess and diagnose your vascular disease, an angiogram may be required for further information or to ultimately treat your arterial disease. In some cases, these procedures can also ve used to treat your veins (venogram).
Endovascular or “key hole” angiogram treatments are minimally invasive procedures that usually require a day-stay or a short overnight stay. They are undertaken with an anaesthetist usually done under a local anaesthetic with sedation providing a “twilight” anaesthetic.
Endovascular procedures are undertaken through a small needle access through your groin directly into your arteries. Dye is injected through the needle or access tube (sheath) to show the flow through your arteries and is shown by x-rays taken during the procedure to confirm the narrowing’s or other disease that needs to be treated. The procedure takes between 45-60 minutes in most cases.
Small angiogram sheath (2-3mm) that key hole procedure is performed through.
They are low risk, essentially pain-free procedures which utilize state of the art modern technologies for excellent outcomes. The results are almost immediate and have a very rapid return to your normal lifestyle.
Preparation for the angiogram
The procedure will have been discussed at length with Mr Ponosh in his office. Mr Ponosh will the procedure to you in an open, straight-forward, jargon-free manner with all options and questions addressed. The benefits and the risks will also be discussed. A consent or permission form will be signed by you and Mr Ponosh.
You will be admitted to the hospital for a few hours in advance of your procedure to prepare for the angiogram. Mr Ponosh’s staff will confirm these times in writing with you and provide clear information on eating, drinking and fasting times. Advice will also be provided by Mr Ponosh and his staff regarding your medications. This will particularly apply to any blood thinners or diabetic medications. Please advise us if you are taking >>>>>>>>>>>>>>>. The anaesthetist will usually contact you in the days before your procedure for further information.
During this preparation time in hospital, if you have any worries or queries do not be afraid to ask. It is necessary to put on a hospital gown and usually the hair at the groin area needs to be trimmed before the angiogram. The procedure will take place in area known as an Angiography Suite. This is like an operating theatre however it is specialized for angiograms and has additional equipment including the special x-ray machines.
Mr Ponosh with Hollywood Hospitals new Siemens pheno Angiography Suite.
The anaesthetist will place a small drip in your hand or arm and start your “twilight” anaesthetic. You will be positioned on the procedure table and your groin skin will be cleaned to prevent infection. The cleaning preparation is often a little cold. You will be then covered with sterile drapes. Occasionally your face will be covered but a “tent” will be made to make you feel comfortable. You will be asked to lay as still as possible however if any concerns or questions arise, the nursing and anaesthetic staff will assist you. You may feel some pushing and pressure in your groin, however the procedure should be as discomfort-free as possible.
During the angiogram
Mr Ponosh will inject a local anaesthetic into the skin at the groin numbing the area. Then the fine tube (sheath) is inserted into the vessel. With the help of wires other small long tubes called catheters can be maneuvered through the blood vessels and positioned as desired. X-ray pictures are taken whilst dye is injected down the catheter into the blood vessels. The dye may cause a hot flush and the feeling of having to pass urine. Both will subside after a few seconds. Multiple injections are necessary to see the full length of the blood vessel and the x-ray machine or the table will be moved in-between them. Mr Ponosh will identify the diseased arteries and treat your disease using either :
Angiogram showing blocked thigh artery (left) and re-opened (right).
Angioplasty
Some narrowed arteries (and rarely veins) are treated by passing a balloon across the diseased segment and then inflating it. The balloon will dilate the narrowing treating the blockage and improving your symptoms. The balloon is then removed. Mr Ponosh may elect to use new state of the art “drug coated” angioplasty balloons in some cases which coat the treated artery with a special drug. These special balloons have been shown to have very good long term outcomes especially in cases of re-narrowing.
Stenting
In some cases Mr Ponosh may decide a stent is the best option to treat your narrowed arteries (or vein). Stents are either a bare metal scaffold or a plastic covered metal scaffold to help hold the artery open. The use of these stents are based upon Mr Ponosh’s vast personal experience and evidence based medicine to provide you the optimal outcome. These are minimally invasive devices which are permanent and often have special drugs coating them to help improve outcomes. Please see the “Patients” section for videos showing stent insertions.
They may be used to treat narrowing or some cases aneurysm’s (blow outs or dilations) of your arteries.
Artherectomy
This is a key-hole device used in conjunction with ballooning or stenting to “drill” or excise out arterial disease. It is used in specific cases to improve outcomes.
Embolization
This is a procedure usually used on veins and occasionally arteries in which small metal coils and permanently placed in vessels to block them off. This is often used on “leaky” veins such as an ovarian vein and may be part of varicose vein treatment. The coils are made from platinum and will not cause issues with other x-rays or airport metal detectors. Mr Ponosh will discuss there use with you if required.
After Angiogram/Venogram
When the procedure is completed all access sheaths are removed from you. A special staple or plug device may be used to the small hole in your artery. Pressure will be applied to the groin for up to fifteen minutes and a small pressure device (Fem-Stop) may be placed on your groin for an hour or so. You will awaken from your twilight anaesthetic and moved to the recovery area where nurses will be keeping a close eye on you. Approximately 2-4 hours of bed rest are necessary to prevent any bleeding from the puncture site. The nursing staff will check the groin, and foot pulses at regular intervals.
Your usual medication may be adjusted after this procedure however this will be clearly detailed to you. Mr Ponosh will speak to you after your procedure and you will discuss any queries or questions with you.
You will either stay overnight or be discharged later in the day if a day case was planned. Nursing staff will keep you well looked after during your stay. Mr Ponosh’s staff will be in contact with you in the days following your procedure to arrange your follow-up in his office and any ultrasounds if required.
Please see Mr Ponosh’s angiogram discharge information sheet for discharge advice.
