Vascular diseases and their treatment

The arterial system is a series of branching and connecting conduits or tubes, all ultimately originating from the heart, the central pump of the body.

The major arterial system originates from the heart. The aorta, a huge, elastic pipe about one inch in diameter leads from the top of the heart down through the abdomen. The aorta passes through the chest into the abdomen, sending off branches to the lungs, gastro-intestinal tract, and kidneys. In the lower abdomen the aorta divides into the iliac arteries, right and left, each about half an inch in diameter. These pass via the groin into the legs, where they are then called right and left femoral arteries. Each femoral artery passes down the leg and, when it reaches the knee, is called the popliteal artery. Below the knee, the popliteal artery divides into three arteries called the anterior and posterior tibial and peroneal arteries. When they reach the ankle and foot they are called pedal arteries. These finally end in tiny twigs in the toes, called digital arteries. Now going towards the brain from the heart are the left and right common carotid arteries located in neck. These branch off to the internal carotid arteries and the external carotid arteries. The external carotid arteries supply the face and the internal supply the brain. These arteries finally end in the cerebral arteries.

Arteries, much like tree branches, become smaller and smaller as they extend out into the periphery of the body. They are designed to carry oxygen-containing blood and nutrients to all parts of the body and receive blood from the heart under high pressure (average=120 mm of mercury) and deliver it at great speeds throughout the body. The blood, itself, is a complex mixture of oxygen-bearing red cells, as well as plasma containing nutrients and innumerable hormones and other chemicals. When an artery is partially or completely closed, blood and oxygen are not delivered to the tissues in a normal fashion.

Peripheral vascular disease (PVD) is a common circulation problem in which the arteries that carry blood to the legs or arms become narrowed or clogged. This interferes with the normal flow of blood, sometimes causing pain but often causing no symptoms at all. The most common cause of PVD is atherosclerosis (often incorrectly called hardening of the arteries). Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called "plaque" that clogs the blood vessels. In some cases, PVD may be caused by blood clots that lodge in the arteries and restrict blood flow. PVD is sometimes called peripheral arterial disease, or PAD.

Symptoms

PVD is a subtle process in most cases. If there are symptoms, they usually begin as just a small cramp here or there in the calf of the leg. It might be thought of as an injury, a strain, or "arthritis". The legs and feet are particularly prone to the development of arteriosclerosis and cause a number of symptoms including:

• Cramps in the calf muscles during walking or exercise
• Numbness and coldness of the feet
• Discoloration of the toes, including a blue color (cyanosis) and paleness (pallor)
• Infection and gangrene of the toes and feet

Medical Evaluation

PVD can worsen and begin to cause foot numbness at rest, discoloration of the feet, coldness and even early infection and gangrene to occur, which may require surgical treatment. If any of these symptoms develop it is urgent that a physician is seen at once. If these conditions worsen to the point where work or recreation become seriously impeded, it is time to consider surgery.

A vascular surgeon will perform a series of vascular examinations to determine the degree to which the leg arteries are clogged and what part of the arterial system is involved. Many of these tests are painless, safe, and extremely accurate. From time to time, if he or she is considering performing surgery, the surgeon may recommend an arteriogram. This involves introducing a catheter into the leg artery, often in the groin region, and injecting x-ray/visible dye into the circulation. This will accurately locate the disease and its extent and help the surgeon to recommend appropriate treatment. There are always risks and some discomfort with these procedures, and they should be discussed with the surgeon and radiologist before the tests are done.

Treatment

Depending on where the arteries are blocked and the degree of blockage, many procedures are available. Some are considerably less invasive than others. The major procedures that should be discussed with the surgeon are discussed below.

