The carotid arteries are the blood vessels that travel from the heart through the neck into your brain. They supply the brain tissue with the oxygen and nutrients it needs to survive and function. Disease of the carotid arteries results from a blockage in them, almost always from thickening and hardening (atherosclerosis) of the arteries. This results in plaque buildup in the arteries. More uncommon carotid artery disorders include carotid dissections, which are tears in the inner lining of the blood vessel, and fibromuscular dysplasia, which can cause narrowing of the artery in the absence of atherosclerosis. 

Stroke from carotid disease usually results from a partial, and not a complete, blockage of the arteries. This partial blockage results in high velocity turbulence in the blood. The turbulence in turn leads to debris forming from the blockage; as blood continues to course up to the brain, some of this debris may break loose and travel into the brain. If this debris (called an embolus) lodges in the small arteries of the brain, it will block that artery causing a lack of blood flow. That part of the brain will suffer damage as a result.

If the debris that travels to the brain is small enough that it only temporarily blocks the artery, it will only momentarily cause damage. This is called a Transient Ischemic Attack (TIA) or “mini-stroke”.  TIA symptoms typically last for up to an hour, by which point symptoms completely resolve. However, an embolus that causes permanent damage to a part of the brain results in a stroke, and this will usually result in long-lasting symptoms.

Stroke can be caused by many factors (not just carotid disease). As a result there are many different symptoms of stroke. However the type of stroke from carotid disease usually results in specific symptoms:

• Weakness or paralysis on one side of the body or one limb (people may describe this as their hand or leg going “dead”)
• Numbness in the arm or leg (much more so than, say, your hand going to sleep when you lie on it in bed)
• Facial droop on one side of the face
• Inability to speak (this is a very dramatic change in speech – usually complete inability to speak, severe slurring, or inability for others to understand you).
• Loss of vision in ONE eye (people describe this as a “shade” being drawn down over one eye

If you experience any of these symptoms, you should seek EMERGENCY medical attention immediately! They may be signs of a stroke.

Some symptoms that may have other causes than carotid disease include: dizziness, blurred vision in both eyes, headaches, or fainting. While these may also be serious conditions, they may not be a result of carotid disease.

Carotid disease without stroke or TIA (Transient Ischemic Attack) is usually completely without symptoms (asymptomatic). It may be discovered by your doctor hearing whooshing noises (sometimes called a “bruit”) over the arteries in your neck, but otherwise may produce no other symptoms you would notice. Carotid disease is usually discovered and confirmed by a test called duplex ultrasound. Other tests may include CT scans or MRI. Screening ultrasounds discovers some carotid disease.  Find out if a screening ultrasound makes sense for you.

Having carotid disease is a risk for stroke, but not an absolute. We know that the risk of stroke increases directly with the amount of blockage (the more the blockage the higher the risk of stroke). The blockage grows very slowly and can usually be followed. In many cases, the most important thing to do is consult with your doctor and usually consult with a vascular surgeon. For many patients, close follow-up with surveillance ultrasounds is all that is necessary. The vascular surgeon can determine the schedule of ultrasounds (usually once or twice yearly), and can determine if and when surgery is necessary to fix the carotid disease.

A large amount of research has been done to find the optimum timing for surgery. Despite what seems like a dangerous condition to have, research has shown that immediately fixing the carotid artery does not always benefit a patient. Some factors to consider:

1. We know that the risk of stroke increases with the amount of blockage – smaller blockages have low risk of stroke.
2. The benefit of surgery is to prevent a likely stroke.
3. The surgery itself can cause stroke and does not completely eliminate the risk of stroke after it is done.

Therefore, it makes sense to only operate on carotid blockage when the risk of a stroke is high. If it is not high, the risk of surgery is worse than the risk of having a stroke while watching the blockage over time. This timing may be affected by other factors (whether you’ve had a stroke or TIA already, whether your surgical risk is high). A vascular expert is trained to determine the optimal course of action for you.

Once the plaque is there, only surgery can remove it. However, steps towards slowing the growth in the blockage can help reduce your chances of stroke. First and foremost: stop smoking! We know that smoking can accelerate the growth of the plaque that causes carotid disease, as well as cardiovascular disease throughout all of the arteries in your body. Maintaining healthy blood pressure and cholesterol levels is also very important. Consulting with your doctor for medications to achieve the best levels of blood pressure and cholesterol (good and bad forms) may also be necessary.

If you have diabetes, work with your doctor to control your diabetes and manage your cholesterol levels. Diabetes is known to increase the risk of arterial disease. If you have diabetes, your cholesterol level needs to be lower than levels for a person without diabetes.

