Interactive Learning : Ask the Expert

Ask the Expert Live Chat Transcript - Tuesday, February 8, 2011

Donna M. Mendes, MD

Attending Vascular Surgeon, Department of Surgery Lenox Hill Hospital

Dr. Mendes generously donated her time to answer our patients' general questions about vascular disease. The below transcript details all of the questions asked by our participants as well as his answers.

Moderator- VDF: Welcome everyone! Thanks for joining us today, we're glad you're here! You may now go ahead and type your questions for Dr. Mendes to answer. We appreciate everyone's patience as she works to answers everyone's questions.

Sue R: My husband has been told he has 50-60% blockage in both of his carotid arteries however his doctor says they are just going to monitor him and do a recheck in 4 months.

Speaker- Dr. Mendes: Narrowing of the carotid artery is considered dangerous when it reaches 70% in patients; 70% if symptomatic then an intervention can be offered. Now he should monitor his risks and follow up with the doctor as scheduled

Sue R: So just staying on his current cholesterol medication and HBP meds is ok then?

Speaker- Dr. Mendes: The best way to treat PAD is to ensure that all of your risks are modified--stop smoking, watch your blood pressure and cholesterol, and of course walking is also very good

Sue R: Yes, that is what he should do

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Speaker- Dr. Mendes: Does everyone know what the risks for PAD are?

VDF Moderator: Oh I do!!! Smoking, diabetes, high blood pressure, high cholesterol, family history...anything else?

Speaker- Dr. Mendes: Excellent!! and if you are African American, you have an increased risk. You are also at risk if you have heart disease, have had a heart attack or a stroke remember that you have to keep your blood pressure in check, your cholesterol in check, cigarettes get thrown away, exercise is important.

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Gail E: 2 years ago I was diagnosed with HTN, hypercholesterolemia, metabolic syndrome, insulin resistance, mitral & tricuspid regurg, palpitations; I have a strong family history of strokes & cardiac disease: mother had 4 major strokes, dad died at age 53 from MI. Had tests showing atherosclerosis involving small and large vessels; plaques measure 4 mm in the carotid arteries (both). My question is: I have been having pain on the sides of my neck as well as in the back of my neck. I also get short of breath when I bend my head back to look at a top shelf. Is this something to be concerned about?

Speaker- Dr. Mendes:Moving your neck does if you have carotid disease does not cause symptoms of pain shortness of breath with bending your neck is also not a symptom of carotid disease.

VDF Moderator: If you'd like more information about carotid disease, please feel free to visit our Web site: http://www.vdf.org/diseaseinfo/carotid/

Gail E: Thanks! Must be something else, I have read that 4 mm plaques are not too worrisome, is this correct?

Speaker- Dr. Mendes: Again, plaques mean that the vessel is somewhat narrowed--4mm is not too worrisome but remember to modify your risks so that more thickening does not occur

Gail E: I received the pamphlets about PAD and found them very helpful. I will check out the carotid disease articles later.

VDF Moderator: Great to know that you enjoy our other pamphlets!

Gail E: Is it normal for people with atherosclerosis to be cold all the time? My body shakes a lot almost daily even when I have two sweatshirts on!

Speaker- Dr. Mendes: Atherosclerosis will cause decreased blood flow to the extremities but one is not "cold all the time." For some of my older patients with cold feet who are otherwise asymptomatic, I tell them to wear socks to bed.

Gail E: Thanks, Dr. Mendes. I do wear socks to bed already and keep my hands under the covers.

Speaker- Dr. Mendes: That is exactly what I would recommend, particularly during the winter months

Gail E: When I did floor nursing in the hospitals I would always tell my patients I may have cold hands but a warm heart! I think I have had this vascular problem for quite some time. My cholesterol has been very high for a number of years but is directly related to my genetics and not my diet. I am on Lipitor 80 mg

Speaker- Dr. Mendes: Were you diagnosed with Raynaud's? There the vessels spasm and cause the patient to have cold fingers

Gail E: My cardiologist or general practitioner never mentioned it but I have done a lot of research about Raynaud's. Actually, I had to ask my cardiologist if I actually had atherosclerosis before she finally told me so. I had a series of cardiac tests at the Rasmussen Heart Center At the University of Minnesota...they did the specialized testing to measure the stiffness. I don't have the exact readings here with me.

VDF Moderator: I thought you might like to listen to this podcast (HealthCast) Episode 19: Raynaud's Disease: A Condition of Vasospasm of Arteries That Happens with Cold or Stress. It's a great episode and I thought might to listen to it and here is some information about Raynaud's for your information: http://www.vdf.org/diseaseinfo/raynaud/

Gail E: Do most people diagnosed with atherosclerosis develop PAD?

