Surgery Race Report

I’ve complained enough about my bad left leg for the last few years now, that it’s become a central assumption around which this blog is based.

Well that should be fixed now.

I just got home from the hospital a few days ago where I had my left iliac artery repaired. Now I will be working on the slow and focused process of rehabilitating and rebuilding from zero over the next couple months. Here’s the ‘race report’ for my diagnosis and surgery.

Summary

• Surgical repair of a major artery in my abdomen last Friday was successful, but more extensive than expected.
• My fitness level made it look like I was recovering normally, while behind the scenes a pretty urgent situation was developing due to unforeseen consequences of the first surgery.
• So I blood doped 4 or 5 times and had a second surgery Tuesday morning to fix the problem.
• After a week in hospital I went home Friday, and I’m now progressing quickly!

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Diagnosis

My Left leg has always been weaker than my Right on a dual-sided power meter. As bad as 40/60% at higher intensities. Over the past 4 years or so I began to have symptoms of pain, cramping, burning at high intensity. Those symptoms actually worsened as I got more fit and pushed higher power.

I tried working on biomechanics, hip/pelvis/core stability, pedaling mechanics, crank length, Q-angle… everything I could think of that might explain the imbalance. But nothing helped. Finally I read about professional athletes who had similar symptoms and were diagnosed with some kind of vascular condition. I pursued the vascular option with my sports med Doc and it immediately ticked a lot of boxes.

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Iliac Artery Endofibrosis

This is a condition where the mechanical forces of cycling cause trauma to the main blood vessel that feeds your leg, causing it to thicken and harden. This results in less ability for the artery to expand and accommodate increased blood flow under periods of high exertion. ie. the artery remains too narrow, limiting your ability to deliver oxygen to your working muscles. Symptoms result from your muscle cells being starved of oxygen and essentially dying of hypoxia.

It’s kind of like how your legs feel right after a maximal 1min effort. But if you think of that sensation as within the visual light spectrum, the symptoms I had of claudication and ischemia also reached into the infrared and ultraviolet spectra. It’s like that typical burning sensation, but stronger, sharper, and duller all at the same time. And once it starts it doesn’t go away….

Note: This isn’t a typical risk for most cyclists.

The risk factors are not completely understood but there seems to be an anatomical or congenital predisposition. eg. a previous injury to tissues in the area, or a naturally occurring abnormality in the artery itself.

After a year consulting and tests with my vascular surgeon, we decided to go ahead with surgery on October 25, 2019. He asked me when I wanted to do it and I told him “as soon as it starts raining for the winter”.

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Surgery

Without getting too graphic, surgery involves exposing the artery through the lower abdomen and making an incision along the affected length. Then a donor vein from my leg is used to patch that length of artery to expand it’s diameter. This process is called endarterectomy and vein patch angioplasty. There are no stents or other implants introduced, since the structures are already vulnerable to mechanical forces and adding hardware would be inappropriate.

So that’s what I had done last Friday. I walked to the hospital on a dreary, rainy morning (I timed it right, at least!) and went through the surgical prep process. I was in the OR for ~4 hours and was told to expect to be under observation in hospital for ~4 days.

I have a diagonal scar across my left abdomen under the belly button, and a smaller vertical scar down the inside of my left leg. The surgeon reported patching a 20cm length, from the origin of the common iliac artery, along the external iliac artery all the way to the femoral artery, and taking 3 lengths of my saphenous vein as the donor patches. This was the longest patch by far this surgeon has ever done. Review articles I’ve read note that fibrotic segments typically measure 2-6cm and as much as 90% of cases only involve the external iliac artery (Peach, 2012; Bender et al, 2004).

We thought the artery was kinked at the arrow, but once the surgeon was in there he found more extensive endofibrosis through the common & external iliac artery above and below the arrow

The next couple days I was pretty dozy from drugs, but by Sunday I was more coherent and eventually able to sit, stand, and even shuffle to the bathroom. However my HR was strangely tachycardic at 120 bpm even laying in bed, and would jump to 150 bpm as soon as I started to move around. Above my Aerobic Threshold! I also had extremely shallow breathing, speaking at a whisper and only able to lift the 600 cc/sec ball in the Tri-ball inspiratory device (for anyone who knows what that means… it’s really, really bad!)

