Ask the Vascular Surgeon (Dr Clair 4 27 11)
Wednesday, April 27, 2011 - Noon
Daniel Clair, MD
Chairman and Vascular Surgeon, Department of Vascular Surgery, Miller Family Heart & Vascular Institute
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. Understand when you should seek the help of a vascular surgeon and have your questions answered during our free online chat with Dr. Daniel Clair, Chairman of Vascular Surgery at Cleveland Clinic.
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Cleveland_Clinic_Host: Welcome to our "Ask the Vascular Surgeon" online health chat with Daniel Clair, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today! Thank you for joining us, let's begin with the questions.
Dr_Daniel_Clair: I am sorry for the delay. Let’s begin with the questions.
Carotid Artery Disease
BernieM: Can you tell me about the difference between carotid stenting and carotid surgery,. My dad needs carotid surgery and I was looking online and found info about the stent? Is that a better option? No surgery?
Dr_Daniel_Clair: Carotid stenting involves a puncture in the groin through which a stent is delivered to carotid artery. The stent pushes the blockage or plaque out of the way and can reduce the risk of stroke long term. Carotid surgery performed through a small incision through the neck removes the plaque completely and reduces the risk of long term stroke.
For both procedures the hospitalization is one night and recovery is short. In randomized comparisons of the two procedures there is a slightly higher risk of stroke with stenting when compared to surgery in healthy individuals. There is a slightly higher risk of heart attack with surgery. Most clinicians would recommend carotid surgery for those who are healthy as the primary goal of this procedure is to reduce the risk of stroke.
Meghan: My mom was having some numbness on and off in her right arm - she went to the doctor and they found she has 89% blockage on the left carotid and 74% blockage on the right. What are the options for her?
Dr_Daniel_Clair: Depending on your mom's age and health status, either carotid surgery or carotid stenting will be best option to reduce the risk of stroke both short and long term. IF the presumption is that the symptoms of arm numbness are due to the carotid artery narrowing (I would assume the two are linked) then she should be treated as sooner rather than later - preferably within 2 weeks of the event, as her risk is much higher during this timeframe.
SandyKI456: My husband is going in for a carotid endarterectomy next week. Can you tell me about the after care - what to expect in recovery. Also - how do you prevent this from happening later - do they put you on certain meds?
Dr_Daniel_Clair: The recover from carotid surgery should be very brief and fairly easy. The surgery is not very debilitating at all. Most people are back to regular activity within a week. The recurrence rate is extremely low (about 5% over 10 years) but the other carotid artery remains at risk. Therapy to reduce the risk of atherosclerosis should be initiated. This would include blood pressure control, Cholesterol lowering, diet modifications, regular exercise, stress reduction, adequate sleep, attention to dental hygiene and a number of things that are not always thought of, have methods to reduce overall heart and vascular disease risks.
RobbyS: My mom was diagnosed with a 4 inch blood clot in her leg - she was put on Coumadin and I wonder why they can't go in and take it out. When do they go in and take out a blood clot? It makes me nervous that it is in there.
Dr_Daniel_Clair: Blood clots in any blood vessel can be treated with clot-dissolving medicine. This treatment has risk of bleeding associated with it. If the size of the clot is small, it’s probably safer to treat with blood thinner. If clot is large then dissolving would be a better therapy. Size varies depending on the location of clot. You should with your doctor to determine what option is best suited for your mother.
Joyce: Hi my sister had an accident last year and has been having symptoms of pain and numbness in her right arm since. I looked on line and saw this could be a symptom of thoracic outlet syndrome. When looking at the website - it seems she could be evaluated by several types of doctors - but where does she start?
Dr_Daniel_Clair: This could be symptoms of TOS. It could also be a cervical spine injury, shoulder injury or local nerve trauma. The best place to start would be with you primary care physician. For people who are suspected of having TOS an evaluation by a vascular surgeon who treats this regularly would be best.
MATT: I am a 30 year old male. When I was younger I was an athlete, played sports. I started having terrible pain in my calf - like terrible. It makes my legs tired and sometimes I have numbness in my foot - in that leg. Wondering if it is a vascular problem.
Dr_Daniel_Clair: This could be a vascular problem, there are several entities that affect young individuals' blood vessels in the leg, including popliteal entrapment syndrome, cystic adventitial disease and some other disease processes. This could also be a musculoskeletal or a neurologic issue, a vascular surgeon could do a fairly simple work-up to asses for a vascular cause.
help1: My mother been thru vascular surgery for her legs but now has more pain than ever so they gave her more test and had her come in for some more surgery when she got there they said they were not able to do anything for her and that her. Basically doctor has no answer etc can you please help me?
