Vascular Surgery

What is carotid stenosis (carotid artery disease)?

The carotid arteries are the two main blood vessels that carry blood and oxygen to the brain. When these arteries become narrowed, it’s called carotid artery disease. It may also be called carotid artery stenosis. The narrowing is caused by atherosclerosis. This is the buildup of fatty substances, calcium, and other waste products inside the artery lining. Carotid artery disease is similar to coronary artery disease, in which buildup occurs in the arteries of the heart. It can cause a heart attack.

Carotid artery disease reduces the flow of oxygen to the brain. The brain needs a constant supply of oxygen to work. Even a brief pause in blood supply can cause problems. Brain cells begin to die after just a few minutes without blood or oxygen. If the narrowing of the carotid arteries becomes severe enough that blood flow is blocked. If a piece of plaque breaks off it can also block blood flow to the brain. In either case, a stroke occurs. Fifteen to 30% of strokes are related to carotid artery disease.

Atherosclerosis causes most carotid artery disease. In this condition, fatty deposits build up along the inner layer of the arteries forming plaque. The thickening narrows the arteries and decreases blood flow or completely blocks the flow of blood to the brain.

Who is at risk for carotid artery disease?

Risk factors associated with atherosclerosis include:

• Older age
• Male
• Family history
• Race
• Genetic factors
• High cholesterol
• High blood pressure
• Smoking
• Diabetes
• Overweight
• Diet high in saturated fat
• Lack of exercise

Although these factors increase a person's risk, they do not always cause the disease. Knowing your risk factors can help you make lifestyle changes and work with your doctor to reduce chances you will get the disease.

What are the symptoms of carotid artery disease?

Carotid artery disease may have no symptoms and they may look like other medical conditions or problems. Always consult your doctor for a diagnosis.

Sometimes, the first symptoms are those of a transient ischemic attack (TIA) or so-called “mini-stroke." A transient ischemic attack (TIA) is a sudden, temporary loss of blood flow to an area of the brain. It usually lasts a few minutes to an hour. You may have short term weakness on one side of your body, or your vision may change suddenly. Symptoms go away entirely within 24 hours, with complete recovery. Stroke symptoms.

If you or a loved one has TIA or stroke symptoms, call 9-1-1 right away. While TIAs generally do not cause permanent brain damage, they are a serious warning sign that a stroke may happen in the future and should not be ignored. TIAs do not precede all strokes, however.

How is carotid artery disease diagnosed?

In addition to a complete medical history and physical exam, tests for carotid artery disease may include:

• Listening to the carotid arteries. For this test, your doctor places a stethoscope over the carotid artery to listen for a sound called a bruit (pronounced brew-ee). This sound is made when blood passes through a narrowed artery. A bruit can be a sign of atherosclerosis. But, an artery may be diseased without producing this sound.
• Carotid artery duplex scan. This test is done to assess the blood flow of the carotid arteries. A probe called a transducer sends out ultrasonic sound waves. When the transducer (like a microphone) is placed on the carotid arteries at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the blood vessels, where the waves echo off of the blood cells. The transducer sends the waves to an amplifier, so the doctor can hear the sound waves. Absence of or faintness of these sounds may mean blood flow is blocked. A carotid artery duplex scan lets the physician know if there’s blockage and what the blood flow is, as well as its speed.
  This test is recommended especially if you have had a "mini-stroke."
• MRI scan. This procedure uses a combination of large magnets, radiofrequency, and a computer to make detailed images of organs and structures in the body. For this test, you lie inside a big tube while magnets pass around your body. It’s very loud. 
• Magnetic resonance angiography (MRA). This procedure uses a combination of magnetic resonance technology (MRI) and intravenous (IV) contrast dye to make the blood vessels visible. Contrast dye causes blood vessels to appear solid on the MRI image so the doctor can see them.
• CT scan. This test uses X-rays and computer technology to make horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays. Like an MRI, it’s sometimes done with IV contrast injected into your veins. 
• Angiography. This test is used to assess the how blocked the carotid arteries are by taking X-ray images while a contrast dye is injected. The contrast dye helps the doctor see the shape and flow of blood through the arteries as X-ray images are made. MRA and CT angiogram both allow the doctor to get a more clear view of the blockage and to better assess the area.

