Vascular Disease Patient Information

Presented by The International

Society for Vascular Surgery

Blood is pumped around your body continuously by your heart carrying the oxygen and food you need to stay alive. Blood first goes to the lungs where it picks oxygen and become bright red. It is then pumped through the arteries under pressure (the blood pressure) to all parts of the body where most of the oxygen is used and it becomes blue and returns to the heart in the veins to circulate again and again. The arteries , veins and heart are collectively called the vascular system. You can imagine that if any of these arteries get blocked, that part of the body will be deprived of the oxygen and food it needs and will die, hence the serious nature of vascular disease.

About Your Vascular System

Vascular DiseaseHardening of the arteries (atherosclerosis) is a disorder in which the arteries become narrowed because fat in the form of cholesterol is deposited in the wall after poisons damage the lining of the arteries, for example cigarette smoke .The fatty tissue then becomes calcified and hard and forms an elevation known as a plaque (atherosclerosis). As this plaque grows, it narrows the inside of the artery reducing blood flow .The result is that various parts of the body such as the heart, eyes, kidney, legs, gut, or the brain get less food and oxygen. The plaque may eventually and often suddenly completely block the artery, causing death of the tissue supplied by that artery, causing for example ,a heart attack, stroke or gangrene.

(Hardening of the arteries)

Sometimes the wall of the arteryweakens instead of narrowing and enlarges under the blood pressure causing what is known as an aneurysm

Peripheral Arterial Disease - PAD

When hardening of the arteries with narrowing affects your legs it is called peripheral arterial disease or PAD. The symptoms it causes are often mistaken for something else and is often undiagnosed. If the underlying causes are not attended to (smoking, high blood pressure, high cholesterol and lack of exercise) it can progress and end with loss of the leg in 5-7% of cases. Symptoms are:• Pain on walking which goes away on resting and restarts when you walk again• The pain is worse if you walk faster or go up hills and comes on quicker• The distance you can walk gets shorter and shorter• Eventually you get pain in your foot even when you are resting and the foot looks red when it is hanging down• Pain in the foot when you are sleeping• Finally the toes go black and gangrene has occurred.

PAD – Your Risk Increases If You:

Are over the age of 50. Smoke or used to smoke. Those who smoke or have a history of smoking have up to four times greater risk of P.A.D. Have diabetes. One in every three people over the age of 50 with diabetes is likely to have P.A.D. Have high blood pressure. Also called hypertension, high blood pressure raises the risk of developing plaque in the arteries. Have high blood cholesterol. Excess cholesterol and fat in your blood contribute to the formation of plaque in the arteries, reducing or blocking blood flow to your heart, brain, or limbs. Have a personal history of vascular disease, heart attack, or stroke. If you have heart disease, you have a one in three chance of also having P.A.D.

Diagnosis of PAD

Your vascular surgeon will take a medical and family history, perform a physical exam, and conduct diagnostic tests.

Medical and Family History

Your doctor will spend time reviewing you medical history, including the presence of diabetes, high blood pressure, high cholesterol , if you are a smoker or former smoker , have a personal and family history of cardiovascular disease, any symptoms that you may be experiencing in your legs while either sitting, standing, climbing, walking other physical activities, and your current medications and diet.

Physical ExamDuring the physical exam, your health care provider may check:Pulses in your legs and feet to determine if there is enough blood flowing to these areas, the color, temperature, and appearance of your legs and feet, and will check for signs of poor wound healing on the legs and feet.

Diagnostic Tests for PAD A simple noninvasive test called an ankle-brachial index (ABI) test may per performed. Painless and easy, the ABI compares the blood pressure readings in your ankles with the blood pressure readings in your arms. An ABI can help determine whether you have PAD, but it cannot identify which arteries are narrowed or blocked. Your health care provider may decide to do a Duplex scan to see whether a specific artery is open or blocked. This test uses sound waves to measure the blood flow in the veins and arteries in your arms and legs. Your health care provider may also perform blood tests to see if you have diabetes and check your cholesterol levels. Other tests are also used to help diagnose P.A.D.

A duplex scan of the leg arteries

How is PAD Treated

The overall goals for treating PAD are to reduce any symptoms, improve quality of life and mobility, and prevent heart attack, stroke, and amputation.

There are three main approaches to treating PAD: making lifestyle changes; taking medication; and in some cases, having a special procedure or surgery.

Your vascular surgeon will determine the best treatment options for you, based on your medical history and the severity of your condition.

