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SUMMER 1995 ISSUE
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SINAI HOSPITAL
Blood Vessels: Some Questions Some Answers
T
SPEC IAL ADVE RTISEMEN T
hree doctors who specialize in
problems involving the circu-
latory system were inter-
viewed by HealthNews. Their
areas of expertise and the con-
ditions they treat are similar, but their
therapeutic approaches may vary.
As background information for the
reader, the circulatory system includes
blood vessels, known as arteries and
veins. The arteries carry blood away from
the heart so that it can provide oxygen
and other necessities to all the cells in
the body. The veins return the blood to
the heart so that it can be reoxygenated
by the lungs.
•
Elie Aboulafla, M.D. is the director of
Ambulatory Vascular Services.
'
His prac-
tice evaluates vascular disorders, deter-
mines the best therapy for each patient,
and provides treatment accordingly.
Those patients who do
not require vascular
surgery receive the med-
ical evaluations they
need to control their dis-
ease. HealthNews asked
Dr. Aboulafia about the
conditions that he and
his staff can treat with-
out surgery.
HN: What percentage of
patients with vascular
disease require surgery?
Dr. Aboulafia: Fewer than
two of every 10 need
surgery. The others
require non-invasive test-
ing and medical treat-
ment.
HN: What are some of the
testing techniques you
use?
Dr. Aboulafia: We use dy-
namic testing and imag-
ing techniques that give
us information about nor-
mal or reduced blood flow
in the upper and lower
extremities, as well as
detection of blood clots
in the veins. For the
carotids, we use color
ultrasonography. These
procedures don't even re-
quire a needle prick, and they give a sur-
geon, internist, or whoever else is
involved, a tremendous amount of
information on which to make clinical
decisions.
HN: What about arteriosclerosis? Can
these laboratory tests help you develop
a plan of action?
Dr. Aboulafia: Yes, because there can be
several causes of the reduced blood flow.
In some situations, the blood vessels go
into spasm in response to abnormal neu-
rological impulses. There are cases in
which the major blood vessels are com-
pletely open, but the small ones are dis-
eased. These often include a group of
diseases like rheumatoid arthritis and
scleroderma. Many of these patients do
not require surgery and can be helped
with medication.
HN: Which patients usually do require
surgery?
Dr. Aboulafla: Those with significant
carotid stenosis — narrowing or stricture
— require surgery, even if they don't have
symptoms. Also, those patients with
limb-threatening ischemia, gangrene,
aneurysm or pain at rest usually need
surgery. Most other circulatory prob-
lems require control of risk factors and
medical management.
a W. Brown, M.D., is chief of the section
of Vascular Surgery. As a vascular sur-
geon, he operates on all the blood vessels
— arteries and veins — in the body.
HealthNews asked Dr. Brown about the
three main sections of the arteries and
how he treats them surgically.
HN: What are the three main artery
sections?
Dr. Brown: The neck arteries, known as
the carotids, the abdominal aorta, and
the leg arteries are the main ones.
vessel. If it gets too big, it will pop. It's
like a weak spot in a tire that bulges out.
It needs to be repaired before it ruptures.
We do that by replacing that segment of
the artery with an artificial bypass graft.
HN: What about the arteries in the legs?
Dr. Brown: Some people experience very
painful cramping when they walk, due
to hardening of the arteries. So, we do
bypasses in the legs to increase the
blood flow.
Hit What materials do you use when you
do bypasses?
Dr. Bravn: When we do a bypass on a ma-
jor blood vessel — like the aorta — we use
Dacron. When we do a bypass in the leg,
we use either the saphenous vein — the
same one used in heart bypasses — or a
material called Gortex.
HN: What are the common risk factors
for vascular diseases?
Dr. Brown: By far, the main risk factor is
smoking. Hereditary factors play a part,
along with a fatty diet and a lack of
exercise.
is an internist who
specializes in superficial vein diseases
of the legs. These include varicose veins,
spider veins, and leg ulcers. HealthNews
asked Dr. Powell about the causes of leg
Above: Varicose veins BEFORE sclerotherapy.
Right: Results following sclerotherapy.
HN: How do you surgically treat the
carotids?
Dr. Brown: I do what is called an en-
darterectomy to remove the plaque
buildup from the lining. This opens the
passage to allow better blood circulation.
HN: How much blockage should there be
before you operate?
Dr. Brown: Until recently, surgeons would
do the procedure with 80 percent to 90
percent blockage without symptoms. We
didn't know whether blockages would go
on to cause symptoms.
But recent studies show that a patient
is at risk with 60 percent blockage, and
such carotids need to be fixed.
HN: What can happen to the abdominal
aorta?
Dr. Browns It's a ballooning of a main blood
diseases and their non-surgical treat-
ment, called sclerotherapy.
lit What is the relationship between sur-
face veins and deep veins, and how do
varicose veins occur?
Dr. Powell: The surface veins drain into
the deeper system of veins at multiple
sites throughout the leg. Valves in the
surface veins help direct the flow of blood
into the deep veins, then to the heart and
lungs, to get recirculated.
When a valve malfunctions, the blood
is unable to empty out of that part of the
sinai
vein. This causes a backup of pressure.
Over time, the increased pressure on the
nearby valve causes them to malfunc-
tion. Eventually, there is distention of
the veins ... or varicose veins.
HN: Who is most likely to get severe
cases of varicose veins?
Dr. Powell: People with hereditary
factors, pregnant women, and obese peo-
ple — especially those in the standing
occupations — often have intense dis-
comfort from varicose veins.
Sometimes, pregnant women in the
last trimester can get varicose veins quite
rapidly, especially if there are underly-
ing hereditary components. After deliv-
ery, though, some of these conditions
return to normal on their own. If they
don't after six weeks, they probably won't
return to normal.
HN: How do you treat varicose veins?
Dr. Powell: First, I do a vascular exami-
nation and, if necessary, duplex ultra-
sound of the lower extremities in order
to evaluate the vein and to find the
exact point of backflow.
Next, I perform sclerotherapy, which
is a series of tiny injections into the dis-
eased veins. This causes an inflamma-
tion of the inner lining of the vein wall,
scarring or closing off the abnormal
portion of the vein. It is
painless and highly suc-
cessful. In large varicose
veins, I use ultrasound to
guide the injections to the
exact sites of reflux or
backflow. This dramati-
cally lowers the risk of re-
currence. Sclerotherapy
in experienced hands us-
ing duplex ultrasound-
guided injections safely
and effectively eliminates
the need for vein surgery
in over 90% of all patients
with varicose veins.
HN: What causes spider
veins... and how do you
treat them?
Dr. Powell: Spider veins
are caused by some of the
same things, plus the fe-
male hormones estrogen
and progesterone, which
stimulate growth of
spider veins in women.
Men don't get spider
veins as often as women.
Usually, sclerotherapy is
all that's needed to elim-
inate spider veins..
HN: What about leg ul-
cers?
Dr. Powell: They are relat-
ed to what is called venous insufficien-
cy. This means the blood is unable to
empty out of the leg very well because of
a prior blood clot, or large varicose veins,
or both. The damage usually is around
the ankle. An open sore can develop.
I treat some of these cases with grad-
ed compression wraps — tight at the
bottom and looser at the top — to help the
blood flow. I also may use sclerotherapy,
rerouting the blood flow through a
healthy vein.