The approval of a new absorbable heart stent offers increased options for treating arterial blockage. The anticipated long term benefits, which have not been proven yet, include shortening the time patients must take blood thinners, simplifying future diagnosis, avoiding new disease forming in metal devices, and avoiding the need for future procedures.
Click below to view a fascinating article from Monday’s Wall Street Journal about this latest advancement in heart stents.
Heart Stent photo credit: The Wall Street Journal
A study conducted by the Charité – Universitätsmedizin Berlin, one of the largest university hospitals in Europe, found that a history of migraine in women is associated with increased risk of major cardiovascular disease. The study showed that women with migraine had a increased risk of myocardial infarction (39%), stroke (62%), and death due to cardiovascular disease (37%).
Just last week the American Heart Association updated their page related to Peripheral Artery Disease (PAD).
Check it out here:
American Heart Association
Every patient with Peripheral Artery Disease is unique but many are on statins. If you or a loved one is on statins and may have PAD, you’ll be interested in an article appearing in last Friday’s Medical News Today. It points to the connection between PAD patients on statins and reduced risk of amputation and death. Read more
In 2010, at age 26, NASCAR driver Brian Vickers was on a trip to Washington DC when he began to experience chest pain. At the time, Vickers was on a meteoric rise as one of the premier drivers in NASCAR. But a condition known as May-Thurner Syndrome was about to put Vickers’ career on hold.
Vickers was taken to the hospital where experts found multiple areas of blood clots in the veins of both Vickers’ legs and lungs. The source of these clots was found to be from a pinched vein in the pelvis. This phenomenon, known as May-Thurner Syndrome, is also referred to as Cockett Syndrome.
May-Thurner syndrome occurs when the main vein draining blood from the left leg, called the left common iliac vein, becomes narrowed by an overlying structure (such as the iliac artery) or scar tissue in the pelvis. This narrowing of the iliac vein can cause the blood flow through the vein to become obstructed resulting in blood clotting in the pelvis or in the left leg.
Statistically, May-Thurner phenomenon is much more prevalent in women than in men, and it also occurs in otherwise healthy young patients.
Occasionally clots from this area can travel with the flow of blood into the lung circulation creating a life-threatening phenomenon known as a pulmonary embolism, or PE. More commonly though, this condition can cause significant swelling, varicosities, ulcerations and/or sensations of heaviness and fatigue in the left leg since venous blood flow drainage from the extremity is compromised. Most commonly, May-Thurner Syndrome presents as a clot in the leg, known as a DVT- or, deep venous thrombosis.
Early recognition and aggressive treatment of May-Thurner phenomenon can be limb or even life-saving. Usually this diagnosis is confirmed with venous ultrasonography or venography.
Treatment is usually initiated with medications including anticoagulation and or antiplatelet agents. However, the current standard of care centers around treatment of the underlying compression of the left common iliac vein.
Balloon angioplasty and/or stenting of the compressed vein segment is the treatment of choice. Additionally, if extensive clotting is involved, treatment may also include removal or dissolution of any existing clot (thrombectomy or thrombolysis). These maneuvers can be accomplished through minimally invasive techniques with catheters as opposed to conventional, open surgical procedures. Usually, most patients can be treated in an outpatient setting.
In the case of Brian Vickers, his treatment was successful. Vickers returned to the NASCAR circuit in 2011 and enjoys a very active lifestyle. (www.brianvickers.com)
John A. Pietropaoli Jr., MD, FACS, RPVI
Fellowship-trained at the Mayo Clinic, John A. Pietropaoli Jr., MD, FACS, RPVI comes to The Vascular Experts with 20 years of practice experience in vascular and endovascular surgery. Read more»
When I was asked to write a blog post about vascular surgery, I had to ask myself: what is it that people want to read about? Perhaps I would ask patients what they are interesting in knowing more about. I could also answer their most common questions. Surprisingly, patients rarely ask about details of complicated aortic or revascularization procedures. On the other hand, there is plenty of confusion and curiosity surrounding vein ablation procedures. Let’s discuss that topic but we will only address questions pertaining to laser or radio-frequency ablation of superficial veins in this post.
