Frequently Asked Questions
Carotid Artery & Stroke and Carotid Endarterctomy (CEA)
There are four major arteries that feed nutrient rich blood from the heart to the brain. Two of these arteries run along the back of the neck, are smaller in diameter, and are named the vertebrals. The larger of the arteries that feed the brain are in the front of the neck and are named the carotid arteries. The carotid arteries are often involved with atherosclerosis (hardening of the arteries) that results in narrowing of the lumen (opening) of the blood vessel and can create a rough surface for the blood to travel over.
Discussion of carotid artery disease must begin with a basic understanding of stroke. Stroke, the third leading cause of death in the United States, should be defined as permanent injury to nerve tissues of the brain. Stroke (the medical term for stroke is Cerebro-Vascular Accident or CVA) can be a result of bleeding into the brain tissue itself, spasm of small arteries that feed nutrients to the brain, or more commonly failure of blood to reach a portion of the brain due to blocked blood vessels. The issue was confused for many years, but now a clearer understanding of how atherosclerosis (hardening of the arteries) results in stroke has been well accepted by the medical community.
Survival of a stroke can leave someone permanently disabled, with loss of function of arms, legs, facial muscles, or speech. The brain has two sides, or hemispheres, with functions assigned to different areas on each side. The ability to move and feel things is located along the outer surface of the brain on both sides. One of the interesting components of stroke is that the nerve fibers from the brain cross as they enter the spinal cord. Thus, injury to the right brain results in left body weakness or numbness, and vice versa. Symptoms of stroke include sudden loss of speech, loss of sensation, loss of movement, loss of vision, in a specific region or ‘side’ of the body. In general, complaints of these events occurring on both sides of the body at the same time (arms, both legs, both eyes) would not fulfil the classic ‘stroke’ pattern.
The most common form of stroke is ischemic in nature (not enough blood to an area of the brain for too long a period of time) and results from sudden occlusion of the branch artery that feeds blood to the outer portion of the brain. The most common artery involved with this sudden occlusion is known as the middle cerebral artery (MCA), which is the major branch of the front neck artery, called the internal carotid artery. Ischemic stroke occurs when a piece of the diseased portion of the artery ‘upstream’ from the brain breaks off and travels downstream to the smaller blood vessels (embolus) until it gets stuck (impacts) and stops blood from flowing to a particular portion of the brain. The diseased portion of the artery can be part of the material of atherosclerosis itself (called plaque-pronounced ‘plack’) or collections of small clots that form on the rough surface of the diseased artery. The main component of these small clots is often a circulating blood component known as the platelet.
Sometimes the ‘clumped’ platelets will impact into the MCA and result in symptoms of stroke, but just as suddenly will break up and circulation to the brain will be restored. These events when symptoms of stroke come and go quickly are called transient ischemic attacks (TIA’s). These are warning signs that a major disabling stroke may be imminent. People who have a transient ischemic attack have a 10-15% chance of having a major disabling stroke within 1 year, and then a 3-5% per year chance after that. Thus, the risk of stroke in these patients can be as high as 20-25% (roughly 1 in 4) in three years with treatment by medications alone.
Since there is no way to replace or to grow brain tissue in the adult, the best treatment for stroke is prevention. Surgery on the artery, called a carotid endarterectomy, is a way of removing the blockage and the reducing the risk of crumbling plaque becoming an embolus and the rough plaque surface causing platelets to ‘clump’. Medications such as aspirin can reduce the chances of stroke and are advocated for this very reason (They also reduce the risk of heart attacks for the same principles). Nevertheless, recent studies have conclusively demonstrated that medication therapy is inferior to surgery in several instances
The surgical removal of the material inside the arteries at the front of the neck that provide blood to the brain is called a carotid endarterectomy (CEA). This procedure can be performed with the patient awake (local anesthesia) or asleep (general anesthesia). Precautions are usually taken to ensure adequate blood flow to the brain during the operation and may include; the monitoring of brain waves (EEG), keeping the patient awake for repeated examinations, monitoring ‘back pressure’ in the clamped artery, or placing a diverting tube to allow continued blood flow to the brain (shunt). Each method is acceptable, and choice should be determined based upon the surgeon, the patient, and the facility at which the operation is performed. The patient has an incision in the front of the neck along where the artery lies. Further description of the procedure can be found at the VESS website at www.vesurgery.org in the photoatlas section.
