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How to Treat Aneurysms, Carotid Disease and PAD: A Vascular Surgeon Explains · Meaningful Medicine with Novant Health

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  Amanda Wilde (Host): Meaningful Medicine is a Novant Health podcast bringing you
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  access to leading doctors who answer questions they wish you would ask.
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  From routine care to rare conditions, our physicians offer tips to navigate medical
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  decisions and build a healthier future.
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  Today, we're speaking with vascular surgeon, Dr.
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  Dale Coffey, about vascular conditions and treatments.
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  I'm Amanda Wilde, your host.
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  And Dr.
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  Coffey, welcome.
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  Dale Coffey, DO: Thank you for having me.
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  I appreciate it.
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  Host: Well, to start with, what are of main risk factors for
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  developing a vascular condition?
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  Dale Coffey, DO: The main risk factors for vascular disease are risk factors
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  that, you know, the primary care physicians and the cardiologists treat
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  on a daily basis that are, you know, very commonplace in the United States.
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  First being high blood pressure, hyperlipidemia, diabetes.
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  And the biggest thing for us for many of the things that we treat is tobacco abuse.
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  Host: Can you explain a little bit about something we hear a
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  lot about, aortic aneurysms?
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  Dale Coffey, DO: Yeah, there are different kinds.
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  Aortic aneurysms are definitely probably one of the most frightening things that
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  our patients have to deal with and one of the biggest things that we treat.
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  We primarily treat in the abdominal segment, although we can treat some
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  things in the thoracic segment as well.
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  I mean, these are most commonly seen in men and commonly seen
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  in people in their 60s and 70s.
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  And they kind carry a lot of the same risk factors.
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  We break it down into modifiable and non-modifiable risk factors.
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  So, you know, these non-modifiable risk factors that some people have, know, their
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  age, their gender, their family history.
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  Or some people have these things that we call collagen vascular disorders.
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  So, these are things that are kind of these zebra conditions like Marfan's,
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  Loeys-Dietz, or Ehlers-Danlos.
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  Those are very rare, but those are certainly things that people are born
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  with that they have no control over.
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  And then, we have, you know, some of the risk factors that we already talked about.
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  But in the aneurysm patient population, these are high blood
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  pressure and tobacco abuse.
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  Host: What is the difference between an abdominal aneurysm
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  and a descending thoracic?
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  Or am even saying that right?
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  Dale Coffey, DO: No, you are, yes.
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  Iit's merely location.
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  Abdominal aortic aneurysms occur in the belly, below the level of the diaphragm.
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  And then, you know, the descending thoracic aortic aneurysms occur
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  above the level of the diaphragm.
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  Primary descending thoracic aortic aneurysms are much less
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  common for a number of reasons.
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  The descending thoracic aorta has much more smooth muscle within the wall of
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  the vessel as well as it has lot more blood supply the outside as well as the
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  inside that the abdominal aorta lacks.
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  And so, why people are much more prone to develop abdominal aortic aneurysms.
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  Host: What kind of treatment do you advise for both these kinds of aneurysms?
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  Is it surgery or other treatment?
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  Dale Coffey, DO: I think a common theme that you'll kind of hear from me and
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  is just kind of pushed forth by the rest of our team, I mean, the first
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  we start with is medical management.
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  And so, you know, it is this counseling on smoking cessation.
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  It is blood pressure control.
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  You know, our goal for people is to be less than 130/80, which are
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  American Heart Association guidelines.
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  Past that, in terms of treatment, it really depends on size criteria.
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  For men, we operate on aneurysms that are greater than 5.5
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  centimeters.
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  For women, we operate on aneurysms that are greater than 5 centimeters.
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  And this stuff has kind of been parsed out over time based upon numerous trials.
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  And we're really going and operating at a time at which, you know,
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  the risks of rupture outweigh risks of surgical intervention.
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  So, we can offer a number of different types of repairs for people.
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  Whether it be an endovascular repair, which can be as little as two tiny
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  poke holes in the groins in order to deliver a graft that goes in
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  there and kind of excludes that aneurysm so it can no longer grow.
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  Or in some patients, we think that the better repair for them is an open repair,
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  which is a bigger open abdominal aortic operation, where we're reconstructing
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  the aorta with our own hands.
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  Host: Just curious, what have you seen in terms of success rate for
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  the surgeries, which sound like they're gold standard of treatment?