How is carotid artery disease treated?

Your healthcare provider will figure out the best treatment for you based on:

• How old you are
• Your overall health and past history
• How sick you are
• How well you can handle specific medicines, procedures, or therapies
• How long the condition is expected to last
• Your opinion or preference

Carotid artery disease is very correctible

If a carotid artery is less than 50% narrowed, it is often treated with medicine and lifestyle changes. If the artery is between 50% and 70% narrowed, medicine or surgery may be used, depending on your case.

Medical treatment for carotid artery disease may include:

Lifestyle changes

• Quit smoking. Quitting smoking can reduce the risk for carotid artery disease and cardiovascular disease. All nicotine products, including electronic cigarettes, constrict the blood vessels. This decreases blood flow through the arteries.
• Lower cholesterol. Eat a low-fat, low-cholesterol diet. Eat plenty of vegetables, lean meats (avoid red meats), fruits, and high-fiber grains. Avoid foods that are processed, and high in saturated and trans-fats. When diet and exercise are not enough to control cholesterol, you may need medicines.
• Lower blood sugar. High blood sugar (glucose) can cause damage and inflammation to the lining of the carotid arteries. Control glucose levels through a low-sugar diet, and regular exercise. If you have diabetes, you may need medicine or other treatment.
• Exercise. Lack of exercise can cause weight gain and raise blood pressure and cholesterol. Exercise can help maintain a healthy weight and reduce risks for carotid artery disease.
• Lower blood pressure. High blood pressure causes wear and tear and inflammation in blood vessels increasing the risk for artery narrowing. Blood pressure should be below 140/90 for most people. People with diabetes may need even lower blood pressure.

Medicines

Medicines that may be used to treat carotid artery disease include:

• Antiplatelets. These medicines make platelets in the blood less able to stick together and cause clots. Aspirin, clopidogrel, and dipyridamole are examples of antiplatelet medicines.
• Cholesterol-lowering medicines. Statins are a group of cholesterol-lowering medicines. They include simvastatin and atorvastatin. Studies have shown that certain statins can decrease the thickness of the carotid artery wall and increase the size of the opening of the artery.
• Blood pressure-lowering medicines. Several different medicines work to lower blood pressure.

When surgery is considered

If a carotid artery is narrowed from 50% to 69%, you may need more aggressive treatment, especially if you have symptoms.

Surgery is usually advised for carotid narrowing of more than 70%. Surgical treatment decreases the risk for stroke after symptoms such as TIA or minor stroke.

Surgical treatment of carotid artery disease includes:

• Carotid endarterectomy (CEA). This is surgery to remove plaque and blood clots from the carotid arteries. The patient undergoes general anesthesia and the procedure involves a cut at the neck. Surgery can take anywhere from 90 minutes to several hours. The patient remains in the hospital for one or two nights.
  

  Surgery is usually recommended if the patient has had no symptoms but the test show 80% blockage or more, or if the patient has had symptoms and has 70% blockage or more. Endarterectomy may help prevent a stroke in people who have symptoms and a narrowing of 70% or more and reduce a patient’s risk of stroke significantly.

• Carotid artery angioplasty with stenting (CAS). This is an option for people who are unable to have carotid endarterectomy. It uses a very small hollow tube, or catheter, that is thread through a blood vessel in the groin to the carotid arteries. Once the catheter is in place, a balloon is inflated to open the artery and a stent is placed. A stent is a thin, metal-mesh framework used to hold the artery open.

The U.S. Preventative Task Force recommends against routine screening for asymptomatic patients but suggest you speak with your primary care physician if you are concerned because of your history. Your doctor may also order a carotid ultrasound based on findings during an exam.

What are the complications of carotid artery disease?

The main complication of carotid artery disease is stroke. Stroke can cause serious disability and may be fatal.

Can carotid artery disease be prevented?