Despite all that, I thought I actually felt good. After some friends visited me on Monday evening, I had a blood test to look at hemoglobin – how much oxygen carrying capacity I had in my blood. That test reported 52. The nurses stuck a line in my other arm and re-tested. This time it was 46….

Things started to move faster around me. Let me explain:

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Hemoglobin

Hemoglobin (Hgb) normal range for a healthy male is 135-175 g/L. I had actually tested myself the week prior at 155 g/L. So 46 g/L is very, very low. I’ve read that a blood transfusion should be administered to “critically ill patients” when Hgb falls to 70. And I have been told that seeing 46 in an emergency room would send people flying into action and yelling “stat!”

The attending Doc indeed ordered two blood bags into me “stat!” After those were literally squeezed into me I went for an urgent CT scan (like, pushed to the front of the line of some much sicker looking patients!) investigating whether I had an active bleed. Luckily there was no evidence of any continuing loss of blood. So I was stable.

I was given an additional two units of blood through the night, taking my blood doping total to 4x blood bags 😀 and bringing my Hgb up to ~85. I was “woken up” (not that I really slept) at 6am Tuesday morning by the surgeon who told me he wanted to re-operate to evacuate a hematoma (a big internal blood clot, like a big bruise) sitting in my abdomen from the original surgery, which he suspected was causing the issues.

What had happened was basically the extensiveness of the first surgery had caused a large slow leak of blood into my abdomen. This hematoma was pushing up on my diaphragm and dropping all my stats. My high fitness level had allowed my body to compensate for this severely restricted hemoglobin and respiratory capacity. That’s why my resting HR was up at 120-150 bpm. And this was why it wasn’t caught earlier. Let’s just say the average hospital patient would would have been much more obvious that something urgent was going on.

This opens the question as to whether the post-surgical monitoring process could be improved for an athletic patient, since this is the patient population that receives this surgery. Since I already have an ongoing case study on myself, this might be another opportunity to improve best practice for future athletes.

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Rapid Progress

I went in for another, much quicker operation Tuesday morning at 9am. By 11am I was in the recovery room (where I might have had a 5th blood-dope bag, I can’t quite remember). But I was already feeling better. My HR was back down to the 60’s, I could breathe more deeply, and I felt noticeably less pressure in abdomen.

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I hadn’t been allowed to eat or drink anything, or to get out of bed for 36hrs. But I had a bunch of friends come by to keep me company. I can’t express how much I appreciate your visits, even those moments you tried to sabotage my abdominal stitches by making me laugh!

By Wednesday midday I was starving in a way that told me I was feeling better. My nurse got me up on the edge of the bed and I didn’t pass out like after the first surgery. I walked to the bathroom with just a cane and took a luxurious sink-sponge bath under my own power (only down to my knees, as far as I could reach without bending over!). Another friend brought a big jar of homemade chicken & pea soup for lunch and that was just about the best meal I could have hoped for. I felt like a million bucks.

Working on my old-man hunched-over shuffle, but I’m on my feet!

Progress from there was rapid. On Thursday I felt like I still needed to be in the hospital to get better. By Friday morning I felt like I needed to get out of the hospital ASAP to keep improving. I dressed myself back in my normal clothes as a power move when the Docs came by that morning, and sure enough I was discharged Friday afternoon.

Saturday I was able to putter around the house, Sunday I just about got myself fully supine laying on the ground, and I walked a loop outside around my building. Monday I re-found my glutes and core with some gentle exercises and walked down the block to the grocery store. Tomorrow my goal is to walk to a coffee shop further down the street. My hemoglobin is still considerably low, probably around 100, meaning I get fatigued very easily. But by next week I want to be hiking around Stanley Park. And one month after surgery I will be back on the bike, on November 25. You can set your watch to that.

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Sincere thanks for the support

Huge thanks to all the Nurses, Doctors, and staff who assisted me in the hospital. You are selfless and ever patient. And huge thanks to everyone who extended moral support to me over the week. Even the briefest of messages let me know you cared and were thinking about me. This past week has really helped me realize how important it is just to know that I have family, friends, and teammates who have my back. Something I’m not taking for granted right now.

Jem