The major risks of CEA are stroke, bleeding, heart attack, death, infection, and cranial nerve injury. CEA does prevent stroke statistically, but there is also a risk of stroke with the operation. Stroke occurs about 2% of the time when the artery is operated for the amount of blockage alone, and about 3-5% of the time when the artery is already causing problems such as transient ischemic attacks (see above). This may seem strange that the operation causes the very thing it is trying to prevent, but it is one of the unavoidable possibilities of this operation. The risk of heart attack is real for many of the patients undergoing CEA. The risk of heart attack is not so much from the stress of the operation, as it is having blockages in your carotid arteries is a risk for having disease in the arteries that feed the heart. The incidence of significant bleeding and infection are actually small. Cranial nerves are nerves that control such things as the tongue, the voice box, the face, and swallowing. These nerves can be injured with operation, usually a ‘stretch’ injury. The vast majority of these nerve injuries are partial, not disabling, and fortunately temporary. There are some superficial nerves that can (and sometimes must) be severed to complete the operation. These superficial nerves provide ‘feeling’ to the ear and neck. Patients comment after the operation of numbness or a strange feeling (especially men who shave), but it is very rare for this to be more than minor problem.
The benefit of CEA has been established in two major United States trials in the last 15 years. These trails were established because of the belief by many doctors that aspirin and drugs were superior in the prevention of stroke to surgical operation. These beliefs were put to the test in a randomized, prospective, blinded, multi-center trails (this represents the best form of medical evidence) in both the United States and Europe. The studies results in Europe and the United States had similar findings, in that surgery significantly reduced the risk of stroke compared to medication therapy in certain instances. The risk of stroke and death in three years on medication for a patient having symptoms from the involved carotid artery was 22%, and only 12.3% if surgery was performed (about half that of medication alone). When the carotid artery was blocked by more than 60% even if not causing the patient any problems, the risk of stroke in five years with medications was 11%, and only about 5% with surgery.
- My physician had me go for a test that they ran a probe over my neck. What is that and what is it for?
The most common test used to find blockages in the arteries of the neck is an ultrasound study called a carotid duplex. The study involves having the patient lay still while sound waves are used to make pictures of the artery and find how tight the blockages in the artery are. The test is not painful, can be accurate if in well trained hands. Your physician may have heard an abnormal sound (bruit) while listening to your neck and may have been concerned that it was caused by turbulent (uneven) blood blow that occurs when a blockage in the artery is present.
- I have a blockage in my artery of the neck and have been told that I would do better with an operation. Who should do the surgery?
The training, experience, and number of similar operations performed by a surgeon, as well as the facility, have been implicated in publications as affecting the results of the operation. Vascular surgeons are general surgeons with extended training in the diagnosis, treatment, and operative intervention of vascular diseases, including carotid diseases. Finding a board certified/board eligible (BC/BE) peripheral vascular surgeon will establish that specialized training in this area has occurred. The understanding of ‘specialists’ in this are can be confusing. Currently the following types of surgeons may perform carotid endarterectomy: Neurosurgeons, Cardiac Surgeons, General Surgeons, and Vascular Surgeons, any of which may or may not be board certified/board eligible in their specialty. The United States studies that established the safety record for CEA were based in institutions were many operations were performed, mostly by BE/BC Vascular Surgeons, but on instances other specialists with high volume of this surgery were included. The finding of ‘results’ and comparing them to expectations for hospitals and surgeons can be difficult. Reasonably, a trained and experienced surgeon, performing at least 25 CEAs a year, who has some verification of results, should be available in your area and provide a safe operation.
- I had my artery operated on and they keep sending me to get more ultrasounds. Why?