Speaker- Dr. Mendes: No -atherosclerosis simply means you have thickening of the arterial wall-you may not have enough to occlude the vessel or make it very narrow which means you may not have any symptoms

Gail E: Once again, thanks for the information. I will go to that site as soon as this chat session is completed!

VDF Moderator: You are most welcome Gail!

Gail E: How can one know what the percentage of blockage may be when you have atherosclerosis? I was told from an ultrasound of my carotid arteries and another test for the small and large veins but nothing beyond that point. Should I request further testing or is the ultrasound reliable even though is only of a small section?

Speaker- Dr. Mendes: When we see patients, from their symptoms and from the physical exam, we determine what tests may be helpful.

Gail E: From what I read the first sign of an occlusion may just be a TIA, is this correct? Is that when the % of blockage is discovered? My greatest fear is having a stroke or TIA because I watched my mother for 4 years have 4 major strokes leaving her unable to care for herself. That is what I want to try to avoid if possible. Guess I just find the word "atherosclerosis" pretty intimidating and frightful.

Speaker- Dr. Mendes: An occlusion is a complete blockage a stenosis is a narrowing of the vessel---the step before an occlusion. We hope to treat patients before the vessel becomes completely occluded. If you have carotid artery disease, you get monitored. With a narrowed vessel, your symptoms usually do not occur until the vessel is very narrowed---we treat before that occurs. Lifestyle changes is the best way.

Gail E: Thanks, Dr. Mendes. Wish I could go to your clinic! I try to put confidence in my clinic and I do follow-up care so they are monitoring this. I already take an ACE inhibitor, a beta blocker, a calcium blocker and diuretic for my HTN so that should help. I have also watched what I eat and walk A LOT! I do not smoke but have been exposed to 2nd hand smoke x 41 years from my husband resulting in asthma. Thanks for your input!

Speaker- Dr. Mendes: Your doctor is also aware of the strong family history and is watching you with a carotid ultrasound, etc. Stay in control of the risks and stay with the docto. You are welcome.

Gail E: Thanks, this was a very informative meeting for me. I will look forward to the next session.

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Peggy: I have been diagnosed with FMD & have a renal stent. So little seems to be known about FMD. Some of the case histories I have read are dramatically worse than what I have experienced. Is it just a matter of time until I have additional symptoms or can I be relatively assured I may only experience this one problem. Are there things I should be doing proactively?

Speaker- Dr. Mendes: FMD of the renal arteries is very nicely treated with a balloon dilatation; I trust you will be good henceforth

Peggy: I have read that FMD patients should not have chiropractic procedures or deep tissue massage. Are there any precautions I should take with exercises, particularly abdominal - I do feel my stent from time to time - or perhaps experience soreness in the general area of the stent.

Speaker- Dr. Mendes:Stents placed in your blood vessels should both be felt---they are in the vessel and should cause no symptoms. I have not read about NOT doing deep tissue massage in FMD patients but pathiophysiologically, there is no reason to avoid such massage

Peggy: So are there any exercises I should avoid, particularly abdominal?

Speaker- Dr. Mendes: Exercise. It is good for you with or without a stent.

Lars H: I have Burger's Disease and like to know if there's any test programs anyplace?

Speaker- Dr. Mendes: Smoking is seen in those with Buerger’s disease; are you a smoker? Stopping smoking is the BEST treatment for Buerger's disease

VDF Moderator: Feel free to visit this link to learn more about Buerger's disease: http://www.vdf.org/diseaseinfo/buergers/

Lars H: Not for the past 50 years.

VDF Moderator: Great news Lars! That's the best thing for Buerger's disease!

Speaker- Dr. Mendes: Great that smoking has stopped and this can usually help those with the pain of Buerger's disease. Please tell me what your symptoms are now

Lars H: If you hear of experimental projects regarding Buerger's, please e- mail me...

VDF Moderator: I just did a quick search on Clinical Trials.gov and found a few trials you might want to visit this link: http://clinicaltrials.gov/ct2/results?term…

Lars H: My father and aunt both died from complications of BD

VDF Moderator: I'm so sorry! Did you read this information on our Web site about Buerger's: http://www.vdf.org/diseaseinfo/buergers/ Perhaps there is something there that will help.

Lars H: Thank you!!!

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Lynnemary: I have shortness of breath and my arm is purple and cold and the pressure in my head, I have to sit quickly on the floor if I can’t get to a chair. I’ve gotten dopplers on the veins and arteries nerve tests on the arm.

