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Ask the Vascular Surgeon (Dr. Clair 4/6/12)

Friday, April 6, 2012 - Noon

Description

The Vascular Surgeons at Cleveland Clinic surgeons treat a wide variety of vascular diseases such as atherosclerosis, aneurysms of the abdominal and thoracic aortas, venous disease and cerebrovascular. Dr. Daniel Clair, Chairman of Vascular Surgery at Cleveland Clinic had to perform an emergency surgery at the time of this webchat. Below are the answers to some of the questions by Dr. Clair and a special thanks to the following doctors who are also answering today's questions: Dr. Kirksey, Dr. Roselli, Dr. Wilkoff and Dr. Hazen. More will be added as the surgeons complete these responses.

More Information


Peripheral Artery Disease

HubbsG: I am 66 and was aerobically active until a few years ago. My feet and hands are so cold that I have given up outdoor activities except in very warm weather. My vascular blood pumping has been checked by several doctors through palpitation. What type of doctor should I see concerning circulation in my feet and hands? My heart is fine according to my cardiologist.
See PAD Web Chat with Dr. Kirskey

SaraB: I had superior mesenteric artery by-pass surgery 2 yrs ago. Since then I have been told that my inferior artery is occluded. A stent did not work on the superior. Is there anything that can be done for the inferior artery? I have been told no.
See PAD Web Chat with Dr. Kirskey

SpencerH: I had laser ablation of both varicose great saphenous veins approximately 2 years ago. Done by a very highly trained vascular surgeon. In one leg the varicosity returned with a vengeance in the same vein. In the other a new equally bad varicosity developed in a different vein. I am not amused. I am wondering what your observations would be. Thank you.
See PAD Web Chat with Dr. Kirskey

chiriaco: Are there new procedures you can recommend for those of us with lower extremity, full occlusions in which traditional angioplasty/bypass is not recommended?
See PAD Web Chat with Dr. Kirskey

chiriaco: which medical facilities on the west coast would you recommend (if travel to Cleveland Clinic isn't possible) that would implement these newest surgical interventions for lower extremity occlusions?
See PAD Web Chat with Dr. Kirskey

whendym: I have been in pain since 4/29 I went to the er they told me I have superficial vein thrombosis in the left leg they gave me nothing.should i still be in so much pain still the swelling went down the pain has went up.
See PAD Web Chat with Dr. Kirskey

bmet12: My wife had a venous ulcer wound on her leg just above the ankle. This was treated surgically by using her saphenous vein on her other leg. It was successful. Within a year the same condition appeared on her other leg in the same spot. Very painful & life altering. Since they will not use her last saphenous vein, is there an alternative for her surgically? Is there another source for a vein? Thank- You, Paul.
See PAD Web Chat with Dr. Kirskey

stevenm: what could happen to make a femoral bypass surgery end up with an amputation on the opposite leg of surgery and a scronectomy performed on my groin destroying my sex life. They say It happens I got gang green in my foot and on my privates. They say it isn't out of the normal for this type surgery to end up like this.
See PAD Web Chat with Dr. Kirskey


Carotid Artery Disease

DeboraG: My father, 85 years old, had a massive stroke on March 1st. His right carotid artery has 90% blockage. He has lost the use of his left arm and leg. We were told that he had a previous stroke that went undetected. It appears from his age and heath condition that he is not a candidate for surgery - what are our options with drug therapy and what is the percentage of it being of any benefit?

Dr. Clair: There are 3 options for treating carotid stenosis. These include: Medical therapy - Which should include standard therapy for decreasing risk of arterial disease in general: Stop smoking, blood pressure control (ideally keeping the upper number below 140-150 and the lower number below 80-85), lowering cholesterol with the use of statins (ideally the bad cholesterol should be kept below 70), and anti-platelet therapy (this is usually done with aspirin, which keeps platelets from "sticking", but is probably better done with Plavix in this situation). Stent therapy - this appears to have a slightly higher risk for stroke in patients who are over 80 and who have already had symptoms from a carotid artery. If your father has had a reasonable recovery from his stroke or appears to be heading in that direction, he may still be a candidate for Surgical therapy or carotid endarterectomy for the narrowing. Seeing a vascular surgeon who does carotid stenting and who can and does treat patients with medical therapy as well will allow your father and your family to discuss what all of his options are and to assure that he is getting all the therapy he needs.

georgeK: I have 100% blockage in the left carotid. My right carotid is 70%. When do they decide to do surgery? I am getting nervous about my chances. Would you also treat a 100% blockage?