In a small number of patients, the artery makes to much scar tissue (intimal hyperplasia) as it heals and this blocks up the artery again. Fortunately, these scar blockages (re-stenosis) do not often require another operation. Another good reason to get the ultrasounds is to monitor the artery that was not operated on, which in fact is more likely to require subsequent operation.
- Why can't you put up a balloon in the artery and open it up like they did in my heart?
Carotid balloon angioplasty (balloon in the artery) is in fact a reality, it must be considered experimental! This procedure is done usually from a groin puncture using a local anesthetic. The risk of cranial nerve injury is very low, as is the risk of infection and bleeding. However, the risk of stroke with Carotid Angioplasty is not well established but appears to be somewhere in the range of 8-12+% (compared to 1.8% for CEA for asymptomatic disease and 3-5% for symptomatic disease). There are many physicians now, most not surgeons, performing carotid angioplasty. The results seem to vary from publication to publication and generally do not contain good controls. While published reports for carotid angioplasty have dotted the literature for more than 5 years, and numerous physicians untrained in the medical treatment of peripheral vascular diseases are performing them, there has been no prospective trail to compare the results to standard surgery yet.
The surgical trails for carotid surgery for blockages demonstrated that a low operative risk was necessary to have statistical reduction in risk of stroke. Thus, if the operation can not be done with a low risk of stroke (<3-4% risk) it should NOT be performed as it would be of no ‘statistical’ benefit to patients. It is ludicrous to justify a procedure (carotid angioplasty) with an 8-12% immediate risk and completely unknown later risks, when the risk of the artery causing a stroke is only 11% in 5 years! Therefore, your five-year risk of stroke with carotid balloon angioplasty could very well be MUCH HIGHER than if you were to have just left it alone. Based upon current evidence, it is strongly suggested that consultation with a BE/BC peripheral vascular surgeon to discuss treatment options and to ensure that “informed consent” have been achieved prior to signing any consent for carotid balloon angioplasty. The issues of risk reduction, operative and procedure risks, natural history, and understanding of the national and international trials, are complex and someone with documented specialty training in vascular diseases can make a significant impact on your, as well as families, potential future quality of life. This is not to say that carotid balloon angioplasty should never be performed, but to ensure that the person who undergoes the risk of stroke well understands the risks and benefits (informed consent) of all treatment options.
- How does my brain get blood while your operating on it?
There are several blood vessels capable of bringing blood to the brain while the operated artery is clamped for repair. The majority of patients (nearly 75% or more) will have adequate blood flow even with one carotid artery clamped to prevent injury. Understanding that the rough surface of the disease inside the artery is causing embolus to travel downstream and block up a small channel rather than a problem with the flow itself explains why the majority of patients can have one artery safely clamped during the time for the operation. The brain can receive blood temporarily via a shunt (a plastic tube placed into the artery above and below that plaque) should it become necessary.
We at the VESS hopes this information as answered what may be some of your questions about carotid artery blockage and surgery.
Abdominal Aortic Aneurysm
Abdominal Aortic Aneurysm (or AAA) is a condition where the large blood vessel that runs down the back is enlarged. As this occurs, the wall also gets thinner, placing the aorta at increasing risk for rupture.
- What causes an AAA?
An AAA is usually the result of atherosclerosis, or hardening of the arteries. In patients who get atherosclerosis, one of the body’s first adaptive responses is to enlarge to account for the narrowing that occurs. As further hardening occurs in most blood vessels, the enlargement is minimal and stops, allowing the artery to pregress to occlusion. In patients who develop aneurysms, the aorta does not stop dilating. This is especially so in patients who have the tendancy in their family history.
Cigarette smoking and high blood pressure are essential risk factors in patients who get AAAs.
- Why should I be concerned?
As an aneurysm enlarges, it can rupture with increasing frequency. Half of patients who rupture their AAA never reach medical attention. And about half of those do not survive treatment. The risk of rupture dramatically increases once an AAA reaches 5 cm. in diameter. Here it is around 25% at 5 years. At 7 cm. the risk of rupture is over 60% at 5 years.
- How do I know if I have an AAA?