	Angioplasty and Stenting: This procedure is sometimes performed by an interventional radiologist or cardiologist and sometimes by a vascular surgeon. It is considered minimally invasive, often requiring nothing more than a puncture wound into the femoral artery. Through a series of catheters, the radiologist or surgeon identifies the narrowed or blocked artery, stretches it open with a balloon and then places a stent in the area to prevent it from collapsing again. The patient may actually go home that day or the next if all goes well.
	Endarterectomy with or without a patch graft:  This is somewhat more invasive than angioplasty and can be used when a very short segment of an artery is blocked or severely clogged. The surgeon identifies the location of the blockage with an arteriogram (injects dye into the artery and observes it under x-ray) and then makes an incision over the area. The clogged artery is opened and the diseased segment removed. The artery is closed or, if this will make it too narrow, a small patch of vein or plastic graft material is inserted as a cap to maintain a large enough opening for the flow of blood. If there are no problems the patient may go home that day or the following day; recovery is rapid. Endarterectomy works well for a clogged carotid artery.
	Bypass Grafting: This is one of the most common procedures used for blockages of the arteries in the leg. The bypass is, in effect, a secondary system, sometimes using a vein of the body and sometimes using a plastic graft. The vein or graft is sutured in place proximal "above" and distal "below" to the obstruction. It requires at least two incisions, one above and one below the blocked artery. Sometimes, especially when veins are used, longer incisions are necessary. The length of hospital stay and recovery period is directly proportional to how many and how long the incisions are in the leg. Veins, when able to be used, usually work better and for longer periods than synthetic grafts.
	Remote Endarterectomy:  Remote Endarterectomy is an effective surgery for advanced stages of Peripheral Vascular Disease (PVD) in the Superficial Femoral (thigh), Proximal Popliteal (just above the knee) and External Iliac Arteries (abdomen). This treatment option allows for the removal of long, solid-segments of plaque from a small single incision in the artery. This surgery is more invasive than PTA/Stenting, but less invasive than Bypass Grafting, and offers good long-term rates of success. First, the surgeon makes a small incision in the groin area and exposes a portion of the diseased artery. The surgeon then takes a x-ray (arteriogram) to identify the beginning and end of the plaque. A small incision is made in the artery to expose and begin dissection of the plaque. The surgeon then passes a series of devices through the incision, and along the length of the plaque, to dissect and remove the plaque from inside the artery. A follow-up arteriogram is typically performed, and PTA/Stenting may be necessary to manage small flow defects. Finally, a small patch may be sewn into the incision in the artery, so that the vessel isn’t narrowed when normal blood flow is restored. Barring any unforeseen complications, the patient typically leaves later in the day, or the next morning depending on their doctor’s orders.

Thrombi (clots) are masses that form within the circulatory system on the inside of arteries, the heart, and prosthetic (artificial) surfaces such as catheters and stents. They are composed of elements of the clotting system, white blood cells (fight infection), and red blood cells. Thrombus formation is a process involving many factors that interact with each other. Although the formation of thrombi may occur as part of a natural "healing" process, inside the arterial system their course is unpredictable and they can cause serious problems. Indeed, acute arterial thromboembolism is a serious medical problem. It is characterized by sudden occlusion of an artery supplying blood to tissues of the body, resulting in loss of function or tissue death if it is not treated immediately or does not resolve spontaneously. Although acute thromboembolism can affect the upper extremities, the vessels supplying the head and brain, and even arteries leading to internal organs, it occurs more commonly in the lower extremities (legs and feet).

Arterial thromboembolism is usually caused by one of the following:

• Ruptured atherosclerotic plaque above the region that becomes occluded
• Acute thrombosis (clotting) on top of existing atherosclerotic disease
• An embolism from the heart, aorta, or other large vessel that breaks off and travels to a vessel "downstream" and lodges
• A dissecting aneurysm (tear in the wall of a major artery that may rupture and spill blood outside the artery)

Arterial thromboembolism is a significant cause of death and disability in the United States. It is a serious problem partly because it is usually the result of a dangerous underlying disease, and also because it often occurs suddenly and without warning. Acute arterial thromboembolism usually occurs at locations where the inner wall of a blood vessel has been damaged or where there is disturbance or change in the pattern of blood flow.

From an anatomical standpoint, acute occlusions typically occur at branch points in an artery. A small area of plaque forms on the inner wall of an artery at the point where the artery splits or branches into two tributaries. This occurs at this location because of:

• The turbulence of the blood flow at this point
• Subsequent damage of the inner layer of the arterial wall
• Increased incorporation of LDL cholesterol and other components into the damaged area
• Deposition of cholesterol and components of the clotting system

Pieces of the plaque can break off and float downstream or a clot may form on the top of the plaque and break off later.