You can prevent or delay carotid artery disease in the same way that you would prevent heart disease. This includes:

• Diet changes. Eat a healthy diet that includes plenty of fresh fruits and vegetables, lean meats such as poultry and fish, and low-fat or non-fat dairy products, Limit your intake of salt, sugar, processed foods, saturated fats, and alcohol. 
• Exercise. Aim for 40 minutes of moderate to vigorous-level physical activity at least 3 to 4 days per week.
• Manage weight. If you are overweight, take steps to lose weight. 
• Quit smoking. If you smoke, break the habit. Enroll in a stop-smoking program to improve your chances of success. Ask your doctor about prescription options.
• Control stress. Learn to manage stress in your home and work life.

When should I call my healthcare provider?

Learn the symptoms of stroke. If you think you are having symptoms of a stroke, call 911 immediately.

Key points about carotid artery disease

• Carotid artery disease is narrowing of the carotid arteries. These arteries deliver oxygenated blood from the heart to the brain.
• Narrowing of the carotid arteries can cause a stroke or symptoms of a stroke and should be treated right away.
• Risks for carotid artery disease are similar to coronary artery disease.
• Eating a low-fat, low-cholesterol diet that is high in vegetables, lean meats, fruits, and high fiber is one way to reduce the risk of carotid disease. Exercise, quitting smoking, blood pressure control, and medications can help.
• Opening the carotid arteries once they are narrowed can be done with a surgery or with angioplasty and a stent.
• Carotid artery disease may not have symptoms, but if you have significant risk factors, see your healthcare provider for screening and diagnosis.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the names of new medicines, treatments, or tests, and any new instructions your provider gives you.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

What is peripheral arterial (vascular) disease?

Peripheral arterial disease (PAD) is a common circulatory problem in which narrowed arteries reduce the blood flow to your extremities (most often the legs). The most common cause of this narrowing is fatty deposits (atherosclerosis) accumulating in the walls of the arteries. As deposits continue to build within the arterial wall, the internal diameter of the vessel decreases, blockage results, and the blood flow to the extremity is jeopardized. Once the artery becomes narrowed, the sluggish flow of blood may result in clots forming completely shutting off the blood flow to an area. This may become an emergency situation. Another concern is that peripheral arterial disease is likely to be a sign of widespread accumulation of fatty deposits in your other arteries. This condition may also be reducing blood flow to your heart and brain, and result in heart attack or stroke.

About half of people with peripheral arterial disease have mild or no symptoms. About one-third to one-half develops more severe symptoms, including intermittent claudication. Intermittent claudication is characterized by muscle pain or cramping in your legs or arms that is triggered by a certain amount of activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is the most common area of intermittent claudication. The severity of pain varies widely. Pain from this condition can range from mildly bothersome to debilitating. Severe intermittent claudication can impair your ability to function and engage in any physical activity. It may interfere with the ability to do your job. Risk factors are similar to those for coronary artery disease and include family history, age over 50, smoking, high blood pressure, hyperlipidemia, diabetes, and smoking.

Other signs and symptoms of peripheral arterial disease include:

• Leg numbness or weakness
• Cold legs or feet
• Sores on your toes, feet or legs that won't heal
• A change in the color of your legs
• Hair loss on your feet and legs
• Changes in your nails

As peripheral arterial disease progresses pain may begin to occur when you're at rest or when you're lying down. This is called ischemic rest pain. This is a more serious condition and suggests a higher risk of limb loss due to gangrene. Rest pain may be intense enough to prevent sleep or to wake you from sleep. You may be able to temporarily relieve the pain by hanging your legs over the edge of your bed or by walking around your room. If you are worried about peripheral arterial disease, contact your physician. Rest pain should lead you to seek more urgent medical attention. Early diagnosis and treatment of PAD is important not only to preserve the health of your limbs, but also to decrease your risk of heart disease, stroke, and other medical conditions.

What is a peripheral vascular angiography?

A vascular angiogram is similar to heart catheterization done for heart, where dye is injected to see how the blood flows through the vessels in the legs, kidneys, neck or other different organs of the body. X-ray pictures are taken and a treatment plan is developed with your doctor if blockages are seen. It is important to tell your doctor if you are allergic to x-ray contrast dye. Your doctor can give you medication to prevent an allergic reaction, like a rash, difficulty breathing or nausea and vomiting.

