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Ask the Vascular Surgeon (Dr. Srivastava 9/21/10)

Tuesday, September 21, 2010 - Noon

Sunita Srivastava, MD
Vascular surgeon in the Department of Vascular Surgery in the Sydell and Arnold Miller Family Heart & Vascular Institute.


Vascular Surgery is used to treat a variety of vascular diseases including arteriovenous malformations (AVM), carotid artery disease, carotid body tumors, iliac and renal artery disease, peripheral artery disease and aortic disease. The surgical treatment of these diseases ranges from catheter-based intervention to traditional surgery for aneurysms and obstructive arterial disease. As a large referral center, Cleveland Clinic vascular surgeons perform over 5,000 procedures a year. Dr. Sunita Srivastava, a Cleveland Clinic vascular surgeon answers your questions about vascular disorders and their treatment options.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Sunita Srivastava. We are thrilled to have her here today. Thanks for joining us Dr. Srivastava, let’s begin with the questions.

Dr__Srivastava: Thank you for having me today.

Arteriovenous Malformation (AVM)

Pam_K: At birth, diagnosed with hemangioma. Condition has caused AVM of the right leg and foot - goes into right buttocks and into right lower back. Leg malformed - excess tissue /swelling. Use 40-50 compression stocking, swim laps 3X week, elevate leg, take ibuprofen as needed. As adult - feel I may have klippel trenaunay syndrome. Now 51 years old. Foot stepped on this summer - had 3 bone fractures in right foot. Podiatrist said blood flow causes weakening of bones. Bones strong in 6 weeks - no weight bearing. Incident caused me to want to verify condition in case there are other things I need to know. I lead an active life / hope I would not need to spend a lot of time testing, but to diagnose and have treatment plan to help me to manage / prevent future complications. Some imaging was completed in the 90's in the form of Cat Scan. I did have an MRI of the foot as a result of the summer trauma which also caused (I think) a callous to become infected. This image is the most recent imaging completed. Please advise me as to whether or not you think it would be beneficial for me to come to  Cleveland Clinic regarding this condition.

Dr__Srivastava: An MRI of your pelvis and right leg should be performed to assess your superficial and deep venous drainage. There are syndromes where the bones can weaken due to avms and KTS (Klippel Trenaunay Syndrome) is one of them. A full MRI can evaluate the flow pattern and may provide information about how extensive the avm is and if there is a feeding vessel that may be amenable to catheter based therapy to plug or embolize it and limit growth of the AVM over time.

dukefan55: I have a dime sized AVM in my brain that was discovered 15 yrs ago. Should I be doing any follow-up on this and I am going to have aortic valve replacement and aneurysm repair and I want to know if this will put me at higher risk when I have that surgery? Thanks for taking my question.

Dr__Srivastava: A current or recent CT scan of the head would help establish the current size of the AVM as this may dictate treatment before cardiac surgery. If the AVM has grown there is a risk of rupture and bleeding warranting treatment. Regardless prior to major surgery involving general anesthesia an assessment of the intracranial AVM should be performed.

rdcorns1: I had surgery for an AVM 28 yrs ago. I have memory loss and seizures. In the past year I have had atrophy of my left side. My neurologist said the atrophy is coming from the surgery but cannot tell me how this might progress. I can't have an MRI due to the clips in my brain. Do you have any thoughts on my condition? Thanks!

Dr__Srivastava: A CT scan of the brain would be helpful to establish your prior resection and also what blood vessels have been impacted by your past surgery. A consultation with a neuro interventionalist may provide you with a future prognosis given your previous surgery.

Celiac Artery

Olivia: My husband suffered a spontaneous celiac artery dissection in May. There was no damage to any other artery aorta. He has been put on Coumadin. A scan was done 4 weeks later that showed no improvement. He continues on the blood thinner and is scheduled for another scan the end of October. We understand this is a rare occurrence and want to know if this course of action is the right protocol. Our vascular doctor initially suggested waiting 6 months for a scan but our family doctor requested 3 months for follow-up scan. Our questions are: How rare is this condition and is this the correct protocol? How likely is it the dissection will heal and will it be compromised and unstable forever? What surgical procedures are there, if any, and has your hospital done any? With what outcomes?