Risk Factors

Although there are other causes, most patients have underlying atherosclerosis, one of the most important contributing factors to arterial thromboembolism. The major risk factors for atherosclerosis include those listed below. Although each of these factors is important alone, they can also be additive if they occur together:

• Hypertension
• Elevated levels of low density lipoprotein
• Reduced levels of high density lipoprotein
• Cigarette smoking
• Diabetes mellitus
• Obesity
• Male gender
• Elevated homocysteine levels
• Family history of premature atherosclerosis

Diseases of the peripheral arteries, such as acute thromboembolism, increase in frequency with age.

Signs and Symptoms

Clinical manifestations of arterial occlusion depend on the vessel involved, the extent of obstruction, how rapidly occlusion progresses, and whether collateral flow is adequate. However, for patients with an acute arterial thromboembolism, the history usually includes:

• Sudden onset of severe pain
• Coldness, numbness, and pallor (paleness) in the affected extremity
• Loss of pulse beyond the site of the obstruction in the occluded artery

Deciding About Treatment

In the past, direct surgical intervention was the only feasible alternative. More recently non-invasive techniques have been developed. When the issue of treatment is being considered, it is important to ask as many questions as possible before the patient and doctor together decide on the optimal treatment. If a patient does not feel comfortable with his or her understanding of the treatment options, it is wise to get a second or third opinion. So what are the options?

Types of Therapy

Many newer treatments for vascular disease, such as an arterial occlusion, avoid open surgery. These treatments may be performed by interventional radiologists, vascular surgeons, or cardiologists.

• PTA:   The primary approach is percutaneous transluminal angioplasty (PTA), whereby a small high-pressure balloon is used to open an obstructed vessel. However, because of the high recurrence rate of obstruction, alternative methods may be necessary.
• Stent placement:  : Stents (metallic meshlike tubes) are often inserted into the vessel at the site of the obstruction. Stents are very strong and may keep the vessel open much better than balloons alone. Moreover, the recurrence rate is reportedly less. Stents work best in large arteries with high flow.
• Thrombolytic therapy:  Thrombolytic therapy involves the infusion of drugs to unclog the artery (break up the clot). This approach, especially by regional catheter infusion, is most effective for acute arterial occlusions of less than two weeks duration.
• Embolectomy: The purpose of this procedure is to remove a localized clot in an artery. An incision is made in the skin over the artery and the artery exposed. A small incision is made in the artery and a small balloon tipped catheter is inserted. The catheter is pushed pass the clot, the balloon inflated and the catheter removed dragging the clot with it.
• Endarterectomy: An incision is made in the skin over the vessel that is blocked with plaque. An incision along the length of the artery is made in the arterial wall and the plaque is peeled out of the artery and the incision closed with or without a patch. The patch is made of a section of vein or an artificial material.
• Bypass graft:  A bypass graft channels blood around a block in an artery. This may be done in combination with one of the other procedures.

Questions for the Doctor

Here are some questions patients should ask the doctor. In some cases, the answers are dependent on the treatment:

• What is the advantage of using clot-busting drugs (or stents or immediate surgery)?
• If the drugs don't work, have we lost time?
  • Have we increased the chances that surgery will fail and I will lose my leg?
  • How long will you try the less invasive methods before recommending surgery?
• Are there any complications to the use of drugs, such as bleeding?
• If I prefer surgery, what are the pros and cons?
  • What treatment would you choose and why?
• How many cases have you performed of this type??
  • What are your results?

Carotid artery disease is a type of cerebrovascular disease that affects the vessels leading to the head and brain. Like the heart, the brain's cells need a constant supply of oxygen-rich blood. This blood supply is delivered to the brain by the two large carotid arteries in the front of the neck and by two smaller vertebral arteries at the back of the neck. The right and left vertebral arteries come together at the base of the brain to form what is called the basilar artery. A stroke most often occurs when an artery supplying brain tissue becomes blocked and the brain does not get enough oxygen.

