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Ask the Vascular Surgeon (Dr. Kirksey 08/13/13)

Tuesday, August 13, 2013 - Noon

Description

The Vascular Surgeons at Cleveland Clinic treat a wide variety of vascular diseases such as atherosclerosis, aneurysms of the abdominal and thoracic aortas, arterial and venous disease. Dr. Lee Kirksey from Cleveland Clinic answers your questions.

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Carotid Endarterectomy and Stenting

CarotidPt: I have a history of thrombus and embolus occluding my carotid artery after endarterectomy. Emergency surgery helped me avoid a stroke. For six months I have been on 81 ASA and 75mg of Plavix daily. My surgeon is recommending surgery on the other side, stopping the Plavix a week before, but continuing aspirin. I have read the abstract from an article in the June 13, 2013 issue (online) of the European Journal of Vascular and Endovascular Surgery “Closing the Loop: A 21-year Audit of Strategies for Preventing Stroke and Death Following Carotid Endarterectomy”. The audit revealed that giving patients 75 mg of clopidogrel the night before carotid endarterectomy, along with 75 mg ASA, has virtually abolished post-operative thromboembolic stroke.

My question: Is this the answer, and do you do this at the Cleveland Clinic? If so, what have the outcomes/complications been? If not, why not?

Levester_Kirksey,_MD: The circumstances around your peri-operative stroke would need to be clarified for me to suggest this is the best approach for you. The recent abstract that you refer to begins by clarifying that strokes around the time of carotid endarterectomy are multi-factorial. That is, they are caused by various factors. The authors in that paper including Drs. Naylor and all, described three measures that in combination over their 21 year experience, have led to a reduction in the rate of stroke during and after open carotid endarterectomy. The authors describe administering aspirin and plavix for a single dose the night before operation, additionally, they described several intraoperative approaches which include trans-cranial doppler and angioscopy. Finally, they describe providing written instructions upon discharge about hyper-profusion syndrome which is known to be a delayed cause of stroke. Usually occurring after a patient has been discharged. So, multiple factors were described in that paper and each of those approaches in combination have proven to be successful for the author. All of those interventions are undertaken in each open carotid endarterectomy performed at Cleveland Clinic.

Nanette: Does anyone at your institution ever combine aspirin with 75mg of clopidogrel the night before carotid artery surgery? I have read where this has been done in Europe to prevent blood clots after carotid endarterectomy, but I am not aware of this approach being taken in the U.S. I have also read where some doctors will give a loading dose of 300mg of clopidogrel right after carotid endarterectomy. Is there anyone at Cleveland Clinic with experience doing this?

Levester_Kirksey,_MD: It is quite common because of the association of cardiovascular disease and carotid stenosis that patients are already on either aspirin or plavix or both agents. There is data to suggest that the combination of aspirin and plavix may reduce one type of stroke that may occur during or after carotid endarterectomy. However, the use of dual anti-platelet therapy, as this regimen is called, is undertaken with careful consideration that it does increase the risk of bleeding complications around the time of surgery.

At Cleveland Clinic, we have a broad experience with the use of antiplatelet agents around the time of both percutaneous stenting and open carotid endarterectomy - and we are currently participating in several clinical trials to determine the most appropriate approach.

Chandler22: My grandfather's carotid artery is 82% blocked - when do you do surgery and when can you do a stent?

Levester_Kirksey,_MD: As a general idea, we treat asymptomatic patients when they have a carotid stenosis greater than 80% if they are at reasonable medical risk to tolerate surgery and if they have a life expectancy of greater than 5 years. The decision to perform open carotid open endarterectomy vs. carotid artery stenting is determined by the patient's underlying medical condition as well as the risk of carotid artery stenting based upon the patient's anatomy. Paradoxically, most research to date suggest that patients older than 80 years of age may be better managed with open carotid endarterectomy.


Diagnotic Testing

DonM: Please give your opinion on endopat test. Thank you.

Levester_Kirksey,_MD: The endo pat test is a non-invasive way to evaluate endothelial function by measuring vascular tone within the blood vessels of the arm. Vascular tone is one indicator of blood vessel stiffness which can lead to atherosclerotic changes within blood vessels.