Your primary doctor may feel it in your abdomen on a routine screeing physical exam. Other AAAs are found incidentally on Xrays or Ultrasounds for other reasons. It also can also show up on a CT Scan of the abdomen.
- Is there any warning of a rupture?
Unfortunately, most AAAs rupture suddenly. A few patients may experience new severe tearing like back pain, but still not yet be ruptured. A patient with a pulsitile abdominal mass, back pain and low blood pressure has a rupturing AAA until proven otherwise.
- How can an AAA be treated?
An AAA must be excluded from the blood stream and pressure. The gold standard is a conventional operation to remove the AAA and replace that part of the aorta. (see one of two Animations of a AAA repair). An exciting new method involves placing a graft right within the aorta with various catheters to exclude the AAA.
- What are the differences in the AAA procedure?
A standard operation has proven durability of 20 plus years with very minimal consequences of longterm problems. It does involve an operation with an open repair that typically can require a 6-9 day hospital stay. For most patients, the operative risk is between two and four percent for mortality. The endovascular repair is still investigational, with the endografts still under FDA Review. While an endograft has the potential to shorten hospital stays to 1-2 days, and shorten recovery to only days, there are some issues to consider. Most centers placing Endografts still are reporting 1-2% operative mortalities around the procedure. This is because of patient risk factors, such as coronary artery disease, that cannot be reduced to zero. AAAs repaired by endografting have not been followed by more than 5 years, and this is only the first few placed. Most centers have at best 2 years follow-up. Even then, all endograft patients require expensive testing every three months to confirm the repair is still good. Endografts have developed delayed leaks (called ‘endoleak’) in up to 15-18% of reported patients. Some endoleaks are treatable, some are not. This has resulted in rupture of the very AAA it was supposed to treat! While this is not common, it remains a long term risk that is poorly defined to those patients with an endograft.
- Which procedure should I have for my AAA?
Any patient needs to talk throughly about the options with the surgeon or team who would do either procedure. At the Jacksonville Vascular Institute, we feel our multidisciplinary approach maximizes your options. We have experience in placing custom measured endografts for AAA, allowing some patients to be treated who might not otherwise have anatomy applicable to the endograt technique. Our surgeons and radiologists are highly trained, continuing our education about new therapies on a regular basis so we can offer the latest and best therapies. For conventional repair, our surgeons have an accumulated experience of over 23 years treating AAAs.
In our opinon, a patient who is somewhat younger with a prolonged life expectancy and good perioperative risk is best served by the proven long term solution: Open conventional repair. However, our team is well suited if a patient has particularly high risk for an open repair to instead treat the AAA with an Endovascular repair. One of our physicians would be able to better answer questions with a face to face evaluation and consultation.
We at the VESS hope this information as answered what may be some of your questions about abdominal aortic aneurysms and their treatment.
Endovascular surgery can be described as the treatment of vascular disease from inside the blood vessel (endoluminal). This basic premise is not new, and easily dates back to the first angioplasty treatment of blood vessels in the 1970’s. Since that time technology has advanced at a rapid pace, and there are numerous ‘endovascular’ options available to patients. Some of the more common peripheral endovascular options include: 1) iliac artery angioplasty/stent 2) Renal artery angioplasty/stent 3) lytic or mechanical clot removal therapy 4) Aortic stent grafts.
- What are the benefits of Endovascular Surgery?
The key component that makes endovascular surgery attractive compared to conventional surgery is usually related to recovery time and patient risk. Endovascular options usually (but not always) have a lower risk than conventional surgical approaches, and usually have shorter recovery times for the patient. Unfortunately, endovascular procedures are often not nearly as durable (stay open or work) as many of the conventional surgical approaches. Therefore, it is intuitive that the risks and benefits of both endovascular and open surgical techniques be considered ON AN INDIVIDUAL basis.
- Who does Endovascular Surgery?
Currently, there are several groups of physicians in some form or another involved in endovascular procedures.