Dr. Clair: Trying to open carotid arteries with 100% blockage puts an individual at higher risk than just leaving the blockage. This is because the risk of debris heading up to the brain from an artery that has previously been completely blocked is higher than normal. Unless there are severe circumstances warranting this to be done, it is not recommended. In most individuals, since there are 4 arteries carrying blood to the brain, the loss of one, does not affect the function or blood flow getting to all parts of the brain.

As for treating the other side, usually, we use a threshold of 80%. This might be lowered a bit in an individual who has had significant progression of the narrowing or who has a narrowing that appears unstable. It is also very important to make sure that you are getting appropriate medical therapy for this problem, which should include cessation of smoking (if you are), blood pressure control (keeping the upper number below 140-150 and the lower number below 80-85), cholesterol control (and here I would recommend the use of a statin, which appear to be helpful not only in reducing risk of progression of disease, but in stabilizing plaque as well), and anti-platelet therapy with at least a baby aspiring (81mg) orally per day. Annual follow-up for the carotid arteries with ultrasound in an ICAVL accredited laboratory is mandatory in this situation.

CharL: Can you talk about when they would do a carotid stent vs. when they would do open surgery? Of course I would prefer to do something less invasive - but why is stenting still not done instead of surgery? 

Dr. Clair:Carotid stenting and carotid endarterectomy have been compared in a number of studies and until recently, nearly all of the studies have shown increased risk with stenting.The results of the CREST trial, which were recently completed, however appear to show similar risks between the two procedures.But the risks really are different and one must make decisions regarding what risk they are willing to accept.Patients who have stenting, and especially stenting for symptomatic carotid disease, have increased risk for stroke.Patients having surgery have increased risk for heart attack.The unfortunate thing from the viewpoint of a physician who performs both of these procedures is that the studies are not being designed to look at what is best for the patient, they are being designed to try and prove that these procedures are either equal or unequal.But there are a number of things which make patients "high-risk" for one or the other of these procedures and our goal should be to try and understand exactly what the risks are for each procedure and how to best provide the lowest risk procedure for each patient.There is in my view a distinct advantage in seeing a physician who performs both procedures because he/she can discuss with you the specific risks for you personally and make recommendations based upon all of the available options which should include medical therapy alone as well.There are some misconceptions regarding surgery that I think need clarifying - Stenting is not radically less-invasive than surgery.

Surgery for carotid stenosis is not disabling and most people spend only one night in the hospital - this is the same as stenting.Most people are back to regular activities within a week of surgery.The recovery is not difficult and I have very little by way of restrictions when they leave the hospital.

Stenting is not routinely reimbursed because there is currently no good evidence that it reduces the risk of stroke as effectively as surgery; however the results of the CREST trial challenge this impression.

For my own patients, in symptomatic patients, I believe the risk of stroke is lower with surgery and unless there is some reason the individual is high-risk for surgery, I think it offers the best chance to limit stroke. 

For asymptomatic individuals, the choices of medical therapy, stenting and surgery should be discussed carefully so that an educated decision can be made to offer the lowest risk therapy for each individual.  

Imgaiso: How sensitive is a carotid doppler and sonogram for plaque in the carotids?

Dr. Clair:As noted for detecting abdominal aneurysm, screening for carotid disease is very well performed with carotid ultrasound.But here it is even more important that the lab in which the study is being performed is an ICAVL accredited lab.Sensitivity varies from lab to lab, but one can expect 98% sensitivity in determining more than 50% stenosis with this study.

Imgaiso: Are the preventative measures for aneurysms and carotid plaque the same as for artherosclerosis? 