Dr__Srivastava: Spontaneous dissections are rare and can be associated with hypertension, collagen vascular disease and fibromuscular dysplasia. If your husband did not/has not had any abdominal pain or changes in eating, conservative therapy is usually the first line treatment with BP control and anticoagulation. There are no studies evaluating treatment of these dissections with open or endovascular(stent) therapy because each case is different and assessed based upon extent of dissection (localized vs diffuse), involvement of branch vessels, false lumen natural history (expansion vs regression vs no change), and rate of change. A CT scan in the first year should be at 1 month, 3 month, 6 month and probably yearly thereafter. You should have 1 physician ordering the CT scans as the exposure to radiation and contrast is cumulative and should not be taken lightly. Arterial duplex (noninvasive ultrasound) can also be used to evaluate size, flow and extent of dissection.

OliviaHolly: Olivia: In regard to my earlier question, what surgical options are there if it doesn't heal and has Cleveland Clinic done any of these types of surgeries and with what outcomes?

Dr__Srivastava: Treatment of the dissection is determined based upon location of the dissection, the branches of the blood vessel involved, and any growth in the dissection.

Blood Clots

LeannH: I am a 67 year old female. I had shoulder surgery--total right shoulder replacement--on June 14. Soon thereafter I developed unilateral swelling of the right leg. The surgeon ordered an ultrasound to check for blood clots. None were found. To me, the leg looks swollen 24/7. My primary care physician would not consider a blocked lymph node. I don't know why. He ordered an MRI which showed decompressed discs and spinal stenosis. Based on that he is sending me to a neurosurgeon. What little reading I've done tells me that lymphedema and symptoms always seem to include pain. I don't really have "pain" with this leg swelling. I would call it minor discomfort. The leg is considerably bigger than my left; especially around the ankle and toes and going up into the calf area; not red or warm to touch, however the skin is very shiny and a little scaly--dry skin has appeared recently, and the skin is getting more and more mottled. So can you help with some feedback, or suggest: reading materials, and also, what kind of doctor do I see? Thank you very much for any info and help you can give me. Leann Hillmer

Dr__Srivastava: The decompressed discs and spinal stenosis will not cause unilateral leg swelling. This is more commonly caused by a blood clot which may not have been detected on the first ultrasound - or lymphedema. A thorough venous ultrasound examination would be indicated. If this is negative an MRI of the leg can distinguish between blood vessel abnormalities and other conditions that may cause swelling.

realgrl: I had a broken ankle about 4 months ago. I then had swelling in my calf and pain and my doctor diagnosed me with DVT. He put me on coumadin. He has done checks and I don't think the clot is going down. Is that ok - can you live with a clot that is chronic or should it be removed some other way if the coumadin is not working. My swelling has decreased and the pain is gone - but the tests show that it is still there.

Dr__Srivastava: while the blood thinners may prevent the clot or DVT (deep vein thrombosis) from getting larger or traveling, it is not uncommon to have residual clot in the vein. Pain and swelling after a DVT is typically treated with compression stockings and elevation. If there is massive swelling, particularly in an early DVT, minimally invasive therapy with the delivery of clot busting medication to the vein and mechanical suctioning may alleviate the clot burden and post DVT symptoms.

Carotid Artery Disease

epittman: what determines whether an endarterectomy or a stenting procedure is done for a carotid artery blockage?

Dr__Srivastava: Open vs. minimally invasive procedure for carotid stenosis depends on several factors. They include:

  • Characteristics of the blockage such as blood clot, plaque, calcification and tortuosity of the blood vessel which may favor one option vs. the other.
  • Your overall cardiovascular risk may make one option better than the other.
  • Symptomatic and asymptomatic blockages can also impact on type of therapy.
  • Your age may also play a role in dictating a better treatment option.

Baird: How do I find the top surgeon for an endarterectomy or stent treatment in northern California. Also, is the use of a stent a satisfactory treatment for a blocked carotid artery? Blockage is about 80%.

Dr__Srivastava: You can find a vascular specialist by logging into the Society of Vascular Surgery website Stent vs open surgery really depends upon the nature of the blockage and symptoms…is there clot, or calcium that may make one therapy better for you.

Second, it depends on your overall health. Some patients are better with stenting because of severe coronary disease or other risk factors that make a minimally invasive approach less stressful on the body.

epittman: How long before normal activity can be resumes after carotid artery repair surgery is performed?

Dr__Srivastava: Most patients can resume activity within 48 hours and drive after 2 weeks.

epittman: What tests need to be performed prior to having carotid artery surgery?