Risks
An angiogram/ angioplasty is a very safe low risk procedure. Mr Ponosh has decided and discussed with you that although there are risks inherent to every procedure, the benefits to you dramatically outweigh them and the angiogram is the best treatment for you. If you have any concerns following the procedure please contact Mr Ponosh’s rooms directly, your GP, or your hospital.
Bleeding
As the operation is performed on blood vessels a small amount of bleeding can sometimes occurs. This is often easily treated with some pressure but it is common to have some bruising to the area after the procedure. You may also develop a small lump which will resolve by itself. Serious bleeding is very uncommon but may require an additional procedure to correct.
False aneurysm
Very rarely a lump may occur which is in flow with the artery. This is because of some continued bleeding from the puncture site. This is called a pseudoaneurysm. This pseudoaneurysm may settle by themselves whilst other may require an additional procedure to fix them.
Pain/Discomfort
Pain and discomfort is usually minimal during the procedure and after. Occasionally you can get some bruising and discomfort to the groin in the following days but this is minor. If you are concerned or the pain is significant please seek advise.
Allergic reactions to the dye
Very rare
Damage to blood vessels
Usually these problems can be dealt with at the time of the procedure, but in rare instances, repair is necessary.
Equipment failure
It is theoretically possible for a catheter, wire or device to break and leave a fragment inside the body. This is extremely rare.
Failure of technique
Occasionally it is not possible to perform the angioplasty or the procedure does not show the desired result. In very rare circumstances a failed procedure can actually make the blood flow worse. Catastrophic outcomes are very rare.
Kidney damage
The dye used is excreted via the kidneys, which in most patients is completely normal. However, especially in patients poor kidney function, the dye can lead to deterioration in kidney function. Angiograms are used in patients with kidney disease often and safely but additional precautions are required such as admission the night before the procedure, additional fluids and modifying your medications. Mr Ponosh will discuss these with you. Patients on dialysis do not need additional precautions and angiograms are completely safe.
Varicose veins are abnormally dilated and tortuous veins, often visible just beneath the skin. They can vary in size from quite small (2-3mm across) to very large (2-3cms across). Very small veins are called “thread veins” or “spider veins”. These veins are different to varicose veins because they are situated much closer or within the overlying skin. Although they may be unsightly, they are mainly a cosmetic issue and are often more challenging to treat. To learn more about Varicose veins click here.
What is Carotid Artery Disease?
Arteries throughout the body can become narrowed or even occluded (blocked) by a build up of cholesterol, fat and calcium known as an atherosclerotic plaque. This can occur to the carotid arteries that supply blood to your brain.
The brain is supplied by two large carotid arteries (right and left) which supply the front two thirds of your brain. These carotid arteries pass up each side of the neck and divide into internal and external carotid arteries. The internal carotid arteries supply oxygen-rich blood to your brain. The external carotid arteries supply oxygen-rich blood to your face, scalp, and neck. It is the of the narrowing internal carotid artery that is of concern as it supplies the brain itself, especially critical areas that are associated with vision, movement & sensation to your face, arms and legs as well as speech. These internal carotid arteries are often treated for severe narrowing.
The back third of the brain is supplied by two smaller arteries known as vertebral arteries. These form a complicated network of arteries with the internal carotid arteries known as the Circle of Willis inside the base of your skull. These vertebra arteries are only very rarely associated with significant symptoms are rarely need treatment.
The narrowing of the internal carotid arteries in many case be associated with no symptoms at all and can be called asymptomatic. However in some instances can cause :
What causes Carotid Artery Disease?
Lifestyle conditions are mostly to blame for the damage caused to the arteries.
Major factors that contribute to this damage include:
These conditions cause damage to the walls of arteries and as part of the healing process, atherosclerotic plaques form which cause narrowing of the arteries.
Suprisingly it is not the reduction of flow in the carotid artery that causes strokes or other symptoms in most instances but is in fact small microscopic particles that dislodge from the plaque that travels to the brain (emboli), blocks the microscopic blood supply causing an area of brain to die. This is what a strokes or mini-strokes is.
Studies have shown the severity of stenosis is a defacto measure of the risk of this emboli forming. Mild-moderate carotid disease is very common but largely not of a significant concern beyond closely watching it. It is the severe degrees of narrowing that pose the greatest risk.
What are the signs and symptoms of Carotid Artery Disease?
Carotid artery disease can go undetected (or be asymptomatic) until a problem develops like:
These symptoms may last up only minutes in a ministroke or may last for days-weeks or even permanently in a major stroke.
The effect of a stroke or mini-stroke may be minor but can be extremely severe or life-changing in many cases.
The brain is “cross-wired” so right carotid disease may cause left sided symptoms or visa versa. Carotid artery disease symptoms rarely effect both sides simultaneously.
Dizziness, or loss of consciousness are very rare symtoms of carotid disease.
What are the stages of Carotid Artery Disease?
Carotid Artery Disease often progresses very slowly over many years and is asymptomatic for a very long time. Once detected, CAD should be monitored on a regular basis by ultrasound and under the guidance of a Vascular Surgeon. This way, if it progresses to a point where the risk of stroke is greater than the risks associated with surgery, appropriate surgery can be performed in a timely fashion.
What should I do?
Carotid Artery Disease should not be left unassessed or unmonitored. It is best to be proactive in seeking regular checkups with your GP, especially if you are in the risk groups mentioned above. Sometimes, if you have other vascular problems, or even heart problems, your doctor will look specifically for Carotid Artery Disease during an examination, because if you have blockages in some arteries you are at increased risk of having blockages in others.
This will normally result in you being sent to have an ultrasound called a ‘Carotid Ultrasound’.
What if I don’t have my Carotid Artery Disease treated?
Some people with Carotid Artery Disease do not require intervention because it never progresses to a point where intervention is warranted.
