Vascular Surgeons and Vascular Disease
Who are vascular surgeons?
Vascular surgeons are physicians who care for patients with diseases that affect the arteries and veins throughout the body. This medical specialty first emerged in the early 1950s as a hybrid between general and cardiac surgery. However, unlike most other surgical specialties, no parallel medial discipline evolved to treat these patients and vascular surgeons were left to manage the full spectrum of vascular disease. Over the next three decades, pioneers in this specialty expanded our knowledge of the disease processes that affect blood vessels and helped to develop many of the diagnostic modalities and treatments that we use today.
Most vascular surgeons spend five years completing their training as general surgeons and then pursue an additional two years of training to acquire the special skills they will need to recognize and treat the full spectrum of vascular conditions they may encounter. In 1982, the American Board of Surgery established the Certificate of Special Qualifications in Vascular Surgery to recognize individuals who had satisfactorily completed such a course of study. Surgeons who qualify for this certification must sit for a comprehensive written and oral examination covering all aspects of vascular disease. The certificate must be renewed every ten years by passing an examination, which tests their familiarity with the latest advances in the specialty.
What kinds of problems do vascular surgeons treat?
Although there are a number of diseases that can affect arteries and veins throughout the body, the most common problem that vascular surgeons treat is atherosclerosis, or hardening of the arteries, as it is more commonly known. This condition affects virtually every artery within the body. However, its preference for several specific locations results in a limited number of disease patterns.
What is Carotid Artery Disease?
Blockage or narrowing of the arteries in the neck can predispose patients to suffer a stroke which occurs when a portion of the brain receives inadequate blood flow and dies. Since it is very difficult to reverse the damage once it has occurred, successful management of this condition requires early recognition of the disease, often even before symptoms occur, and prompt, safe treatment.
What are Aneurysms?
The aorta which is the main artery carrying blood from the heart to every part of the body can develop a focal weakness of its wall due to atherosclerosis. This results in the formation of a dilated segment, or aneurysm, which if left untreated, will continue to enlarge until it ruptures resulting often in the death of the patient.
Other arteries, usually in the legs, can also become aneurysmal. However, leg aneurysms rarely rupture. In fact, they are more likely to become filled with blood clot which can break off and block main arteries of the lower leg. Such an occurrence can result in loss of limb.
What is leg artery blockage?
When the arteries to the legs are narrowed by atherosclerosis, a characteristic recurrent muscle pain occurs in the legs following exercise. This symptom, which is called intermittent claudication, usually is promptly relieved by rest alone and does not get progressively worse. In a small number of advanced cases, the pain may become constant and keep the patient from sleeping. If this "rest" pain is ignored, approximately one patient in ten will develop gangrene and may require amputation of part, or all, of their leg. However, few patients with intermittent claudication ever develop this disastrous complication.
What other arteries in the abdomen can become blocked?
Several of the main arteries within the abdomen can become narrowed by atherosclerosis. When this affects the arteries to the kidneys, the patient can develop severe hypertension, or high blood pressure, and ultimately kidney failure. Although this problem occurs in less than 10% of people with high blood pressure, it is important to recognize because the patient's high blood pressure can be completely cured, or dramatically improved, by restoring circulation to the kidneys.
Rarely, the main arteries to the intestines can become blocked by atherosclerosis or by a blood clot from another part of the body resulting in severe abdominal pain after meals and weight loss. If not recognized, this condition can result in gangrene of the intestines and death.
Do vascular surgeons care for varicose veins?
Yes. Although problems with the veins are not as dramatic as those that follow arterial obstruction, they are a source of pain, suffering and economic loss to patients. The superficial leg veins can become very dilated and tortuous. If left untreated, these varicose veins will continue to enlarge and may be complicated by the development of blood clots or in advanced cases, by leg ulcers.
What are blood clots?
The veins deep within the legs are prone to develop blood clots, especially in patients who are bedridden or following surgery. This results in a common, and serious, condition known as deep venous thrombosis, or DVT. Although this problem usually improves dramatically following the administration of anticoagulants, or "blood thinners", these blood clots can break loose and go to the patient's lungs. Five to 10 years later, the patients can develop disabling leg swelling and ulceration.
Do vascular surgeons always recommend a surgical procedure to treat these problems?
Quite the contrary! Many problems seen by vascular surgeons, such as intermittent claudication and DVT, are usually treated medically. Others such as small, asymptomatic, abdominal aortic aneurysms or moderate narrowing of the neck arteries are followed with noninvasive tests. As long as there is no evidence of progression, these problems are also left alone.
