Abdominal Aortic Aneurysm

Endovascular Aortic Aneurysm Repair

Peripheral Arterial Occlusive Disease

Balloon Angioplasty

Carotid Artery Occlusive Disease

Renal Artery Stenosis

The Foot at Risk

S Y R A C U S E • N E W Y O R K

Presented by The Department of SurgerySection of Vascular Surgery

SUNY Upstate Medical University

A b o u t

DEPARTMENT OF SURGERY • SECTION OF VASCULAR SURGERY

Performing Vascular and Endovascular Surgery

VascularDisease

Renal Artery StenosisCarotid Artery Occlusive Disease The Foot at Risk

For people with diabetes or poorcirculation, proper foot care is veryimportant. Many people with diabeteshave nerve damage resulting infoot numbness. Foot injuries maygo unnoticed and untreated for longperiods of time. Those with diabetesare more likely to get infections andhave poor circulation in their legs andfeet which may result in amputation.Poor circulation or arterial blockagescan prevent healing and increasethe risk of leg amputation. Guidelinesfor good protective foot care arelisted below.

Carefully check the feet and legsevery day for injury, blisters, cuts,bruises, or signs of infection includingredness, swelling, warmth ordrainage. Use a mirror to fully seethe bottoms of the feet. If youcannot see, have someone look atyour feet for you. Report anyabnormal findings to your doctor.

Keep legs and feet clean. Wash themdaily in warm (NOT HOT) water. Hotwater may cause burns or blisters.Dry feet carefully, especially between

the toes. Applya light moistur-izing lotion tothe legs andfeet every day.Don’t apply lotionbetween thetoes.

Do not walk barefoot or wear opensandals, not even at home. Anyinjury (for example, a splinter) cancause an infection that might causethe loss of part of a foot or leg.

Wear properly fitted clean socks orstockings. Always wear socks withshoes. Avoid socks that do notallow moisture to dry.

Properly fitting shoes are important.Special shoes may be prescribed.New shoes should be worn only forshort periods. Examine feet often tocheck that no sores are developing.Alternate shoes daily or allow the shoesto dry thoroughly between wearing.

Trim toenails straight across but nottoo short to minimize the possibilityof ingrown toenails, which areprone to infection. If you can’t seewell or have known blockages inthe arteries, a podiatrist should trimyour nails. In addition, a podiatristshould cut any corns, calluses oringrown toenails.

If your feet are cold at night wearsocks. Do not use hot water bottles,heating pads, warm compresses, orheating lamps near your feet.

If you smoke, STOP now! Not smokingwill help preserve your circulation.

What is carotid artery occlusivedisease?The carotid arteries are twoblood vessels, one on each sideof the neck, that carry blood fromthe heart to the brain. Thesearteries can become partially orcompletely blocked therebydecreasing blood flow to thebrain. It is caused by a conditioncalled atherosclerosis, alsoknown as hardening of thearteries. Atherosclerosis iscaused by a build up of choles-terol and calcium on the inside ofthe arteries. These deposits arecalled plaques, which mayeventually become so thick thatthey completely block the flow ofblood through the arteries.People with untreated blockedcarotid arteries are more likely tohave strokes.

What are the risk factors?People who smoke cigarettes,are diabetic, have high levels ofblood cholesterol, have highblood pressure, or have agenetic tendency toward it are athigher risk for developing ablocked carotid artery.

What are the symptoms?Most people with blockedcarotid arteries have nosymptoms. The most commonsymptoms are transient ischemicattacks (TIAs), which aresometimes called mini-strokesand can last from minutes to 24hours. Examples of TIAs include:slurred speech, weakness of thearm or leg, loss of vision,unsteady gait, or loss of coordi-nation. A person suffering TIAs isat increased risk for a majorstroke and should seekimmediate medical attention.

How is it diagnosed?The doctor will listen to the neckarteries with a stethoscope.Blood flow through narrowedarteries is noisier than normalblood flow. Depending on what is

heard, tests may be ordered tomeasure the amount of blockage.These tests include ultrasoundscans and/or special x-raysincluding an arteriogram, CT arteriogram, or magneticresonance angiogram (MRA).

How is it treated?Carotid artery occlusive diseaseis a permanent but correctablecondition. Treatment is designedto prevent further blockage andstroke.