Lifestyle Changes PAD

PAD treatment often includes making long-lasting lifestyle changes. If you have PAD, or are aiming to prevent it, your health care provider may prescribe one or more of the following: Quit smoking. Don't smoke, and if you do, quit. Consult with your health care provider to develop an effective cessation plan and stick to it. Lower your numbers. Work with your health care provider to correct any high blood pressure, cholesterol, and blood glucose levels. Follow a healthy eating plan. Choose foods that are low in saturated fat, trans fat, and cholesterol. Be sure to include whole grains, vegetables, and fruits. Get moving. Make a commitment to be more physically active. Aim for 30 minutes of moderate-intensity activity on most, preferably all, days of the week. Aim for a healthy weight. If you are overweight or obese, work with your health care provider to develop a supervised weight loss plan.

Medication for PAD

• Drugs to control cholesterol

• Drugs to control your blood pressure

• An anti platelet drug such as aspirin

• Very few if any drugs can actually improve the blood supply to your legs and are generally not worth taking

• Good control of your diabetes if you are a diabetic

Surgical treatment of PAD

Generally speaking if you cant walk too well because of pain your condition can be improved by the life style changes already mentioned or an sustained increase in your daily exercise .If this fails or your condition deteriorates to the point where you have pain at rest or at night in bed then you need treatment. Your vascular surgeon will advise you about the treatments available and which one suits you best. Some problems can be easily dealt with by stretching the narrowed artery with a balloon and inserting a stent but others will need something called a bypass operation where the blocked artery is bypassed with a piece of vein or plastic to reestablish blood flow. These techniques work well but there are risk and your vascular surgeon will discuss these with you.

AneurysmsThis is a swelling of the artery caused by a weakening of the wall and most commonly affects the main artery in the body – the Aorta.This artery is “the motorway” of the arterial system and carries blood to all parts of the body. It most commonly becomes an aneurysm in the abdomen (stomach).The aneurysm gradually increases in size and if left untreated will suddenly burst and lead to internal bleeding ending in death. The aim of treatment is to prevent rupture and death.

Anyone can have an Abdominal Aortic Aneurysm but most often men between 50 and 70 are affected. They occur in 5-7% of people older than 60.Weakening of the aortic wall can also occur after trauma or infection when younger people can be affected. Abdominal Aortic Aneurysms occur more frequently in :

People with hardening of the arteries (atherosclerosis) Smokers

Those with a high blood pressure Chronic lung disease Those with a family History

Abdominal aortic aneurysms (AAA)

Symptoms Abdominal Aortic Aneurysm (AAA)

Pulsating sensation in the abdomen Pain in the abdomen or back -- severe, sudden and often constant. The pain may radiate to the groin, buttocks, or legs. Tenseness of the abdominal muscles Anxiety Nausea and vomiting Clammy skin Rapid heart rate Collapse Abdominal swelling

Abdominal Aortic Aneurysm (AAA)

Diagnosis

First your vascular surgeon will examine your abdomen and the pulses in your legs .

Your vascular surgeon may order the following tests:

Abdominal ultrasound CT Scan of Abdomen Angiography of aorta

Treatment Options Abdominal Aortic Aneurysm (AAA)

If the aneurysm is small and there are no symptoms your vascular surgeon may recommend periodic evaluations This can include a yearly ultrasound, to see if the aneurysm is getting bigger.

Aneurysms that cause symptoms require surgery to prevent complications. Patients with aneurysms bigger than 5.5 cm in diameter and aneurysms that rapidly increase in size require surgery. Surgery can prevent further complications such as a ruptured and death from occuring.

Routine screening for people over 65 is now becoming available and will allow this otherwise often silent but potentially lethal condition to be diagnosed and treated

Abdominal Aortic Aneurysm (AAA)Treatment

There are two surgical approaches to treatment. In a traditional (open) repair, a cut is made in the abdomen to access the aneurysm. The abnormal vessel is replaced with a graft made of synthetic material, such as Dacron.The other approach is called endovascular grafting (keyhole surgery). With this approach the graft is inserted into the aneurysm through a plastic tube called a catheter .The catheter is inserted via the groin using small incisions and the stent graft released to bridge the aneurysm. Not all patients with abdominal aortic aneurysms are suitable for this type of keyhole surgery.

In the hands of a trained vascular surgeon more than 95% of patients will survive open surgery and have an excellent outcome if the operation is done before the aneurysm ruptures. Once it does, only 60 % will survive hence the importance of early diagnosis and treatment in appropriate cases. Endovascular surgery (keyhole) is a relatively recent treatment and although it has a slightly lower mortality its long term outlook is as yet uncertain. Your vascular surgeon will be able to tell you the pros and cons of both treatments and advise which one is best for your particular case. Suffice to say tht both are very effective in saving your life.

