Ivan Dimitrov was referred to UMBAL Burgas from Kazanlak, judging that his case is too complicated. The diagnosis is chronic arterial insufficiency of the limbs. Both legs are almost without blood supply – blue, swollen, painful and cold, with a serious risk of amputation. Ivan is a passionate smoker – the main reason for his serious condition, as well as his long experience as a professional driver.
In order to restore the blood supply, the vascular surgeons at UMBAL Burgas perform a femoro-popliteal bypass on the left. The left leg is already warm and painless, but the man begins to complain of pain in the abdomen, which continues to the back.
The scanner detects an aneurysm (enlargement) of the abdominal aorta. It is the largest artery through which blood reaches many organs. Its diameter is more than 6 cm, in normal 3. The examination also reveals a thrombus attached to the wall. The condition is urgent because it threatens the supply of oxygen to the organs. There are two options: severe open surgery with incisions through the abdomen or minimally invasive access through the femoral arteries. The second is many times more gentle for the patient, but more difficult to perform due to the fact that the aneurysm also covers the renal arteries.
The procedure involves the implantation of a special stent-graft, which, however, needs to be modeled further due to the involvement of the renal arteries by the aneurysm. After detailed preliminary 3D sizing, the operating team makes precise openings in the places through which the renal arteries must pass, so that the blood supply to both kidneys can be preserved through them. “The anatomical location of the kidneys is individual in each patient. Therefore, accuracy is extremely important. Otherwise, we would have to perform open surgery on the patient and reimplant the renal arteries manually, which is an extremely severe trauma for the patient and can lead to severe and irreversible consequences – renal insufficiency. But instead of the patient, we preferred to model the prosthesis itself,” explained Prof. Dr. Valentin Vassilev. The option of waiting for the prosthesis to be modeled in the factory is eliminated because the operation is urgent and the patient cannot wait for days.
But there is another challenge – the aneurysm’s parietal thrombus is so large that it allows only one part of the stent to pass through, and so there is a risk that one limb will be left without a blood supply. The solution is to redirect the blood from one leg to the other with the so-called crossover bypass. Two days later, an additional femoro-popliteal bypass was performed on the right leg, fully restoring blood supply to both legs.
In reality, a new blood supply system is being built in this patient. “Imagine that you have a central water supply system in an apartment block. Somewhere on the floors there are blockages and there is no way for the water to reach some of the apartments. Bypasses are made and the water goes through new pipes. This is the simplest way to explain what we do, but in the human body, and without blood at that,” explains Prof. Vassilev. Done sounds like a miracle, especially against the backdrop of difficult and traumatic operations in previous decades, but it is entirely possible with today’s medical advances and the skills of surgeons. The operation was performed entirely by the Health Insurance Fund, without any costs for the patient.
Today, Ivan Dimitrov is recovering in the Vascular Surgery Clinic and shares that he feels very well and is grateful to the entire team of the Clinic. He is doing exercises, gradually moving his legs and can now walk. But he hesitates whether to continue smoking or to quit smoking for good.
His case will be presented in a scientific publication, as it is one of the few in the country. Annually, no more than 10 similar operations are performed in Bulgaria.