How Carotid Arteries Become Diseased Carotid artery disease increases the risk of stroke in 3 ways: By fatty deposits, called plaque, that severely narrow the carotid arteries. By a blood clot becoming wedged in a carotid artery narrowed by plaque.. By plaque breaking off from the carotid arteries and blocking a smaller artery in the brain (cerebral artery). One of the leading causes of stroke, especially in older patients, is carotid stenosis or the clogging of the arteries in the neck. Each carotid artery divides in the middle of the neck into an internal and external carotid artery. The internal carotid artery goes straight to the brain and is the brain's major supplier of blood. In the middle of the neck where the carotid artery divides into the external and internal carotid artery, a partial obstruction may gradually develop. This blockage is caused by deposition of cholesterol and components of the clotting system, a disease called atherosclerosis. These blockages form over a variable period of time and often go unnoticed until the severity or degree of blockage reaches about 60%.

Transient Ischemic Attacks

Ulcerations may begin to appear within the blockage. This allows small particles to break off and wash from the neck into the arteries inside the brain. These particles of blood and cholesterol debris are called emboli and the condition is called carotid embolism. The particles often lodge in a cerebral artery and can cause temporary loss of blood, called transient ischemic attacks or TIAs, which are brief intervals when normal nerve functions are interrupted.

The symptoms associated with these TIAs can include blurred vision, loss of coordination, slurring of speech, or weakness or numbness in an arm or leg. The symptoms often last only a few seconds but may sometimes last up to 24 hours. If a patient has any symptoms of TIAs, it is important to have emergency medical treatment as soon as possible. These symptoms should not be ignored, as they could be a warning sign that a more serious stroke may occur.

Risk Factors for Stroke

The list below includes some of the major risk factors for stroke caused by carotid artery disease. Although they do not diagnose the presence of carotid artery disease or a stroke, per se, doctors use them to assess a patient's overall risk for stroke. By knowing the risks, the doctor can recommend changes in lifestyle or medications to help reduce the risk, or additional diagnostic tests to determine whether a patient may need surgical intervention. If a patient is aware of any of these risk factors in his or her own history, they should be brought to a doctor's attention.

• Family History: Having relatives who have suffered from strokes or heart attacks increases the risk of stroke in other family members. The closer the relationship (e.g., mother, father, sibling), the higher the risk.
• Age: The risk of stroke increases with age. Patients over age 67 are especially at risk.
• Gender: Men are more likely to develop carotid stenosis but it also can occur in women.
• Hypertension:  High blood pressure damages the wall of the arteries and causes an acceleration of the atherosclerosis process.
• Previous Symptoms: Multiple transient ischemic attacks, as described above, occurring within one month indicate unstable or ulcerated plaque, and repeated emboli are common. These episodes are a very serious warning sign and call for immediate examination by a qualified physician.
• Smoking: Stroke is now one of the well-documented health risks of smoking.
• Diabetes: Problems with the body's production or utilization of insulin increase the chance of stroke. Patients are especially at risk if they have insulin-dependant or Type I diabetes.
• Heart Attack: History of damage to the heart muscle may also be a warning sign for stroke.
• High Cholesterol: Elevation of cholesterol in the blood increases the risk of stroke, particularly LDL or low-density-lipoprotein cholesterol.
• Intermittent Claudication: Pain in the calf muscle when walking, which disappears within a minute of rest and reappears predictably during exercise, may herald the presence of atherosclerosis and should sensitize any patient to the risk of stroke.

Patients with one or more of these risk factors should be screened regularly for carotid artery disease.

Medical Evaluation and Treatment

A primary care physician may listen to the sounds of the carotid artery with a stethoscope as part of a routine physical examination. Even in people without any symptoms suggesting carotid disease, the physician may hear a noise called a "bruit" within the carotid artery. This is a "whooshing" sound that is present in many people who have a partial blockage of the artery. It is usually caused by turbulence in the flow of blood inside the underlying artery. The sound is typically heard each time the heart ejects blood into the circulatory system.

Anyone with a bruit should have a carotid ultrasound test to determine whether there is evidence of obstruction in the artery. Unfortunately, many people with diseased arteries — even those with severe carotid stenosis — do not have bruits. Without any obvious clues, it may be necessary to do ultrasound-screening tests to identify people who are at risk.

Patients over the age of fifty with any of the risk factors noted above should request a carotid ultrasound to screen for carotid stenosis. Depending on the results, the physician may recommend ultrasound screening at regular intervals. If there is evidence of moderate to severe blockage, additional tests may be needed to confirm the severity of the blockage. If a significant stenosis is confirmed, surgery may be recommended. Surgery to remove the blockage is called a carotid endarterectomy.

