Treatments for Vascular Disease
Treating Vascular Disease
The goal of treatment is to prevent aneurysm rupture; however, it’s important to note that not all aneurysms need to be treated since many may simply require close observation.
Treatment of an aortic aneurysm depends upon the size of the aneurysm, rate of aneurysm growth, and whether the patient is experiencing any symptoms. In general, all of these factors can combine to predict an aneurysm rupture.
There are two ways to repair aortic aneurysms: 1) With open surgery and 2) with minimally invasive endovascular repair that is completed through an “endograft,” which is a stent inserted through a small puncture in the groin. The method of repair should be personalized for each individual, so it’s important that patients discuss their options with a qualified vascular surgeon.
We favor a minimally invasive endovascular approach whenever feasible; however, there are some instances in which we recommend open surgery because it may be more beneficial to the patient. For high-risk patients who cannot undergo open surgery and are dealing with a thoracoabdominal or complex aortic aneurysm which, cannot be treated by conventional endovascular repair, modified endografts are an option. These endografts allow the patient to be treated with a unique, innovative approach that does not require an incision. Following repair, patients are required to be monitored with ultrasound or CT scans at regular visits to the office every six to twelve months.
Carotid Artery Disease
Treatment of carotid disease generally comes in three forms: medical management, open surgery, and minimally-invasive carotid stenting. All patients with carotid stenosis—regardless of the severity—should receive “best medical management,” which consists of minimizing risk factors. This is accomplished through medications to control blood pressure and cholesterol (beta-blockers and statins), antiplatelet medications (aspirin, Plavix), smoking cessation, exercise and weight loss, blood sugar control for diabetics, and optimizing any other cardiac or vascular conditions.
The need for further treatment depends upon the severity of the narrowing and whether the patient has symptoms or not. In general, if a patient is ASYMPTOMATIC and has 70% or greater narrowing (stenosis), they will require treatment. If a patient is SYMPTOMATIC and has 50% or greater stenosis, they will require treatment. This treatment is aimed at eliminating the blockage or narrowing within the carotid artery, as well as improving the blood flow to the brain. Both of these treatments can be completed through an open surgery called carotid endarterectomy (CEA) or by utilizing the minimally-invasive endovascular approach of carotid stenting.
Carotid endarterectomy usually requires general anesthesia and involves making an incision along the front of the neck, opening up the carotid artery and removing the plaques. The carotid artery is then sewed closed with the help of a patch. This procedure usually requires a one-night stay in the hospital and patients can expect to return to normal activity within four weeks.
Carotid stenting is performed under local anesthesia through a small needle puncture in the groin artery. A catheter is then advanced into the carotid artery and a small balloon is inserted at the location of the plaque and inflated to widen the artery. A stent is then placed across the plaque to keep the artery open and prevent it from narrowing. This procedure also requires a one-night stay in the hospital; however, patients can expect to a recovery time of only one or two days.
Both treatment options are extremely effective when completed by an experienced surgeon, but it’s important to remember that treatment for carotid disease must be individualized for each patient. Some patients benefit more from surgery, while others fare better with stenting. In short, it is vital for patients to seek the consultation of a vascular surgeon who is practiced and knowledgeable in both areas.
Peripheral Artery Disease
- Many cases of peripheral artery disease can be treated with medications and risk factor modification. These include smoking cessation, supervised exercise programs and weight loss, antiplatelet medication (aspirin, Plavix), statins to lower cholesterol, blood pressure control, glucose control for diabetics, and optimization of any other cardiac or vascular conditions which might exist.
- To alleviate symptoms, improve wound healing, or prevent the possibility of amputation, severe cases may require revascularization or restoration of blood flow to the legs and feet. This can be accomplished through either open surgical bypass or endovascular repair. A surgical bypass allows a blood vessel made of the patient’s own vein (or a synthetic fabric) to allow blood flow around the blocked or narrowed artery, while endovascular repair will require the arterial insertion of a mesh framework (angioplasty or stent) to keep the artery open.
- In addition, there are several new advanced endovascular technologies such as an atherectomy, which can be used to remove the plaque from within the artery through a simple skin puncture that does not require an incision. Again, treatment should be individualized for each patient.
The initial mainstay of treatment for all forms of venous insufficiency is graduated compression stockings and leg elevation. For patients with DVT, an anticoagulant medication or blood-thinner may be administered. For those with mild venous disease, such conservative therapies may be enough to control symptoms; however, if they are not successful, other procedures may be necessary to prevent serious complications should the following problems persist:
Large, Painful Varicose Veins and Spider Veins
Severe Venous Reflux
Deep Vein Thrombosis refractory to medications
Non-Healing Ulcer or Sores
Vein Stenosis (narrowing)
Venous Thoracic Outlet Syndrome
Pelvic Congestion Syndrome
Most treatments may be performed as an outpatient in the office and will involve injections or minimally-invasive catheter-based procedures that either seal off the diseased veins or removes them altogether. This prevents blood from refluxing backwards the wrong direction and pooling in the legs. Over time, the body will then turn the closed vein into scar tissue and nearby veins will take over the normal one-way blood flow back to the heart.
- In addition, we have innovative endovascular techniques to remove blood clots from the veins through a tiny puncture in the skin, which allows blocked or narrowed veins to be opened through ballooning or stenting.
- Patients with pelvic congestion syndrome may be treated with a variety or medications, including progesterone. If this fails, percutaneous embolization of the varices and diseased veins, with or without sclerotherapy, is an effective treatment.
- For venous thoracic outlet syndrome, physical therapy exercises are used as a first-line of treatment in an effort to stretch out the space between the first rib and clavicle. If this is unsuccessful, then partial first rib resection—through a small incision—may be necessary.