For those conditions in which some form of intervention is necessary, a number of new, innovative techniques are available. Manipulation within the arteries using specially designed balloons and catheters can often restore circulation or the integrity of the vessel wall without the need for an open surgical procedure or extended hospital stay.
Because vascular surgeons are trained in all forms of treatment, from medical to catheter-guided procedures to open surgery, they are uniquely qualified to offer their patients a variety of therapeutic options while exposing them to the least risk.
Abdominal Aortic Aneurysm (AAA)
What is an aneurysm and how do they form?
When the wall of an artery becomes weakened, the pressure within the vessel can cause the wall to bulge out forming a localized dilation, or aneurysm. Although a small percentage of such cases are due to inherited factors, the vast majority appear to represent a variant of atherosclerosis and like atherosclerosis, they tend to occur in a limited number of locations. Most aneurysm seem to occur in the abdominal aorta, the main artery lying in the center of the abdomen. Other common sites include the groin and the vessels behind the knee.
What happens to an aneurysm once it forms?
Once an aneurysm forms, it tends to progressively, but slowly enlarge. As the aneurysm enlarges, the wall of the artery becomes thinner until eventually the aneurysm bursts or ruptures. The process of enlargement rarely causes symptoms. Unfortunately, the initial symptom is often severe abdominal or back pain as the aneurysm ruptures.
Is a ruptured AAA usually fatal?
An aneurysm that ruptures has a mortality rate of 80%. Many individuals do not survive long enough to reach the hospital. Ruptured aneurysms were responsible for the deaths of Albert Einstein, Lucille Ball, Conway Twitty, and George C Scott.
How do we prevent a ruptured AAA
Early detection with ultrasound imaging or CT scan is the initial step in preventing rupture. If an AAA is detected, monitored and appropriately treated, rupture can be prevented. The mortality for elective repair ranges from one the three percent. Therefore the effort toward early detection can reduce a frightful mortality of 80% to an acceptably low rate.
Who is at risk for an Abdominal Aortic Aneurysm?
Individuals with the following characteristics are at risk for developing Abdominal Aortic Aneurysms:
Age over 60
High blood pressure
Family history of AAA
Hardening of the arteries
Females and younger people can have aneurysms.
How do I know if I have an aneurysm?
The presence of an aneurysm and its increase in size seldom elicit symptoms. Most aneurysms are asymptomatic until they rupture.
In thin people, an aneurysm can often be felt on physical exam but otherwise most aneurysms are found during diagnostic testing, or on screening exams. Ultrasound exam is one of the best initial screening exams available; however, CT scan is generally the test of choice once an aneurysm is felt to be large enough to be dangerous.
What happens after an aneurysm is discovered?
Decisions regarding the approach to an AAA are predominantly based on the size of the aneurysm and the risk profile of the individual. If small the aneurysm will be monitored every 6 to 12 months with ultrasound imaging. Once the aneurysm reaches a moderate size (5.0 5.5 cm) repair is considered.
The risk factors of note in patients with aneurysms include heart, lung and kidney disease. When these problems are present in a significant fashion the size indication may increase. Less invasive alternatives are also given greater consideration.
How are aneurysms repaired?
Possible reparative procedures include:
Standard Open Operative Repair
New minimally invasive endovascular Stent Graft Repair
The Standard open repair requires a large operation, a 4 to 5 day hospital stay, and a recovery of 6 to 8 weeks. The operative mortality is 1 to 4% depending on the risk profile. The long term expectations are extremely good based on fifty years of experience
The new Endovascular Stent Graft repair is a minimally invasive procedure requirng a 1 to 2 day hospital stay and a recovery of 2 to 3 weeks. The procedure carries a mortality of 1% and may be applied to elderly and high risk individuals. The short term expectations are good. Since the experience in the vascular community with this new procedure only includes the last several years, the long-term expectations are less certain. Recent studies do indicate that the stent graft repair is both safe and durable.
The criteria used to determine the optimal method of repair depend on the individual’s age and risk profile and certain features, sizes and angles of the aneurysm and adjoining arteries.
Carotid Artery Disease
Why are we concerned about Carotid Artery Disease?
The Carotid arteries are located on both sides of the neck as they conduct a majority of the blood to the brain. Blockage due to atherosclerosis or cholesterol build up in the carotid arteries can result in stroke. Blockage, or “stenosis”, in the neck or carotid arteries accounts for over 200,000 strokes annually in this country. These are strokes that can be avoided if the blockages are found beforehand.
How does blockage in the carotid artery cause stroke?
High Cholesterol can cause plaque formation in the carotid artery in the neck. As the plaque enlarges several adverse circumstances can be produced. Larger plaques become friable and can release particles that migrate to the brain. Once in the brain these particles can block small blood vessels causing a stroke. The enlarging plaque can also completely block the carotid artery depriving the brain of blood resulting in a stroke.
