Vascular Surgery

A dissection is a tearing of the layers of the aorta. These tears can lead to blockages of the branching vessels that lead to important parts of the body. This damage also weakens the vessels and can lead to aneurysms.

Signs and symptoms of aortic aneurysm/dissection include: Pulsating mass of the abdomen. Ask your doctor about this for a possible referral to a Vascular Surgeon. Symptoms requiring emergent medical attention/calling 911 would be a sudden severe and tearing pain of the abdomen spreading to the back.

Risk factors for aortic aneurysms or dissections include: Smoking/nicotine use, high blood pressure (hypertension), use of stimulant drugs (cocaine/meth), or family history of connective tissue disorders (e.g. Marfan, Ehlers-Danlos).

Testing includes: Abdominal ultrasounds and CT angio scans.

If you are older than 65 years old and have had any history of smoking, it is recommended you are screened for AAA.

Treatment:

Traditionally, open aortic repair is a major surgical procedure performed by Vascular Surgeons, after which patients stay in the hospital for about a week in recovery before discharge. The aorta is repaired by making an incision on the abdomen so that the vessel can be repaired directly with surgical techniques and an implanted graft to replace it.

A minimally invasive approach is a possibility for some patients and utilizes endovascular technologies (EVAR/TEVAR). This would be a percutaneous procedure only involving small incisions and recovery is generally much shorter for patients with most able to discharge home the next day. A covered stent graft is used to re-line the aorta so the aneurysm sac is no longer pressurized and at high risk for rupture.

We offer all of these procedures and our surgeons are happy to discuss which is right for you.

Carotid Disease

(Stroke, stenosis)

The carotid arteries are two large vessels that run alongside of the neck that importantly supply blood to your brain. When these arteries become narrowed or blocked with plaque (carotid stenosis), blood flow to your brain is diminished. Outside of irregular heart rhythms, carotid stenosis is a leading cause of stroke.

Some signs and symptoms of a stroke to temporary stroke (TIA):

• Sudden loss of vision, blindness
• Sudden weakness, tingling, numbness on one side of the body
• Slurred speech or difficulty talking
• Facial droop
• Confusion

If you or someone you know are having signs and symptoms of a TIA or stroke, call 911 immediately. It is impossible to predict whether a TIA/stroke will worsen, so it must be treated as an emergency.

Risk factors for carotid disease include: smoking/nicotine use, hypertension (high blood pressure), high cholesterol levels, diabetes, family member with history of stroke, other diagnosis of coronary artery disease (heart vessel disease/CAD) or peripheral vascular/arterial disease (PVD/PAD), and increasing age >60 years.

Testing includes: Carotid ultrasound, CT angio scan, or cerebral angiogram.

If significant disease is left untreated, small pieces of the plaque or a blood clot can break off and flow into the brain to cause stroke/TIA.

Treatment:

Open surgical management of carotid stenosis is called a carotid endarterectomy and has been performed by Vascular Surgeons for many decades. It involves an incision made along the side of the neck to carefully remove the plaque build-up within the carotid artery. A patch is then used to close the opening made in the artery to ensure the vessel does not get narrowed by the surgery. Most patients stay overnight in the hospital and are able to discharge home the next day.

TransCarotid Artery Revascularization (TCAR) is an innovative, minimally invasive manner of placing a stent the carotid artery to support the vessel from the inside. A small incision is made at the base of the neck and after accessing the carotid artery using catheter-based techniques, a specialized system to prevent debris travelling to the brain during the procedure is used, so that manipulation of the plaque (which could otherwise cause stroke) can be safer during stent placement compared to other carotid stenting techniques. Please ask your Vascular Surgeon why TCAR can be a safer approach than transfemoral stenting (stenting from the leg vessel).

Carotid procedures can be performed to prevent stroke in addition to treating strokes that have already occurred due to carotid stenosis. If you have any of the risk factors listed, speak to your primary doctor about being screened for carotid disease or for a Vascular Surgeon referral.

Hemodialysis Access

(Chronic kidney/renal disease)

Over 660,000 Americans have end stage kidney disease (ESRD). The most common causes of kidney disease are high blood pressure and diabetes. When your kidneys fail, your body is unable to remove chemical toxins and excess water from your body. The treatment for kidney failure is dialysis or kidney transplantation which can take years to receive.