However, everyone with significant Carotid Artery Disease should be under surveillance to monitor whether the disease is progressing or not, so that treatment can be provided when appropriate. In most cases this becomes a decision to when the risk of the narrowing causing a stroke exceeds the risks of treating it. Mr Ponosh will discuss this at length with you.
What treatment options are available?
Conservative management
If your tests suggest that the Carotid Artery Disease of low risk and the risks of treatment outweigh the benefits no treatment is required. You will need to simply monitor your symptoms and maintain regular visits with your GP and Mr Ponosh. This may change as time progresses but the vast majority of patients do not ever need treatment.
Surgery
Two main surgery methods for treating CAD are:
Carotid Endarterectomy
This is an open procedure that involves an admission into hospital and a 3-5 day stay in hospital following the procedure.
A Carotid Endarterectomy is performed under a general anaesthetic in most circumstances and usually takes approximately 2 hours.
During a Carotid Endarterectomy the surgeon makes a vertical or curved incision in the neck to expose the affected carotid artery. The aim of this procedure is to clear the buildup from inside the artery, so the surgeon will clamp the artery, make an incision and clean out the problematic plaque. The clean artery will then be closed with a hand sown ‘patch’ made from a synthetic material, and finally, the neck incision will be closed.
Carotid Stenting
Carotid Stenting is the insertion of a stent (metal scaffold) through a small incision in the groin. Special X-ray equipment and dye allow the surgeon to safely move the stent from your groin to your carotid artery in your neck.
The stent is designed to keep the artery open and to trap any plaque.
Stenting is minimally invasive, since the surgeon will only make small incisions in the groin area, rather than a larger neck incision.
The surgeon will consider very carefully whether you have disease morphology that is suitable for stenting. Stenting is usually reserved for patients who cannot undergo a Carotid Endarterectomy.
Stenting is performed under angiographic control, with a local anaesthetic and sedation and usually takes approximately 2 hours. The hospital stay and admission is similar to the Carotid Endarterectomy.
Risks of Carotid Treatment
General Risks include :
Specific Risks of Carotid Endarterectomy include :
Specific Risks of Carotid Endarterectomy include :
After treatment
Unfortunately, Carotid Artery Disease cannot be cured, but rather, treated with surgery, adjustment of lifestyle factors and the taking of blood thinning medications. Sometimes, even with diligent following of the doctor’s instructions and good management of lifestyle factors, the disease can recur, so it is important to have ongoing surveillance with your Mr Ponosh.
This will usually involve ultrasound of the carotid arteries, along with consultation. By doing this on a regular basis, you and your doctor can identify if your disease is recurring or progressing and offer adjustments to your treatment.
What is a Thoracic Aortic Aneurysm?
An artery is a blood vessel that carries oxygen-rich blood from your heart to all the parts of the body. An aneurysm is a condition where the walls of the artery dilate or “balloon” out. This ballooning may increase in size and finally burst leading to bleeding or the artery blocking off. A Thoracic Aortic Aneurysm (TAA) is an aneurysm in the aorta (major artery of the body arising from the heart) that is within your chest.
What is an Abdominal Aortic Aneurysm?
An artery is a blood vessel that carries oxygen-rich blood from your heart to all the parts of the body. An aneurysm is a condition where the walls of the artery dilate or “balloon” out. This ballooning may increase in size and finally burst leading to bleeding or the artery blocking off. A Abdominal Aortic Aneurysm (AAA) is an aneurysm in the aorta (major artery of the body arising from the heart) that is within your abdomen (belly).
They are the commonest form of aneurysm we see.
AAA’s are a progressive dilation of the aorta. Most aneurysms start and stay small. The normal male aorta measures 15-17mm and in some cases over time will progressively dilate. They are of concern when they approach 50mm or demonstrate more rapid patterns of growth in many instances.
Abdominal Aortic Aneurysm
What causes an aneurysm?
Most aneurysms are caused by degeneration or the process of aging on the wall of the artery. The strength of arteries is associated with collagen and elastin, the same structures that give our skin elasticity. As time goes on, these structures degenerate or breakdown causing weakness of the artery that can cause the ballooning of the artery. In some cases they can be caused by inflammation, leading to the weakening or breakdown of the artery walls. This inflammation can result from atherosclerosis, which is characterized by the deposition of plaque (calcium, cholesterol and minerals). The plaque deposits weaken the inner wall of the artery, making it more susceptible to swelling and rupture.
In some rare instances diseases like Marfan’s syndrome (genetic disorder that affects the tissues holding the body’s cells, tissues and organs together) can cause aneurysms as well as trauma or a variety of much rarer causes. Infection and trauma are other rare causes.
The cause of aneurysms are not well known, but there are numerous risk factors that include:
What are the symptoms of an AAA?
The majority of aneurysms may not show any symptoms. Most aneurysms are found by accident, usually during the investigation of other complaints. When symptoms do appear, they generally depend on the position of the aneurysm.
What do AAA’s do?
In most cases, small aneurysms are completely safe and should not worry you. They also have minimal or no symptoms. These stable or slowly growing aneurysms simply need a regular check up with a ultrasound or CT scan with your vascular surgeon to ensure they remain safe.
Treatment may never be needed but if it does require treatment these close surveillance allows safe and effective treatment at the right time avoiding the severe complications that aneurysms can occasionally pose.
As they grow often over a period of years, the walls may thin as the aneurysm balloons to a point that the aneurysm may leak or rupture. This in most cases is associated with aneurysms in excess of 50mm. This is a life-threatening complications and is associated with severe internal bleeding and clots. More easily manageable, or smaller aneurysms simply need lifestyle changes, a watchful eye and regular checkups with your vascular surgeon.
What happens if I think or have a AAA
Most aneurysms are found by accident during other tests. Your GP may then send you to see Mr Ponosh directly.