The most important principle of surgery for carotid disease is to open the blockage without dislodging the plaque into the artery itself. Two options exist:

1. Open surgery – called carotid endarterectomy. This uses a small incision in the neck directly over the carotid artery. The artery is then opened and the plaque is removed entirely from the artery.
2. Carotid stent – using an arterial catheter inserted in through the skin in the groin (in a similar fashion as those getting a heart stent), a stent can be placed within the carotid plaque. Using an angioplasty balloon, the stent is deployed so that it both opens the plaque and maintains the opening over time.

Patients do very well with both surgeries.  However, both surgeries carry rare, but potentially serious, complications. While it is appealing to be able to treat the carotid stenosis with a stent and avoid open surgery, the most recent studies have shown a higher risk of atherosclerotic material getting up into the brain with stenting procedures than with open surgery (stroke rates are higher with stenting). Stenting has a somewhat lower risk of heart attack during the operation. The typical carotid artery surgical incision is not very uncomfortable, with the great majority of patients going home the morning after their open surgery. Most experts agree that stenting is best for those patients who have compelling reasons not to operate. These include previous neck radiation, severe fixed curvature of the spine in the neck, or heart or lung disease severe enough to make the risk of surgery higher. 

Our vascular surgeons offer both stenting and open surgery and can recommend the best treatment for you.

An aneurysm is a weakening of the wall of a blood vessel that results in that local segment of the blood vessel ballooning or expanding. Think of a weak spot in a tire that develops an outpouching because pressure pushes that point outwards. In our bodies, a very common location for aneurysms is the aorta (the largest artery in our body that courses from our heart to the lower abdomen). By far the most common spot for an aortic aneurysm to form is in the lower abdomen, below the kidneys. This is referred to as an Abdominal Aortic Aneurysm (AAA).

As the wall of the blood vessel weakens, that part of the artery expands.  Over time as the artery wall expands it becomes thinner (imagine the walls of a balloon as it gets increasingly inflated). The abdominal aorta is approximately 1 inch (2.5 cm) in diameter; aneurysms can expand that diameter to 2 inches or greater (5 cm or more) at which point they have a much higher risk of rupturing.

Unlike a balloon, the aorta usually ruptures in a small focal spot. However with such high-flow through the aorta, this is enough for massive bleeding (internal bleeding). The result can be catastrophic. Half of all patients with ruptured AAA do not survive long enough to reach the emergency room. Clearly, our emphasis for our patients is to fix an aneurysm before it ruptures.

The vast majority of patients with AAA do not realize they have it (they are asymptomatic).  Some people may notice back pain, although this is not usually the case. Most AAA’s are discovered by scans or studies that were done for other reasons (such as looking for kidney stones or gallbladder disease). The two most common tests for discovering and following AAA’s are abdominal ultrasound and CT scans. Screening ultrasounds of the abdomen discovers some AAA’s. Find out if a screening ultrasound makes sense for you.

In the end there is no one single cause, but we do know there are factors that put a person at increased odds to develop AAA, some treatable, some not. First and foremost of the preventable causes is smoking. Although not all smokers get AAA’s, and not all AAA patients are smokers, we know that patients who do smoke have higher rates of AAA. Other common factors include long-term high blood pressure, cholesterol issues (hyperlipidemia), age greater than 60, and male gender (AAA is more common in males). An important risk factor for AAA is family history. While it is not a true genetic condition passed down from one generation to the next, it definitely is seen more commonly in patients with family members who have AAA than patients without such family histories. 

Although the risk of rupture makes having a AAA very worrying for you, we know that it is very much a manageable condition.  The first thing to realize is that AAA’s expand quite slowly and predictably. They are also fairly easily to track (in terms of size and shape) with ultrasounds done regularly over time (once or twice yearly). In the meantime, maintaining healthy living is your best action. Smoking is not only a cause of AAA, but it is also a high risk factor for causing a ruptured AAA; so smoking cessation is our first goal in AAA patients who smoke. Also, keeping your blood pressure in a good range, and maintaining healthy cholesterol levels will benefit you.

There are not many things to avoid, even if you have a AAA. Excessive strenuous lifting (say, lifting greater than 30 pounds repeatedly) may elevate your blood pressure and therefore should be avoided. However other forms of exercise are still beneficial.

Again, because we know how aneurysms grow and behave, a great deal of work has studied the optimal timing of fixing them. In the past, all aneurysms were fixed as soon as they were discovered; we have changed that attitude for two reasons: 1) small AAA’s very rarely ruptured, and 2) the risk of surgery to fix AAA itself carried a definite risk of complications.

Based on these facts most surgeons agree that AAA’s less than 5 cm in diameter have a low risk of rupture – low enough that it does not justify the risk of surgery. Greater than 5cm AAA’s begin to carry higher risk of rupture over time, and therefore do warrant fixing the aneurysm for the prevention of a future rupture.

Two methods currently exist to repair AAA.