Although it is a relatively new test, in all likelihood it will end up being an additional measure to identify patients who are at risk of cardiovascular disease so that we may initiate treatment more promptly.

KWhee2: What tests would you like completed prior to me referring you a patient if I suspect arterial problems of the lower limbs?

Levester_Kirksey,_MD: The most helpful test is pulse volume recordings or ankle brachial index. This provides us with a baseline assessment of the circulation of the lower extremities. Beyond that I spend a lot of time talking to the patient to understand the degree of disability that results from their arterial occlusive process. Feel free to contact my office and I can discuss specific patients with you.


Peripheral Artery Disease

jimvicki: I have had femoral to femoral by pass surgery and still have a fistula in my leg. Is there any connection to the fistula and my having a high heart rate while walking? In short distances I can get as high as 150.

Levester_Kirksey,_MD: It is possible that if the communication between the artery and vein is increasing the volume of blood that is returning to the heart - this may be the cause of your elevated heart rate with exertion. We would initially evaluate you by determining the size of the existing arterial fistula and then consider alternatives for treatment. Symptomatic fistulas should be treated.


Venous Disease

Reflux Worry: If the Greater Saphenous Veins in both legs were treated because of venous reflux disease, is it critical to also treat the Lesser Saphenous Veins, both also having venous reflux disease, in a timely manner? Is 10 months between the two treatments too long? Also, can this 10 month lapse between treatments cause additional problems in the legs? If so, what problems can it cause?

Levester_Kirksey,_MD: The first important determining factor is what symptoms one is experiencing from venous reflux disease. In your case, what symptoms indicated treatment? These symptoms can vary from minor leg swelling to severe pain and throbbing with prolonged standing. And in the most severe presentation, patients can develop ulceration secondary to venous reflux disease. Depending upon where you fall along this spectrum and what symptoms you have, the time may or may not be critical. 10 months does not seem too long and this should not affect the outcome that you would experience if in fact you actually warrant treatment.

garnet: 1) I have read that there are new reconstructive therapies for diseased veins being developed. Creating a "scaffold" with collagen and then using stem cells that grow upon it to strengthen the vein walls? 2) Read about "free" estrogen and testosterone being elevated in people with varicose vein problems...

Levester_Kirksey,_MD: There are many exciting treatments for patients with diseased veins that can be quite disabling to patients. Also, collagen tubes impregnated with stem cells are creating blood vessels that can be used in various types of arterial blood vessel reconstruction including the treatment of heart and peripheral blood vessel disease.


Aortic Aneurysm

bobrenzi: It was first brought to my attention through a Cat scan that I had a lightly larger than normal thoracic aorta is aneurysm in 2008 around 4.2 cm. I have had an MRI in 2010 and 2011, my upper aorta measured 3.7 both times. The doctors at UPMC Aortic Center in Pittsburgh said that I do not have an aneurysm, only a mildly dilated aorta. They recommended to have another MRI in 3-5 years, and if there is no change, then not to have any more. Would you be in agreement with this diagnosis? I am an active 66 year old man who is 6'2", 180 pounds and in overall good physical condition.

Levester_Kirksey,_MD: I am not certain what is responsible for the discrepancy of two measurements in 2008 and 2011. In general, the natural history of aneurysms is variable but they tend to grow 2 - 3 mm per year. It seems appropriate to repeat your imaging study in 2 - 3 years to determine if any growth has occurred. Additionally here at Cleveland Clinic we are very interested in the genetic aspect of aneurysm development and I would encourage you to seek a genetic predisposition to family members. Specifically aneurysms tend to run within the male side of families if there is a genetic component and in your case, I would recommend that if you have brothers, uncles they should be evaluated for the presence of abdominal or thoracic aneurysm. We would be happy to see you here in our Genetics program or Aorta Center.

gm3: What happens when you have an AAA stent in place and the Aneurysm Sac continues to grow and eventually bursts? Also, if embolization of an Enodleak II on a lumbar artery is not possible via transarterial or translumbar procedures, can a clip be placed on the artery to stop the leak or back pressure into the Aneurysm Sac? In repairing an Endoleak II, which type of embolization, glue or wire, is the best type of repair?