If you think you are at risk of having an aneurysm OR have a family history of aneurysm you should:
See your GP: Your GP will assess you and may organize an ultrasound scan. If evidence presents of an AAA, your GP will almost always send you onto a Vascular Surgeon, such as Mr Ponosh.
If you know you have an AAA which is under surveillance or observation by Mr Ponosh (ie; it is asymptomatic and smaller than the treatment cut-off size), you would normally have a non-invasive ultrasound at a specialised vascular ultrasound practice on a regular basis and be observed every 6-12 months by Mr Ponosh.
If you AAA reaches a size of approximately 50mm or demonstrates a period of rapid growth, Mr Ponosh may suggest consideration for treatment. A CT scan is usually arranged at this time for more accurate assessment of your aneurysm and its anatomy.
How are AAA’s repaired?
Mr Ponosh will keep a very close eye on your AAA. When it reaches an appropriate size it may be considered for repair. This not only depends on the size of the AAA but also on the location, anatomy, your age and your general health.
Ongoing observation
If you have very complicated aneurysmal anatomy, especially if the aneurysm is very close to other main arteries (kidney or bowel), due to the increased complexity of the repair options and the risk this imposes, Mr Ponosh may suggest maintaining close observation until the AAA reaches a larger size. At this point the risk of repair is more appropriate to the risk of the aneurysm. Also if you general health is poor, Mr Ponosh may also suggest ongoing observation rather than repair due to the risks to your life and lifestyle.
Endovascular Repair (EVAR)
If repair of your AAA is recommended in the majority of cases Mr Ponosh will recommend an endovascular or “keyhole repair”. In most cases this is a very straight forward and uncomplicated procedure. This has been proven to be a very effective and durable repair using special “stents” to seal the aneurysm. In this procedure usually conducted under a general or spinal anaesthetic, Mr Ponosh makes a very small incision (5mm) in the groin region and guides a catheter (thin tube) through the blood vessel. He then uses live X-ray images to guide a stent-graft to the site of the aneurysm. The graft re-lines the aorta, sealing the aneurysm and prevents it from rupturing. It takes in most cases approximately 60 minutes. You may be required to stay in hospital for 2-3 days until recovery. In time, the aneurysm may even shrink because of the stent-graft.
In some cases a more complicated EVAR known as a Fenestrated Endovascular Repair (FEVAR) is undertaken. This is usually cases where the aneurysm is close to other important arteries such as kidney or bowel. This requires a custom made, hand sown stent that seals above these important arteries. This custom made graft has small holes (fenestrations) which are carefully lined up with important arteries, through which additional stents are placed from the main graft to seal the aneurysm. This may take 3-4 hours in more complicated cases and is a riskier procedure.
Endovascular AAA Stent Repair
Open Surgical Repair
This is the traditional repair method for aneurysms. This type of repair is only undertaken in 5-10% cases. They are usually reserved for cases that are not suitable for EVAR or FEVAR, are urgent and can not wait for custom made grafts, or occasionally in young patients.
It is a more involved procedure undertaken through a long cut in your abdomen in which a new plastic tube is hand stitched in place by Mr Ponosh. It takes several hours to complete, has a hospital stay of 10-14 days and several week to recover from.
Open AAA Repair
General Risks of Aneurysm Repair
Mr Ponosh will spend a lot of time discussing aneurysm repair and the risks with you in detail and in a easy to understand, reassuring manner. The risks of aneurysm treatment can include:
While the risks of treatment are large, the risk of not treating the aneurysm can be worse. Mr Ponosh will be able to provide you with the information you need to make an informed choice and be reassured and fully informed.
What is a Peripheral Arterial Aneurysm?
An aneurysm is a condition where the walls of a blood vessel weaken. Over a period of time, the pressure of the blood flowing through the vessel causes it to expand and dilate at the point of weakness.
A peripheral arterial aneurysm (or ‘PAA’) is called thus because it occurs in the arteries other than the aorta, your body’s largest artery.
Peripheral arterial aneurysms most commonly develop in the popliteal artery, which is located behind your knee. Less common areas for a peripheral arterial aneurysm to occur in are:
What causes a Peripheral Arterial Aneurysm?
The cause of aneurysm is not known, but there are numerous risk factors that include:
If a peripheral arterial aneurysm is found in one leg, you are at greater risk of having one in the other leg. Peripheral arterial aneurysm also increases your risk of developing an aortic aneurysm.
What are the signs or symptoms?
Most people do not feel any symptoms with a peripheral arterial aneurysm, especially if it is small. Whilst aortic aneurysms have a risk of leaking or rupturing, peripheral aneurysms have a higher risk of blocking off or sending off small clots impairing your blood supply.
Sometimes there are no symptoms, however, if the aneurysm does become symptomatic, the signs can include:
How will a Peripheral Arterial Aneurysm affect my health?
The effects of a PAA on your health is dependant on its size and how quickly it grows.
As aneurysms get larger, the risks increase. Whilst rupture is rare, it is the possible impairment in blood supply that is of the concern.
Peripheral Arterial Aneurysms smaller than 2cm may only need lifestyle changes, a watchful eye and regular checkups with the doctor.
A Peripheral Arterial Aneurysm will never go away unless treated.
What treatment options are available?
Conservative management
For small, manageable or asymptomatic PAA’s, conservative management is an ideal first step. This involves observation, tests and actions from you and your medical professionals:
Not all aneurysms will require treatment and, for some patients, the risk of treatment is higher than the risk of the aneurysm. A watch and wait approach is best.
Surgery
Surgical treatment of aneurysms can be a large operation that carries risks. Once it is considered that surgical treatment of an aneurysm is less risky than leaving it untreated, surgery will be arranged.
Procedures include:
Endovascular Aneurysm Repair (EVAR) – C
EVAR is a minimally invasive surgery where a stent graft (a fabric covered wire frame in the shape of a tube) is inserted inside the artery via small entry incisions under twighlight sedation. The stent acts as a structural support and strengthens the arterial wall.