Questions to Ask the Primary Care Doctor

Patients with any risk factors for carotid disease should tell their doctors about them and ask that their carotid arteries be examined, at least with a stethoscope. Other questions that patients should ask their doctor, particularly if they have any of the risk factors for stroke, include:

• Do you hear any bruits or abnormal noises in my carotid arteries?
• Does the lack of any abnormal noises in the artery mean I have no disease or is it necessary to have an ultrasound of my carotid arteries?
• How often should I have these arteries checked?
• Should I now see a neurologist or a vascular surgeon or any other qualified specialist concerning my carotid arteries?

Questions to Ask the Surgeon: During the Examination

If a patient has been asked to see a surgeon because of carotid disease, here are some questions to ask the surgeon:

• How narrow is the blockage in my carotid artery (e.g. 75% stenosis)?
• At what degree of stenosis or percent blockage do you recommend surgery?
• What are my risks of having a stroke if I do not choose to have the operation now?
• If I decide not to have surgery, how often should I have my carotid arteries checked?
• Is it wise to be on any medication such as aspirin or Coumadin (a brand name for sodium warfarin)?
• What are the risks of having a stroke if I do have this operation?
• What other complications can occur from the surgery?
• How many carotid operations do you perform each year?
• Does the hospital have a registry indicating your stroke rate and the stroke rate of other surgeons on your staff?
• What is the acceptable stroke rate for this surgery throughout the country?

Carotid disease and carotid surgery are both very risky business. These and other questions must be asked and then discussed with your primary care physician or other surgeons.

Surgical Procedures for Carotid Disease

The surgeon will probably discuss whether the procedure should be done under local anesthesia or general anesthesia and whether any type of monitoring will be used during the operation to protect the brain from cerebral ischemia (lack of oxygen). During a carotid endarterectomy, the surgeon identifies the location of the blockage and makes an incision over the area. The clogged carotid artery is opened and the blockage is meticulously removed.

Sometimes a shunt or tube is placed in the vessel; this allows blood to continue flowing to the brain while the diseased area is worked on. The use of a shunt is important if general anesthesia is used and no other brain monitoring is being performed. This will ensure that there is adequate blood reaching the brain. There are a number of different shunts available, some are less traumatic to the vessel than others due to their size and the way they are held in place in the vessel.

The surgeon should explain how the procedure will be performed and why this particular method was chosen. If the surgeon does not explain all of these things, patients should ask. Patients should always seek a second or third opinion if they have any doubts or concerns.

Questions to Ask the Surgeon: Before Surgery

Here are some questions about the procedure that patients should ask the surgeon:

• What are the advantages and disadvantages of doing the operation under local versus general anesthesia?
• Do you prefer the local or the general anesthesia method and why?
• If you use general anesthesia, how do you monitor the brjavascript:void(0)ain to be sure it is getting enough oxygen?
• Do you use a carotid shunt to protect the brain during the operation?
• What kinds of shunts exist, what kind do you use, and what are some of the advantages and disadvantages of each?

Some less invasive procedures that avoid an open operation include the use of balloons that stretch open the diseased artery and then hold it open with a stent. This is called angioplasty, and stenting and has been used successfully in other parts of the body. If the surgeon is recommending this procedure, be sure to ask about the extent of his or her experience, the results, and complications.

 

Risk Factors for Peripheral Vascular Disease Arteries are similar to a plumbing system that can begin to clog with time. This happens when plaque builds up within the arteries, preventing the delivery of blood to tissues and organs supplied by the affected artery. Body tissues can die due to this loss of blood supply and the nutrients and oxygen it carries, if a critical artery clogs up completely. This disease is called atherosclerosis. Sometimes the term "hardening of the arteries" is used; however, this is really a colloquial name that originally referred to disease of smaller vessels (arteriosclerosis), but is used incorrectly to refer to atherosclerosis.

Risk Factors that Cannot be Changed

There are several risk factors for heart and vascular disease. Certain risk factors cannot be changed, such as:

• Family medical history
• Gender (men are at higher risk than women until women reach menopause; then the risk is the same)
• Age

However, there are several important risk factors that can be changed. These provide every patient with an opportunity to lower his or her risk for atherosclerosis by modifying lifestyle.