Dr_Daniel_Clair: We see a lot of patients who have been offered no option to save their limbs or improve their ability to walk and have been able to help them. There are number of skilled vascular surgeons here who I am sure will be able to provide some assistance. We also have programs for people who have no operative options that involve medical therapies to aid in these situations.
Sharon: I have large varicose veins - when do you see a surgeon for varicose veins?
Dr_Daniel_Clair: Varicose veins almost never life threatening. They can however ache, itch, burn, cramp throb When they are unresponsive to conservative measures (compression stockings) they can now be treated by a number of minimally invasive means. If your veins are causing you symptoms like these this might be time to seek an opinion by vascular surgeon who treats these regularly.
Arteriovenous Malformation (AVM)
Kay: My 93 year old mother has an arterio venous malformation in her skull, diagnosed by .dr. Sila at Cleveland clinic many years ago. Mom is very healthy, however, she now has blocked carotid arteries, more than 75 percent, both sides. She will have MRI and MRA done, but she is against having surgery. Would she be a candidate for surgery, first of all, and if not, how to manage? Thank you on her behalf.
Dr_Daniel_Clair: With your mother's age and confounding factor of her arteriovenous malformation, I would be very hesitant to recommend any therapy for her carotid artery narrowing. This narrowing does pose some risk of stroke, but that risk is relatively low and I am not sure she would gain tremendous risk reduction benefit by treating the carotid artery narrowing.
Klippel-Trenaunay Syndrome (KTS)
Muhammad: What would be the treatment for "Klippel-Trenaunay Syndrome" which is associated with de-shaped lumber vertebrae and painful knee and hip joint.....?
Dr_Daniel_Clair: KTS is an abnormal collection of veins in an extremity, combined with port-wine stain. The vascular component to this problem can often be treated with minimally invasive means. If the venous problem is severe enough it can affect the knee, the hip or other aspects of the limb and in some instances treatment of the malformation will improve these symptoms. Means of treatments may include sclerotherapy or laser ablation or some combination of the two. As this is an unusual condition you might want to make sure has dealt with numerous times before. We have several physicians who have a broad experience in dealing with KTS.
Inferior Vena Cava (IVC)
Gerri_L: I was told I have a 100% blockage of my IVC - and that there is no treatment for that. Is that true? What does this mean?
Dr_Daniel_Clair: Your IVC drains the majority of venous blood from your lower body back to your heart in some situations that can mean complete blockage cannot be treated because of scar or other problems. We have seen a number of people who have this problem and have been able to help them. Many times the treatment for this can be provided through minimally invasive means.
Superior Vena Cava (SVC)
Kevin_J: My grandfather has lung cancer and was just diagnosed yesterday with SVC syndrome. Can you explain that to me and what his options are for treatment.
Dr_Daniel_Clair: SVC syndrome is a blockage of the superior vena cava that leads to head and arm swelling. IT can be very dangerous as it can lead to brain swelling as well. The treatments for it vary, depending upon the cause. If this cause is related to the cancer, then the treatment should be aimed at the tumor, if the cause is related to the scar in the vein then the treatment should be aimed at opening the scar to get normal flow through the vein. Sometimes a combination of treatments is necessary to correct the problem.
TKM: Hi. I was having terrible high blood pressure and my doctor sent me for a renal artery scan and found I have renal artery stenosis. I am going to the doctor for the appointment next week and wonder what the treatment is for this.
Dr_Daniel_Clair: renal vascular hypertension or narrowing of the kidney arteries that leads to high blood pressure is most often currently treated with renal stenting, however, the use of this currently is somewhat controversial as there are several studies that have not documented sustained benefit over medical therapy. An additional non-invasive test would be in order before even considering any therapy to treat the renal artery narrowing.
josik98: If a patient is experiencing Aortic Stenosis, Mitral damage, and A-Fib. He is 76 yrs old and all of these are life-long problems, we believe coming from infant rheumatic fever. He is fit enough for a sternotomy. Do you offer any advisable minimally invasive procedures either during the same operation or relatively close together in time that would correct these three conditions?
Dr_Daniel_Clair: This problem would be better dealt with a cardiac surgeon rather than a vascular surgeon. I think there are procedures that can help with all three conditions. Hopefully if this patient is being referred to surgery, hopefully his surgeon will discuss with him.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Clair is now over. Thank you again for taking the time to answer our questions about vascular surgery.
Cleveland_Clinic_Host: If you have additional questions, chat online, by phone or through email with a Heart and Vascular nurse.
Dr_Daniel_Clair: Thanks for having me.
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