Planning for this type of repair is very precise and your surgeon will often seek advice on latest stent technologies from manufacturers and review all CT images in great detail.
EVAR is a technique that Mr Ponosh has a great deal of experience in. He will spend time with you to discuss each stage of the surgery in detail. Everyone is different and every aneurysm is different, so rest assured that your unique case details will be intricately planned for.
Open aneurysm repair – A & B
This treatment is often reserved for cases not suitable for endovascular treatment (EVAR). This is because it places the body under much greater stress than an endovascular approach. This is the ‘traditional’ treatment for aneurysms, involving an open surgery to replace the diseased blood vessel with an artificial blood vessel (graft).
In the conventional open operation, a large incision is made to reveal the aneurysm. The blood vessels above and below the aneurysm are clamped and the aneurysm itself is opened. Any blood clot in the aneurysm is removed and any bleeding blood vessels are controlled. The artificial graft is then stitched into place using permanent stitches.
Alternatively, a synthetic or natural bypass graft is attached to the artery to reroute the blood away from, or around the aneurysm.
Ulcers are unfortunately a not uncommon problem that Mr Ponosh sees. They also are a very serious problem. They are a challenge to treat, and a frustration and significant disability for patients
Ulcers are open wounds, commonly to legs, ankles, feet and toes that occur spontaneously or more frequently after minor trauma such as a new pair of ill-fitting shoes.
They can be superficial or can be deep wounds with areas of skin and tissue loss. They do not heal quickly or only deteriorate, persisting for weeks or more
Causes of Ulcers
There are many causes of ulcers that cause wounds to spontaneously occur or worsen a minor injury :
How ulcers can appear
Ulcers can most commonly present as an area of skin and tissue loss. These may be small or in some cases which have been left untreated may be quite large. They can occur at areas of trauma such as the shin, or heel/toes after wearing ill fitting shoes. They can spontaneously occur over the ankles and on/in between your toes.
They may be painful, however in some cases especially if you are diabetic may be completely unnoticed and pain free. They may become infected with red, hot and swollen skin around them. Most concurringly, if they progress underlying bone and tendons can be exposed which is a very serious problem.
Ulcers can often be ignored and underappreciated by medical practitioners, however they should never be and always should be seen and managed by an expert such as Mr Ponosh. Most small ulcers are relatively straight-forward to fix but if they are large or complicated, they can take months to heel and are more challenging.
All ulcers with a known cause, presumed cause or risk factor or persisting for more than 2-3 weeks should be referred to a specialist wound service such a Mr Ponosh provides.
Mr Ponosh has a vast experience in managing ulcers and it is an area or particular interest. Mr Ponosh has a long history as a Senior Consultant to the Sir Charles Gairdner Foot & Leg Ulcer Clinic.
What if I don’t have my Chronic Ulcers treated?
Ulcers in most people with underlying causes will never heal by themselves.
Left untreated, ulcers will often progress and place you at risk of severe infection or even blood poisoning (septicaemia). Chronic ulcers can cause you to feel chronic pain, feel chronically ill and tired and may get in the way of your quality of life.
Ulcers may stop you proceeding to other operations such as hip or knee replacements.
Most concerningly, as these ulcers progress and expose tendon or bone, these ulcers may put toes or even your foot at risk.
Seeing Mr Ponosh
Your GP may contact Mr Ponosh’s office directly, however in some cases they will provide you a referral to contact the office yourself. Mr Ponosh’s caring and helpful staff will walk you through the process of making an appointment with Mr Ponosh. His staff may also contact you directly. For further information please regarding referrals, please go to Make an Appointment.
When you see Mr Ponosh, he will undertake a full history and appropriate examination. In many instances (if required) he will order appropriate tests before he sees you to streamline your management and avoid unnecessary appointments. These tests are bulk-billed at all times if possible. These tests may include ultrasounds, CT scans or blood tests. In some cases, additional tests and appointments may be required.
Based upon Mr Ponosh’s expert specialized review, an appropriate treatment plan will be suggested and explained to you in an open, straight-forward, jargon-free manner with all options and questions addressed.
Treatment Options
They key to curing your ulcers is the diagnosis and treatment of underlying causes. Treating ulcers effectively also relies on a team approach which Mr Ponosh will supervise and co-ordinate. Mr Ponosh’s multidisciplinary ulcer team includes :
In most cases these treatments can be undertaken as a outpatient with Mr Ponosh managing you through his rooms but occasionally if more severe, Mr Ponosh may need to admit you to hospital for more appropriate treatment.
Treatment may include :
How long to heal my Ulcer?
Some ulcers will be relatively simple to treat over a few weeks, however other ulcers may take many weeks or months to heal even with aggressive treatment.
Patience, persistence and compliance is the key to healing these wounds.
In almost all cases we do heal the ulcer although there is the rare instance of unusual ulcers that do not heal. This is very rare.
Ulcers, especially in damaged skin such as venous ulcers do have a tendency to recur, however with Mr Ponosh’s advice, these is a very infrequent and rare outcome.
What is kidney failure?
The kidneys work as a filter to remove waste products that build up normally in the blood stream. These waste products are then passed from the kidneys to the bladder by two tubes (ureters) running from the kidneys to the bladder. The waste products are dissolved in water and stored in the bladder as urine. Kidney failure occurs when the kidneys are unable to remove waste products from the blood stream and they build up in the blood stream (uraemia).
Early on this may not be a problem, as the kidneys may continue to do some filtering work and are able to compensate for a mild degree of failure. The kidneys are able to compensate even when one of them is removed, but eventually they are unable to keep pace with the build up of waste products (chronic renal failure). If treatment is not started the patient with kidney failure will die. In these patients there is usually time to permit full discussion and planning of treatment as the kidney failure develops slowly.