Abdominal Aortic Aneurysm (AAA)outcome

Abdominal Aortic Aneurysm (AAA)How can you avoid one

• Do not smoke as smoking is a potent cause of aneurysms• Watch your diet and remember that vegetables are good for you• Have your cholesterol checked and if it is high have it treated• Have your blood pressure measured and if it is high get treatment• Look into your family history and find out if any of your relatives died of this condition. If they did see a vascular surgeon and get a check up• If you are 65 and particularly if you are male,get a scan of your abdomen to check for an aneurysm.

StrokesThere are several causes of stroke but a common one is narrowing of the carotid artery caused by atherosclerosis. The carotid arteries come off the aorta in the chest and one runs up each side of the neck dividing into two branches just below the angle of the jaw. One branch supplies the face and the other passes directly to the brain (internal carotid artery) .The diseased area occurs in the internal carotid artery just after the branching. Blood clot forms on this narrow area (stenosis) and bits can come off and travel upstream to block off the small arteries which supply the brain or eye.

StrokesWhen these bits of clot pass into the brain, they are usually very small and cause a temporary stroke a so called mini stroke which recovers after a few minutes or hours. This is called a transient ischaemic attack.During these attacks the patient can lose the use of the arm or leg or both on the opposite side. If the left carotid artery is affected in a right handed person there may be a temporary loss of speech. If the clot goes into the eye it can cause a temporary loss of vision which is often likened to a blind being drawn down over the eye and then lifted again as the sight recovers.These attacks are called amaurosis fugax .Attacks of TIA or amaurosis fugax are a warning sign and you MUST contact your physician. If the narrowed artery blocks completely then a permanent stroke will usually occur.

The symptoms to watch out for are;• weakness of the arm or leg or both on the opposite side of the body (the right side of you brain controls the left side of your body and vie versa)• Loss of sensation, numbness and /or tingling in the arm , leg ,face, or body on the opposite sideof the body to the affected artery.• Loss of all or part of the vision in the eye on the same side as the affected artery which islikened to a blind being drawn down over the eye and then lifted again.•These symptoms last for a few minutes or hours and then complete recovery occurs.

Transient Ischemic Attacks - Ministrokes

Do not panic Seek advice from your physician immediately Stop smoking

What You Should Do If You Experience These Symptoms

You should then be referred to a vascular surgeon by your Physician and be investigated

• Physical examination• Blood tests (cholesterol)• A Duplex scan ( to see your carotid arteries)• You will probably be put on a small dose of aspirin

The scan is non invasive and does not hurt. It is essential thatIt is done by a properly trained practitioner and will show the doctorIf you have a significant narrowing of your carotid artery which needs treatment

Duplex scan

Treatment options for carotid stenosis

• lowering the cholesterol , controlling the blood pressure , giving antiplatelet drugs such as aspirin and stopping smoking are essential in all cases• A mild degree of stenosis (narrowing) needs nothing else• Severe stenosis needs an operation and this can be either carotid endarterectomy (open surgery) or the insertion of a stent

CEA is a surgical procedure in which a vascular surgeon makes an incision in the neck using local or general anesthesia. The Carotid artery is opened and the narrowed part removed in an operation called an endarterectomy. This is a bit like peeling an orange, you keep the skin and throw the orange away.This restores the artery to its normal thin consistency and some surgeons widen it further by sewing on a patch .No procedure is completely safe and stroke or death can occur in about 5% of cases. Trials have shown that the vast majority of patients having this operation do very well and future strokes are avoided.It is vital after surgery that you do NOT start to smoke again and take appropriate drugs to control your cholesterol and blood pressure.

Carotid Endarterectomy (CEA)

Carotid Angioplasty & Stenting This is a new technique where the narrowed carotid artery is widened without direct surgery. A wire is passed by the vascular surgeon from the groin and into the narrowed artery in the neck using local anesthesia. A small balloon is then passed over this guide wire and the narrow area stretched. A metal stent is then passsed into the stretched area and expanded to keep it wide .There are dangers to this technique because the wire and balloon can dislodge bits of clot and they can go into the brain and cause a stroke. Trials have shown that the open operation (carotid endarterectomy) is safer than angioplasty which is reserved for patient who are not fit for surgery or in whom surgery is risky, for example in patients who have had neck irradiation. Your vascular surgeon will be able to advise which is the best option for you.

Vascular SurgeonsWhy should you see a vascular surgeon for treatment?

• Vascular surgeons are the only physicians exclusively treating vascular disease and able to provide you with ALL the options available.

• Vascular surgeons can give you appropriate advice about lifestyle changes and the medications which you need.

• Vascular surgeons can treat you with endovascular (keyhole) treatments if they are appropriate for you

• Vascular surgeons can operate on you if that is what you need

Remember that ONLY vascular surgeons can offer you all of these options and therefore pick which is the best tretment for you