Q: If I have a superficial vein problem, does that mean I am at risk for deep vein thrombosis (DVT)?
A: Short answer – No.
The deep veins and superficial veins seem like two completely unrelated systems in the body. Even getting a clot in a superficial vein does not significantly increase the risk of DVT. Therefore, a vascular surgeon must adopt a completely different approach to problems with deep veins and superficial veins. Most of the superficial vein procedures are actually geared towards shutting down the vein, when it is actually filled up with the clot.
Q: If I have a clot in the vein, does that mean that I can get a stroke?
A: Short answer – Extremely unlikely.
The superficial vein clots are not prone to “travel” through your body. Very rarely, they may extend into the deep veins, in which case there is a risk for a clot to move. If the deep vein clot moves, or in medical terms, embolizes, it almost always goes to the lungs. There is a small chance that a patient may have an abnormal connection within the heart and the clot travels from the venous side to the arterial. There is an even smaller chance that of all the vessels in the body, a clot will “choose” to go into the carotid artery. In essence, the risk of stroke after a superficial vein procedure is negligible.
Q: If the clot does go to the lungs, isn’t that lethal?
A: Short answer – Very rarely.
Your lungs are extremely adept at filtering out small and medium sized clots from the veins. Most of the pulmonary emboli (clots in the lungs) are silent. Because that risk does exist, we routinely scan veins after the vein ablation procedure to make sure that the clots stay within the superficial veins and do not travel. If a clot protrudes into the deep veins, we start you on a blood thinning medication.
Q: Assuming everything goes as planned and the vein is successfully shut down, how does the blood return from the leg after that?
A: Short answer – Blood is not supposed to travel in those veins anyway.
Of the two types of veins we have in the legs, only one type is functional – the deep veins. The other type is “superfluous”, the superficial veins. Truth be told, there is no clear reason why we even have superficial veins at all, as they do not seem to have any useful function. The normal superficial veins can be used as conduits for a bypass surgery, but the varicose veins are not useful for surgeons, and in fact, are only a source of trouble. Shutting refluxive superficial veins down will actually improve the blood’s return flow, because it eliminates backward flow and unloads the deep vein system.
Q: Once the vein is shut down, isn’t it just going to come back?
A: Short answer – The vein we shut down with laser or radio-frequency usually does not re-open. Most studies demonstrate more than a 90% success rate even after a couple of years. Even if the vein does reopen, it can easily be closed again. What happens more often is that another vein may develop reflux.
Q: How many veins can be shut down?
A: Short answer – The number depends on ultrasound findings; generally up to two veins on each side can be closed.
All superficial veins can be treated, however, only veins with significant reflux should be considered for ablation. We have two main superficial veins on each leg: one on the inside of the thigh and another one on the back of the leg below the knee. Sometimes a parallel branch of the main superficial vein has significant reflux, which may need to be closed as well.
Q: Can the leg edema and tiredness be cured?
A: Short answer – It can be cured; however, usually there are several reasons for edema. Vein closure procedure will certainly help to control swelling.
No matter what causes swelling, compression stockings and leg elevation will provide significant relief. I still advise to use conservative therapy even after successful vein treatment. Another little modification to your lifestyle is to limit your salt intake. Salt causes water retention (as well as hypertension); therefore, reducing sodium levels in your daily diet can make a significant difference.
Q: I have a friend, who has had a dozen procedures and still has leg edema and vein problems returning. It seems that his ordeal never ends; more vein procedures are recommended every time.
A: Short answer – Ask your friend where the procedures were performed. Knowing who the performing physician was may explain the number of procedures done as well as the results.
We don’t know which procedures your friend has undergone—vein ablations, sclerotherapy, or perhaps vein stripping. We also do not know whether the procedures were indicated or not—for instance, were the veins enlarged with significant reflux? Although procedures are technically easy, ask for a Board Certification of the performing physician. It may be the judgment that is lacking, not the mere ability to shut down the vein. The fact that a doctor calls himself or herself a “vein specialist” does not mean that the doctor is specially trained in the field. Only Board Certification testifies to the level of specialization.