Sometimes kidney failure can develop more suddenly (acute renal failure). In these circumstances there is little time to plan treatment, which must be started immediately. This may happen as an isolated problem or as part of a serious acute illness.
What treatment is available for kidney failure?
The treatment for kidney failure is dialysis. Dialysis is a way of removing the waste products from the blood stream when the kidneys cannot cope. It is like having an artificial kidney.
There are two main methods of dialysis: HAEMODIALYSIS or PERITONEAL DIALYSIS (CAPD).
Peritoneal dialysis involves placing a plastic tube into the abdomen and running special fluids in and out of the abdomen. The waste products dissolve in the fluid and are removed when the fluid is removed from the abdomen.
Haemodialysis is a method that requires access to the blood stream. In other words a connection between the blood stream and the artificial kidney (dialysis machine) is needed to enable this method to work. There are many ways of making this connection to the blood stream:
Central Venous Access
This is where a hollow tube (central line or Hickman) usually with 2 ports is placed into a main vein. They are usually placed in a main vein in the neck, but are also sometimes placed in veins in the leg. When dialysis is required the tube is connected to the dialysis machine. These tubes are in common use and are especially important for a patient who requires dialysis in an emergency. Because there is a permanent connection from the blood stream to the outside there is a risk of blood stream infections developing (septicaemia).
Creation of a fistula
A direct connection between an artery and a vein is created at a surgical operation. This new connection is called a fistula. The vein enlarges over a period of weeks because arterial blood at a higher pressure is now flowing through the vein. When dialysis is required needles are inserted into the vein and connected to a dialysis machine. Planning for the creation of a fistula should take place before dialysis is required. Patients who have a fistula in place ready for dialysis, when required, have a better chance of surviving their renal failure than patients who have no fistula.
How do fistula work?
All fistula share a common theme. The theme is the creation of a connection between a high flow, high pressure artery and a low flow, low pressure vein. This diverts blood from the artery into the vein increasing the blood flow and the pressure in the vein.
Over time the veins expand and the vein walls become much thicker (vein maturation). The time taken for the vein to mature can vary depending on which type of fistula is created. Wrist (radiocephalic fistulas) take approximately 4-6 weeks. Brachio-basilic (upper arm) fistulae take longer, approximately 8 weeks, to mature.
When the vein matures it is much easier to insert needles into the veins, as the veins are larger. The veins can also withstand repeated needle punctures over many years.
What are the different types of fistula?
There are many different types of fistula that have been devised to help patients to dialyse. Fistulae are performed in 2 major parts of the body – in the arms or in the legs. Arteriovenous fistulae created in the arm are by far the commonest type of fistula used for dialysis.
Any fistula, whether it be in the arm or the leg, can be formed in 2 ways. Firstly, the surgeon may use the native arteries and veins found in different parts of the body and, using various surgical techniques, join a vein to an artery. These are called autogenous fistulae and are always the first choice because they are likely to work for longer and need less maintenance to keep them going.
The alternative technique uses an artificial material (usually gortex (PTFE)) as a bridge between an artery and a vein. This type of operation is commonly performed at the elbow with the loop of artificial material placed in the forearm. In patients who have artificial material implanted, dialysis needles can be placed directly through the material to enable dialysis to take place. This can be a very successful technique, but in general these fistulae do not last as long as autogenous fistulae and need more maintenance procedures to keep them functioning.
Artificial materials should only be used when there is no obvious autogenous fistula that can be created or the chances of success are clearly worse than trying to use an artificial graft.
Radiocephalic wrist fistula
This is the most common fistula and is created at the wrist (primary radiocephalic fistula). A small vein (cephalic vein) and a small artery (radial artery) are joined together using very fine stitches (see below). This fistula was first devised in the mid 1960s and is still the most common fistula in use for haemodialysis.
Brachio-cephalic fistula
A brachio-cephalic fistula is formed at the front of the elbow by connecting the cephalic vein and the brachial artery at the elbow. The cephalic vein is found towards the outside of the upper arm and as it enlarges this vein can be used for dialysis.
Brachio-basilic fistula
A brachio-basilic fistula is formed at the elbow by connecting the basilic vein and the brachial artery at the elbow. The basilic vein is found on the inside of the upper arm but it is also quite deeply placed and so it needs to be transposed (moved) to a more superficial position. This involves extra incisions along the inside of the upper arm and the graft is then tunnelled in the subcutaneous tissues to enable easier access. Once a brachio-basilic fistula has been formed it is more difficult to form a brachio-cephalic fistula and so surgeons will usually attempt to create a brachio-cephalic fistula first if possible. Fortunately, if the brachio-cephalic fistula fails it is still possible to create a brachio-basilic fistula.
PTFE loops
Sometimes it is not possible to create fistulae using autogenous or native vein. In these cases an artificial plastic tube is attached to the brachial artery at the elbow and tunnelled as a U-shaped loop in the forearm or upper arm. It is then joined to a vein at the elbow and the tube itself can be used for dialysis.
PTFE may also be placed in the upper arm as a graft between the brachial artery and the axillary vein in the armpit.
Leg loops
If it is not possible to create a fistula in either arm then it may be possible to form either a vein loop or a PTFE loop in the thigh.
There are many other types of fistulae available to surgeons but they are required much less frequently than those listed above. The more unusual variations although not routinely required can be very useful in patients who have already had multiple operations to provide vascular access.
Which type of fistula is the best?
It has become clear that the best type of fistula to have created should use the native veins and arteries. Although artificial grafts can be used successfully they are usually not as useful for as long and require far more procedures, such as angioplasty, to keep them patent and useful for dialysis.
It is best to create a fistula as close to the hand as possible so that a long length of vein on the forearm and arm is available for dialysis. It is usually preferable to use the non-dominant hand (use the left wrist if the patient is right handed).
