Vascular surgery specializes in diagnosing and treating diseases of all of the blood vessels of the body (arteries and veins), with the exception of the vessels of the heart. Vascular surgeons restore blood flow to the body after trauma or disease damages the blood vessels, and work with patients with blocked arteries, aneurysms, and venous disease. Vascular Surgeons at Northside Vascular Surgery are trained in both traditional open surgery and the latest minimally invasive endovascular techniques. Common procedures include repairing damaged arteries and veins, reopening clogged arteries with balloons and stents, repairing aneurysms, and placing bypasses around blocked arteries. Unlike general surgery trainees, diplomats in vascular surgery have significant experience and training specifically designed to treat patients with all types of vascular disease, including diagnosis, medical treatment, and reconstructive vascular surgical and endovascular techniques.
An aortic aneurysm (AA) is a ballooning or dilation of the aorta, the body's main artery that carries blood from the heart through the chest and the abdomen. Aortic aneurysms may form anywhere along the aorta, but are most common in the belly region (abdominal aortic aneurysm) and the upper body or chest region (thoracic aortic aneurysm). Medical problems, such as high blood pressure and atherosclerosis (hardening of the arteries), weaken artery walls and can cause them to bulge outward. When aortic tissue is overstretched and weak, it can burst and cause serious bleeding. Sometimes, aortic aneurysms may cause complications such as blood clotting and strokes.
Most aortic aneurysms don't cause symptoms, but some people may complain about belly, chest or back pain and discomfort.
Aneurysms may be diagnosed through screening tests or by chance during regular exams and tests. If your doctor thinks you have an aneurysm, you may need a CT scan, MRI, or ultrasound to find out where it is and how big it is.
Treatment of an aortic aneurysm depends on the size of the aneurysm and whether the patient is experiencing any symptoms. Larger aneurysms require surgery and doctors may either repair the blood vessel with a stent or replace it with a graft during open surgery. Small aneurysms can be monitored and treated with blood pressure medication.
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Carotid artery disease, also called carotid artery stenosis, refers to the narrowing of carotid arteries, the two large blood vessels that supply oxygenated blood to the large, front part of the brain. It occurs when fatty, waxy deposits called plaques clog your carotid arteries. Buildup of plaques in the carotid arteries blocks blood supply to your brain and puts you at an increased risk of stroke.
Carotid artery disease develops slowly and often doesn't produce any symptoms. Sometimes, the first sign of carotid artery disease is a stroke.
Stroke symptoms include:
- Sudden numbness or weakness in the face or limbs, usually on one side of body
- Trouble speaking or understanding speech
- Trouble seeing
- Sudden onset of a severe headache
Even if symptoms don't last very long, see your doctor as soon as possible. These could be important signs that you are at a high risk for having a stroke.
Since there are often no symptoms of carotid disease, it's very important to see your doctor for regular physical examinations. If your doctor detects an abnormal sound in the neck where the carotid arteries are located, this could mean you have carotid artery disease.
Other tests include:
- Carotid ultrasound
- Carotid Angiogram (allows doctors to see blood flow in real time)
- Computerized tomography angiography (CTA) ( detailed x-ray)
- Magnetic Resonance Angiography (uses powerful magnet to gather information )
Treatment of carotid artery disease usually involves a combination of lifestyle changes, medications and, in some severe cases, surgery or a stenting procedure. When you have a severe blockage, it's best to remove plaques in the arteries through open surgery. There are two ways to do this:
- TransCarotid Artery Revascularization (TCAR) TCAR has been clinically proven as a less-invasive alternative to carotid endarterectomy, a traditional open surgery performed to treat carotid artery disease. What’s unique about TCAR is it temporarily reverses the blood flow during the procedure, so that any small bits of plaque that may break off during the procedure are diverted away from the brain, preventing a stroke from happening. A stent is then placed inside the artery to stabilize the plaque, minimizing the risk of a future stroke.
- Carotid endarterectomy, which involves making an incision along the front of the neck, and removing the plaques. The artery is repaired with either stitches or, preferably, a graft.
- When the location of the narrowing or blockage is too difficult for the surgeon to access, your doctor may recommend a procedure called carotid angioplasty and stenting. While you're under local anesthesia, a tiny balloon is threaded by catheter to the area where your carotid artery is clogged. It is then inflated to widen the artery, and a small wire mesh coil called a stent is inserted to keep the artery from narrowing again.