Hemodialysis (HD) takes the place of your kidneys by removing wastes and extra chemicals from your body and restoring normal pH balance. Some patients may be candidates for peritoneal dialysis but HD is often more common. Catheters underneath the skin (Permacath/Vascath) can be used as a short term access for HD, but it is not preferable for most patients. These catheters must be kept clean and dry which can complicate hygiene routines such as showering.

To create a more long-term HD access for you, a vascular surgeon needs to perform a surgical procedure. This procedure connects an artery and a vein of the arm with the intent of making the vein big enough for the dialysis catheters to perform HD. This surgically connected artery and vein is called an “AV fistula.” Sometimes, surgeons use a prosthetic graft instead of a fistula which is called an “AV graft.” This fistula or graft then becomes the access site for HD.

Unfortunately, these AV fistulas and grafts can become clogged or narrowed over time making HD difficult or impossible. Just like a car, AV fistulas and grafts require routine maintenance to ensure long-term usage.

Washington Health offers another option for patients with dialysis access problems called the HeRO graft device. The HeRO Graft (Hemodialysis Reliable Outflow) is a fully subcutaneous AV access solution clinically proven to maintain long-term access for hemodialysis patients with central venous stenosis. Our surgeons have inserted more HeRO graft devices than any other local hospital.

If you have been newly diagnosed with ESRD or have been on dialysis using a catheter, speak to your primary doctor or Nephrologist about a referral to one of our Vascular Surgeons to discuss your surgical HD access options.

Peripheral Vascular/Arterial Disease

(claudication, rest pain, limb salvage)

Peripheral vascular/arterial disease (PVD/PAD) refers to any disorder or disease of the network of blood vessels that carry blood throughout the body. As plaque builds up (atherosclerosis) in the lining of the blood vessel walls, a decreased amount of oxygen rich blood is carried to the legs or arms.

Signs and symptoms of peripheral arterial disease include: Pain/fatigue when walking, pain with the leg/foot at rest, coldness of extremity, or poor healing of distal wounds.

Risk factors of PVD/PAD include: Smoking/nicotine use, hypertension (high blood pressure), end stage renal disease (ESRD), diabetes, high cholesterol, being physically inactive, other diagnosis of coronary artery disease (heart vessel disease/CAD), past heart attack (MI) and increasing age.

Testing for PVD/PAD includes: Ultrasounds (ankle-brachial index) and CT angio scans.

When the arteries of the legs become narrowed or blocked due to atherosclerosis, the blood flow to the distal extremity becomes “ischemic” due to the lack of oxygen-rich blood flow. Upper extremity vascular disease is less common and often the result of atherosclerosis or a blood clot that has dislodged from a larger artery and blocked an artery in the arm.

If you suspect PVD/PAD or have been diagnosed, your vascular anatomy should be evaluated by a vascular specialist.

Treatment:

Many interventions are performed in a day-surgery setting at the hospital and are done with local anesthetic and light sedation in our catheterization lab. These are called endovascular/angiographic procedures and most patients can discharge the same day. Frequently, your surgeon can use balloons to stretch the vessels from the inside (angioplasty) or sometimes use stents to support the vessels open.

More extensive surgical procedures require general anesthesia, such as endarterectomies (focal plaque removal) and leg bypasses. A surgical bypass of an artery re-routes the blood flow around blockages. Surgeons may use a vein or prosthetic graft to ‘bypass’ the blocked artery to restore normal blood flow. These procedures tend to require a short stay in the hospital for recovery.

Vascular Surgeons are able to provide both approaches to our patients and are highly skilled at both. Depending on your vascular issue, your surgeon will discuss the option that works best for you.

In addition to the above treatment options, Washington Health has a Wound Healing Center to treat chronic, non-healing wounds. This center is staffed by specially trained nursing staff and physicians using state of the art techniques such as hyperbaric oxygen therapy.

Thoracic Outlet Syndrome (TOS)

TOS is an uncommon conditions that results from a narrowing of the area where your collarbone and rib cage meet. In this area near the shoulder, the arm’s artery, vein, and nerves can be compressed causing various symptoms. This is a complicated diagnosis and evaluation by a Vascular Surgeon specialist is needed to differentiate this condition from other common conditions of the arm.