What are the risk factors for carotid artery disease and stroke?
Individuals with any of the following are at risk for carotid artery disease and stroke:
Family history of stroke or heart disease
High blood pressure
Lack of exercise
How do I know if I have a carotid artery blockage?
Physicians can often hear a rushing sound or “bruit” over the neck when listening during physical exam. Some people have “brain attacks” or TIA’s (Transient Ischemic Attack) before a major stroke that can alert their doctors to test the carotid arteries. Still, most people remain asymptomatic and only through screening tests such as carotid duplex ultrasound exam are we able to find the blockages. These procedures are noninvasive, non-painful, relatively quick, and exceedingly accurate for detecting carotid artery blockage.
What happens if carotid artery blockage is discovered?
Minimal to moderate blockage is followed with serial exams and medical management is initiated. A Duplex ultrasound image of the carotid arteries performed every 6 to 12 months can alert the physician to progression of disease and higher risk of stoke.
When more severe blockage is detected, more intensive therapy is considered.
What treatments are available for carotid artery disease?
The available treatment options include:
Medication This includes medications which block platelet function such as aspirin or Plavix.
Operation A carotid endarterectomy removes the plaque
Angioplasty and stent The blockage is dilated with a balloon and held open with a stent
The presence of atherosclerosis in the carotid artery prompts consideration for anti-cholesterol medication and consideration for the presence of coronary artery disease (heart disease).
Leg Artery Blockage
What is leg artery blockage?
Blockage in the leg arteries is predominantly caused by hardening of the arteries or atherosclerosis. Hardening of the arteries starts with fatty or cholesterol deposition in the wall of the artery. The cholesterol plaque builds up and worsens to the point of complete blockage depriving the leg of sufficient blood supply.
Thirty million people in the United States have leg artery blockage.
What are the risk factors for developing artery problems?
The main risk factors for hardening of the arteries are smoking, diabetes, hypertension, high cholesterol, family history of hardening of the arteries, obesity, and sedentary life style.
What are the consequences of blockage in the arteries of the legs?
The legs have a remarkable ability to compensate for complete blockage of main arteries by utilizing secondary pathways called collaterals. The compensation can be of such magnitude that some individuals have no symptoms. When the compensation is insufficient, the person often experiences limitation in walking distances such as two to four blocks. In more severe forms of blockage and inadequate compensation the blood supply can be inadequate at rest. In this situation the person will experience pain in the feet during the night or poor healing of small ulceration of the feet and toes. When the deprivation of blood supply is severe the entire leg can be in jeopardy of gangrene and limb loss.
Is all leg pain due to artery blockage?
No. Other causes of leg pain include arthritis, varicose veins, venous blood clots, spinal stenosis, diabetic neuropathy, and myalgias
How are most artery problems identified?
Your physician can do a complete physical exam, which include the feeling of pulses in the legs. In addition, he can obtain a noninvasive Doppler exam of the legs that can definitively diagnose the problem. Screening procedures using the Doppler to determine the blood pressure at the ankle are also accurate means to diagnose leg artery blockage.
What are the chances of progressing to gangrene if I have only minimal walking symptoms from leg artery blockage?
Due to the legs remarkable ability to compensate for leg artery blockage, the chances of progressing to gangrene and the threat of limb loss is actually quite small. Experience indicates that when simple conservative measures are utilized progression of disease occurs in less than 10% of individuals.
What are the treatment options for leg artery blockage?
The treatment options include:
Conservative therapy centered on walking and medication
Minimally invasive endovascular procedures utilizing angioplasty and stents
Invasive operations based on plaque removal or bypass.
What about walking when leg artery blockage causes limitations?
Walking exercise is the main therapy to be utilized in all situations, even when major operations are necessary. Individuals with leg artery blockage are instructed to walk for 45 minutes at least 5 times per week. The person should walk just beyond the point where pain is experienced, rest until the pain resolves, and walk again to the point of pain. Such activity can lengthen the walking distance before the onset of pain. It can also reduce the likelihood of disease progression and the need for therapeutic procedures.
Why are even asymptomatic patients interested in knowing if they have leg artery blockage?
People with leg artery blockage are three times more likely to have a heart attach or stroke. Detection of leg artery blockage can alert your physician to the presence of hardening of the arteries, prompting preventive measures.
How can people reduce their risks for artery problems?
The number one way is to stop smoking. Other important measures include control of diabetes, control of cholesterol, maintaining normal blood pressure, and adhering to a frequent exercise program.