Speaker- Dr. Mendes: I hope you told the vascular surgeon all of that.

Lynnemary: He didn’t give me a chance.

Speaker- Dr. Mendes: So the artery, vein and nerve test results were?

Lynnemary: Re-canalized, it’s the large vein, not sure if it’s the outer or inner one if I lean forward slightly the arm goes purpler and purpler, it is not getting blood or oxygen. If I do a lot of reaching, it’s hard to breathe. My mom had an artery (valve?) opened up, but they used a finger not a balloon

Speaker- Dr. Mendes: That was probably a valve in her heart?

Lynnemary: Yes, then 10 yrs later, they had to open up the other one as well.

VDF Moderator: I thought you might enjoy reading this article on visiting your health care provider: http://www.keepingincirculation.org/articl…

Lynnemary: Should I see a different vascular surgeon? Or what should I do now?

VDF Moderator: You are always entitled to a second opinion. And if you don't feel like you are getting what you need from your doctor, by all means seek another opinion. That is your right as a patient! VDF has a free doctor finder on our Web site: http://www.vdf.org/resources/findspecialist.php

Lynnemary: It’s so hard to breathe and the arm I drag it I dont think I can do this anymore its been 4 yrs after the blood clot.

VDF Moderator: You need to learn about DVT, please send us your name and address to info@vdf.org and we will send you a brochure. You can also read about DVT online: http://www.vdf.org/diseaseinfo/dvt/ . You should also read about post-thrombotic syndrome: http://www.vdf.org/diseaseinfo/pts/

Lynnemary: Thank you, I haven’t gotten a brochure for a few years now.

VDF Moderator: You are welcome, I will send you a few things in the mail, but please e-mail us your address!

Lynnemary: Yes post thrombotic info, much appreciated thanks. Yesterday, the vascular surgeon told me to lift bags of flour, and take aspirin daily. Also told the vascular surgeon about the sharp pains I get, sometimes they last a long time, he said it’s not the veins. I do get heart burn but it’s not heart burn the last time I had it I even awoke the next morning still feeling pain around the hear area

Speaker- Dr. Mendes: Do you have both PAD and DVT or just DVT?

VDF Moderator: You mentioned you had a blood clot, that is DVT, but your doctor has said you don't have a problem with your veins. Has he explained what your diagnosis is?

Lynnemary: They tested the arteries, but i see on the results that it says, "left arm" - this is affecting my right arm, wondering if the test is incorrect and I think it’s the arteries in the arm they checked maybe I should focus on the heart area?

VDF Moderator: Well, for PAD they would check blood pressure in the ankles and arms, not just the arms. Again, please e-mail us your address so we can send you some literature.

Lynnemary: He didn’t explain my diagnosis. I remember when I got the blood clot, the doctor was so heartfelt he looked at me and said I will have DVT for the rest of my life and I might even be on medication for the rest of my life.

VDF Moderator: Yes, with DVT that is right and not uncommon. Do you also have an arterial blockage of just DVT?

TRF: Have you had experience with renal aneurism?

Speaker- Dr. Mendes: Yes, what is the question?

TRF: What are the risks for a surgery for renal aneurysm, why is it considered risky? I have a renal aneurysm but they are hesitating to do an operation. I'm not asking about me specifically because I understand you cannot treat a patient in a chat room. So my question is in general what are the risks and why don't they just treat an aneurism when they see it so that one does not have to fear rupture. In my case it is small 8mm and stable just for reference. OH one more thing it's cause is FMD.

Speaker- Dr. Mendes: A renal artery aneurysm is a dilation of the artery going to the kidney and is considered an aneurysm when it is twice the size of a normal renal artery. The potential for problems occurs when they get larger

TRF: What you wrote about RAA answers my question. Were you leading up to an answer or was that the answer?

Speaker- Dr. Mendes: Based on autopsy studies the incidence of RAA is 0.1%. W

TRF: I meant to write it does not answer the question is what I meant to write. sorry.

Speaker- Dr. Mendes: FMD is a disease of the carotid artery and renal artery. It has the appearance of a corkscrew and the treatment is a balloon dilatation

VDF Moderator: I thought you might like to read more about FMD. You can get information on our Web site: http://www.vdf.org/diseaseinfo/fmd/ or through the FMDSA: http://www.fmdsa.org/

Speaker- Dr. Mendes: In FMD the layers of the wall of the artery become degenerative this leads to the aneurysm formation

TRF: Thank you my question isn't really about FMD but specifically aneurysm of the kidney.