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  Dale Coffey, DO: Sure.
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  The surgeries themselves are highly successful.
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  I mean, we go into these cases looking at the CT scans and having a very good plan.
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  There's some nuance that goes into creating these plans for repair.
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  Not every exactly like the other.
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  And so, that's an interesting part of the job.
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  If it's sized appropriately and the case goes well, these
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  are very good, durable repairs.
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  When we talk about the difference between endovascular and open repairs,
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  the endovascular repairs, you know, they can be very easy to recover from
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  in comparison to that of the open repair, which is certainly an advantage.
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  But the caveat to that being these patients, it's imperative that they
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  follow up with us, on an annual basis so that we can kind of monitor the
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  graft and monitor for any growth.
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  There can be these things that are called endoleaks that develop
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  within the graft or around the graft that we need to go fix so that the
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  aneurysm doesn't continue to grow.
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  And so, you know, if there's any room for failure over the
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  course of many years, it's that.
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  It's not having people follow up with us.
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  When comes to open repair, that is a very durable repair.
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  People get this surgery, it's certainly more difficult to recover from.
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  It takes a stay in the ICU, which can be days and then, you know, up
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  to a couple of weeks in the hospital to kind of recover from this.
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  But in terms of durability, you see very good results from this.
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  And over the course of many years, the need for re-intervention for
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  these people is very, very low.
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  Host: And sometimes surgery is just necessary.
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  And what said about follow-up and you keep an eye on patients long after a successful
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  surgery, I think is very reassuring for those who are facing that option.
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  Vascular conditions can impact areas throughout the body, as we know.
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  This is one I have had and I have heard about plaque buildup in
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  the carotid arteries the neck.
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  How do you treat this one proactively?
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  Dale Coffey, DO: Yeah.
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  So, the whole goal behind carotid artery management is that of stroke prevention.
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  And, you know, again, like I said, a common theme of is medical management.
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  So, you know, we're really not going and intervening on these people
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  until they develop severe stenosis or severe narrowing, because, you
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  know, the risks of surgery certainly do not outweigh the risks of medical
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  management until you get to that point.
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  So from a medical management standpoint, you know, this is antiplatelet
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  therapy with you baby aspirin.
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  This is management your cholesterol, management of your
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  blood pressure, smoking cessation.
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  And when we talk about treating people, we kind of lump carotid
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  arteries into the symptomatic patient as well as the asymptomatic patient.
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  The symptomatic patient is somebody that to us in the hospital, typically.
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  They've a stroke or a TIA, or mini-stroke.
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  And, you know, we have no other identifiable cause for their stroke
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  except for their carotid arteries.
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  And if they have greater 50% narrowing, then we'll recommend revascularization
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  to prevent a future stroke.
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  In the asymptomatic patient population, you know, somebody who's not had a
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  stroke, TIA, or or visual disturbances that might be secondary to their carotid
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  arteries, we'll generally wait until they get be at least 70% stenosis or more.
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  Host: You mentioned revascularization treatment for those whose
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  arteries are intensely blocked.
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  What is that?
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  Dale Coffey, DO: Yeah.
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  I mean, these are our surgical options that we're talking about.
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  You know, we offer three different kinds of surgical options for people.
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  And there's some nuance that goes into decision as well.
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  You know, these decisions are upon the patient's age, the patient's
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  anatomy, the patient's current quality of life and their lifespan
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  or their projected lifespan rather.
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  And so, the things that we would offer for surgical revascularization
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  would be something called a carotid endarterectomy, endarterectomy,
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  which is a larger incision on neck.
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  We go down and basically clamp the carotid artery, open it up, clean
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  out the inside, and sew a patch over top in order to, you know, make sure
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  that that area is wide open now and there's no risk of it clotting off
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  or throwing any bits of calcium up into the brain causing a stroke.
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  That's option number one.
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  Option number two that we offer people is something called a TCAR, otherwise
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  known as a transcarotid revascularization.
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  I know that's a mouthful, but really what that is, in short, is ballooning
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  open the carotid artery and then stenting stenting it, but it's doing so in a
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  very particular way in which we make a small incision in the neck, and we
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  introduce a sheath in the carotid artery.
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  We then put a sheath in the femoral vein in the leg, we connect
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  those two sheaths with a cannula.
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  So, blood is therefore going from the high pressure carotid system
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  down into the femoral system.