It is sometimes suggested that elderly patients are not as suitable for primary fistulae because their blood vessels may be more damaged and patency rates are not as good. This is not true. Elderly patients can benefit just as much as younger patients from primary fistulae. In patients with diabetes, wrist fistulae are much more likely to fail early but are still worth considering as a first option.
How will I be assessed before surgery?
History
The surgeon will need information about previous vein punctures (such as from taking blood or IV drips), central lines (tubes placed in large veins in the neck) and arterial lines (tubes placed usually in the radial artery at the wrist). General health information and medication will be important especially if the patient is taking warfarin which can cause bleeding.
Examination
The arms of the patient should be examined with and without a tourniquet looking for veins that may be suitable for fistulae. Scars from previous central lines, intravenous lines and arterial lines are also important. The arterial pulses in the arms should be checked.
Investigations
Sometimes a history and examination will be enough for the surgeon to decide on which operation is required. This is often the case when patients are undergoing fistula formation for the first time. There is an increasing use of imaging to help in planning the optimum surgery. Ultrasound is commonly used in the planning of your fistula.
How are fistula operations performed?
All of the operations to create a fistula require some sort of anaesthetic. Commonly, a local anaesthetic and sedation is used for most fistulae. This requires the injection of an anaesthetic under the skin which then numbs or freezes the area where the operation will be performed.
Other types of fistulae, especially prosthetic ones require a regional or general anaesthesia.
The choice of anaesthetic may be made after discussion between the surgeon, anaesthetist and patient and will also depend on which type of operation is being performed. Most operations will not take longer than 90 minutes.
How will I know if my fistula is working?
After the artery and vein have been joined together there will be a much faster blood flow in the vein. Because the join is an artificial connection, the flow is not as smooth as in normal blood vessels. Turbulence is created in the blood, much as it occurs in river water passing over rocks and boulders. This turbulence can be felt through the skin of the arm over the vein as a buzzing sensation (medically termed “a thrill”). This turbulence also creates a noise (bruit) that can be heard with a stethoscope.
If a thrill or buzz is present, your fistula is working. If it is not present your fistula may have stopped and medical help should be sought immediately.
How long will a fistula last?
How long a fistula lasts depends upon what type of operation is performed and the condition of the artery and vein before surgery. One year after surgery to create a fistula at the wrist (radiocephalic fistula) approximately 70-80% of patients will have a functioning fistula that they can use for dialysis.
Can I prolong the life of my fistula?
There are no fool proof ways of ensuring that your fistula continues to work well. Varying the needle insertion sites for dialysis may be helpful. Avoidance of blood pressure tests and blood tests from the fistula is also important.
It is important not to smoke. Loose clothing on the arms will prevent constriction of the veins. Avoid working with the arm up (eg painting a ceiling) as this can lead to compression of major veins around the shoulder and lead to thrombosis (blockage of the vein by blood clot).
If you notice any changes in the fistula they should be reported to your doctor. Changes which may be important are the buzz becoming fainter, the buzz disappearing and the fistula becoming softer. Problems with flows on dialysis or increased return pressures are also important but there appears to be no benefit for routinely monitoring flow as a screening tool for potential graft/fistula flows.
What are the possible complications from fistulae?
The fistula may block
Although most patients will leave the operating theatre with a functioning fistula and a palpable “buzz”, the main problem they are likely to run into later is that the fistula will block. The easy way to tell if a fistula has blocked is to feel the fistula. If the buzz or thrill has disappeared then it has probably blocked. If you think this has happened it is important to see a doctor immediately. Sometimes further surgery can save the fistula and keep it running, but it is often better to construct a new fistula.
Failure to mature
Sometimes the fistula may continue to work, but the vein may not enlarge sufficiently to permit its use for dialysis (failure to mature). It is not always clear why this occurs, but it usually means a new fistula will have to be created.
Vascular steal
Because blood from the artery is being diverted into a vein before it reaches the hand some patients can develop problems from shortage of blood to the hand (steal syndrome). This does not occur in most patients, but can be a serious problem if it does arise. It is very uncommon in patients who have fistulae at the wrist. It is more likely to arise when fistulae are created in bigger blood vessels aound the elbow, when it may occur in up to 10% of patients but in the majority of patients resolves without issue.
Symptoms of steal can include a cold hand, pain, discolouration and ulceration. Symptoms are typically worse on dialysis. Steal may be more likely to develop if the patients has peripheral vascular disease and/or diabetes. Before treating the steal it is important to fully investigate the cause with a fistulogram and/or an ultrasound. On some occasions an arterial narrowing proximal to the fistula can be responsible and it often easily treated with angioplasty.
If steal syndrome develops the fistula may have to be tied off to restore blood flow to the hand. This will solve the steal but the fistula will then be lost. Sometimes other procedures are available to improve blood flow and at the same time to preserve the fistula. These procedures include banding, interposition grafting and the DRIL (distal revascularisation and interval ligation) procedure. Interposition grafting with a tapered synthetic graft can be effective and has the advantages that normal arteries are left intact. It is essentially a more controlled form of banding.
Vein narrowing
In some patients narrow portions (stenosis) can develop in the vein. These may cause reduced flow in the fistula or high return pressures when the patient is on dialysis. The fistula thrill may reduce and the fistula may become noticeably softer. When this happens further investigations are required such as ultrasound scans or a fistulogram. A fistulogram involves placing a needle into the vein and injecting a dye to obtain an outline of the fistula when an X-ray is taken. Narrow sections of a fistula can either be treated by angioplasty, stenting or surgery to open up the narrowing.
Treating a venous outflow narrowing appears to be best performed with a stent-graft rather than just simple angioplasty. Longer term outcomes will be important to monitor.
Other complications
Small and even large aneurysms can develop in the veins. These sometimes require treatment but are often left alone unless they become very large.