Arterial TOS: The artery is damaged and blood clots can fall down towards the hand causing tissue damage. Sometimes blood flow is restricted and can lead to early fatigue with arm use. Sometimes this is caused by an extra bone called a “cervical rib.”

Venous TOS: The vein is damaged and scarred from the tight space leading to blood clots in the arm. Signs and symptoms of this can be a swollen, purple and painful arm.

Nerve TOS: The arm nerves are compressed and this can sometimes cause scarring around the area. Signs and symptoms of this include pain, numbness/tingling, and early fatigue of the arm when doing upwards movements such as brushing your hair.

Some patient are born with this space being narrow. Most of the times, patients can develop TOS because they have jobs that involve a lot of upward arm movement. Some examples are those who work with high shelves, painters, or contractors. Even athletes such as volleyball or baseball players can develop TOS over time! Traumatic arm/shoulder injuries can also cause TOS.

Treatment:

If symptoms are mild, physical therapy can allow the compressed space between the collar bone and first rib to be relaxed and no surgery is required. If symptoms are more severe or continue despite physical therapy, a first rib resection can be performed to create more space and reduce the compressive effect of that narrow space. Due to the sensitive structures in that area, this procedure is performed by specially-trained Vascular Surgeons. Dr. Joyce Lu specializes in utilizing the axillary approach where the incision is well-concealed in the underarm area and this is favored for most patients whenever possible.

Venous Insufficiency

(Varicose veins and wounds)

Veins are the soft blood vessels of the body which bring blood back to the heart after it has been used in the body to deliver oxygen. Blood flows slowly in the veins and have to fight gravity to travel all the way from the legs back up into the chest. The body uses one-way valves to allow the blood to travel up in increments but sometimes these valves do not work well (become faulty), and that condition is called “venous insufficiency.” Most commonly, the veins affected are the greater saphenous and small saphenous veins (GSV/SSV).

Signs and symptoms of venous insufficiency in the legs include: Varicose (bulging) veins, leg swelling, darkening of the skin around the shins/ankles, wounds around the shins/ankles, tenderness, burning, itching, heaviness, fatigue, and blood clots (venous thrombosis/DVT/SVT).

Risk factors for venous insufficiency include: Family history of varicose veins, long periods of standing or sitting-often related to your job, and history of blood clots in the legs.

Testing includes: Venous insufficiency ultrasound which includes special maneuvers such as squeezing the leg gently to examine forward/backwards flow within the veins.

Venous insufficiency can affect your quality of life and successful treatment can greatly help improve your daily comfort.

Treatment:

Compression stockings are a non-invasive therapy that can either be standalone treatment for venous insufficiency or an aid for your Vascular Surgeon to determine if surgical management is more likely to be successful for you. Most treatment plans include a trial of compression and this is often required by your insurance company prior to any vein procedures.

Radio Frequency Ablation (RFA) is a longstanding vascular procedure used to close down faulty veins so that the body can redirect blood to travel in the good veins instead. Your surgeon places a special catheter in the GSV or SSV and then injects a surrounding layer of fluid around the vein to protect the tissues from any generated heat while the RFA is performed.

VenaSeal is an innovative method to close down faulty veins using a surgical adhesive glue placed within the vein. Similarly, the body redirects blood to the good veins once the faulty vein is closed by the glue. Since this procedure does not generate heat, injection of fluid is not necessary around the vein prior to treatment. Patients who are sensitive to adhesives or allergic should not have this procedure.

Sclerotherapy is injection of a special medical foam which chemically irritates the inside of the faulty veins so they can form scar and close down so your blood can be re-directed to the good veins.

Phlebectomies are surgical excisions of large varicose veins through small incisions. These veins are too large to close down with any of the methods mentioned above.

All of these procedures are often comfortably done right in our outpatient clinic as opposed to performing them in the hospital.

Many patients require a combination of the above treatment options performed over a period of time. Venous disease is complex and even if you have had vein procedures in the past, the disease can come back on its own with aging. Talk to your primary doctor about a referral to a Vascular Surgeon to develop the treatment plan that is right for you.