Risk Factors that Can be Changed Smoking cigarettes: Although smoking has been associated with lung cancer, it also increases the risk of heart disease and peripheral vascular disease (disease in the vessels that supply blood to the arms and legs). Although nicotine is the main active agent in cigarette smoke, other chemicals and compounds like tar and carbon monoxide are also harmful to the heart and blood vessels. Smoking may raise the blood pressure, which increases the risk of stroke in people who already have high blood pressure. Chemicals in cigarette and tobacco smoke lead to the buildup of fatty plaque in the arteries, possibly by injuring the vessel walls. Elevated cholesterol: One of the major risk factors for heart and vascular disease is high blood cholesterol. Cholesterol, a fat-like substance carried in the blood, is found in most of the body's cells. The liver produces cholesterol to form cell membranes and to manufacture certain hormones. Extra cholesterol enters the body when a person consumes foods that come from animals (meats, eggs, and dairy products). Although people often blame the cholesterol found in foods for raising blood cholesterol, it is really the saturated fat in food, not the cholesterol, per se. Even though a food does not contain cholesterol, it may still have large amounts of saturated fat. Foods rich in saturated fat include butterfat in milk products and fat from red meat. Eating trans fats found in some commercially baked cookies and crackers can also raise your cholesterol. Too much low-density lipoprotein (LDL or "bad cholesterol") in the blood causes plaque to form on artery walls, which initiates atherosclerosis.

Obesity: Extra weight is thought to lead to increased total cholesterol levels, high blood pressure, and an increased risk of coronary artery disease. Obesity increases a patient's chances of developing other risk factors for heart disease, especially high blood pressure, high blood cholesterol, and diabetes. Many doctors now measure obesity in terms of body mass index (BMI), which is a formula of kilograms divided by height in meters squared (BMI =W [kg]/H [m2]). According to the National Heart, Lung and Blood Institute, being overweight is defined as having a BMI over 25. Those with a number over 30 are considered obese.

Diabetes: Heart and vascular problems are the leading cause of death among people with diabetes, especially in the case of adult-onset or Type II diabetes (also known as non-insulin-dependent diabetes). Certain racial and ethnic groups (African-Americans, Hispanics, Asian and Pacific Islanders, and Native Americans) have a greater risk of developing diabetes. If a person has diabetes, he or she may already be aware that good control of blood sugar levels can reduce the risk of cardiac and vascular disease.

Hypertension (high blood pressure): High blood pressure increases the risk of heart disease, heart attack, peripheral vascular disease, and stroke. Though other risk factors can lead to high blood pressure, it may occur in the absence of other risk factors. Combining obesity, smoking, and high cholesterol with high blood pressure increases a patient's risk substantially. Blood pressure can vary with activity and with age, but a healthy adult who is resting generally has a systolic pressure reading between 120 and 130 and a diastolic pressure reading between 80 and 90 (or below). Inactive lifestyle: People who are not active have a greater risk of heart and vascular disease than people who exercise on a routine basis. Exercise not only burns calories, helps to control cholesterol levels and diabetes, but also may actually lower a person's blood pressure. Exercise helps to preserve the flexibility of peripheral blood vessels.

Stress: Stress is considered a contributing risk factor for heart and vascular disease, although little is known about how stress exerts an influence on the cardiovascular system. The effects of emotional stress, behavior habits, and socioeconomic status on the risk of heart disease and heart attack have not been proven. That is because people deal with stress differently so there is no predictable outcome for patients experiencing stress.

Eliminating Risk Factors

The elimination of certain risk factors can help alleviate symptoms:

Stop smoking completely: quitting for one year reduces the risk of coronary heart disease by half; quitting for one day returns pulse and blood pressure to normal.

Check cholesterol levels: lowering of serum cholesterol is beneficial in patients with known atherosclerosis; every 10% reduction in cholesterol translates into a 12-16% decrease in mortality for patients with coronary artery disease.

Maintain healthy body weight: the less you weigh, the less weight the legs have to carry, which reduces muscular stress and diminishes pain and fatigue.

