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SAINT THOMAS HEALTH MEDICAL MONDAYS: Endovascular Advances -- March 11, 2013 -- Dr. Bryan T. Fisher & Dr. John E. Keyser

Posted: Updated:

Monday, March 11, 2013
TOPIC: Endovascular Advances
Bryan T. Fisher, MD: endovascular surgeon
John E. Keyser, MD: vascular surgeon

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The surgeons within the Endovascular Center at Baptist Hospital use the latest advances to
treat patients with PAD (Peripheral Artery Disease), CAD (Carotid Artery Disease) and AAA
(Abdominal Aortic Aneurysm)—providing patients the most advanced technology and surgical
expertise for their patients.

Peripheral Vascular Disease Overview

The circulatory system consists of 2 types of blood vessels: arteries and veins. These are tubular
structures that carry the blood throughout the body.

Arteries carry oxygen- and nutrient-rich blood from the heart to the organs and cells.

Veins carry oxygen-depleted blood and wastes through the kidneys, liver, and lungs, where
wastes are filtered out and removed from the body. The venous blood is then again filled with
oxygen in the lungs and returned back to the heart.

The two are interconnected by small weblike vessels called capillaries.

Peripheral vascular disease refers to any disease or disorder of the circulatory system outside of the brain
and heart.

Although the term peripheral vascular disease can include any disorder that affects any of the
blood vessels, it often is used as a synonym for peripheral artery disease.

Peripheral vascular disease is the most common disease of the arteries.

It is caused by build-up of fatty material within the vessels, called atherosclerosis.

Another name for this condition is arteriosclerosis, or hardening of the arteries.

This is gradual process in which the artery gradually becomes blocked, narrowed, or weakened.

When this condition affects the arteries of the heart, it is called coronary heart disease (coronary
artery disease).

Atherosclerosis is known for affecting the arteries of the heart (coronary arteries) and the brain (carotid
arteries). Of the peripheral arteries, those of the legs are most often affected. Other arteries frequently
affected by atherosclerosis include those supplying blood to the kidneys or arms.

When an artery is blocked or narrowed, the part of the body supplied by that artery does not get
enough blood/oxygen. Medical professionals call this ischemia.

This can cause various symptoms depending on which organ system is affected. The symptoms
range from pain, cold feet, and bluish discoloration to stroke or gangrene; if it is not reversed, the
body part affected is injured and eventually starts to die. It is important to detect the narrowed
artery before damage occurs. The pulses in the arm or leg are decreased or absent, indicating a
lack of arterial blood flow.

Peripheral vascular disease is a very common condition in the United States.

It occurs mostly in people older than 50 years. Peripheral vascular disease is a leading cause of
disability among people older than 50 years and in those with diabetes.

About 10 million people in the United States have peripheral vascular disease, which translates to
about 5% of people older than 50 years.

The number of people with the condition is expected to grow as the population ages.

Men are slightly more likely than women to have peripheral vascular disease.

Peripheral vascular disease is more common in smokers, and the combination of diabetes and
smoking almost always results in more severe disease.

About half of people with peripheral vascular disease do not have symptoms. Of those who do, another
half do not tell their health care providers.

Many people seem to think that this is a normal part of aging, and that nothing can be done
or that the only alternative is surgery. Today, however, surgery is only one of several effective
treatments available for peripheral vascular disease.

Treating peripheral vascular disease medically is the best way to prevent worsening of the
condition or complications. This is especially true for patients with hypertension or diabetes, those
with high fats or lipids in the blood, and those who smoke


The most common cause of peripheral vascular disease is peripheral artery disease.

Peripheral artery disease is due to atherosclerosis. This is a gradual process in which a fatty
material builds up inside the arteries.

The fatty material mixes with calcium, scar tissues, and other substances and hardens slightly,
forming plaques of arteriosclerosis.

These plaques block, narrow, or weaken the vessel walls.

Blood flow through the arteries can be restricted or blocked totally.

Other causes of peripheral vascular disease include the following:

Blood clot: A blood clot can block a blood vessel (thrombus/emboli).

Diabetes: Over the long term, the high blood sugar level of persons with diabetes can damage
blood vessels. This makes the blood vessels more likely to become narrowed or weakened. Plus,
people with diabetes frequently also have high blood pressure and high fats in the blood, which
accelerates the development of atherosclerosis.

Inflammation of the arteries: This condition is called arteritis and can cause narrowing or
weakening of the arteries. Several autoimmune conditions can develop vasculitis, and, besides
the arteries, other organ systems are also affected.

Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood
vessels. Both salmonellosis (infection with Salmonella bacteria) and syphilis have been two
infections traditionally known to infect and damage blood vessels.

Structural defects: Defects in the structure of a blood vessel can cause narrowing. Most of these
cases are acquired at birth, and the cause remains unknown. Takayasu disease is a vascular
disease affecting the upper vessels of the body and affects usually Asian females.