Levester_Kirksey,_MD: The goal of endovascular exclusion of an abdominal aneurysm is to reduce pressure within the aneurysm sac. The most reliable indication that this has occurred is the shrinkage of the sac over time. Continued pressurization of the sac and aneurysm sac enlargement is associated with considerable potential morbidity including aneurysm rupture and death. Multiple options exist for treating various types of endoleaks including type II endoleaks. These include placement of coils or glue by way of intra-arterial catheters or translumbar catheters. These procedures can usually be done with minimal morbidity for the patient. When these treatments are not successful and the sac continues to increase in size, in some cases the stent graft may need to be removed and the aneurysm treated by conventional open surgery. Cleveland Clinic is world renowned for the management of complications of endovascular aneurysm repair including all types of endoleaks and graft explanation.

See recent Aorta web chat transcripts for more information.


Aorta Dissection

XavierC: Hello my name is Xavier, age 27, diagnosed with Marfan Syndrome, already have 2 valve replacements, and now I have a Thoracoabdominal Dissection type B. For 3 months has been controlled with Blood Pressure Meds, I saw one option "endovascular aortic stenting" but my Cardiologist says it won’t last because my aorta walls are too thin. So if surgery needed he's recommending the Open Surgery, I already went through 2. I’m scared of going for number 3. Is this true that that option won’t last? Do I have more options? Thanks so much for reading me. Xavier

Levester_Kirksey,_MD: The treatment of dissection and aneurysm pathology in patients with Marfan syndrome is constantly evolving. It is dependent upon the anatomy and the extent of the dissection or aneurysm and the underlying medical condition of the person suffering from the problem. In some patients endovascular treatment is quite appropriate and may provide a durable result or a bridge to future treatment. I would recommend seeking a second opinion. We have a large experience in treating connective tissue disorders like Marfan Syndrome and tailor the approach to both the patient's anatomy and the patient's ability to undergo operation.


Mesenteric Venous Dilatation

Kathy W: Hello: I have suffered with constipation for no apparent reason for the last 2 years. After much persistence, it was revealed on a venagram last week that I have "dilation of the superior mesenteric vein" Is there any information that the 2 could be associated? Also I understand from my surgeon that if it gets larger surgery may be needed but there is little information about this diagnosis and it is very rare. Can you make a suggestion of where to seek medical attention. I live in Buffalo NY, but will travel anywhere to seek the proper medical attention.

Levester_Kirksey,_MD: Mesenteric venous dilatation or aneurysms are uncommon and the association with chronic constipation is unclear in your description. At Cleveland Clinic, Vascular Surgery Dept., we are able to treat venous aneurysms by both minimally invasive and open surgical approaches, depending upon their size, location and symptomatic presentation. We would be happy to see you.


Hemodialysis

myosick: For catheter-dependent patients, what are your thoughts on receiving the HeRO Graft for hemodialysis and no longer being catheter-dependent? What has your experience been with the HeRO Graft in your practice, and what difference has it made in your patients' lives that were catheter-dependent?

Levester_Kirksey,_MD: The HeRo graft represents one option for catheter dependent dialysis patients. I frequently see patients referred for catheter dependence and begin the evaluation from point A starting all over. In doing this I find that many catheter dependent patients have other surgical options including chest wall dialysis access and lower extremity access.


Vascular Dementia

lori0430: My mom is 72 with vascular dementia. A shoulder injury (2 tears on labrum) required surgery to eliminate pain (not my idea). Now this orthopedic doctor is "not happy with the results" and feels she needs to go under anesthesia again to improve mobility of her arm. She is not yet totally dependent and still lives on her own. We are concerned this procedure is not necessary and she is being taken advantage of. We believe other options are available, but Dr 'Arrogant' is too snippy to guide us. My questions: does a vascular dementia person have a greater risk going under anesthesia? Her post operative cognitive dysfunction was remarkable after the May surgery, so couldn't this be even more serious so soon after? Shouldn't the shoulder be given more time than 3 months to heal for a 72 year old? Thank you so very much. Lori Armstrong

Levester_Kirksey,_MD: Hospitalization of patients who have baseline dementia can exacerbate the condition by way of the stress of illness and the unfamiliar surroundings of the hospital environment. In this particular situation that you describe I would suggest having a heart to heart discussion with the surgeon to explain your concerns. It is true that it is likely that she will have the same postoperative experience and it may actually be worse because of the short period of time between interventions. If you are concerned a second opinion is always warranted.