- Peripheral Vascular Surgeons
- Cardiothoracic surgeons
- General Surgeons
- Interventional Radiologists
- Interventional Neuroradiologists
Internal Medicine Physicians include:
- Interventional Cardiologists
- Vascular Medicine Specialists
- Who should do my Endovascular Surgery?
This is a question that hasn’t been answered by the medical field at this time, nor will it be answered in the near future. The best guidelines for qualification probably are based upon the newest recommendations from the major groups that have credential recommendations to perform these procedures and they are the Society of Cardiovascular and Interventional Radiology (SCVIR), Society for Cardiac Angiography and Interventions (SCAI), American college of Cardiology (ACC), Society of Vascular Surgery/International Society Cardiovascular Surgery (SVS/ISCVS). When so many groups have guidelines, and they are all substantially different, it becomes obvious that there will be no easy answers as to which qualified practitioner should perform your specific intervention. The question above is valid, but perhaps as important or more important is “Who should decide when I should have endovascular surgery?”.
- Who should decide when I should have endovascular surgery?
Actually this question is the most important to ask in our opinion. The first intervention into the peripheral vascular system can be the most important in that it can change a relatively innocent problem, or finding, into a limb or life threatening one down the road. Informed consent (the sheet of paper that you sign before the doctor does something) involves not only a discussion about the risks and benefits of a particular intervention, but also a discussion about the risks and benefits of other treatment options. When you ask your physician the questions about those factors they should be able to give an informed/educated answers and discuss the options available for different forms of treatment, some of which they may not perform. To date, there is only one group of specialists that must attain and demonstrate this knowledge to be board certified/board eligible in their respective specialties, the Peripheral Vascular Surgeon (via the American Board of Surgery). While the actual intervention may be performed by anyone from a number of specialties, and perhaps not by the peripheral vascular surgeon in particular, the training requirements for this specialty require an understanding of the options and outcomes for peripheral vascular treatments.
- What is an angioplasty?
An angioplasty is a technique used to dilate a stenosed artery with a balloon catheter. The angioplasty balloon (deflated) is placed across the area of arterial narrowing and then inflated to dilate the blood vessel. This technique has been used in various vascular beds throughout the body, one of the most common is the coronary arteries (heart) and the iliac arteries (arteries to the legs).
- Why did the Angioplasty not work?
Angioplasty treatment depends upon many factors. The narrowed portion of the blood vessel must be accessible to the balloon. The blood vessel must be such that the balloon can ‘crack’ or dilate the substance of the blood vessel. Also, there is a risk of tearing the artery inside (dissection) that can result in acute closure of the artery. The blood vessel after such dilation can have an intense scarring reaction (intimal hyperplasia) that can cause it to scar closed. Also, many vessels in the body react differently based on size and their blood flow capacity. Importantly, continued smoking and tobacco abuse accelerates the intimal hyperplastic response, leading to rapid rates of recurrence.
- What is a Stent?
A stent is a device used to hold open the wall of a vessel or to hold something in place in the vascular system usually with or after angioplasty. These devices are usually metal mesh in nature and are either expanded by angioplasty balloons in place or self-expand when deployed.Their deployment may allow an angioplasty technical failure to be retreived and salvaged. However, there is a paucity of data supporting the concept that stents markedly improve long term patency in peripheral vessels.
- I have an aortic aneurysm and was wondering what the options were for treatment?
There are several options for treatment of aortic aneurysms. Here again, understanding the risks and benefits of the different forms of treatment options are critical. For the remainder of the discussion we will consider aneurysms limited only to the abdomen in the most common configurations, and descending, ascending, and thoraco-abdominal aortic aneurysms will not be included. The options for treatment of Abdominal Aortic Aneurysms (AAA) include:
Observation: The risk of a small abdominal aortic aneurysm (less than 4.5cm) resulting in significant problems is low and in general below this size it is felt that the risk of repair is higher than the risk of the aneurysm. In aneurysms, size does matter, and the risk of an AAA causing problems is dependent upon the diameter of the aneurysm. In general, open repair is an option when the aneurysm reaches a minimum diameter of 4.5-5.0cm. Since patients with significant other medical problems can be higher risk for repair, the size that the repair is less risky than the aneurysm depends upon the patient. Repair of small aneurysms, less than 4.5cm, that are not causing problems or growing rapidly is not indicated by any method. Serial cat scans (CT’s) or Ultrasounds are generally used to follow small aortic aneurysms. If the aneurysm grows significantly (0.5cm in diameter in 6 months, or 1cm in a year), causes pain or other problems, or grows to a diameter that the risk of repair is less than that of the aneurysm, then repair of the AAA is indicated.