Eat a well-balanced healthy diet, rich in vegetables and fruits: low-fat diets are the rule for those who wish to decrease the buildup of arterial plaque. Exercise regularly: low-to-moderate intensity activities for as little as 30 minutes a day can be beneficial. These activities may include:

• Pleasure walking
• Climbing stairs
• Gardening
• Yard work
• Moderate-to-heavy housework
• Dancing
• Home exercise

See a doctor for diabetes and hypertension control: undetected and uncontrolled diabetes is a major problem. Adequate control of diabetes with diet, tablets, insulin injections, and exercise is important. Goals for hypertension control generally include the following:

• Less than 140/90 mm Hg
• Less than 135/85 mm Hg in diabetics
• Initiate lifestyle modification in all patients with hypertension
• Drug therapy whenever required
• Remain always on the alert for peripheral vascular disease, especially if there are any family traits concerning poor circulation or heart disease

Remember …
Reducing or eliminating risk factors is always a good approach, whether patients have symptoms of cardiovascular disease or not. However, many patients may need some type of surgical or endovascular intervention, even if they are successful at lowering their blood pressure, reducing their cholesterol levels, or controlling their diabetes.

А

Abdominal 

Pertaining to the abdomen.

Acute Thromboembolism

A quick and severe blocking of a blood vessel by a blood clot dislodged from its site of origin.

Adventitia

The membranous outer covering of an organ or a blood vessel.

Aneurysm

A sac-like widening of a blood vessel.

Angioplasty

The surgical repair of a blood vessel, either by inserting a balloon-tipped catheter to unblock it, or by reconstructing or replacing part of the vessel.

Aorta

The main trunk of the systemic arteries, carrying blood from the left side of the heart to the arteries of all limbs and organs except the lungs.

Arteriogram

An x-ray of blood vessels, which becomes visible after an injection of contrast solution into the circulation that appears on the x-ray film.

Arteriosclerosis

A chronic disease in which thickening, hardening, and loss of elasticity of arterial walls result in impaired blood circulation.

Artery (pl. Arteries)

Any of the muscular elastic tubes that form a branching system and that carry oxygen-rich blood away from the heart to the cells, tissues, and organs of the body.

Atherosclerotic

Having or relating to atherosclerosis.

B

Bruit

A sound heard with a stethoscope suggesting a narrowed vessel.

Bypass Graft

An alternative passage created surgically to divert the flow of blood.

C

Carotid Artery

Two major arteries of the neck and head that branches from the aorta.

Catheter

A hollow flexible tube for insertion into a body cavity, duct, or vessel to allow the passage of fluids or distend a passageway.

Central venous catheters

A catheter (tube) that is passed through a vein to allow concentrated solutions to be infused with less risk of complications.

Cerebrovascular

Relating to the brain and the blood vessels that supply it.

Circulatory System

The bodily system consisting of the heart, blood vessels, and blood that circulates blood throughout the body, delivers nutrients and other essential materials to cells, and removes waste products. Also called cardiovascular system.

Clot

A lump of material formed from changing a liquid (i.e. blood) to a thickened or solid state.

D

Dialate

To make wider or larger; cause to expand.

Dialysis

The separation of smaller molecules from larger molecules in a solution by selective diffusion through a semipermeable membrane. Part of the hemodialysis process.

Dialyzer

A machine equipped with a semipermeable membrane that allows passage of certain, especially small, molecules but acting as a barrier to others and used for performing dialysis.

Distal

Farthest from the center of attachment, center of the body, point of attachment; the opposite of proximal.

E

Electrodesiccation

Use of an electric current to seal off veins.

Embolectomy

Surgical removal of a mass, such as an air bubble, a detached blood clot, or a foreign body, that travels through the bloodstream and lodges so as to obstruct or occlude a blood vessel.

Embolism

Occlusion of a blood vessel by a loose clot, air bubble or other particle.

Endarterectomy

Surgical excision of the inner lining of an artery that is clogged.

Endoluminal

Within the inner space of an artery or vein.

Endovascular

A form of minimally invasive surgery that was designed to access many regions of the body via major blood vessels.

F

Femoral Vein

An upward continuation of the popliteal vein that carries blood from the leg back to the heart.

H

Hemodialysis

A procedure for removing metabolic waste products or toxic substances from the bloodstream by washing the blood over a membrane with a special fluid.

Hypertension

Abnormally elevated blood pressure.