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  So, you're kind of reversing flow, flow that otherwise would
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  have going up into the brain is now going through this cannula.
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  And the importance of that is we can then feel free to go and balloon the
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  carotid artery and place stent there, and any debris that otherwise may have
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  gone up into the brain will kind of be shunted through that cannula that
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  has a filter in it to catch anything.
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  And the last thing we offer people is a transfemoral carotid stent.
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  That's where we go through the artery in the groin in order to
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  deliver a stent up into the neck.
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  That's kind the thing that we offer as a vascular surgery practice last
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  for multiple reasons that I think are beyond the scope of this podcast.
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  But we typically reserve that for patients that have had, you know,
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  extensive neck dissections for for head and neck cancer or radiation.
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  So, it's a fairly hostile surgical area.
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  Host: Right.
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  Gotcha.
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  So, there are these three options for revascularization as we've just learned.
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  Before that, you hope to treat it in the ways that you outlined.
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  I also want to ask about peripheral artery disease, which can affect the legs.
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  Can you describe some of the hallmark symptoms, and then we'll
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  talk about treatment options?
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  Dale Coffey, DO: This exists on a spectrum.
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  You know, there no role for asymptomatic peripheral arterial disease.
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  So for example, if someone ever got a a CT scan or an ultrasound
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  of their legs, and someone noted calcium within their blood vessels,
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  but these people are asymptomatic, there's no role for treatment, just
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  kind of medical optimization, which falls in kind of a category that we
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  talking about antiplatelet therapy, statin therapy, so on and so forth.
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  And like you said, we'll get into that in a second.
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  But so, on one end of the spectrum, you have this asymptomatic patient.
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  And then, as we move along, patients develop claudication, which is when
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  they walk, they can get pain in their calves or their thighs because their
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  muscles are asking for more oxygenated blood than their body can provide.
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  And so, the hallmark symptom of that is pain with ambulation, but
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  it gets better when they stop.
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  This can progress to something we call rest pain, which is when the blood
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  flow is so bad that they're hurting all the time, in particular in kind of
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  the distal aspect of the feet, and more specifically when they're lying in bed
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  at night and they put their legs up.
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  And when that happens, they've kind of taken gravity out of the equation,
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  and they can develop some significant pain that then improves once they
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  dangle their legs off the bed again.
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  And then, on the far end of the other spectrum is tissue loss.
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  So, people can develop ulcers or, you know, wounds that they're unable to heal.
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  Host: Dr.
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  Coffey, as we prepare to close, want to ask you, the things you describe
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  do are very complex and delicate, what drew you to focus on vascular surgery?
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  Dale Coffey, DO: From kind of an academic surgical perspective, there's
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  a lot of variety in vascular surgery.
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  I mean, we touched on three kind of pathologies that we treat.
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  But, you know, there's a number of other things that we also treat that are kind
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  outside of the scope of this discussion.
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  So, that variety to be able to do multiple different things.
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  Also, kind of the variety of options for repair, you know,
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  between open and endovascular.
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  And when you're doing things
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  endovascularly, this is requiring technology, and this technology is
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  ever-evolving, and I think that really promotes this or allows for this room
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  for creativity when you're talking about repairing a certain issue.
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  You know, you can do things open or endovascular.
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  You can do a little bit of both in order to make sure that you
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  give the patient the best outcome.
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  And so, you know, when you're talking about all this
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  stuff, and I think, you know,
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  the same sentiment is shared by my partners, it's kind of an opportunity
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  to make a difference, and you're able to see that difference, you know,
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  as soon as you get done or over time longitudinally, whether it be saving
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  someone's leg or, you know, preventing them from having a stroke or, you
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  know, preventing an aneurysm rupture.
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  And I think these things are the kind of the crux of vascular surgery, is to
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  maintain patient's quality of life, at least that they deem to be acceptable.
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  So, I think that that's our goal as well.
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  And so, you know, working with the patient and giving the best option
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  for repair is certainly a challenging but rewarding part of the job.
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  Host: Yes, it is challenging, and it's comforting to know
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  that you're on the case.
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  I really appreciate you sharing your knowledge and expertise today.
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  Dale Coffey, DO: Absolutely.
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  Thank you so much for having me.
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  I really appreciate it.
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  Host: That was vascular surgeon Dr.
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  Dale Coffey.
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  To find a physician, visit novanthealth.org.
• 14:40
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• 14:43
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• 14:46
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