Chris Holdaway has performed hysterectomies under canvas, and repaired major aortic aneurysms in pristine operating theatres. Medical backgrounds don’t come much more varied than that of Braemar Hospital’s senior vascular surgeon, who is also a lieutenant-colonel in the Royal NZ Army Medical Corps.
This is a man who has operated in third world countries under the most makeshift of conditions. As a member of the Territorials, with a distinguished service that saw him become commanding officer of the army’s medical facility in Auckland, he served as a member of peacekeeping forces in Bosnia and twice in Timor.
Away from war zones, he has also taken army operating teams to Pacific Islands including the Solomons and Fiji, and even operated on the likes of hernias and varicose veins in tented theatres in parts of New Zealand including East Cape and the Hokianga.
These days he is no longer active as a frontline member, but that doesn’t mean he’s taking things easy. Thirty-plus years of army life gave him a solid grounding in leadership which he has put to good use. Obviously someone who relishes responsibility, he is a director and trustee of Braemar and head of surgery at Waikato Hospital.
As one of two vascular surgeons at Braemar he performs the full range of operations on arteries and veins, a job that he describes in colourful terms. “As a vascular surgeon I’m like a plumber. I’m dealing with people’s arteries and veins all the time so my milieu, if you like, is blood.”
At the major end of the spectrum are repairs of abdominal aortic aneurisms. This sometimes involves the relatively uninvasive EVAR technique, repairing remotely using small cuts in the groin, and sometimes the traditional open method, akin to heart surgery.
“The new angio suites we have at Braemar are fantastic; they’re state of the art, they’re world class, and they make invasive aortic surgery very, very do-able,” he says.
He also operates on carotid arteries, which carry blood to the brain. “Unfortunately a lot of people don’t realise they have carotid disease until they’ve had a stroke – hopefully a minor one. So it’s a bit like earthquakes. Some people get a major earthquake right out of the blue; other people get little quakes before. If you’re lucky enough to get the little quake before, then we can get on to it and either put a stent in it or do an open operation.
“One of the great things about Braemar in terms of this high tech surgery is that it has a fantastic special care unit, and that really is a requirement for doing both the aortic surgery and the carotid surgery.”
Then there are major reconstructions of the arteries in the legs and also operations on varicose veins, where his focus is on the likes of ulcers, particularly in people with longstanding varicose veins who require open surgery.
A growing area of work is inserting Portacaths and catheters in patients on chemotherapy. These sit permanently in a spot just below the collarbone, making the process far easier and less stressful for patients.
All this and Chris Holdaway continues to advise the army on surgical issues. When he does so, he can also reflect with satisfaction on his army career, including those stints of active duty. He and his teams did a lot of good civilian work, he says. In Timor, in particular, there was a lot of humanitarian operating. In fact, the commonest operation he performed there was caesarean section – not something in which he would normally be involved.
The experience was “fantastically satisfying”.
“You see these people in the third world who are just totally patient, suffering far more than anyone should ever have to, but doing it without complaining. You come back and suddenly everything’s in far more perspective.”
5 Commonly Asked Questions:
1) What are leg ulcers?
Leg ulcers are non-healing “sores”, usually situated over the shin, ankle, top of the foot or toes. They are often painful, and affect people’s independence greatly. The majority of ulcers have an underlying vascular cause, with chronic venous insufficiency (varicose veins) or arterial blockage (peripheral vascular disease) being the most common. Venous ulcers can readily be healed by graduated compression (bandages or stockings) in greater than 70% of cases over an 8-week period. Venous surgery is also very effective.
Arterial ulcers are also readily healed by non-operative intervention, such as angioplasty or stenting. Where this is not possible, there are a variety of arterial operative options available. Ulcers are curable.
2) How do I prevent stroke?
Strokes are “acute brain attacks” due to areas of brain death. The majority of strokes are due to embolic material arising most commonly from the carotid arteries and, to a lesser extent, the heart or aorta, breaking off and passing up into the small arteries in the brain, thus blocking them. Less commonly, strokes can be due to brain bleeding (haemorrhagic) related to uncontrolled blood pressure or weak brain blood vessels.