Open Surgical Repair: This is the gold standard for treatment of AAA that has indication for repair. The risk of open surgical repair of a AAA includes: Death, heart attacks, limb loss, organ ischemia or organ loss (especially the large bowel), sexual dysfunction in males, bowl injury, embolization, wound problems, graft infections, graft erosions, renal failure/dysfunction. The accepted death rate for repair of an AAA is 2-5%, but can be higher or lower if the pelvic or renal arteries are involved and the extent of involvement of those vessels. Also, a patient’s comorbid conditions can affect the outcome. Follow-up requirements are usually only to bi-yearly or yearly visit to the surgeon who performed the procedure.
Endovascular Repair: Endovascular grafting, via groin punctures or incisions, is the newest treatment for AAA disease. The repair holds promise to decrease the death and complication rate associated with open surgical repair, and to get patients home and back to work quicker. The procedure seems to be a success in getting patients out of the hospital quicker, but has not been shown to decrease the death rate compared to open surgical repair. Unfortunately, there is no long-term data on either FDA (Food and Drug Administration) approved (Aneurex and Ancure) aortic endovascular graft for this repair. Also, there have been troubling recent reports of aneurysm rupture and patient death with these devices in place, and this risk may be increasing the further out from repair the individual gets from implantation. The follow-up requirements for endovascular grafting have not been well established, but seem to require CT scans , plain x-rays (multiple views), and perhaps ultrasound studies, roughly every 4-6 months for the remainder of the patient’s life. Also, there is a continued risk that further endovascular interventions will be needed to keep the grafts functional. While endovascular grafting may be beyond the ‘experimental’ stage of development it exact place in the scheme of treatment of AAA for individual patients has yet to be well delineated.
The person or team who does your abdominal aortic aneurysm, whether open or endovascular, should be capable of dealing with the most common problems that develop with the procedure. The risk of conversion to open operation is between 1-5%, the need for surgical exposure of the groin arteries is nearly 100%, and the risk of complex repair of the femoral arteries is common. Having a board eligible/board certified peripheral vascular surgeon assures that the individual is capable at dealing with the common problems that develop with this technique or an institution with defined excellence in this arena. The patient considering this technique must specifically ask who will treat the most likely scenarios/complications associated with AAA graft implantation. The devices are being implanted by individuals who may not have experience with peripheral vascular disease, AAA treatment, or any specific surgical experience, in a setting (catheterization laboratories without surgical equipment or lighting) were emergencies (aneurysm rupture, limb ischemia, arterial injury, and bleeding) cannot be adequately treated. We personally recommend that anyone considering this alternative for treatment of AAA ask about how these common outcomes will be dealt with.
Lower Extremity Disease
Peripheral vascular disease is also called PVD by many poeple. It is a condition where hardening of the artieries from atherosclerosis affects blood flow to the legs or arms. Depending on a patient’s severity of PVD, it can cause pain or even gangrene of a limb.
- What are PVD symptoms?
Common symptoms of PVD include leg pain during walking, weakness in the legs, numbness or burning in feet or toes when resting, or sores that do not heal on a leg or foot. If some symptoms are ignored, it can progress to gangrene – requiring an amputation. The condition, when in a milder form, can be called intermittent claudication
- Am I at Risk?
Patients at greatest riskare over the age of 50, are tobaccosmokers, have high blood pressure, and do not exercise. A family history of other atherosclerotic problems is also important.
- How do I know if I have PVD?