Injury: Blood vessels can be injured in an accident such as a car wreck or a bad fall.

Risk factors for peripheral vascular disease (and atherosclerotic disease of all arteries throughout the

Positive family history of premature heart attacks or strokes

Older than 50 years

Overweight or obesity

Inactive (sedentary) lifestyle



High blood pressure

High cholesterol or LDL (the "bad cholesterol"), plus high triglycerides and low HDL (the "good

People who have coronary heart disease or a history of heart attack or stroke generally also have an
increased frequency of having peripheral vascular disease.


Only about half of the individuals with peripheral vascular disease have symptoms. Almost always,
symptoms are caused by the leg muscles not getting enough blood. Whether you have symptoms
depends partly on which artery is affected and to what extent blood flow is restricted.

The most common symptom of peripheral vascular disease in the legs is pain in one or both calves,
thighs, or hips.

The pain usually occurs while you are walking or climbing stairs and stops when you rest. This
is because the muscles' demand for blood increases during walking and other exercise. The
narrowed or blocked arteries cannot supply more blood, so the muscles are deprived of oxygen
and other nutrients.

This pain is called intermittent (comes and goes) claudication.

It is usually a dull, cramping pain. It may also feel like a heaviness, tightness, or tiredness in the
muscles of the legs.

Cramps in the legs have several causes, but cramps that start with exercise and stop with rest
most likely are due to intermittent claudication. When the blood vessels in the legs are completely
blocked, leg pain at night is very typical, and the individual almost always hangs his or her feet
down to ease the pain. Hanging the legs down allows for blood to passively flow into the distal
part of the legs.

Other symptoms of peripheral vascular disease include the following:

Buttock pain

Numbness, tingling, or weakness in the legs

Burning or aching pain in the feet or toes while resting

A sore on a leg or a foot that will not heal

One or both legs or feet feel cold or change color (pale, bluish, dark reddish)

Loss of hair on the legs


Having symptoms while at rest is a sign of more severe disease.

When to Seek Medical Care
When you have symptoms of peripheral vascular disease in a leg or a foot (or in an arm or a hand), see
your health care provider for an evaluation.

Generally, peripheral vascular disease is not an emergency. On the other hand, it should not be ignored.

Medical evaluation of your symptoms and effective treatment, if indicated, may prevent further
damage to your heart and blood vessels.

It may prevent more drastic events such as a heart attack or stroke or loss of toes and feet.

If you have symptoms of peripheral vascular disease along with any of the following, go to the nearest
hospital emergency department.

Pain in the chest, upper back, neck, jaw, or shoulder

Fainting or loss of consciousness

Sudden numbness, weakness, or paralysis of the face, arm, or leg, especially on one side of the

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden dizziness, difficulty walking, loss of balance or coordination

Sudden severe headache with no known cause

Do not try to "wait it out" at home. Do not try to drive yourself. Call 911 right away for emergency medical


The best way to prevent peripheral vascular disease is to reduce your risk factors. You cannot do
anything about some of the risk factors, such as age and family history. Other risk factors are under your

Do not smoke.

Eat nutritious, low-fat foods; avoid foods high in cholesterol.

Maintain a healthy weight.

Engage in moderately strenuous physical activity for at least 30 minutes a day. At least walk
briskly for 20-30 minutes daily.

Control high blood pressure.

Lower high cholesterol (especially LDL cholesterol or the "bad cholesterol") and high triglyceride
levels, and raise HDL or "the good cholesterol." If exercise fails to lower your cholesterol, certain
medications (statin drugs) can be taken to decrease the bad cholesterol.

If you have diabetes, control your blood sugar level and take scrupulous care of your feet.
Ask your doctor what your HbA1C is, a measure of how well your blood sugar is controlled; it
should be less than 7.0. If it is greater than 8.0, it is not controlled, and your risk of blood vessel
complications (eyes, heart, brain, kidneys, legs) escalates.

Smoking is a very strong risk factor for developing peripheral vascular disease and can significantly
worsen the disease, especially in diabetics. Quitting smoking can reduce the symptoms of peripheral
vascular disease and lower your chance that the disease will get worse.


If untreated, peripheral vascular disease can develop complications:

Permanent numbness, tingling, or weakness in legs or feet

Permanent burning or aching pain in legs or feet

Gangrene: This is a very serious condition. It is the result of a leg or foot or other body part not
getting enough blood. The tissues die and begin to decay. The only treatment is amputation of
the affected body part.

People with peripheral vascular disease are at higher-than-normal risk of heart attack and stroke.