Synthetic grafts can develop infection from multiple punctures and this can be a serious problem which requires removal of the graft and loss of the fistula.
Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body. Doctors call this lining the peritoneum. It is undertaken through a soft tube, called a catheter, in your belly a few weeks before you start treatment. The tube is left exposed allowing you to commence dialysis.
The choice of dialysis is usually made by you and your kidney specialist. Mr Ponosh is directed by your kidney specialist. In some cases a fistula and a peritoneal dialysis catheter may be requested. Peritoneal dialysis has the advantage of allowing you to lead a more active lifestyle as the process can be conducted at home, although it does rely more on you to undertake the process
You will have extensive education and follow-up support by the dialysis teams co-ordinated by your kidney specialist so do not worry or be s.cared about taking control of your own dialysis
When you start peritoneal dialysis, dialysis solution—water with salt and other additives—flows from a bag through the catheter into your belly. When the bag is empty, you can disconnect your catheter from the bag and cap it so you can move around and do your normal activities. While the dialysis solution is inside your belly, it soaks up wastes and extra fluid from your body. After a few hours, you drain the used dialysis solution into a drain bag. You can then dispose of the used dialysis solution, which is now full of wastes and extra fluid, in a toilet or down the drain of a sink or bathtub. Then you start over with a fresh bag of dialysis solution.
The process of first draining the used dialysis solution and then replacing it with fresh solution is called an exchange. Most people do four to six exchanges every day, or during the night using a machine that moves the fluid in and out. The process goes on continuously, so you always have dialysis solution in your belly soaking up wastes and extra fluid from your body.
Peritoneal dialysis tubes are inserted by Mr Ponosh. They are usually undertaken under a brief general anaesthetic through a small incision near your belly button. They require an overnight stay and you will return to normal activities over a few days.
The risks of this procedure include :
What is Renal or Mesenteric Disease?
Renal (Kidney) and Mesenteric (bowel) arterial disease is a condition caused due to hardening and narrowing of the arteries to the kidneys or bowel. Normally, your arteries are smooth and unobstructed on the inside but a collection of fats, cholesterol and calcium can build up forming a ‘plaque’ builds up in the artery walls. This process is called as atherosclerosis, or hardening of the arteries. Formation of these plaques in the renal and mesenteric arteries will restrict the blood flow (stenosis) in the arteries.
Renal Arterial Disease
The kidneys perform functions such as removal of body waste in the form of urine, and regulation of the blood pressure by secreting a hormone, renin. If the kidney arteries are narrowed or have a clot, the kidneys will not function properly causing your blood pressure to rise which will further lead to kidney failure. These narrowing’s can cause deterioration in your renal function over time that may not be recoverable.
Renal artery stenosis may not have any symptoms. The disease develops slowly. The first sign of renal artery stenosis if you have high blood pressure is worsening of the high blood pressure or uncontrolled hypertension even with use of antihypertensive medications. Other signs include decreased kidney functions, congestive heart failure, or a small shrunken kidney. Treatment is normally reserved for extremely poorly controlled blood pressure or if there is evidence that the kidney itself is at risk.
Mesenteric Arterial Disease
The bowel, and other organs such as your liver and spleen are provided blood via three arteries that arise off your aorta, the biggest artery in your body. These three arteries are :
These three arteries form a network between each other and thus all contribute collectively. In most cases severe disease needs to occur in 2 or the 3 arteries to cause symptoms.
Mesenteric arterial disease is not uncommon but is not often treated. In most cases the narrowed arteries cause no symptoms and can be left alone. In some cases it can cause post-eating pain (known as post-prandial pain or mesenteric angina). This is severe pain that comes on after meals that lasts several hours. It is often associated with avoiding meals, loss of weight and in some cases malnutrition. It is caused by the narrowed arteries stopping enough blood getting to the bowel when needed for digestion. This is a serious and life threatening condition that needs to be treated as in some rare cases it can be so severe that it can cause sections of the bowel to die which is a catastrophic and life threatening emergency. This is a condition however that develops slowly over time. In some rare cases it can be associated with a sudden or acute event but this is associated with clot landing in these arteries associated with an irregular heart beat like atrial fibrillation or AF.
What Investigations are done to look for these conditions?
Blood tests and kidney function tests are done to evaluate the kidney functions. Other diagnostic tests such as Duplex ultrasound scan, CT scan, and angiography are done to detect the exact location of the blockage.
In some cases a review by a kidney specialist may be required.
What treatments are available for Renal & Mesenteric Disease?
The two procedures used to treat the narrowing of renal or mesenteric arteries are balloon angioplasty and stenting which are minimally invasive keyhole solutions.
Balloon angioplasty – In this technique, your surgeon inserts a catheter through a small needle which passes through the blood vessels into the renal or bowel arteries. The catheter carries a small balloon that inflates and deflates. When this is passed into the blocked artery, the balloon is inflated which will push the plaque against the artery wall helping the artery allow more space to increase the blood flow
Stenting – It is performed during an angioplasty procedure. Stent is an artificial device, a mesh-like tube which is made up of stainless-steel that has the ability to expand inside the blocked artery. Stents are mounted on narrow tube (catheter) which has a deflated balloon towards the end. This stent is inserted into the blocked artery and the balloon is inflated which allows the stent to expand inside the artery. Later the balloon is deflated and removed
Please see our information sheet above on Angiograms for further information.
Surgery – Rare and not often used due to the effectiveness of key-hole solutions.
Pelvic venous congestion syndrome (PVCS) is a cause of chronic pelvic pain and is a secondary cause of leg varicose veins in approximately 13-40% of women. Pelvic congestion syndrome is condition often caused by the dilatation of the ovarian or other pelvic veins, like varicose veins but in the pelvis. To leave more about Pelvic venous congestion syndrome (PVCS) click here.