The first, and most common, is called endovascular stent-grafting. Based on minimally invasive techniques, catheters are place into your arteries through small incisions in the groins. These catheters contain grafts that can be deployed in such a way as to seal off the aneurysm while continue blood flow through the main aorta (imagine replacing the inner tube of a tire, rather than replacing the whole tire). This technique is very effective, and very well tolerated with patients recovering quite quickly from the surgery.

The second method, called open repair, is done through an incision into your abdomen or flank to expose your abdominal aorta. Once there, the aneurysm is opened and a graft is sewn into its place, thus completely replacing that segment of the aorta. Although this is more invasive than endovascular repair, it is extremely long-lasting and time-tested. Furthermore, not every patient is a candidate for the endovascular stent graft due to the shape of the aorta and other factors.

If you have been diagnosed with a AAA, a vascular surgical consultation is key to evaluating your next steps. The surgeons at Lake Washington Vascular are specialty trained vascular and endovascular surgeons who are experts at evaluating, managing and fixing AAA’s. With the help of the entire Lake Washington Vascular staff, they can determine the size of your aneurysm, the need for follow-up ultrasounds, and when repair (surgery) is needed. Once your aneurysm is repaired, a schedule of maintenance visits will keep close tabs on your aorta.

Peripheral Arterial Disease (PAD) results from blockages in the blood vessels (arteries) that lead into our legs. The vast majority of cases result from plaque build-up in the arteries (atherosclerosis, “hardening of the arteries”). This blockage inhibits blood from reaching its destination; in this case that is typically the feet and muscles of the legs.

PAD can be a complex disease to diagnose and manage, but trained vascular specialist can best identify and characterize your disease giving you the best information and treatment options. 

For some people, PAD may produce no symptoms at all. Symptoms occur due to limited blood flow to the feet or legs. In the early stages, blood still gets through the blockage but is definitely decreased. So when the muscles of the legs are resting they feel fine. However when you begin to exert those muscles (for instance when you walk) they need more oxygen. Because of the limitations in blood flow from PAD, those muscles do not receive more oxygen and then begin to ache. Symptoms from this blockage usually occur in stages:

Patients describe walking a typical distance (usually 1 block or so) when they feel begin to feel tightness or cramping in the calf or calves. They stop walking and the pain goes away and they are able to begin again. Pain may also occur in the buttocks, hips or thighs. This kind of pain is called claudication.

As the blockage becomes more severe, the blood flow to the legs and feet may be hindered enough to prevent the tissues from getting enough oxygen to survive even when resting. When this happens, the tissues will ache even if you are not walking or exerting yourself. This often begins as pain in your feet while you lie in bed. This pattern of pain is called rest pain. Rest pain represents a potential threat to your leg.

Finally the blockage may be so complete as to cause the tissues of your feet or legs to lack enough oxygen to survive. When this occurs the skin can suffer from non-healing wounds (ulcers), infections, or even gangrene. Such conditions are all forms of limb threat – conditions that can lead to loss of the limb (amputation) if no action is taken.

Yes, although most patients will have the symptoms described above. Some other common symptoms might be numbness in your leg or weakness. However, these symptoms can also have many other causes, not related to your arteries. An evaluation by a vascular surgeon can determine if you have PAD.

There are dozens of causes of leg pain, many of which have nothing to with arteries – causes such as arthritis, spinal stenosis, or sciatica. In other cases, PAD patients may have no symptoms at all. Studies of the arteries can start with simple tests to measure blood flow into your legs and feet, studies such as ultrasound, special blood pressure readings, and treadmill testing. Even if you have no symptoms, screening of the arteries may detect early stages of PAD.

PAD is a disease of plaque buildup in your arteries. The plaque in your leg arteries causing problems could also be building up in other arteries of your body, such as in your heart (which could lead to heart disease) or your carotid arteries (which could lead to stroke). So the blockages in your leg can cause symptoms only in your leg, but they may be a warning sign that you have similar blockages elsewhere, and this may be the signal to have those other arteries checked.

The principles behind treatment for PAD depend upon your stage of PAD. Treatment is divided into OPERATIVE or NON-OPERATIVE options. Reasons for OPERATIVE treatments include: 1) any evidence of limb threat, 2) rest pain, or 3) claudication that affects you daily and limits your quality of life. Claudication that is considered mild can be treated with NON-OPERATIVE therapy; your vascular surgeon and you can determine together which options best suits you.

For patients with mild claudication non-operative treatment is often the best option. Although the blockage in the arteries will not “go away on its own” there are things you can do to improve your symptoms and ability to walk farther and with less pain.

Most importantly, if you are a smoker, is to STOP SMOKING. Smoking causes pain in claudication in several ways: it speeds up the buildup of plaque in your arteries, it causes the arteries you have to spasm, and it hampers the delivery of oxygen to your working muscles.