Dr__Srivastava: A carotid duplex scan in an accredited vascular lab and possibly a CTA of the neck are the most common imaging studies performed.

clmk09: How narrow does the carotid artery need to be to intervene?

Dr__Srivastava: For symptoms (TIA or stroke) any level of blockage may require intervention depending upon the lesion in the carotid artery. For asymptomatic carotid diseases (no stroke or temporary symptoms) usually 70% and above

epittman: In stenting for a carotid artery, what determines whether tube is inserted through leg or arm?

Dr__Srivastava: Carotid stenting is typically done through the femoral artery in the groin.

epittman: How does one find out OUTCOMES of specific procedures at a given hospital and by a specific surgeon?

Dr__Srivastava: The CMS (Medicare) website and Googling best hospitals for carotid stenting will provide you with some data. Our annual outcomes book is online and contains data regarding Cleveland Clinic's outcomes with respect to carotid stenting and surgery.

Peripheral Artery Disease (PAD)

Joe_N: I recently had a ABI and Arterial Ultrasound of the lower extremities with abnormal results. The post exercise Ankle pressures. were very low The ABI at 1 minute was 0.25 (R) and 0.31 (L). The impressions were as follows: 1. Monophasic waveforms seen in bilateral external iliac artery suggest more proximal aortoilliac disease 2. Severe (>75%) peripheral vascular disease of the right mid-superficial femoral artery 3. Mild to moderate (50-75%) peripheral vascular disease of the right proximal popliteal artery 4. Moderate (50%-75%) peripheral vascular disease of the left mid superficial femoral artery. 5. ?? Short segment occlusion, indicating possible severe peripheral vascular disease of the left mid superficial femoral artery. Question: Do you perform Percutaneous Transluminal Rotational Atherectomy? Do you perform Cutting Balloon catheter. I am trying to avoid bypass surgery of my legs. I had CABG X 5 in 2001. Thank You

Dr__Srivastava: It would be helpful to know if you have pain when you walk, pain in the foot with it up or tissue loss (nonhealing wounds in the legs. Your us suggest multilevel disease of which some can be treated with balloon and stents. You may not need atherectomy. The choice of tools for minimally invasive therapy are vast and what may work best for you depends upon your symptoms and your angiogram (dye test) to identify the critical blockages that need to be treated. I would see a vascular surgeon.

smithk: I have PAD both legs with a left femoral artery aneurysm. Is it possible to have a rupture in my aneurysm? What do they do for peripheral aneurysms? When do they decide to treat them?

Dr__Srivastava: The risk of aneurysms include: growth with potential for rupture; thrombosis or clotting off; and embolization or breaking off pieces of clot. Aneurysms are assessed for size; amount of clot; and symptoms.

When the aneurysm size is twice that of the normal vessel, surgical therapy is recommended. However, if there has been rapid growth, embolization with impairment of your circulation, more emergent therapy is needed.

Cleveland_Clinic_Host: Dr. Srivastava, during the Peripheral Artery Disease chat with Dr. Gornik, there were a few questions that were deferred to today's chat. Can you please answer the following questions submitted?

Dr__Srivastava: There is no surgeon specific data in any informational source.

TWILLIAMSLMSW: My father was evaluated on 09/13 for angioplasty. However, this will not be an appropriate option. It appears that the "by pass" is the next plan of care. Are there any specific questions that we should ask the physician regarding any other options? plans of care? if he receives the bypass ...what is the typical hospitalization? recovery? He also is dx with polycythemia. He is a currently pharmacist working prn.

Dr__Srivastava: The consultation with your vascular surgeon should include a conversation with respect to hospital stay, post operative activity instructions, and risks of surgery. These are dependent upon the individual patient, extent of surgery, and other medical risk factors. Most patients with a simple bypass are in the hospital from 3 to 7 days. Early ambulation is encouraged.

555pol: what can be done for a 100% blockage in a right leg artery?

Dr__Srivastava: Options depend upon the location of the 100% blockage and the existence of collateral circulation that may provide additional blood flow. If symptoms include pain in the foot and non-healing, the blockage should be addressed.

carolee: My aunt had angioplasty in her leg. She is still having claudication. Does that mean the test was unsuccessful.