The Vascular Experts team has the required training and experience to ensure the best results for your vein ablation procedure.
Please contact Dr. Kucher at firstname.lastname@example.org with any additional questions.
Taras V. Kucher, MD
What is a Diabetic Foot Ulcer?
One of the most common vascular issues treated by Vascular Surgeons is diabetic foot ulcers (DFUs). Up to 25% of diabetic patients will have a foot ulcer during their lifetime. Diabetic foot ulcers are wounds of the lower extremities that develop because of poor blood circulation. These ulcers most commonly occur on the feet and toes, sometimes on the ankles. There are usually several factors that contribute to the development of these wounds — including poorly fitting shoes, neuropathy, and disease of the arteries. DFUs are often missed and must be carefully sought after on physical examination. It is important for diabetic patients to regularly check their feet for development of ulcers.
Is a DFU a serious condition?
Diabetic patients often develop calcified plaques in their arteries, which can lead to narrowing or blocking of the artery (this is called ‘arterial disease’.) This can lead to decreased or complete absence of blood flow to the foot. The arteries commonly involved are the arteries below the knee.
I distinctly remember caring for a young diabetic woman during my vascular surgery fellowship, who had a small lesion on her foot. Unfortunately, she missed a couple of appointments and returned 2 weeks later with a severe infection of her toe. I performed an angiogram and found a blockage in one of the arteries of her leg. I treated the blockage with ballooning and stent in order to restore blood flow to her foot. Luckily, with ongoing wound care and close follow up, the ulcer healed completely. I feel fortunate that we were able to avoid needing to amputate part of her foot.
Some patients may have what we call ‘multi-segment arterial disease,’ which means that there is narrowing or blockages in the arteries of the thigh or, even higher up, in the pelvis. Blood brings oxygen and nutrients needed for the DFUs to heal. When DFUs don’t heal they can lead to uncontrolled deeper infection (sometimes involving the bone). Sometimes a procedure is needed to restore blood flow so that DFUs can heal properly.
How are DFUs Treated?
Simple vascular tests can be performed to diagnose and treat arterial disease. These tests can often be done in the same office visit, and allow planning for the next step in treatment.
An angiogram is often the next step to diagnose and treat arterial disease. An angiogram is a minimally invasive procedure performed either in the hospital or the office. The procedure involves a small needle puncture, usually in one of the arteries in the groin, and injecting dye or contrast. This allows the Vascular Surgeon to see exactly where the narrowing and blockages are located. Often these can be treated during the same procedure with ballooning and/or placement of stent.
Angiography is often the next step in diagnosing the type and location of the arterial disease more accurately. One advantage of an angiogram is that it can be both diagnostic and therapeutic. Meaning, most blockages or narrowing in arteries could potentially be treated with ballooning and/or stenting at the same time. Angiograms are performed both in an outpatient and inpatient settings.
Appropriate testing and proper diagnosis of DFUs can save limbs, not to mention lives. Many of the above mentioned procedures are performed in our office locations. If you or someone you love is a diabetic and suffers from foot pain, call The Vascular Experts for an appointment today.
Please contact Dr. Shahmohammadi at email@example.com with any additional questions.
Kaveh Shahmohammadi MD
Kaveh Shahmohammadi MD is a board eligible vascular surgeon at Southern Connecticut Vascular Center (The Vascular Experts). His areas of interest include doctor-patient relationship and communication, arterial and venous ulcers, aortic disease, carotid disease, and peripheral vascular disease. Read more»
My Grandmother was an amazing woman. Born and raised in southern Rhode Island she was the classic example of New England grit and vigor. She was always on the go, doing something. She loved the beach and going swimming, even when the waves chase away people much younger than her. She was a champion duck pin bowler at in her 60s. She was a dangerous person to play cards with. No matter the game, she was better than you. I have very clear memories of painful walks to the beach with her in the early summers. The walks were painful because she wouldn’t allow sandals, so we would develop calluses on our feet to protects from stepping on shells in the water. I also remember, at the age of 10 going to see her in the hospital. I was too young to really understand what was going on. I just knew that my grandmother, usually so full of energy was plugged into a machine that made her tired. Dad said the machine was helping her kidneys, I didn’t really know what a kidney was at the time. I just trusted that she needed it. Unfortunately she died about 6 months after that first visit.