If there is some blockage butthere are no symptoms, treat-ment may be just regular check-ups, with ultrasound studies tomonitor the condition andmedications that thin the bloodor prevent the blood cells fromforming clots. Even severenarrowing may produce nosymptoms. If the blockage is verytight, surgery may be recom-mended to decrease the risk ofstroke, even if there are nosymptoms.

The most common surgery,carotid endarterectomy, involvesremoving the plaque from theartery. For some patients, aballoon angioplasty (inflation of aballoon to flatten the plaqueagainst the artery wall), withplacement of a stent, may beperformed.

What is renal artery stenosis?Normally, the kidneys rid the bodyof waste by filtering the blood andmoving the waste into the bladder.Renal artery stenosis means thereis a “blockage” or “narrowing” inthe arteries that bring blood to thekidneys. It causes the kidneys toreceive an abnormally low amountof blood flow. Renal artery stenosiscan lead to high blood pressure andkidney failure. When a blockage ornarrowing occurs, the kidneys releasehormones that increase bloodpressure to a point that even strongmedications cannot control it. Thedecrease in blood flow also makes itharder for the kidneys to remove waste.Eventually the kidneys stop working.

What causes renal arterystenosis?“Hardening of the arteries” oratherosclerosis causes most casesof renal artery stenosis. Normallyyour blood vessels have a smoothinner lining. As you get older, abuildup of calcium, cholesterol, andother materials can stick to thisinner lining causing a blockage.Atherosclerosis typically causesrenal artery stenosis in older people.In young people a disease calledfibromuscular dysplasia causes thewalls of the kidney blood vessels tobecome abnormally thick, whichleads to narrowing and blockage. Itis a condition that people are bornwith and is more common inwomen who are 20–40 years old.

What are the symptoms? Renal artery stenosis usuallydevelops slowly and many peopledo not have any symptoms. Doctorslook for it in people who have highblood pressure despite takingmedications to control it. Young

people with very high bloodpressure may also have it. It canalso cause kidney failure, conges-tive heart failure, or a build up offluid in the lungs (pulmonary edema).

How is it diagnosed?Several tests can detect renalartery stenosis. An ultrasound testuses sound waves aimed at thekidneys and can tell doctors if thekidney arteries are normal,narrowed, or completely blocked.An angiogram involves placing asmall needle in the upper thigh andinjecting contrast material (dye) intothe kidney blood vessels. Doctorsthen take x-rays of the vessels todetect areas of narrowing orblockage. Computed tomography(CT scan) and magnetic resonanceimaging (MRI) can also be used.

How is it treated?Treatment usually starts withmedication to lower the bloodpressure. If the medicine does notwork well enough or the stenosisbecomes worse, treatments areperformed that directly treat theblockage. Balloon angioplasty andstenting involves using a smallballoon catheter to open theblocked or narrowed arteries.Doctors insert the catheter into asmall needle which is guided to theblockage. When the ballooninflates, it flattens the blockage(plaque) against the walls of theartery. A tiny metal-mesh, expand-able tube called a stent is thenplaced to hold the artery open. Forsome patients, surgery is the besttreatment for renal artery stenosis.Bypass surgery detours around theblockage so that blood can flownormally. Endarterectomy isanother surgical treatment whichremoves the blockage.

Why is treatment important?Renal artery stenosis can causeextremely high blood pressurewhich damages the kidney andincreases the risk for stroke andheart attack. Blockage can alsolead to dialysis.

Vivian Gahtan, MD, Chief, Section of Vascular SurgeryJohn D. Fey, MD, Chief of Surgery, VA

Michael J. Costanza, MDKwame Amankwah, MD

DeAnna Holtman, NP

Patient Appointments 464-1800Academic Offices 464-6241

Vascular Laboratory 464-4454

ICAVL Accredited Performing ultrasound studies for the diagnosis of peripheral vascular disease

Inpatient and Outpatient Services

750 East Adams Street • Syracuse, New York 13210

www.upstate.edu/vascular

Foot Ulcers

Carotid Artery Occlusive Disease

with blockage

University Hospital 06.1

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Abdominal Aortic Aneurysm (AAA)

What is an abdominal aorticaneurysm?The aorta is the main artery ofthe chest and abdomen thatcarries blood from the heart to allthe body’s vital organs, andeventually to the legs and feet.An abdominal aortic aneurysm(AAA) is a weakening in the wallof the aorta that causes awidening or “ballooning” of aportion of the artery itself, much like a weak area of an old-fashioned rubber inner tube.An aneurysm may continue togrow larger and, if not treated,can burst (or rupture), oftencausing death.

