Vascular and Endovascular Surgery
Peripheral Vascular Disease
Interestingly, veins, which carry blood back to the heart have the same three layers as an artery, but the middle layer is extremely small. Therefore, veins are not affected by peripheral vascular disease as are arteries. Veins have an entirely different set of problems (see our section on venous treatments).
Peripheral vascular disease can result in blockages in the arteries or abnormal enlargements of arteries (aneurysms). Risk factors for peripheral vascular disease include a family history of peripheral vascular disease, heart disease, aneurysm disease (genetic component), history of known peripheral vascular disease, smoking, and hypertension. Artery blockages can occur anywhere but the two common areas are in the lower extremities and in the carotid arteries (the arteries in the neck that take blood to the brain). In each area, there is a unique set of symptoms that occur. Advances in technology have now given vascular surgeons a large compendium of techniques to fix these problems; many of which are minimally invasive.
Lower extremity peripheral vascular disease
Resting for a minute allows the lactic acid to be flushed out as the oxygen supply builds back up. The patient can then go on to walk again, but only to be stopped at the same distance again from the cramps in the calf.
In some patients, the blockages are so severe that the tissues in the lower extremities do not even have enough oxygen at rest. This results in tissue break down, wounds, and pain at rest. This becomes an emergency; unless blood flow is restored, the patient will require an amputation.
Advances in technology now give vascular surgeons many different options for repairing artery blockages due to peripheral vascular disease. Most often, patients can be treated with angioplasty (using a balloon to open up the artery) or stenting (putting a spring in the artery to keep it open). Other options include manually cleaning out the artery call endarterectomy (End-Art-Er-Ek-Toe-Me) or a surgical bypass around the blockage.
Once the artery is fixed, patients are monitored using ultrasound surveillance. All patients with vascular disease must be followed with ultrasound. Fixing an artery in a patient with peripheral vascular disease does not cure the disease, it only fixes the affected artery.
Peripheral vascular disease will progress over time and re-intervention may be required. Re-intervention is easier if found early rather than waiting for the symptoms to recur.
Carotid Artery Disease
Blockages in the carotid artery can result in a stroke. Unfortunately, carotid artery blockages are often silent until the first event occurs. This can be a TIA (a transient ischemic attack—a warning sign of a stroke) or an actual stroke. Symptoms of a stroke include fascial droop, inability to speak or understand, blindness in one eye, or loss of function of an arm or leg or both. Screening for carotid artery disease is important because by the time that symptoms occur, it may be too late. Screening for carotid artery disease is done with ultrasound.
Repairing a blockage in the carotid artery is most often done with an endarterectomy. This is where the artery is cleaned out using an open surgical approach. While there are other methods available, such as stenting, carotid endarterectomy remains the standard of care.
As with peripheral vascular disease treatment in the lower extremities, vascular disease in the carotid arteries must be followed with ultrasound after treatment. Plaque can recur and re-intervention may be required in order to prevent a stroke.
An aneurysm (An-Ur-Ism) is an abnormal enlargement of an artery. Nearly any artery can develop into an aneurysm. Aneurysms are analogous to blowing up a balloon. The larger the balloon gets the easier it is to blow up; eventually rupturing if it gets large enough. Therefore, the biggest risk of having an aneurysm is for it to rupture suddenly. If it ruptures the chance of making it to the hospital and surviving an emergency repair is very low. While the risk for most aneurysms is the risk of rupture, aneurysms can also develop so much clot inside them that they completely block off the artery resulting in a sudden lack of blood flow to any structure down-stream of the blocked artery. Usually that occurs in the popliteal arteries (the arteries behind the knees) resulting in potential limb loss.
Aneurysms are silent (they do not cause any symptoms) so the only way to know if you have an aneurysm is to look for one with screening ultrasound testing or to find one incidentally on an ultrasound, CAT scan, or MRI done for other reasons. Risk factors for aneurysms include a family history of aneurysm disease (genetic component), history of known peripheral vascular disease, smoking, and hypertension. If you have risk factors for aneurysm disease, you should consider being screened by age 65. Medicare actually has a “welcome to Medicare” option of a free screening for an abdominal aortic aneurysm (see below.)
Aortic aneurysm can also occur in the thoracic aorta (the portion of the aorta in the chest). These are less common than abdominal aortic aneurysms and usually present at an older age; usually over 70 years old.
Patients who are found to have an aortic aneurysm are put into a surveillance program (see our section on vascular surveillance). Abdominal aortic aneurysm can be followed with ultrasound. Thoracic aneurysms must be followed with CAT scanning because ultrasound cannot see well enough into the chest because the lungs prevent visualization of the thoracic aorta. Because abdominal aortic aneurysms are so much more common than thoracic aneurysms, most patients with aneurysm disease are followed with ultrasound surveillance. If you have an aortic aneurysm, it is extremely important to have regular ultrasound surveillance. All aneurysms grow over time. If they get large enough they must be repaired to prevent complications. Remember that aneurysm are silent until they either rupture or clot off. Ultrasound is the only way to know if you have an aneurysm and if it is large enough to be fixed.
Fixing an aortic aneurysm is not nearly as difficult as it has been in the past thanks to the major technological advances in fixing this disease. Historically, aneurysms were repaired via large open incisions. This was a major surgery resulting in a prolonged hospitalization for at least one week and a recovery time of nearly three months! Now, aneurysms can be fixed endovascularly (entirely from within the inside of the artery. This is a one hour surgery, with an overnight hospital stay and a recovery time of one to two weeks at most!! Repair of an abdominal aortic aneurysm is called an EVAR (EndoVascular Aneurysm Repair) and repair of a thoracic aortic aneurysm is called a TEVAR (Thoracic EndoVascular Aneurysm Repair).
The following animation illustrates how this is done in the operating room.
Play the video to see how we fix an aneurysm in the operating room.
Once the aneurysm is repaired, patients are placed into a surveillance program to monitor the repair. It is very important to maintain ultrasound follow up of the repair. Occasionally, these grafts do require some maintenance. If identified early through continued surveillance, maintenance can usually be done endovascularly as a quick outpatient procedure.
Hybrid Operating Room
Advances in the treatment of peripheral vascular disease include the development of the hybrid operating room theater.
By definition, a “hybrid” is anything that is made by combining two different elements. We see examples of “hybrids” in many different aspects of our daily lives. These include hybrid cars, hybrid plants, and even hybrid cultures. A hybrid operating room is a standard surgical theatre that is equipped with advanced medical imaging devices that would normally be used in a cardiac catheterization laboratory. This equipment includes a movable Image intensifier (C-Arm used for taking X-rays), a movable gantry (Operating table that can be used for x-ray fluoroscopy), a power injector for injecting contrast, and monitors and support systems that allow for complex x-ray imaging. While this may not seem like a big change, in fact, it has revolutionized the treatment of vascular disease.
The hybrid operating room is a powerful new tool in the management of patients with vascular disease. Because it has all of the capabilities of a standard operating room, nearly any open vascular surgery case can be performed. However, with the addition of advanced X-ray imaging, as well as other tools such as intravascular ultrasound, the surgery team can perform complex vascular repairs and reconstructions with minimally invasive methods that were never before possible. This minimally-invasive hybrid endovascular surgery is less traumatic with minimal discomfort and provides for shorter hospital stays as well as quicker recovery.
Carson Tahoe Regional Medical Center, has a modern, technologically advanced, hybrid operating room theater. The vast majority of our patients undergo treatment in this room which helps ensure a minimally invasive surgery with less post-operative discomfort, shorter hospital stay, and faster recovery.