Dr__Srivastava: It is possible that the angioplasty has failed and an ultrasound can assess for current blood flow and flow in the angioplastied vessel. If her claudication has improved by allowing her to walk longer distances or with fewer stops then the angioplastied vessel may still be open. Consistent surveillance with an ultrasound is a useful tool to manage patients who have had minimally invasive therapy.

cat12: I have PAD almost no circulation in my legs, Did have a bypass 2 months ago, but no improvements. Does it take some time to feel better after bypass

Dr__Srivastava: If the bypass is successful there should be some improvement in pain and in walking distance. An ultrasound evaluation of the bypass can assess the patency of the bypass. Unfortunately post operative incisional pain, swelling, and deconditioning result in some delay of improvement of the operated limb.

andydoodah: Is the bypass surgery different and more difficult for the right leg than the left?

Dr__Srivastava: There is no difference.

Varicose Veins

alexdan: How is it determined if you have varicose veins? What are the treatments? Non-invasive vs. invasive.

Dr__Srivastava: A valvular incompetency test in an accredited vascular lab will demonstrate if you have superficial or deep venous valvular problems. Compression stockings are typically the initial therapy. For patients who continue to have pain, surgical options include laser ablation or stripping.

ten23: Can you replace the valves in the veins or bypass veins? What do you do if you have bad veins in your legs. I have a lot of pain, in addition, my legs look terrible

Dr__Srivastava: An ultrasound evaluating the deep and superficial veins with respect to valve function, old blood clot, and reflux will be helpful. Medical therapy with compression and elevation is the first line treatment. Surgical options exist for superficial vein incompetency and are typically minimally invasive. Deep valve incompetency is a difficult problem with poor results with open surgery. Leg compression is recommended.

Fibromuscular Dysplasia (FMD)

Edna: I have FMD in my renal arteries and have had 6 renal angioplasties due to this. The interventional radiologist has stated that I may need to have an renal artery bypass at some point. My question is what factors go into the decision to do a bypass compare to an angioplasty?

Dr__Srivastava: Failure from medical and minimally invasive therapy are indications for open surgery. If the kidney function has declined, or the kidney has atrophied and if you are having systemic symptoms from renal artery stenosis, further surgical treatment is warranted.

hockeymom: I have FMD bilaterally in my brachial arteries. I have numbness and tingling in one arm down to the fingers as well as pain and tenderness at the FMD sight, about a 2 inch section. It has been this way since March. Neurology has determined it is not neurological in nature. Can I assume that as my body grows more collateral vessels the numbness and tingling will eventually go away as will the tenderness?

Dr__Srivastava: If you have numbness and tingling from FMD, an angiogram and possible ballooning will help improve the blood flow. We see many patients with FMD and once they have life style limiting symptoms, minimally invasive therapy can improve limb function.

FranS: This is for the Vascular live chat today at 12 noon EST: I have carotid FMD bilaterally and thankfully no dissection. Is it important to minimize the activities that increase pressure in the head or is it contraindicated altogether? For instance; being tipped head down in the dentist chair for long procedures like crown work, tipping your head back in the basin at the beauty shop, doing certain yoga positions that require you to have your head hanging down while standing, I was told about no sky diving, scuba diving, neck manipulations but I'm unclear on the other activities. Thank you.

Dr__Srivastava: Lifestyle limitations from FMD really depends upon the nature and severity of the blockage. A consultation with a vascular specialist to tailor a treatment regimen and guide activities of daily living may be helpful.


CoralM: Hi I will endeavor to explain my predicament. I have Scleroderma [CREST] which I have had for 30 years. I sadly trod on a piece of glass and as a result developed an ulcer. The ending was I had a trans metatarsal amputation. I have recently developed an ulcer on the side of the same foot from a scratch. The treatment here is simply Bacitracin ointment which doesn't help at all!! and next step amputation of my leg below the knee. There is a program in which I hope to be accepted into which is a simple blood pump and a peripheral access device, they have had a lot of success with. My ulcer is ischemic arterial and I believe the most difficult to heal. Hoping to hear from you regarding this. I am 70 but very active and the thought of leg amputation is very scary. Kindest regards

Dr__Srivastava: A roadmap of your circulation with a CT scan or diagnostic angiogram may help identify the level of blockage that you have and dictate minimally invasive therapy such as ballooning or stenting. If you have small vessel disease from your scleroderma, expectant management with excellent foot care, podiatry consultation, and avoidance of trauma will help avoid amputation.

The vascular pump is an excellent tool for people with small vessel disease to help with local blood flow for ulcer healing.

Inferior Vena Cava

Jodie_D: Seeking advice on cement leakage from vertebroplasty, into inferior vena cava; I am looking for a second opinion on how to approach this. I would like to have a venogram study done there if possible Have any doctors there seen this before?