What are the risk factors?People over the age of 60, whohave a family history of AAAs,suffer from high blood pressureor smoke are at increased risk.AAA is more common in menthan women. A family history is of special concern, so if anymembers of a person’s immediatefamily have an AAA, they shouldlet their doctor know and ascreening test can be scheduled.

What are the symptoms?Most of the time no symptomsare associated with AAAs. Mostare found by chance duringroutine physical examination, or when tests or x-rays are donefor other health problems.Occasionally, a person may havelow back pain or abdominal pain.Symptoms associated with anAAA require immediate attention.

How is it diagnosed?AAAs may be found when beingexamined by a doctor or by x-rays, such as an ultrasound, CT scan, or MRI. To get moreinformation about the aneurysmand associated blood vessels, an arteriogram may need to bedone. This involves the injectionof an x-ray visible dye into anartery to get more detailedpictures of the aneurysm.

How is it treated?After an AAA reaches a certainsize, repair is needed to avoid thepossibility of rupture. No treat-ment with medicines alone issufficient for treating an AAA.

Surgery for AAAs has been donefor more than 50 years. It hasbeen successful in treating AAAsand has good long-term results.During surgery, the weakenedportion of the aorta is replacedwith a polyester or teflon graftthat is carefully matched andsewn into place. The incision ison the abdomen or the flank.

New endovascular graftingtechnology allows the vascularsurgeon to repair the AAA bydelivering a graft inside the bloodvessels through a small incisionin each groin. Endovascular repairis not possible for every AAA.

Endovascular Aortic Aneurysm Repair Peripheral Arterial Occlusive Disease Balloon Angioplasty

What is peripheral arterialocclusive disease?It is a type of atherosclerosis, ahardening and narrowing of thearteries that supply blood to thearms and legs. Atherosclerosis iscaused by a build up of cholesteroland calcium on the inside of thearteries. These deposits are calledplaques. The plaques may becomeso thick that they completely blockthe flow of blood through thearteries. In most cases, it affectsthe legs. Problems result whenblood flow to the extremities isseverely decreased.

What are the risk factors?People who smoke cigarettes, arediabetic, have high blood cholesterollevels, high blood pressure, or havea family history of circulationproblems are more likely to developperipheral artery occlusive disease.

What are the symptoms?This disease progresses silently,without symptoms, until the arterieshave become seriously blocked.The first symptom is usually pain inthe legs when walking or exercising.As the blockages worsen, so doesthe pain. One or both legs may beaffected and pain may also be feltin the thighs or buttocks. This painusually occurs with walking,quickly goes away when resting,and returns when activity is startedagain. Feet may seem cooler. Somehair loss may happen on the legs andthe top of the feet. Cuts and scrapestake longer to heal. When thecirculation is bad enough a personmay have pain even while restingor have sores that will not heal.

How is it diagnosed?The doctor will do a physicalexamination and take a medicalhistory. Pulses should be checkedin the feet, legs, and groins. If thepulse exam is abnormal, ultrasoundmay be performed to identify thelocation and amount of arterialnarrowing. Other special x-rays, suchas an arteriogram may be required.

How is it treated?If you smoke, stop! Prescribedmedications should be taken asneeded to lower blood pressure orlower the level of fats in the blood.Diet changes may be needed.Exercise is also important tomaintaining good arterial circulation.

Not all blockages require a procedure. However, procedures toimprove circulation may be requiredfor serious blockages. The treatmentchoices include: (1) removing theblocked portion of the artery; (2)creating a bypass using a piece ofvein or synthetic material; or (3)catheterization and balloon dilation,where a small tube is inserted intoan artery in the groin and a smallballoon is inflated to widen theblocked area of the artery. If thedisease is extremely severe andimproving the circulation is notpossible, amputation of a leg or foot may become necessary.

What is a balloon angioplasty?Balloon angioplasty is a way ofopening a blocked blood vessel.Instead of using surgery to cutthe blood vessel open, doctorscan slide a small tube on theinside of the blood vessel anddirect it to the area that isblocked using x-rays. Inflatingthe balloon on the end of the tube pushes the blockage out ofthe way and allows more bloodto flow through the artery.