Speaker- Dr. Mendes: Most patients with FMD are healthy young women and the renal artery appears as a string of beads with the aneurysm at the renal bifurcation"'

VDF Moderator: Oh sorry TRF!

Speaker- Dr. Mendes: You have a renal artery aneurysm and you said that it was due to FMD

TRF: I have an 8mm aneurysm in my kidney that is due to FMD. My question is what the risks and reasons for not doing a operation of some sort to fix the aneurysm to prevent rupture

Speaker- Dr. Mendes: 8mm is not twice the size of a normal renal artery so I would be hard pressed to say you have an aneurysm

TRF: They diagnostic test says aneurysm and I believe it said 8mm. They are referring the case to doctor Stanley in Michigan. Regardless of whether I have an aneurism which my angioplasty report says I do. The question remains the same what are the risks of renal aneurism surgery and why don't they do it if there is a possibility of rupture, I'm assuming they don’t run to do it because it is small but what are the risks that keep them from doing it

Speaker- Dr. Mendes: there are two kinds of veins in the legs---the superficial and the deep--the superficial veins are the ones used for a heart or leg bypass--the deep vein can take care of getting the blood back

TRF: If it were a simpler procedure like an angioplasty which is done every day I know they would do it.

Speaker- Dr. Mendes: Regardless of whether I have an aneurism which my TRF angioplasty report says I do. the question remains the same what are the risks of renal aneurism surgery and why don't they do it if there is a possibility of rupture

VDF Moderator: Dr. Stanley is Head of the Vascular Surgery Service at the University of Michigan so it sounds like you're in good hands!

TRF: The report says approximately 8mm diameter right renal artery aneurysm arising from bifurcation of the right main artery which has not changed since last angioplasty.

Speaker- Dr. Mendes: I was copying your message if a renal aneurysm is less than 2 cm in size, and the patient is not a female who can become pregnant, most surgeons would not operate. Note, aneurysm rupture has been noted in an aneurysm as small as 1.5 cm. The physician would take all of your concerns, including the size and whether or not you have hypertension into consideration

TRF: I am waiting to get pregnant right not once they decide if they will do the aneurism

Speaker- Dr. Mendes: If you are a woman in the child bearing age then an asymptomatic renal artery aneurysm would be VERY closely evaluated. Dr. James Stanley is one of the best!!

TRF: Have you ever done surgery on a renal aneurysm yourself?

Speaker- Dr. Mendes: Yes

VDF Moderator: I hope we were able to help you!

TRF: Nope but it's ok I will eventually speak with someone it's just a new diagnosis for me.

VDF Moderator: Sorry TRF, with more in depth cases, it can be difficult to get clear answers. It sounds like Dr. Stanley is really good so I think you're in good hands! Stay in touch with us and let us know how it goes!

TRF: Thank you. __________________________________________________________________________________________________

Irene: Thanks for having this chat. My question deals with renal FMD. In the last 6 1/2 years I have had 6 angioplasties due to renal FMD. Have been told that I may at some point need renal artery bypass. What factors decide the option for bypass. Thanks

TRF: I think the reason they might need bypass in the future is due to wear tear on the arteries like in my case they may need to do bypass because of aneurism.

Speaker- Dr. Mendes: If multiple angioplasties have not been successful, then a bypass is the next step

TRF: FMDSA may have more answers for your question. Good luck!

Irene: Thank you.

Speaker- Dr. Mendes: If the artery cannot be successfully treated then you will remain hypertensive and that can cause long term problems.

VDF Moderator: And yes, do contact FMDSA: http://www.fmdsa.org

TRF: You have had a lot of angioplasties in a short amount of time so it makes a lot of sense.

Irene: It does for awhile but soon the pressures go up. I was also diagnosed recently with CAD and pulmonary hypertension so I have concerns about surgery.

Speaker- Dr. Mendes: The long term hypertension can only make your pulmonary worse, so have a long talk with your surgeon and go over the pros and cons--make 2 lists

Irene: Thank you so much. It gives me things to think about.

VDF Moderator: Great Irene, you are most welcome! Best of luck

Speaker- Dr. Mendes: Thank all of you for being here today and I hope I was helpful; Dr. M. the best of luck

Moderator- VDF: Thank you all for joining us today and thanks to Dr. Mendes for her time. We wish you a healthy day! Please join us on March 8, our guest Ask the Expert Dr. Meghal Antani.

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Disclaimer

The material provided on VDF's Web site and Live Ask the Expert chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.