Dr__Srivastava: A CT scan of the abdomen and pelvis with contrast would verify foreign object or material in the IVC and would be less invasive.

Thoracic Outlet Syndrome

chmnG: my nephew had surgery for TOS when he was around 16 and now 10 years later is complaining of swelling and numbness in his arm and pain sometimes. I think he needs to see a vascular surgeon again - could this be TOS?

Dr__Srivastava: Thoracic outlet syndrome (TOS) is a general term used for compression of the artery, vein or nerve in the arm or chest. Your nephew may be experiencing symptoms of continued altered flow in the artery or vein despite his surgical decompression (removal of the bone). An assessment of the blood flow in the artery and vein will help determine if his symptoms are from scarring, clot and continued abnormality in the blood vessel.

Subclavian Steal

blueee: Do you treat subclavian steal? I am finding a surgeon who treats this as I believe it is rare?

Dr__Srivastava: Subclavian Steal can be successfully treated with minimally invasive stenting and is not uncommon. A consultation with a vascular surgeon is highly recommended and we have vascular surgeons at Cleveland Clinic who have extensive experience in treating subclavian steal.

Mesenteric Artery Ischemia

smithM: I have had abdominal pain after I eat for about 5 months now with no idea of what was causing it. Finally a doctor told me that I have mesenteric artery blockage which is causing the pain. He suggested I find a surgeon who has experience with stenting this area. Can you tell me about your experience at Cleveland Clinic? I think I need this done pretty soon. Is that possible?

Dr__Srivastava: You have mesenteric angina. The first line treatment for this is typically an angiogram and stenting. The vascular surgeons at Cleveland Clinic are very experienced with this entity and treatment.

Popliteal Entrapment Syndrome

walkertina: My son has popliteal entrapment syndrome with fem pop bypass. Do you have a surgeon with this experience? Can you tell me what the long term care is of this condition?

Dr__Srivastava: Popliteal entrapment is a congenital developmental abnormality of the popliteal artery blood vessel at the level of the knee. There are five different kinds and they consist of some abnormal location of the gastrocniemius muscle (calf) or path of the popliteal artery. Surgical therapy depends upon the type of popliteal entrapment discovered by angiogram or at the time of surgery. Sometimes the decompression can be incomplete resulting in return of symptoms. An MRA (magnetic resonance angiogram)or CTA (CT angiogram) are non-invasive diagnostic tests that can assist in determining the diagnosis.

Ulceration of the Ascending Aortic Arch

sammy: I have been diagnosed with an ulceration of the descending aortic arch. My current vascular surgeon is reluctant to repair this and has told me to limit my activities quite a bit which is very discouraging. Can you tell me if this can be treated at Cleveland Clinic? How do I go about having my CT scan reviewed to see if there is something you can do for me?

Dr__Srivastava: Aortic ulceration is common with age and atherosclerotic disease. First line treatment is typically cholesterol lowering medication, blood pressure control, and surveillance of the affected aorta. CT scan is very helpful and we can offer a second opinion evaluation through our online MyConsult service or if you would like to travel to Cleveland Clinic we would be happy to see you.

General Questions

hockeymom: If we have diseases that must be monitored with CT scans, as you mentioned earlier there is a cumulative effect. Is there a maximum number of CT scans in a life time? Thanks,

Dr__Srivastava: Radiation exposure is becoming a national concern in the health care field. A typical CT scan is equivalent to 30 - 400 chest xrays. This depends upon the type of CT scanner used and time of exposure during the CT. We try to limit radiation exposure from CT, angiograms, and xrays by keeping track of the number of tests ordered for a particular patient and utilizing alternative technology such as ultrasound. You should ask for alternatives that don't involve radiation for long term surveillance of a particular disease such as ultrasound.

epittman: What is the aftercare procedure for patients who come to your clinic from out of state?

Dr__Srivastava: We have many patients who come from out of state. We have a medical concierge that assists with travel. We provide instructions, placement in rehab facilities either locally or close to your home, as well as local accommodations for those who want to stay in the area. All postoperative patients are typically assessed by physical therapy for activity limitations and a case worker to assist in finding the safest environment for recovery both locally and in your area.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Srivastava, is now over. Thank you again Dr. Srivastava for taking the time to answer our questions about vascular surgery and diseases.

Dr__Srivastava: You are welcome. Thank you for having me today

Reviewed: 09/10

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