A vascular surgeon, a specialist in diagnosis and treatment of PVD is the best first stop. A consultation and examination can arrive at a diagnosis of PVD and what is exactly affected. Other testing, such as Non invasive pressures and ultrasound can confirm a vascular surgeon’s impression. Angiography is not for diagnosis, but can guide the route of treatment.
- How can my PVD be treated?
PVD treatment depends on sypmtoms, and the artery or arteries involved. Some patients can benefit from an endovascular approach, perhaps with angioplasty of a narrowed vessel. Other patients may require bypass of a blocked artery to restore normal blood flow. No matter what else, all patients with PVD need nonoperative therapy of the underlying condition – atherosclerosis. Smoking cessation, control of blood pressure, exercise, and control of high cholesterol are essential fundamentals.
- Who can treat my PVD?
A truly thorough approach to PVD treatment is best done by specialists with multidisciplinary experience. Just because a physician treats other problems and symptoms for you, such as your cardiologist for your heart, that may not mean that they are best suited to treat blockages in your legs. Ask your petential treating specialist about other aspects of how he/she can treat your condition beyond the procedure they initially offer. A specialist in PVD or a mutlidisciplanry group who focuses on PVD can offer the full spectrum of therapy. That is our approach here at the Jacksonville Vascular Insitute.
- What if I need an operation?
Most PVD operations involve a bypass. This means placing a new tube to carry blood flow around a blocked artery. If the larger vessels, such as your aorto or iliac artery, cannot be treated with angioplasty (ballon widening of your artery), a piece of artificial blood vessel is needed. These grafts are typically made out of medical grade teflon today. In your leg below the groin, the vessels are smaller, so teflon or plastic grafts do not work as well. The artificial grafts tend to block off on their own quicker. The artifical grafts also carry a higher risk of infection. If a piece of your own vein is available in the leg, this makes the best graft to use. This would be the same vein a cardiac surgeon would use for a heart bypass operation. Other issues of where an incision may go, and recovery times are best discussed with your surgeon.
Angioplasty is one potential treatment for vascular disease and blocked or narrow arteries. An angioplasty is using a balloon to expand and dilate a narrowed or blocked vessel. Not all vessel bloackages are best treated with an angioplasty. The JVI is committed to having the latest in technology that can allow endovascular techniques such as angioplsty to be available to patients.
- How does an angioplasty work?
Angioplasty uses a high pressure ballon of a diameter close to that of the intended target vessel. By expandning the balloon, the atherosclerotic plaque is disrupted and remodeled into a larger lumen. This is done via a catheter and guidewire placed into your vessels. Typical patients can go home the same day if an angioplasty is all that is required.
- Where does an angioplasty work the best?
Angioplasty works best in large vessels with short, even narrowings. As a vessel becomes smaller (as in the smaller vessels in the leg), completely blocked (or occluded), unevenly narrowed, or the lesions become longer, an angioplasty has less benefit.
- How can an angioplasty not work?
An angioplasty can fail immediately by causing a vessel to ‘dissect’, or split on the inside. It also can not break the hardened artery in a way that does not recoil. Over time, an angioplasty can narrow down from scarring on the inside, or from progression of your hardening of the arteries from continued Atherosclerosis. This is especially so if you are a smoker of tobacco and continue to smoke!
- What can be done if an angioplasty is not successful?
Some vessel angioplasties can be salvaged for a good outcome with the placement of a Stent. A Stent is a mettalic mesh frame in the shape of a tube that is of similar size to your actual vessel. This can correct for the dissections that occur. Stents also decrease elastic recoil of the vessel. Stents as a primary mode for angioplasty have not been shown to increase long term patency however. The stented vessel is still subject to internal scarring and progressive hardening of your arteries. Many times a patient who cannot get a satisfactory result from an angioplasty can be treated by a bypass operation
- How come my heart vessels can get an angioplasty, but my leg vessel cannot?
A patient who has a coronary angioplsty is receiving treatment for a different problem – Coronary Artery Disease. Every vessel in your body is a little different. It may be bigger, smaller, in an area with a lot of movement, or more involved with hardeining of the arteries. At the JVI, our caridologists can and do perform coronary vessel angioplasties for many patients. There are also many times where a patient is better served with a heart bypass rather than balloon angioplasty. This can also be the case in treating your legs or carotid arteries.