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Treatment for carotid disease must be individualized for each patient. Some patients benefit more from surgery and some more from stenting. It is important to seek consultation with a health care provider who is experienced and knowledgeable in both of these areas.
Peripheral Artery Disease (PAD)
Peripheral artery disease (PAD) is a common circulatory problem that occurs when your extremities — usually your legs —don't receive enough blood flow to keep up with demand. Peripheral artery disease is also likely to be a sign of a more widespread accumulation of fatty deposits in your arteries (atherosclerosis).
Other symptoms include:
- Painful cramping in your hips, thighs or calves after activity
- Coldness in your lower leg of root
- Sores on your toes, feet or legs that won’t heal
- Change of the color of your legs
- Weak pulse in your legs and feet
Diagnosing peripheral artery disease is simple and painless. Most commonly, doctors use the ankle-brachial index (ABI), which compares the blood pressure in your ankle with the blood pressure in your arm. For severe peripheral artery disease, an angiogram can allow a doctor to see the exact location of the blockage.
Many cases of peripheral artery disease can be treated with medication but more severe cases may require endovascular repair like angioplasty and bypass surgery. For angioplasty, the doctor may insert a mesh framework called a stent into the artery to help keep it open. This is the same procedure doctors use to open heart arteries. With bypass surgery, the doctor may create a graft bypass using a blood vessel made of synthetic fabric to allow blood to flow around the blocked or narrowed artery.
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Renal and Mesenteric Disease
Renal and mesenteric disease occurs when the arteries supplying blood to the kidneys or intestines begin to narrow.
Patients with renal disease may develop high blood pressure that is very difficult to control, and in extreme cases kidney failure. Narrowing of the mesenteric arteries (intestinal arteries) can lead to unexplained weight loss and severe abdominal pain that occurs upon eating.
One or more of the following imaging tests will be necessary to determine the location and the extent of the arterial narrowing (stenosis):
- Duplex Ultrasound
- Magnetic Resonance Angiography (MRA)
- CT Scan
In many cases, a procedure may be required to relieve the narrowing in the artery and restore blood flow to the leg. The arterial stenosis may be treated using minimally invasive procedures such as angioplasty and stenting to improve blood supply or if the disease is very advanced, or if it occurs in an artery that is difficult to reach with a catheter, arterial bypass surgery may necessary in order to restore blood flow.
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Peripheral aneurysms refer to those aneurysms that affect arteries other than the aorta. Most peripheral aneurysms occur in the popliteal artery, which runs down the back of your lower thigh and knee. Peripheral aneurysms do not rupture as often as aortic aneurysms, but there is still a risk. More commonly, peripheral aneurysms form clots that may block blood flow to your limbs.
Possible symptoms include:
- A pulsating lump that you can feel
- Leg or arm pain or cramping with exercise, called claudication
- Leg or arm pain with rest
- Painful sores or ulcerations involving the toes or fingers
- Radiating pain or numbness in your leg or arm, which is caused by nerve compression
- Gangrene, or tissue death, which results from a severe blockage in your limb and usually requires some form of amputation.
Warning signs of a peripheral aneurysm may be detected during a regular physical examination. If your doctor suspects a peripheral aneurysm, you may have one of the following tests done:
- Duplex/Doppler ultrasound
- Magnetic Resonance Angiography (MRA)
- Computed Tomography (CT) scan
Treatment depends on the location and size of the aneurysm, as well as whether or not the aneurysm is completely blocked by clots. Some peripheral aneurysms require watchful observation, while others require treatment with either stenting or surgical bypass using a man-made grafts or vessel replacement.
Venous disease refers to all conditions caused by abnormal or diseased veins. It usually involves veins in the legs or pelvis, but can also involve veins in the arms, and most commonly includes blood clots (thrombosis), varicose veins, vein stenosis (narrowing), venous insufficiency or ("reflux" of blood causing swollen, discolored legs), and spider veins.
Veins have valves that keep blood flowing one-way back to the heart from the rest of the body every time the heart beats. When there is an interference of this one-way transport, venous disease occurs. Varicose and spider veins are the most common early signs of vein disease, and occur when vein valves break down and cause blood to leak the “wrong way” and pool in the legs. They affect as many as 1 in 3 women, and though they are often only seen as a cosmetic problem, they may be a sign of serious vein disease that can worsen over time without proper treatment.
