Have you come across a term on this website and found yourself unsure of what it actually means? Take a look at our glossary below for an explanation.
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Aneurysms that affect the abdominal aorta (AAA) can be one of the most deadly diseases if not detected and treated early. An aneurysm is essentially an abnormal enlargement of a blood vessel. The aorta is the largest blood vessel in the body extending from the heart down to the belly button. AAAs involve that portion of the aorta between the rib cage and the belly button. Most aneurysms get larger over time.
Allowed to get large enough, many of these AAAs will rupture. Ruptured AAAs kill approximately 75% of individuals affected by it. Unfortunately, AAAs tend not to cause symptoms until they rupture, making early detection difficult and necessary. Indeed, most AAAs are found incidentally on ultrasound or CAT scans done for other reasons. It is for that reason that many experts recommend screening in older patients and others at high risk.
Although there are many factors associated with aneurysms there is no known actual cause. In some patients AAA may be inherited. In fact brothers, sisters and older children of patients with AAA’s should be screened for an AAA.
Aneurysms below a certain size may be watched closely but over a certain size, strong consideration should be made for possible treatment. Treatment may include a big operation in which the abnormal artery is replaced or a smaller operation in which the aneurysm is “excluded” from the inside.
When an aneurysm is detected, one should be seen by a vascular surgeon to see what, if any treatment is necessary.
What is Atherosclerosis or Plaque?
Atherosclerosis is the deposition of cholesterol, calcium, waste products and old blood into the lining of blood vessels. The buildup of these materials is called “plaques”, and they are responsible for strokes, heart attacks, kidney disease and leg gangrene. The process begins at birth, but accelerates as the person ages, become prominent after 40 or 50 years of age. Many factors are involved in the formation of plaques, but scientists believe that damage to the inner lining of the artery is responsible for most atherosclerosis.
Three proven causes of arterial lining damage are high blood pressure, high serum cholesterol, and smoking. When the plaques accumulate and the arterial damage increases, the inner diameter of the artery becomes smaller. Less blood can pass through the blocked artery and less oxygen arrives at the tissues. This results in heart attacks, strokes, pain with walking, and leg gangrene.
Cholesterol is a chemical found normally in the body. It is use to construct cell walls, membranes and hormones. Is also found throughout the blood. Cholesterol in the body originates from the liver, or it may be absorbed through diet. Most animal products, such as meats, dairy, and eggs contain cholesterol. Plant materials usually don’t.
Although we need cholesterol to function properly, our diet should not be high in excess cholesterol, otherwise the abnormally large amount of cholesterol may contribute to atherosclerosis and accelerate plaque formation. A high level of cholesterol in the blood is termed hypercholesterolemia.
Risk Factors for Atherosclerosis
Factors that have been shown to increase the chance of getting atherosclerosis are male gender, age over 65, family history of atherosclerosis, high blood cholesterol levels, smoking, high blood pressure, diabetes, obesity, and physical inactivity. Current methods for reducing your risks of atherosclerosis are treatment of high blood pressure, smoking cessation, control of diabetes, reduction of high serum cholesterol and exercise. While some of these methods of treatment are with medications, other forms of risk reduction may be obtained through lifestyle changes. Moderate exercise, weight loss, low fat diet, and smoking cessation all help to prevent atherosclerosis.
Smoking a major cause of preventable deaths in the U.S. It is the biggest risk factor for peripheral vascular disease and directly results in heart attacks and sudden cardiac deaths. Smokers are twice as likely to suffer a heart attack than nonsmokers. If you do smoke, get help to stop. As soon as you stop smoking your risks of vascular disease drops.High blood pressure is known as a “silent killer.” It may be present without any symptoms, and yet it results in heart attacks, strokes, heart failure and kidney failure. High blood pressure causes the heart to work harder and damages the arteries. If you have high blood pressure, you should work hard to control it with proper diet, salt intake and exercise.
High cholesterol levels can increase your chances of vascular disease, especially when combined with other risk factors, such as high blood pressure, smoking and obesity. Normally, your liver makes all the cholesterol necessary for proper metabolism. But a diet high in saturated fats increases cholesterol levels. Methods of cholesterol reduction include eating a diet low in saturated fats, maintaining a relatively healthy weight and exercise. If cholesterol levels remain high, then your physician may prescribe a medication to lower your cholesterol.
Obesity and physical inactivity greatly increase your susceptibility to several diseases, including atherosclerosis. A regimen of moderate exercise and weight loss coupled with a healthy diet are the best treatment for obesity and inactivity.