Some 20 years later, having just completed my training in vascular surgery, I have met hundreds of people in the same condition as my grandmother. The number of people requiring dialysis has increased greatly since my grandmother’s time and so has the life span of people on dialysis. That combination means more dialysis patients needing access and needing it for longer. The need for optimal dialysis access has increased and will increase even more. So what does this mean for you? Who needs dialysis access? What is the optimal dialysis access?
Well, let’s take the second question first. The simple and definitive answer is the arterio-venous fistula, or AVF. During this procedure your surgeon hooks up one of your veins directly to one of your arteries. Doing this provides enough blood flow to allow the dialysis machines to work. Why is the optimal access? According to the national kidney foundation fistulas have:
- Lower risk of clotting
- Lower risk of infection
- Reduced treatment times
Your body has many veins and many arteries but only one point needs to be selected for dialysis access and you and your surgeon should discuss this prior to any procedure. Many factors weigh on this decision, from anatomic factors regarding the arteries and veins, to whether you are a righty or a lefty, to what kind of hobbies you enjoy. All these factor need to be taken into account and are important to discuss with your surgeon. Here at the vascular experts we take a patient centered approach to these procedures to make sure that all of these factors are taken into account and to make sure that we fit the right access to the right patient. Naturally, all fistulas need to be monitored carefully. Here at The Vascular Experts you can expect routine monitoring visits so we can identify and repair any issues before they become problems.
Now for the first questions, Who needs dialysis access? The simple answer is people with renal failure. But like much in medicine the answer is never quite that simple. Most fistulas require 3 to 6 months to mature before they can be used. Thus it is essential to talk with your Nephrologist about when you will need dialysis. We take a team based approached, and work closely with our Nephrology, and primary care colleagues to identify people who will need this procedure, to identify any problematic fistulas and when possible to anticipate when an intervention will be needed or an access be created. Our goal is to provide a seamless experience to our patients so they can receive the care they need.
If you have renal problems it’s important that you find a surgeon who is fully trained in dialysis access, who practices a patient centered and team based approach to your care. Our goal at The Vascular Experts is to provide you with the vascular access care you need in a way that, like my grandmother, you can keep bowling or playing cards or doing those things you love doing. But if you will indulge my sore feet, please let your kids or grand kids wear sandals.
Please contact Dr. Kelly at firstname.lastname@example.org with any additional questions.
Brian J. Kelly, MD
Brian J. Kelly, MD is a board eligible vascular surgeon at The Vascular Experts, where he treats a full spectrum of vascular disease. His interests include aortic disease, carotid disease, peripheral arterial disease, and venous disease. Read more»
We live in Connecticut where there is an abundance of natural parks and endless opportunities to engage in recreation. With summer upon us, what better time is there to get outside and enjoy some of the natural beauty Connecticut has to offer?
But, do you ever feel that cramping leg pain is preventing you from enjoying your summer activities? Does it feel like your muscles are starving for oxygen? That may be exactly what’s going on. If your tissues aren’t getting the amount of oxygen they require, they start to cramp. This pain (called claudication) only goes away once you stop whatever activity was causing it (e.g. walking, biking, etc). That doesn’t mean you should stop engaging in physical activity.
Actually, it’s been proven that regimented exercise programs offer substantial relief to people suffering from lower extremity vascular disease, also known as peripheral vascular disease. With time, your blood vessels actually branch out to form additional routes for blood and oxygen to get to these hungry tissues. This process is called collateralization and it can be very effective in relieving some symptoms of vascular disease. Some people however, need a little extra help, and that can be in the form of medication or simple office-based minimally-invasive procedures such as balloon angioplasty or stenting. These procedures are often done within an hour or two and patients get to go home the same day.
“So, who gets peripheral vascular disease? “ Overall, the most well-known risk factors are smoking, elevated cholesterol and/or blood pressure, advancing age and those with a family history of vascular disease. Remember, blood vessels travel throughout the body so if you’ve experienced problems with your heart’s or brain’s vessels, you can very likely have something going on in your legs or elsewhere.