Dr. Clair:The most significant risks for aneurysm are smoking and high blood pressure.So avoiding smoking and assuring blood pressure is well controlled are the two most important issues in reducing risk of aneurysm.For carotid artery stenosis, which is really atherosclerosis in the carotid arteries, the risks are similar to those of atherosclerosis anywhere else and prevention measures are exactly what they would be for prevention of atherosclerosis anywhere else.


Carotid Body Tumor

ThomasK: My dad was just diagnosed with a carotid body tumor by CT scan. Are they cancerous? How do they treat them? I saw on the internet they can be hereditary - should I get checked?

Dr. Clair:Carotid body tumors are growths within the nervous tissue around the carotid artery.This tissue is involved in the control of blood pressure and heart rate, and it transmits information regarding blood pressure and heart rate to remote centers in the brain which control this.Some individuals can develop abnormal growth in these cells (the carotid body) and form a carotid body tumor or growth.These are rarely malignant or cancerous, but they can locally become problematic by obstructing or interfering with normal structures in the neck.In most instances, surgical excision is the best therapy, and in experienced hands, the risk of resection should be VERY low.Increased size of the tumor can increase the risk, but especially with larger sized tumors, if a team of surgeons is involved, the risk can still be very low.We see a large number of these tumors here; have a great deal of experience with removing them and have excellent outcomes.The key in dealing with this is getting an experienced team and assuring the resection is performed safely.

These can occasionally be bilateral and may be associated with other neuro-endocrine tumors.Assessment for this possibility should be performed at the time of initial evaluation.If it is associated with other tumors, then it may be a familial concern, which would indicate the need for assessment of other family members.


Abdominal Aorta Aneurysm

Imgaiso: I have a family history of AAA. I have had my abdominal aorta check with ultrasound and it is normal. I also have had the aortic arch check by echocardiogram since I have aortic regurg. However, I understand that there is a portion of the decending aorta that neither of these two tests can view. I understans that CT or MRI would be necessary to view that portion. Do you think that I should have either test? I am 44 and lift weights.

Dr. Clair:Risk of aortic aneurysm increases with age, and you are at a VERY young age with respect to aortic problems like this.Normally, I would not think someone your age would need screening unless there is a connective tissue disorder that is the risk factor.Some examples of this would be a familial inherited disorder such as Marfan's syndrome, where collagen is created abnormally, or Ehler's-Danlos syndrome, where elastic tissues are abnormal.In most instances, unless a family member had an aneurysm at a very young age, the risk realistically develops at 50 or over for men and 60 or over for women.If the AAA ultrasound and the echocardiogram of the ascending aorta and arch are normal, I would not routinely recommend a CT scan for the intervening segment and especially at your age, I would not think this is indicated.It should be noted that a negative screen at your age does not assure you will never have problems like this and I would think you should be screened again in no earlier than 10 years from now, unless there is a heritable disorder of significant risk such as those mentioned above.

Imgaiso: How sensitive is an echocardiogram for detecting an aneurysm in the aortic arch?

Dr. Clair:An echocardiogram is a very good test for assessing the size of the aortic valve and the ascending aorta.It can also assess the size of the first part of the arch, but it is not as good for detecting aneurysm disease of the posterior aspect of the arch.This actually can be done with either a CT scan or alternatively, the radiation could be avoided by using a trans-esophageal echocardiogram, where the ultrasound probe is passed down the esophagus.This is an excellent way to look at the posterior part of the arch and the descending thoracic aorta.But there should be a very good reason to look for this and that would include either connective tissue disorders, such as Marfan's or Ehler's-Danlos syndrome, in which the body does not make the normal connective tissues.

Imgaiso: How sensitive is an sonogram for detecting an abdominal aneurysm ?

Dr. Clair:Sonography is the most sensitive and specific screening test for this problem.It has no radiation or contrast risk and in the hands of an experienced ultrasonography technologist, it is by far and away, the best test to be used to screen for this problem.It is important to make sure that the lab in which the screening is done is ICAVL accredited, which assures there are standards and valid assessment of the studies performed in the sonography lab.


Klippel-Trenaunay Syndrome (K-T)

kileyL: Can you talk about surgical treatments for K-T? I wonder if there is a more permanent treatment to decrease the swelling.