Diabetes is a disease in which the body fails to make insulin for the conversion of sugars to energy. People with diabetes must carefully control their diet and take medications to maintain a healthy metabolism. Poorly controlled diabetes accelerates many disease processes, including atherosclerosis and the leading cause of death in diabetics is cardiovascular disease.
Each year more than 500,000 people become the new stroke victims in the U.S. It is the third leading cause of death in the U.S. and it is responsible for some of the biggest expenditures in health care dollars in America. Not to mention there is an enormous incalculable cost in lifestyle adjustment and rehabilitation to the individual and their family in a patient who has had a stroke.
Stroke is a disease of the blood vessels that affects the brain. A stroke occurs when a blood vessel to the brain suddenly bursts or becomes blocked. This part of the brain then begins to die. Nerves from this part of the brain no longer have control over part of the body. The result is usually permanent because the body cannot replace brain cells. Such brain injury may affect the ability to speak, to move the arms, to move the legs or to move the facial muscles. A stroke may affect behavior patterns, thoughts, memory, emotions, or sensations. Paralysis or weakness of one side of the body is common.
Carotid artery stenosis is the narrowing of the carotid arteries. The carotid arteries are the main arteries in the neck that supply blood to the brain. When atherosclerotic plaques develop in the arteries, the carotid arteries are often involved, causing the narrowing. These plaques are formed from cholesterol, fat and other substances that arise from the lining of the arteries. These atherosclerotic plaques in the carotid arteries are a risk factor for stroke.
Carotid artery stenosis may or may not cause symptoms. A doctor may hear an abnormal sound when listening to the artery with a stethoscope. Carotid ultrasonography may also detect the stenosis by placing an ultrasound probe on the neck.
Treatment of carotid artery stenosis depends on the degree of narrowing in the blood vessel. The greater the degree of stenosis, the more likely that a stroke will occur. Treatment of the stenosis may result in a dramatic reduction in the chance of stroke. Treatment regimens include medications, plaque removal, and plaque dilatation.
Medication for the treatment of carotid plaques includes classes of drugs known as antiplatlet agents and cholesterol lowering agents. Antiplatlet agents such as aspirin reduce clots in the blood vessels. Cholesterol lowering agents known as statins control levels of blood cholesterol and may decrease the inflammation of the plaques. Medical treatment of hypertension and diabetes also prevents strokes. Medical therapy is the first line treatment of carotid stenosis and should be used for most blockages less than 50%.
Narrowing of carotid arteries greater than 70% or plaques with dangerous ulcers should be considered for more aggressive therapies. These plaques are treated with procedures to remove the blockages. Treatment has the potential to reduce relative stroke risk by over 70%.The most commonly performed procedure is known as carotid endarterectomy. Carotid endarterectomy removes all of the plaque that caused the artery to narrow. These procedures have been shown to reduce the risk of stroke by between 50 and 70%. Another treatment is carotid artery stenting, which uses balloons and stents to dilate the plaques. This method is particularly useful for high-risk patients or plaques in unusual places.
What should I expect with my procedure? During your office visit, you will discuss the procedure with one of our physicians and he will select the most appropriate procedure for your treatment. Preprocedural testing requires blood tests, cardiac evaluation and special imaging studies of the arteries.
Most procedures require two or three days of admission to the hospital. You will be admitted to the hospital in the morning of the procedure. After the procedure is completed you will be admitted to the vascular unit of the hospital. Once you are discharged, you will return to our office usually about two weeks after the procedure. You will be seen in surveillance about every six months after the procedure for follow up ultrasonography to monitor for the small chance that the plaque will return.
Deep Vein thrombosis (DVT) is a condition in which blood clots form in the deep veins. This typically occurs in the legs, but can occur in the arms as well. The greatest risk of these blood clots is that they can break off and travel to the lungs. This condition is known as pulmonary embolism (PE) and can be instantly fatal. In fact, almost 200,000 people die per year from some complication of DVT. Other complications from DVT include development of leg sores that result from the destruction of the leg vein valves by the clot itself.
DVT may be associated with the following factors: cancer, surgery, leg fractures, pregnancy and any situation with immobility. In fact, recent press has been made about the so-called “economy class syndrome”, a condition in which people on long flights have developed DVT from prolonged periods of time sitting. Other people are at an increased risk for forming clots in general because of their genetic make-up. [break][break]The symptoms that may occur include leg swelling, sudden pain in the calf or thigh, shortness of breath (representing PE), or no symptoms. It is usually diagnosed with a non-invasive study called a duplex ultrasound.