“OK, my symptoms fit the description but how do I know it’s my blood vessels and not something else like my muscles or nerves?” A simple test in one of our many offices, in most cases involving not more than some blood pressure measurement in your legs, is a good start and offers a great amount of information. If further tests or imaging are needed, we can discuss the options and come up with an appropriate plan together.
We at The Vascular Experts can help you tailor a program that best fits your symptoms, and if something more is needed, our Board-Certified surgeons are here to guide you through the process and deliver the best care in Connecticut.
Don’t let pain and cramping interfere with getting the most out of another beautiful New England summer. Call us today!
Please contact Dr. Ranaudo at email@example.com with any additional questions.
Jeffery M. Ranaudo, MD, MS
Jeffrey M. Ranaudo, MD, MS, is Board-certified in general surgery and a Board-eligible vascular surgeon at Southern Connecticut Vascular Center. Read more»
Repair Surgery for Abdominal Aortic Aneurysms
The risk for Abdominal Aortic Aneurysms (AAAs) increases dramatically after the age of 60. As the aneurysms enlarge, they can eventually rupture, and when they do, will almost always result in death. That’s why it is so important to screen for the presence of an AAA, and more so if you have one of the risk factors listed below. Once diagnosed, your healthcare provider will monitor your aneurysms and might suggest that you get it repaired before it reaches a size when it can rupture.
When are you at risk for AAA?
Although it is not clearly known what causes the abdominal walls to weaken and bulge around the belly button (an aneurysm), age and being a male will typically increase the likelihood of it happening. Men are much more likely to develop AAAs than women.
Other risk factors include:
- Age over 60 years
- High blood pressure
- Family history
- History of heart disease or peripheral arterial disease (PAD)
- Hyperlipidemia (elevated levels of fat in the blood)
- High blood pressure (hypertension)
- Family history of AAA
AAA affects about 5% of males over 65 and has resulted in over 150,000 deaths in 2013. That is why the U.S. Preventive Task Force highly recommends a screening ultrasound for AAA in males over 65 years of age who have ever smoked.
Symptoms and signs of AAA
In many cases, there may be no symptoms of AAA and the aneurysm will only be discovered when it ruptures. Typical signs, if any, include:
- A pulsating feeling in the abdomen, near the navel
- Deep, constant pain in your chest, abdomen, lower back, or flank (over your kidneys), that spreads to the groin, buttocks, or legs
- A “cold foot” or a black or blue painful toe, which can happen if an abdominal aortic aneurysm produces a blood clot that breaks off and blocks blood flow to the legs or feet
- Fever or weight loss, which is typically caused by an inflammatory aortic aneurysm
Getting treated for AAA
Most AAAs are found incidentally during imaging, like a CT scan or ultrasound, performed for another reason. The size of the aneurysm is one of the strongest predictors of whether it is likely to rupture. Aneurysm diameters of greater than 5.5 cm are typically high-risk and recommended for repair surgery.
The repair of AAAs has changed dramatically over the last decade. At The Vascular Experts, patients undergoing endovascular aortic aneurysm repair receive no incisions at all and are subject to very little downtime. Most patients go home the very next day and can immediately return to their normal activities. This is markedly different from the standard, open repair surgical procedure for AAA which was a major surgery with a large incision and required many days spent in the intensive care unit.
The Vascular Experts team relies on their vast experience and state-of-the-art equipment to ensure the best and safest results. Our Board Certified vascular surgeons, have led the way in many of the advances related to the endovascular repair of aortic aneurysms. We were the first team of physicians to fix AAAs without incisions and lead many trials that led to newer, safer treatments. Your doctor will explain the procedure and offer you the opportunity to ask any questions that you might have.
Please contact Dr. Muhs at firstname.lastname@example.org with any additional questions.
Bart E. Muhs MD, PhD, FACS
Bart E. Muhs MD, PhD, FACS is a Board Certified, internationally respected vascular surgeon who brings a wealth of vascular knowledge and experience to The Vascular Experts. Read more»
Dr. Muhs practices at the Middletown office of The Vascular Experts.