A full vascular angiogram is usually completed in 30-40 minutes. The catheters the doctor uses are similar to a large IV. You should not feel pain once the catheter is placed, and you will not feel the catheter moving inside your body. When the catheter is in position, a dye is used to form a picture of your arteries. You may feel some warmth in your neck, arms, legs and abdomen for a few seconds as the dye is injected. At this time the doctor and radiology technologist may ask you to hold very still or take a deep breath as the table and camera move to take pictures from different angles.

The x-ray picture of the dye injection creates a map of your arteries called an angiogram. The doctor will be able to see blockages in your arteries and will discuss with you several methods of treatment. You may require vascular bypass surgery. This will be determined after consultation with your vascular surgeon. You may also be a candidate for angioplasty, which can be performed at the same time as your angiogram. You and your doctor will decide on the best treatment for you.

Angioplasty and stenting

An angioplasty may be done to treat blockages within your arteries. An angioplasty is performed when a very thin wire and a small balloon is passed across the blockage in your vessel. The balloon is inflated to compress the cholesterol plaque. While the balloon is inflated, you may feel some cramping pain. This is only temporary and will go away once the balloon is deflated. After the balloon is deflated, the blockages will improve and blood flow in the artery will be restored.

“Stenting” refers to the method by which a small metal slotted or coil tube is placed against the artery wall to hold the artery open. Balloon angioplasty is usually done before and after the stent is placed. These stents remain permanently in the artery after the procedure.

Occasionally, in the case of a particularly dense blockage, a small mechanically driven cutter shaves the plaque from the artery wall. This is referred to as atherectomy. The catheter is placed over a guide wire to the narrowed segment. Balloon angioplasty may be done after the atherectomy. The different types of atherectomy catheters that may be used:

• Rotational atherectomy uses an abrasive diamond coated burr at the tip of the catheter. The catheter is rotated rapidly (like a dental drill) to grind or sand the plaque into tiny particles that float away in the blood stream.
• Extraction atherectomy uses a rotating blade inside the tip of the catheter to cut the plaque. The plaque is then vacuumed into the catheter and removed.

When the procedure is completed an intravascular ultrasound may be performed. A sonogram (ultrasound) catheter is placed in the diseased artery and pictures of the interior of the vessel are made as the catheter is slowly removed. This is used to determine the level of blockage and the size of the artery.

Most procedures are done on an outpatient basis or may require a one-night stay in the hospital. Patients recover quickly and can resume normal activities sooner than with traditional surgery.

What are the risks of the procedure?

Because this is an invasive test there are certain grave risks that you need to be aware of. Fortunately we encounter these extremely rarely. The risk of death, heart attack or stroke is less than 1 in 1000. Bruising at the access site occurs in many people but very few of these will have enough bleeding into the groin that we have to surgically address this. The IV contrast can rarely cause an allergic-type reaction in people with a history of iodine allergy and can be harmful to patients with poor kidney function.

Varicose veins are a very common problem, generally appearing as twisting, bulging rope-like cords on the legs, anywhere from the groin to the ankle. While many people have heard of varicose veins, very few truly understand their underlying cause and the potential they have for developing into a serious medical issue.

Spider veins are similar to varicose veins, but they are smaller. They are often red or blue and are closer to the surface of the skin than varicose veins. They can look like tree branches or spider webs with their short jagged lines. Spider veins can be found on the legs and face. They can cover either a very small or very large area of skin.

Varicose Veins Vs. Spider Veins

What Causes Varicose Veins?

Arteries carry blood from your heart to your extremities, delivering oxygen deep into the tissue. Veins then return the deoxygenated blood back to your heart to be recirculated

To return this blood to the heart, your leg veins must work against gravity. Small one-way valves in the veins open to allow blood to flow upward, towards the heart, and then close to prevent it from flowing backwards.

Varicose veins occur when the valves in superficial leg veins malfunction. When this happens, the valve may be unable to close, allowing blood that should be moving toward the heart to flow backward (called venous reflux). Blood collects in your lower veins, causing them to enlarge and become varicose.