Depending on where the DVT is located the treatment usually involves the use of some type of blood thinner to prevent the expansion of the DVT and to give the body a chance to break the DVT up. Under certain circumstances treatment may include the direct infusion of the clot with medications that dissolve the clot. Occasionally, the clot can’t be treated directly, but “treatment” involves placing a filter in a position that limits the risk of PE from the DVT.
If you have new leg swelling, sudden leg pain or any concerns about having a DVT, you should contact your physician immediately to determine if an ultrasound would be warranted to detect a possible DVT.
End Stage Renal Disease (ESRD) is the irreversible loss of kidney function. The two most common causes are Hypertension (high blood pressure) and Diabetes. The treatment for ESRD is either Kidney Transplantation, or Dialysis and can be done through the Bloodstream (Hemodialysis). As Vascular Surgeons, we are asked by Kidney Doctors (Nephrologists) to provide the means (Access) by which Dialysis can be accomplished.
There are two types of access for the arms: fistulas and grafts. Fistulas involve connecting the patient’s own artery and vein, to create a high blood flow system. There are typically three types of fistulas: Radio-cephalic, Brachio-cephalic, and Brachio-basilic transposition, named for the various connections. The placement of an Arterio-Venous graft on the other hand, involves using an artificial tube that is connected to an artery and vein. Fistulas are generally preferable to grafts, and we as Surgeons, are always committed to whatever we can to place a fistula.
Peripheral Vascular Disease (PVD) is a term that refers to a collection of illnesses that occur due to blockages in arteries. When the disease occurs in the arteries to the legs, it is typically also called Peripheral Arterial Disease (PAD). The symptom that occurs due to the plaque in the arteries of the legs (resulting in “poor circulation”) is called Claudication, a cramping of the muscles that occurs with activity, and is relieved with rest. This is also known as “angina of the legs,” as it is caused by the same mechanism that causes chest pain from heart disease, or angina. Blockages in the arteries to the muscles of the legs limit the ability to increase blood flow to those muscles during exercise, with the result being pain. The risk factors for progressive narrowing of the arteries are increasing age, diabetes, high blood pressure, elevated cholesterol, and smoking.
It is estimated that between 8 and 12 million Americans have PAD, with many having no symptoms, due to the fact that the blockages are not yet severe enough. As the plaque worsens, symptoms appear. Vascular surgeons typically divide patients with PAD into several categories: non-disabling claudication, lifestyle limiting claudication, and limb threatening disease. The decision to treat at all is individualized, depending on the patient, and their severity of disease. The type of treatment is also always individualized, based on the extent and distribution of disease, and the severity of the patients’ symptoms.
It is important to recognize that most patients with PAD remain stable in reference to their leg symptoms. PAD however is a significant marker for heart disease. If you have PAD, whether symptomatic or not, your life expectancy is shortened. It is very important to remember that it is not normal to have leg pain merely because one is getting older.
The medical treatment of PAD is basically an attempt to halt the progression of disease (by risk factor modification) and to create a healthier life style in general. The hallmarks of conservative or medical therapy are exercise, blood pressure control, the stopping of smoking and the improvement in cholesterol levels and patterns. Some of the medications used are platelet inhibitors (aspirin and Plavix) to help prevent clotting along plaques, and statins to lower cholesterol. Currently, Cilostozol (Pletal) is the only medication that will improve walking distance. [break][break]When leg symptoms are disabling or lifestyle threatening, and medical therapy is either inappropriate or has been ineffective, the treatment needs to be more involved and aggressive. If the diagnostic arteriogram (x-Rays) demonstrates focal (non-diffuse) blockages of the arteries, then a balloon angioplasty/stent procedure can be considered. If the blockages however are complete or in multiple areas, then a surgical bypass must be done to improve blood flow.
In the most severe category of disease, limb threat, a bypass is typically required, and angioplasty is only rarely considered to be either appropriate or sufficient. Limb threat is defined as the presence of gangrene, a non-healing wound, or pain at rest in the foot. The limb will be lost if successful reconstruction is not accomplished.
Large twisted veins in the legs and pelvis are known as varicose veins. Normal veins contain valves that enable blood to return from the legs to the heart. Varicose veins have damaged valves, and the blood is pulled backwards to the leg by gravity when standing. The veins then swell and enlarge. Besides the cosmetic effects, legs can become heavy and painful. The leg may become discolored or swollen. Sometimes, this can lead to more serious medical problems.
Vascular Specialists offer a variety of nonsurgical and surgical treatments for varicose veins, encompassing all types of venous problems. These include sclerotherapy, support stockings, radiofrequency or laser ablation, and vein strippings. By offering all forms of venous treatment, a patient’s individual therapy is therefore tailored to their specific needs.