The second strategy for mild claudication is scheduled walking. Constant walking encourages more blood to flow through you arteries to your working muscles. It also allows your muscles to work more efficiently with the limited blood flow it does get. The best scheduled walking regimen includes daily walking, at least 30 minutes, where you walk continuously, stopping for short rests when pain occurs, but starting again as soon as the pain goes away. Walking should be logged (on paper or in a book) so that your progress can be recorded. If this type of walking can be done consistently, over time your distance that you walk before you feel pain will increase. This may not return you to completely normal walking, but many patients find that their quality of life can improve dramatically just by being able to go farther with less pain.

Finally, control of your blood pressure and cholesterol levels are important with any vascular and cardiovascular disease. There are some medications that can help control your PAD such as aspirin, and some that may even help improve your walking. These can be discussed with your vascular surgeon.

Operative Treatment is divided into two categories: endovascular and open. Most patients will start with endovascular options.

Endovascular Surgery

This starts with angiogram (also called arteriogram), which is done by placing a small thin catheter through a needle hole in the skin directly into your arteries. This is usually done through the groin into your femoral artery. These catheters can be steered throughout your arteries, and, using X-rays, a temporary dye is injected to map out your arteries and the blockages.  These same catheters can then be used to deploy angioplasty balloons (hard balloons that force open the plaque blockages) or stents (small metal mesh tubes that spring open and keep the blockages open).

Endovascular surgery is considered minimally invasive. It is often done as an outpatient and you can return home several hours after the procedure is done, with minimal restrictions to your activities afterwards.

Open Surgery

Not all blockages can or should be fixed with angioplasty balloons or stents. We know some simply cannot be opened with catheters, or are in bad positions for balloons or stents (such at the knee or hip joints). Patients with these types of blockages will require open surgery, such as bypass grant surgery or an endarterectomy.

Bypass surgery involves operating on your arteries and grafting a new “artery” to bypass around the blockage. The replacement “artery” can be one of the “spare” veins in our legs (long veins in our legs that are “extra” or redundant veins) or artificial arteries (made usually from synthetic materials). An endarterectomy surgically removes the blocked lining from the artery while keeping the outer wall of the artery in place.

While open surgery does require a stay in the hospital (usually 2-5 days), and involves more recovery time than endovascular surgery, this is still an excellent option that can be done on almost all blockages with very good long-lasting results.

Lake Washington Vascular surgeons are committed to offering excellent care to patients with kidney failure. The relationship between a dialysis patient and the vascular surgeon is important and long lasting. The types of dialysis access are Central Lines (or Central Venous Catheters), Arteriovenous Fistula (AVF) and Prosthetic Grafts.

These are placed when dialysis needs to be initiated urgently or access fails. Central lines can be used right away but are not considered permanent. They can become clogged and stop working and sometimes cause infection. They can also cause central vein thrombosis (clotting).

Central venous catheters are positioned into the deep veins of the upper chest for the purpose of pulling and returning blood to and from the dialysis machine. Central venous catheters are usually inserted through a neck vein, and may be tunneled so as to exit the skin below the collarbone.

The veins through which the central venous catheter passes are at risk for clotting. For these reasons, unless dialysis is expected to be temporary, permanent dialysis access should replace central venous catheters as soon as possible.

The optimum access is a primary arterial venous fistula (AVF) using the patient's own tissue if they have adequate vein. Vascular surgeons always prefer to start as far peripherally as possible and prefer to use the non-dominant arm if the vein there is suitable. Vascular surgeons follow these guidelines in creating AV fistulas:

• Always use natural vein before going to synthetic grafts.
• Try to use the patient's non-dominant arm if the vein is suitable, so as to free up the dominant arm during the time on the dialysis machine.
• Start as peripherally as the vein allows, to increase options for the future if needed.
• Upper extremity fistulas are always preferable to lower extremity fistulas.
• The risks of creating an AVF or inserting a graft include bleeding, infection, clotting off of the fistula or graft with need for revision or re-operation, steal syndrome where too much blood goes out of the arm up the fistula and not enough is left in the hand. In some circumstances this could require tying off the fistula. After creation, fistulas need to "mature" (or grow in size) for a minimum of six weeks before use. 

When veins are too small for an Arteriovenous Fistula, a prosthetic graft is used. This can be used for dialysis within two weeks of surgery. Grafts don't last as long as fistulas and can become infected. If an artificial graft is placed and it becomes infected, it usually needs to be removed to help eradicate the infection. 

There is no fistula or graft that works forever. We pledge to continue to work with our patients as needed to maintain access so they can continue to dialyze, but they have to understand that this might require revisions. It is in their interest for us to start as far peripherally as we can and move up the arm if needed rather than do the easiest procedure first, which might limit long-term options.

For more information about dialysis access, go to www.Vascularweb.org for patients with kidney failure. Additional information can also be found at the National Kidney Foundation and American Association of Kidney Patients.