Erythromelalgia (EM)

boninarias: What is Dr. Kirksey's understanding of Erythromelalgia (EM) and how can this condition be supported by the vascular disease interventions he has been working on? Thank you.

Levester_Kirksey,_MD: Erythromelalgia can manifest as either a primary or secondary condition. Patients generally experience severe burning or pain commonly of the upper or lower extremities within the hands or feet. The exact underlying pathophysiology has yet to be definitively determined. It is believed that EM is a neuropathic condition related to nerve pain and small vessel vasospasm. To date common medications used to treat EM include lyrica and calcium channel blockers. Our vascular medicine team, including Dr. Gornik, has extensive experience in treating such vasospastic conditions.


Hereditary Hemorrhagic Telangiectasia (HHT)

vegC81: I had an angiogram done and they confirmed that I have an AV malformation/hemangioma on my left upper lobe of the lung. They found it on a CT scan because I was admitted into hospital for a blood clot in left eye, high blood pressure, high temperature, rash on chest and face, migraine and weak left arm. After tests and hospital and appointments after appointments I was told they would like to leave the large mass in the lung because I developed the rash on my chest while I was seeing the cardio surgeon for a check up. They suspect HHT, which is connected with the lung hemangioma and they now want to watch it and scan it every 6 months. Should I have it out, go and see another doctor, or wait 6 months for the next appointment?

Levester_Kirksey,_MD: This seems like a very complex and challenging problem that you have. Cleveland Clinic has a program that is a center of excellence for HHT. Please contact Dr. Parambil for an appointment or second opinion.


Cerebrovasular Disease

yogij: I am a 57 year old female w/ a right nasal arteriovenous fistula supplied by the right internal maxillary artery, facial artery and lacrimal artery arising from the right opthalmic artery w/ a single draining vein through the facial vein. It was embolized in 2010 at Cleveland Clinic but has returned. I am considering surgery but few surgeons have experience w/ AVMs. Do you do this type of surgery? If not, how do I proceed with finding a competent vascular or microvascular surgeon? What questions do I ask to determine the best course of treatment? Obviously, I am concerned about the integrity of the right opthalmic artery.

Levester_Kirksey,_MD: It is not uncommon for AVMs to recur. In my opinion, I would return to the team that previously treated you. They are very experienced in the broad range of treatment options for AVMs.

James2576: Hi my names is Jamshed and I belong to Pakistan. My 4 yrs old daughter have been diagnosed for AVF (Pial Fistula). Doctors said embolization can be cure. I want to ask that after successful embolization my daughter's normal life will be come back I mean to say she can play soccer / running / jumping can go to joyland and enjoy the life like other normal children do. Second thing, after successful embolization has she need to take any medicine for the rest of her life. More importantly is there any chance that embolic agent can be failed after two or three years because any foreign object in brain can be resisted by self mechanism immune system of body. Please address my fears. Thanks.

Levester_Kirksey,_MD: The neuro surgery program at Cleveland Clinic has extensive experience in treating arteriovenous fistula of the brain and I would suggest you contact Global Patient Services to be connected to a specialist there for a second opinion.

smc212: I am confused but apparently you offer advice on surgery for TN. Do you do surgery for GN, geniculate neuralgia? That is compression of the intermediate nerve, requiring decompression of cranial nerve 5, 9 and 10 plus sectioning or cutting of the intermediate nerve. Will this resolve deep ear pain, bitter taste, and facial pain?

Levester_Kirksey,_MD: This would best be answered by a specialist in neurology.


For more information on cerebrovascular conditions:

Reviewed: 08/13

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