Dr. Clair: K-T or Klippel-Trenaunay syndrome is an abnormality of the venous system which results in what is essentially a venous malformation or an abnormal collection of veins in the superficial space of the leg. While many have stated that patients with K-T don't have a deep venous system, the fact is, most of the patients with this diagnosis do have a functioning deep venous system. Anyone suffering from this process must understand that the goal of someone treating this is function of the affected limb.

The concept that the affected limb can be made "normal" is unrealistic and our goal in treating people is to make sure the leg performs as it is needed to and that there is limited disability. Attempts to decrease the swelling to zero will not be successful. One must understand that there is likely some dysfunction of the lymphatic system in the affected limb as well. But patients with this process can lead normal lives.

The best initial therapy is compression and this is best done with compression stockings. This should initially be with the amount of compression the individual can tolerate. If the swelling gets bad enough to limit joint motion or there are repeated bouts of infection or pain, then laser ablation of dysfunctional longer superficial veins can be performed usually in conjunction with ligation at the entry point into the deep system. This can be combined initially with ligation and resection of larger dilated veins and then subsequently with sclerosis of "nests" of dilated veins in the areas of problems. Using this technique, we have been able to keep patients with this diagnosis happy and functional and have limited their disability from this problem.


Inflammatory Markers

TREEDK: I have a complicated medical past including pustular psoriasis with internal damage, fibromyalgia, chronic migraines, numbness and tingling. I just had blood work done with borderline high cholesterol. However, inflammatory marker are very high; Lp((a) 81, hsCRP 7.2 LpPLA1 381. How serious is this and what do you recommend?

Dr. Hazen: In primary prevention (no known cardiovascular disease), we recommend an LDLc (bad) cholesterol goal of less than 100. In the setting of elevated CRP and other markers of inflammation, even if LDL is below 100, we recommend starting a statin (eg Lipitor or Zocor since they are generic). Recent clinical trials show that even in those with so called "normal" LDL, in the setting of elevated CRP (>3) for any reason (whether known or not), taking a statin is associated with 35-50% reduction in risk of heart attack, stroke, need for revascularization (CABG, angioplasty and/or stenting) and death. Dr. Stan Hazen, Section Head, Preventive Cardiology


Pacemakers

FibroJoe: After pacemaker, periods of what I call "loud pulsing" happen randomly, particularly while at rest. When I move quickly or bend over while performing a task, or climb stairs, I feel the pulsating, throbbing sensation in chest, throat and fingertips and feel as if I cannot catch my breath. (However, aerobic exercise is fine with no symptoms.) Palpitations disappear quickly after each episode except when trying to fall asleep. Resorted to Ambien nightly due to this situation. Unbearably loud pulse is heard and felt which drives me crazy until I fall asleep. Frequently awakened by this pulsing/tightness in my chest. My physicians have each evaluated the condition. No solution. Cardiologist diagnosed PVCs and prescribed metoprolol. No effect for the last 9 months. Loud pulsing and shortness of breath continues. I need help coping. What should I do?

Dr. Wilkoff: Patients have palpitations for many different reasons. These “loud pulsing” episodes would be one way of describing what physicians include into the category of palpitations. Usually this is associated with the heart beating out of sequence with the lower chambers (ventricles) beating before the upper chambers (atria). This could happen because of the way the pacemaker is programmed, which is means that it could be adjusted in a better way. Or it could be because your heart is going faster than the pacemaker on its own, meaning that the pacemaker is not participating in the symptoms. Without knowing the precise circumstances it is not possible to suggest a solution. However the good news is that this is not likely to be either be putting you in any danger or harming your heart. PVCs would be your own heart working on its own and happens in patients with and without pacemakers. Often the use of an anti-adrenaline medication called a beta blocker will help these symptoms. Sometimes increasing the rate of your pacemaker can also help. The principle here is to find out precisely what your heart rhythm is doing when you are having the symptoms and then designing an approach to reduce that situation. Bruce L. Wilkoff MD, Director: Cardiac Pacing & Tachyarrhythmia Devices

More questions will be answered in the next week.

Reviewed: 04/12

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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