Why do people need aballoon angioplasty?Balloon angioplasty treats blockagesthat usually occur because ofatherosclerosis (hardening of thearteries). Arteries are tubes thatblood flows through in order tobring oxygen and nutrients to allof the body’s vital organs andmuscles. When blockages occur,blood flow decreases and theorgans or muscles that the arterysupplies do not get enoughoxygen or nutrients. This problemcan cause different symptomsdepending on which artery isblocked. For example, blockagesin the leg arteries can causecramps with walking while block-ages in the kidney arteries cancause high blood pressure andeventual kidney failure.

Can all blockages be treatedwith balloon angioplasty?No. Some blockages are besttreated with surgery. The locationof the blockage and the patient’ssymptoms often help doctors deter-mine which treatment is better.

What is a stent?A stent is a strong, flexible, metaltube that can be permanentlyplaced on the inside of a bloodvessel. After balloon angioplastystretches a blood vessel to opena blockage, doctors often use astent to hold the blood vesselopen and increase blood flowthrough it.

What is an angioplasty like?Is it painful?Most patients feel somepressure during angioplasty butthe procedure is not usuallyuncomfortable. The doctor useslocal anesthesia (lidocaine) tonumb the skin on the upper thighbefore placing a small needleinto the leg artery. The needle isthen removed and replaced witha flexible tube through which thedoctor can complete the rest ofthe procedure. Injecting asubstance called contrast agent(x-ray dye) helps the doctor seethe blood vessels on the x-rayand direct the balloon or stentinto position. After balloon angio-plasty patients usually spend onenight in the hospital for observation,and they can return to their fullactivity level 24 to 48 hours later.

Which blood vessels can betreated with angioplasty?Although angioplasty is possiblein almost any artery, it is mostcommonly used to treat blockagesin the coronary (heart), iliac/femoral (leg), renal (kidney), andcarotid (neck) arteries.

What is an endovascularabdominal aortic aneurysm(AAA) repair?

Endovascular means “inside ablood vessel.” In an endovascularAAA repair, doctors place a strong,flexible tube called an endograftinside the aorta (blood vessel).Instead of one large incision on theabdomen, two small ones are made near each hip. The doctorsthen slide the endograft throughthe femoral arteries (leg bloodvessels) and into the aorta. Whenit’s in position it expands and sealsoff the aneurysm so it can’t breakopen and bleed.

How is the repair done?Before a repair is scheduled, thedoctor uses special x-rays (CT scansand angiograms) to measure theexact size of the blood vesselsabove and below the aneurysm.Based on these measurements, thedoctor chooses an endograft thatwill fit the size of the blood vessels.The doctor makes the two smallcuts (near the crease between theabdomen and the thigh). Each partof the endograft is placed into thepatient’s blood stream with the helpof x-rays. The endograft thenexpands to become a strong,flexible tube that seals off theaneurysm and reinforces the bloodvessels (aorta and iliac arteries).An x-ray confirms that blood isgoing through the endograft andnot leaking into the aneurysm.

What is recovery like? Because it uses small cuts,endovascular AAA repair maycause less discomfort aftersurgery. Many patients have ashort hospital stay of only a fewdays and often return to normalactivity within 4 to 6 weeks.

Why is follow-up important?It is possible for problems to occur without causing noticeable

symptoms. The doctor can checkfor these problems by gettingpictures (CT scans, ultrasounds) ofthe endograft at regular intervals. If a problem is detected it may needtreatment. Follow-up includes acheck up and CT or ultrasoundscan at one month, six months, 12months and every year thereafter.

Can all patients with AAAhave an endovascular repair?No. In order to work properly, anendograft must fit into andcompletely seal off the aneurysm. If the blood vessel is too large orhas too many twists and turns, theendograft will not fit or seal off theaneurysm and the AAA will not berepaired. Doctors decide who canhave an endovascular repair bylooking at the x-rays (CT scans andangiograms).

Are thoracic aortic aneurysmstreated with endografts?In the chest, the aorta travelsbehind the lungs alongside thebackbone. When this part of theaorta becomes enlarged it is calleda thoracic aortic aneurysm (TAA).These aneurysms can be surgicallyrepaired by splitting the ribs andreplacing the enlarged part of theaorta. Some of these aneurysmscan be treated with an endograft,which requires only a small incisionon the groin area. The size, shape,and location of a TAA determinewhether doctors can perform anendovascular repair.

Angioplasty

Balloon Angioplasty

Endovascular AAA

Leg BypassAbdominal Aortic Aneurysm

Aneurysm

KidneyBalloon

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