Hemodialysis is therapy a nephrologist uses to treat a patient’s lack of adequate kidney function. when the kidneys fail, fluid and other body waste products accumulate as they cannot be eliminated in the urine. It is one mode of renal replacement therapy. You may be told that peritoneal dialysis, or renal transplantation or viable options for chronic renal failure, but if your nephrologist determines that you would need hemodialysis, a surgeon must create the access by which you could be dialyzed by.
- What do you mean by hemodialysis?
Hemodialysis takes patient blood and circulates it through a mean to filter out excess fluid and waste before the blood returns to the body. Most patients need 2-3 sessions a week to maintain their state of health. Each session can last from two to four hours, depending on individual condition and the flow rates their access generates
- How do I get hemodialysis?
Patients need a way for blood to be removed from the body to go to the dialysis machince. Then the blood has to be returned to the body. There are temporary catheters inserted into a vein that can be used. More durable modes of access include creation of an ateriovenous fistula (AVF) or with a prosthetic AV graft (AVG).
- Why not just leave the catheter in - like a big Intravenous?
Longterm catheters develop frequent problems that increase over times beyond 2-4 weeks. They can lead to serious infections, central vein blockages, and inability to generate enough flows for the machines.
- "Flow Rate" seems to come up frequently. What is it and how does that matter to me?
Flow rates are how many ccs a minute can be passed through the dialyzer. Good dialysis strives to acheive at least 400ccs a minute. Adequate dialysis can occur with 250ccs a minute. Catheters can deliver 250-350 ccs per minute. Depending on the quality of a patient’s vein used for an AVF or AVG, a surgically created AV access can deliver over 600 ccs per minute.
- What is an AVF?
An AVF (arteriovenous fistula) is where a surgeon connects a small artery to a vein that runs underneath your skin. Over time, the vein then grows larger from the pressure and influence of carrying arterial blood. The vein then can be punctured with needles through the skin so blood can be carried to the dialyzer. The radial artery and cephalic vein near your wrist is a common artery/vein pair that can support an AVF. A successful AVF must develop a vein that is near the skin, and can grow to high flow rates. If an arm’s veins near the wrist cannot support an AVF, one can possibly be created near your elbow. This would then let the veins in the upper arm grow for use. A good AVF can take between 4 and 8 weeks to develop enough for good use. 70-80% of good AVFs are working at one year, and then out to five years for many patients. Because an AVF is natural artery and vein, infection is very inlikely.
- Why might I get an AVG?
Many times the superficial veins in the arm for use as a good AVF have been damaged by intravenous therapy. An AVG typically uses a plastic tube as a conduit placed inbetween a deeper artery and vein. The plastic part lies under the skin, allowing the dialysis staff to place the needles needed. An AVG can be used immediately if it s absolutely required. However, it is best to allow 10-21 days of healing. AVGs have less patency and period of use than an AVF. Only 50% have a 12 month primary patencyin many centers. Secondary patency (after a procedure to salvage the graft) still is around 50-60% at two years. AVGs also can get infected, as the plastic undet the skin is a place an infection can set up in and not be treated except by removing the AVG. Also, the vein that the AVG plugs into can get internal scarring, or intimal hyperplasia. As the vein outflow narrows, the graft can clot off and close up.
- What be done for a clotted or poorly working AVG?
At many vascular centers, a multidisciplinary approach maximizes useful life from hemodialysis access. Interventional radiology physicians can sometimes suck clot out from a clotted access. Many of the discovered narrowing (or stenoses) can be dialated and enlarged with an angioplasty balloon. Other times, the graft material has just fallen apart, or the clot cannot be removed through a catheter. Then a surgical team can open up most grafts and clean them out under direct vision. If the vein that was supporting the AVG is too narrow, a short bypass to a new, larger vein can save use of the AVG. Sometimes, a whole new AVG in a new site has to be placed. Essentially all dialysis access procedures are done as outpatient procedures.