Symptoms

In addition to the visual appearance, many patients may experience one or more of the following leg symptoms:

• Pain (an aching or cramping feeling)
• Heaviness/tiredness
• Burning or tingling sensations
• Swelling/throbbing
• Tender areas around the veins

If you are experiencing any of the above, consult your physician, as treatment may be required. Delaying treatment may cause symptoms to progress to more serious complications, including:

• Inflammation (phlebitis)
• Blood clots (e.g., deep vein thrombosis)
• Ankle sores or skin ulcers
• Bleeding

Prevention

The underlying conditions described above usually make curing varicose veins impossible. However, certain measures – exercise (walking is ideal), weight control, support stockings and avoidance of standing/sitting for long periods – may help relieve discomfort from existing varicose veins and prevent others from arising.

Since these measures do not treat the underlying cause of the disease, varicose veins will usually enlarge and worsen over time. Legs and feet may begin to swell and sensations of pain, heaviness, burning or tenderness may occur. If and when this happens, consult your physician immediately.

Treatment

Your physician will usually first try preventative methods to relieve your symptoms. Your physician may ask you to:

• Get regular exercise focusing on strengthening the legs and improving circulation; Walking or running are good choices.
• Lose weight to reduce pressure on the legs. Sit with your feet on the floor, rather than crossing your legs.
• Prop up your feet.
• Avoid sitting or standing for too long.
• Support the legs with elastic support stockings.
• Avoid tight-fitting clothing.
• Stick to a diet that's low in salt and high in fiber.

If your varicose veins do not respond to this conservative therapy, more active treatment may be required. Vein stripping is a surgical procedure involving one or more incisions followed by the insertion of a special wire into the vein. This is usually only done in patients who are having a lot of pain or who have skin sores.

New minimally invasive techniques allow effective treatment of varicose veins with no hospitalization, no scarring, minimal postoperative pain, and almost immediate relief from varicose vein pain. An ultrasound may be performed to see if you could benefit from surgery. Procedures include:

• Endovenous Laser Therapy (EVLT)
  Closes the underlying vein to decrease the pressure creating the visible varicose vein. Requires only local anesthetic, involving virtually no recovery time. Performed in under an hour.
• Radiofrequency Ablation
  Uses intense heat through a catheter to treat the vein. The heat will close off and destroy the vein and the vein will disappear over time.
• Sclerotherapy
  Injection of a chemical solution into the varicose vein usually guided by an ultrasound. The vein will harden and then disappear.

Vein Mapping

This is a non-invasive, outpatient test that is a more detailed ultrasound evaluation of the veins in your legs or arms. It can be done in the arms or legs for placement of an arterio-venous fistula for dialysis or in the legs before treatment for varicose veins. Vein mapping of the upper extremity also is done to evaluate superficial veins to determine if they can be used for creation of arterial grafts for use during coronary or peripheral bypass procedures.

Vascular studies pertain to an examination of blood vessels, either arteries or veins. These studies are non-invasive which means that the tests are performed without actually entering your blood vessels in any manner.
These tests require no medications, dye, needles or incisions and involve studies of the arteries, veins and carotids.

Equipment used may include blood pressure cuffs, ultrasound and other sensing machines.

Vascular Studies include:

• Carotid artery ultrasound
• Renal artery ultrasound
• Aorta and peripheral artery ultrasound
• Pulse volume recordings of the upper and lower extremities - thoracic outlet & duplex
• Exercise and treadmill testing of both upper and lower extremities (respectively)
• Venous ultrasound of both the upper and lower extremities
• Venous reflux testing
• Vein mapping
• Arterial mapping studies
• Intra-operative duplex ultrasonography
• Lower extremity graft surveillance

Venous Ultrasound for Reflux

Venous reflux testing with ultrasound is a non-invasive, outpatient test that utilizes high frequency sound waves to obtain images of veins in the arms or legs and evaluate for reflux. This test is used to identify the presence and duration of venous blood flow reversal or reflux in the extremities. It is done when there is suspected chronic venous disease, pain, swelling, pigmentation changes, or ulceration of the lower extremity. This test is used to determine if there are problems with the vessels which may result in varicose veins, pain, and swelling. The sonographer applies an acoustic gel to your extremities being tested. A painless instrument called a transducer is gently moved across that portion of your body to visualize the inside of the veins. A physician interprets the results of this test and makes recommendations.