Most embolic strokes are due to carotid disease and these can be treated, and even prevented, with early treatment. Treatment options include carotid endarterectomy operation (with a 2-3% peri-operative stroke rate), carotid stenting (an 8-10% peri-interventional stroke rate) or best medical management (which has a 12-20% risk of stroke per annum). Carotid artery disease can easily be investigated and diagnosed with carotid duplex ultrasound scan.
3) What is peripheral vascular disease (PVD)?
Periperal vascular disease is arterial disease of the limbs, which is found more commonly in the legs. The vast majority of PVD is due to atheroma (hardening of the arteries) blocking or severely narrowing the major inflow arteries (iliac, femoral or popliteal). There are multiple other causes of peripheral vascular disease, including diabetic small vessel occlusion.
Peripheral vascular disease causes a spectrum of symptoms. Claudication is pain in the calf muscles on walking, which can occasionally affect thigh muscles also. More severe is pain at rest, usually affecting sleep at night. Most severe is ischaemia (lack of blood) leading to tissue loss (ulcer, digital gangrene or total foot gangrene).
Peripheral vascular disease can easily be investigated by duplex scan or MR scan.
Treatment options include minimally-invasive interventional options (angioplasty or stent) and operative alternatives (bypass or endarterectomy).
PVD, if untreated and without risk factor modification, can lead to Joss of limb or leg.
4) Can my aortic aneurysm be treated?
The aorta is the major arterial outflow of the heart. For reasons no~ completely understood, in some people the aorta starts to expand (dilate); in men usually in their 60s or 705 and, in women a decade later. If the aortic aneurysm measures 3.5S.Ocm in diameter, we are happy to treat this conservatively with six-monthly ultrasound surveillance scan. Once aneurysms reach 5.0cm in diameter, or more, the risk of rupture increases rapidly. A ruptured aneurysm will kill you unless treated emergently.
Elective treatment is available. Options include minimally-invasive EVAR procedure, performed through femoral artery cutdowns in both groins, and open aortic aneurysm repair. The EVAR procedure is only technically possible in 60-70% of people with abdominal aortic aneurysms, but is associated with significantly reduced operative risk and recovery time. It is, however, associated with a greater than 30% 5-year risk of further minor surgical or interventional procedures being required.
Open aortic aneurysm surgery is a very major open operation, with a 5-8% risk of major complications or death. Once completed, there is minimal risk of further procedures (less than 10%) and it is, in effect, a true cure.
5) Should I have my varicose veins treated?
Varicose veins develop because of “leaky valves” in the groin or behind the knee. Minor varicose veins cause minor symptoms, such as aching and swelling. Moderate to severe varicose veins will, over time, cause more serious complications, such as discolouration of the medial shin, skin damage, risk of ulceration, venous bleeding. or superficial vein clotting (thrombophlebitis). For this reason moderate to severe varicose veins are best treated.
Treatment options include compression (stockings), sclerotherapy, EVL T or surgery. Foam sclerotherapy, performed under duplex guidance, is a reasonable treatment for minor varicose veins in traditional positions, but has a high recurrence rate and often involves multiple treatments.
EVL T, using a laser probe, can be used for more major varicose veins to good effect. Its recurrElnce rate is higher than that of varicose veins surgery. There is a risk of adjacent nerve “bum” and permanent damage, and it requires a secondary procedure to remove unsightly varicosities.
Saphenofemoral ligation (in the groin) and saphenopopliteal ligation (behind the knee), carefully performed, are still the standard way of treating varicose veins, associated with little stab avulsions, and have the lowest recurrence rate. Eighty percent of people who have such operations are not troubled in a significant way by further varil;;ose veins. The veins are simply assessed by duplex scan. The procedure is performed under general anaesthetic with an overnight stay. Usually people stay away from work or the gym for 10-14 days.