High Cholesterol Is A Threat To The Entire Vascular System, Not Just
Heart Vessels

Everyone understands the importance of maintaining healthy cholesterol levels to protect their
heart, but many are not aware of how high cholesterol levels threaten the health of their entire
vascular system. Vascular diseases cause strokes, death from ruptured aortic aneurysm, and
pain when walking, or leg amputation in the worst cases.

It is just as important to maintain healthy levels of cholesterol for your entire vascular system
as it is for your heart. High levels of low-density lipoprotein cholesterol are one of the major risk
factors for vascular disease that can result in paralysis, blindness, or speech abnormality due to
stroke and even death by a ruptured aortic aneurysm.

The vascular system is made up of all the body's arteries and veins. Healthy vessels are
smooth and unobstructed, allowing oxygen-rich blood to flow freely and deliver glucose and
nutrients to the vital organs, brain, legs, and arms. Typically with age, the vessels build up
plaque, a sticky substance made up mostly of fat and cholesterol. The plaque narrows the
passageway within the vessels and causes them to become stiff. Vascular disease results when
the vessels become too narrow or obstructed, and limit the flow of blood.

Here are a few suggestions to take control of your cholesterol levels:

Keep your refrigerator filled with only good foods, like fresh fruits, vegetables, and low-
fat or fat-free daily foods in your refrigerator.
Pay attention to food labels when you shop. Purchase foods that are low in saturated fat
and cholesterol.
Control the portion size of your meals.
Exercise. Even moderate physical activity, like walking 30 minutes daily will help
maintain your cholesterol levels.
Know what your cholesterol numbers are.
Follow your doctor's treatment if you have trouble lowering your cholesterol levels.

Other risk factors for vascular disease include: high blood pressure, smoking, obesity, lack of
exercise, and diabetes. People who are 55 or older, particularly those who have a family history
of vascular disease, should discuss their risk factors with their primary care physician. The three
most prevalent vascular diseases are:

Peripheral Arterial Disease (PAD)

Peripheral arterial disease occurs when the peripheral arteries in the leg become too narrow or
obstructed and limit the blood flow to the legs. If left untreated, peripheral arterial disease can
cause pain or aching in the legs, difficulty with walking, resting pain in the foot at night in bed,
non-healing sores or infections in the toes or feet, and can lead to limb loss in its most sever
form. In addition, it can be associated with other serious arterial conditions leading to heart
attacks and stroke. African Americans and Hispanic populations have a higher occurrence of

Carotid Artery Disease (CAD)

Carotid artery disease occurs when the carotid arteries in the neck become narrow and stiff with
plaque. Strokes result either from obstruction of the blood flow to the brain by or when bits of
plaque and clots break off from the plaque and flow to the brain.

Abdominal Aortic Aneurysm (AAA)

Abdominal aortic aneurysms (AAA) occur when the wall of the aorta, the largest artery in
the body, progressively weakens and begins to bulge. An AAA may continue to enlarge and
eventually rupture if left untreated, causing severe internal bleeding and possibly death.


Varicose Veins Overview

Veins are blood vessels that return deoxygenated blood from the outer parts of the body back to the heart
and lungs. When veins become abnormally thick, full of twists and turns, or enlarged, they are called
varicose veins. Generally, the veins in the legs and thighs have a tendency to become varicosed.

The thickened, twisting or dilated parts of the vein are called varicosities.

Varicose veins can form anywhere in the body, but they are most often located in the legs.

In the United States alone, about 19% of men and 36% of women have varicose veins.

Varicose veins tend to be inherited and become more prominent as the person ages. Veins in the
leg are either superficial or deep.

The superficial veins and their branches are close to the skin. These veins typically become varicosed.
Also included in this category are the communicator or perforator veins, which connect the superficial
veins with the deep veins.

The deep veins are encased by muscle and connective tissue, which help to pump the blood in the veins
and back to the heart. The veins have one-way valves to prevent them from developing varicosities.

Generally, blood travels from the superficial veins to the deep veins. From there, the blood travels through
a network of larger veins back to the heart.

Varicose Vein CAUSES

Many theories exist for why varicosities occur in veins, but the consensus is that defective/damaged
valves within the veins are to blame.

Valves prevent backward flow of blood within the vein. They keep blood in the vein moving
toward the heart. Why the valves stop working is up for debate.

Some experts think inherited problems cause some people to have too few valves or valves that
do not function properly.

Some people may be born with abnormalities of the vein wall. The resulting weakness may
predispose the valves to separate and become leaky.

The result is that when a person with poorly functioning valves stands up, the blood flow actually
reverses and flows down the superficial veins, when it should be flowing up, toward the heart.

When the muscles surrounding the deep veins contract, emptying the deeper veins, a build-up of
pressure occurs.

This causes even more blood to go the wrong way from the deep to the superficial veins through
faulty valves in the perforator veins.

This increases pressure in the superficial veins and causes varicosities.

Many factors can aggravate the situation.


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