Another type of serious venous disease is deep vein thrombosis, or clotting of the deeper veins. Blood clots may result from an injury, blood-clotting condition, or prolonged inactivity (such as a long airplane ride or bed rest).If the clot breaks lose, there is a chance that it could travel to the lungs and cause a pulmonary embolism. This can be fatal and may cause "pulling" sensations in the calf, pain, warmth, redness, and swelling. Other times, symptoms may go completely unnoticed. Â DVT occurs in over 2½ million people annually and causes 200,000 deaths from pulmonary embolism (blood clot that travels to the lung) each year. It's vital that patients with DVT be promptly diagnosed and treated to avoid complications.
Superficial vein damage can be diagnosed through careful physical examination. Doctors may also perform a duplex/vascular ultrasound test or a venogram, an X-ray that uses intravenous dye, to assess for blood clots, venous reflux, or vein stenosis.
Women are most at risk and as many as 1 in 3 women have some form of venous disease. Certain risk factors that may lead to the development of venous disease include:
- Family history
- Prolonged standing
- Prior episodes of blood clot formation
For those with mild venous disease, basic lifestyle changes like graduated compression stockings may be enough to control your symptoms. However, surgical procedures may be necessary to prevent serious complications if you have:
- Large varicose veins
- Severe Reflux
- Deep Vein Thrombosis
- Non-healing sores
- Vein stenosis (narrowing)
Most treatments may be performed in-office and involve injections or minimally invasive catheter-based procedures to seal off the diseased vein, or remove it altogether. This prevents blood from flowing backwards (the wrong-way) and pooling in the legs. Over time, your body will turn the closed vein into scar tissue and nearby veins take over the normal one-way blood flow. In rare cases, you may need a procedure to open a blocked vein, or to repair damaged valves in the veins.
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Thoracic Outlet Syndrome
Thoracic outlet syndrome occurs when the blood vessels or nerves in the thoracic outlet, the space between your collarbone and your first rib, become compressed. This can cause pain in your shoulders and neck and numbness in your fingers. Common causes include physical trauma, repetitive movements in the arms and shoulder, and certain anatomical defects, such as having an extra rib.
People who perform activities with repetitive movements of the arms and shoulders such as athletes, hairdressers, construction workers, manual laborers are more likely to develop this condition because the repetitive motion causes extra pressure on the nerves and blood vessels.
- Pain, numbness, and tingling in the pinky and ring fingers, and the inner forearm
- Pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse)
- Signs of poor circulation in the hand or forearm (a bluish color, cold hands, or a swollen arm)
- Weakness of the muscles in the han
Diagnosing thoracic outlet syndrome can be difficult because symptoms vary greatly. To diagnose thoracic outlet syndrome, your doctor may perform a physical exam and ask about your medical history. Your doctor may also opt to do provocation tests, which are designed to reproduce your symptoms and help determine the cause of your condition. To confirm the diagnosis of thoracic outlet syndrome, your doctor may also order the following tests to determine the area and cause of compression:
- Electromyography (EMG)
- CT Angiogram
In many cases, conservative treatment such as physical therapy and medication is effective, especially when the condition is diagnosed early. However, if symptoms still continue to worsen and you experience incapacitating pain or signs of blood vessel blockage or significant nerve damage, surgery is recommended. The most common surgical procedure for thoracic outlet syndrome treatment involves partial resection of the 1st rib through a small incision under the collarbone or in the armpit which creates more space between the rib and collar bone and releases the pressure on the vessels and nerves. Occasionally the vessels need to be repaired as well.
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Northside Hospital Limb Preservation Program
Each year, nearly 160,000 Americans lose their limbs due to complications from peripheral artery disease (PAD)*. Many of these amputations can be avoided, and patients may fail due to a delay in coordination with specialists, or a lack of communication between specialties.
To avoid unnecessary amputations, the Northside Hospital Limb Preservation Program brings together a multidisciplinary team of specialists who work to quickly identify patients with a threat of limb loss, and treat them using the latest advancements in evidence-based medicine and minimally-invasive surgery.
The highly-trained team of specialists includes physicians trained in wound care, infectious disease, diabetes and nutrition and podiatry, as well as the surgeons of Northside Vascular Surgery, and serves as an extension of care for referring primary care physicians and specialty clinics. The program features a dedicated Limb Preservation Nurse Navigator who schedules the initial evaluation of patients with a threat of limb loss and guides the patient through followup appointments with the different specialties.
For more information, please visit northside.com/limb.
*Allie, David E., et al. “24-carat gold, 14-carat gold, or platinum standards in the treatment of critical limb ischemia: bypass surgery or endovascular intervention?.” Journal of Endovascular Therapy 16.1 suppl (2009): 134-146.