I

Iliac Vein

One of three veins draining the pelvic area.

Infrarenal

Located below the renal arteries.

Intermittent Claudication

An aching, crampy, tired, and sometimes burning pain in the legs that comes and goes due to poor circulation of blood in the arteries of the legs. Typically occurs with walking and goes away with rest.

Internal fistula

A passageway in the body, a bridge or connection between an artery and a vein, either abnormal or created surgically.

Intima

The innermost membrane of an organ or part, especially the inner lining of a lymphatic vessel, an artery, or a vein.

Intravenous

Administering fluids and/or surgical instruments into a vein.

Ischemia

A decrease in the blood supply to a bodily organ, tissue, or part caused by constriction or obstruction of the blood vessels.

L

Lipoprotein

A conjugated protein having a lipid component; the principal means for transporting lipids in the blood.

M

Media

The middle, often muscular layer of the wall of a blood vessel.

O

Occlusion

An obstruction or a closure of a passageway or vessel.

P

Percutaneous Transluminal Angioplasty (PTA)

The use of a balloon-tipped catheter to enlarge a narrowed artery.

Phlebitis

Inflammation of a vein.

Plaque

A deposit of fatty material on the inner lining of an arterial wall.

Popliteal Vein

A vein arising in the knee and ascending to become the femoral vein.

Prosthetic

Serving as or relating to an artificial device used to replace a missing body part.

Proximal

Nearest the center of attachment, center of the body, point of attachment, or point of reference; the opposite of distal.

R

Radiologist

A medical specialist who uses radioactive substances and X-rays in the treatment of disease.

Red Blood Cell

A cell in the blood that transports oxygen and carbon dioxide to and from the tissues.

S

Saphenous Vein

There are two, the great and the small saphenous veins – they serve as the principal veins running near the surface up the leg. The great saphenous vein (also called the large saphenous vein) goes from the foot all the way up to the thigh. The small saphenous vein runs behind the outside of the ankle joint, comes up the back of the leg and joins the popliteal vein in the space behind the knee.

Sclerotherapy

Procedure where a fine needle injects a solution directly into the vein. This solution irritates the lining of the vein, causing it to swell and the blood to clot. The vein turns into scar tissue that fades from view.

Shunt

A passage between two natural body channels, such as blood vessels, especially one created surgically to divert or permit flow from one pathway or region to another; a bypass.

Stenosis

A constriction or narrowing of a duct or passage.

Stent

A slender thread, rod, or catheter inserted into a tubular structure, such as a blood vessel.

Stent Graft

A tube composed of fabric or other material supported by a metal mesh called a stent. It can be used for a variety of conditions involving the blood vessels, but most commonly is used to reinforce a weak spot in an artery called an aneurysm.

Stroke

A sudden loss of brain function caused by a blockage or rupture of a blood vessel to the brain, characterized by loss of muscular control, diminution or loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severity of the damage to the brain.

T

Thoracic

Pertaining to the chest.

Thrombolytic

A kind of drug that can break up clots blocking the flow of blood to the heart muscle.

Thrombus (pl. Thrombi)

A clot formed in a blood vessel or in a chamber of the heart.

Transient Ischemic Attack (TIA)

A neurological event, often caused by the narrowing of the carotid arteries, with the signs and symptoms of a stroke, but which go away within a short period of time. Also called a mini-stroke, a TIA is due to a temporary lack of adequate blood and oxygen (ischemia) to the brain.

U

Ultrasound

The use of ultrasonic waves for diagnostic or therapeutic purposes, specifically to image an internal body structure.

V

Varicose

Abnormally swollen or knotted.

Vascular

Relating to the blood vessels (arteries, veins and capillaries) of the body. The blood vessels of the body, as a group, are referred to as the vascular system.

Vascular Surgeon

One whose profession or occupation is to cure vascular diseases or injuries of the body by manual operation.

Veins

Any of the membranous tubes that form a branching system and carry oxygen-depleted blood to the heart.

Ventricle

Either of the two lower chambers of the heart that, when filled with blood, contract to propel it forward.

W

White Blood Cell

Blood cells that engulf and digest bacteria and fungi; an important part of the body's defense system.

"Your KemAngioprotez" A Guide for Vascular Bioprosthesis Recipient