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Video Transcript: Arteries and Veins

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. On the show today we'll be talking about treating a variety of problems in the vascular system. The network of arteries and veins that keeps blood supplied to all parts of the body. My guest is Dr. Rajabrata Sarkar. He’s the chief of vascular surgery at the University of Maryland Medical Center and is also a professor of surgery and head of the division of vascular surgery at the University of Maryland School of Medicine. Welcome to the show.

Rajabrata Sarkar, M.D.: Thank you.

Ellen Beth Levitt: What are some of the common problems you treat as a vascular surgeon?

Rajabrata Sarkar, M.D.: We treat problems in the arteries and the veins. Problems in the arteries are usually aneurysms are blockages in the arteries throughout the body. On the vain side of the circulation we see varicose veins and problems with deep vein thrombosis.

Ellen Beth Levitt: I would guess vascular problems affect a wide variety of people?

Rajabrata Sarkar, M.D.: They do. There is a perception most of the patients are elderly. But the reality is we see patients of almost all ages with vascular problems.

Ellen Beth Levitt: Let's talk about some of the problems you treat that affect the arteries. I think one of them you mentioned aneurysm. What is an aneurysm?

Rajabrata Sarkar, M.D.: An aneurysm is the medical term for a swelling in an artery that is due to weakening of the wall. So there is good flow in the artery. But as the wall weakens, the artery enlarges. And as you see in this diagram, this can happen in the aorta. The aorta is the large artery in the middle of your body and the segment in the abdomen can sometimes weaken and enlarge and starts to swell like a balloon as you see in the right hand side of this diagram.

Ellen Beth Levitt: Can aneurysms occur in other vessels around the body as well?

Rajabrata Sarkar, M.D.: They are most commonly found in the aorta but they can occur in the legs and more rarely in other parts of the body and I we treat those as well

Ellen Beth Levitt: So what can happen if an aneurysm develops in the wall of a vessel and it gets weak and weaker sort of balloons out, right?

Rajabrata Sarkar, M.D.: As you can imagine, if the aneurysm continues to grow, at a certain point there is a risk of rupture. If that happens in an aortic aneurysm, that can unfortunately often be fatal. We try and find these before they rupture and fix them.

Ellen Beth Levitt: Are there any symptoms when someone has an aneurysm?

Rajabrata Sarkar, M.D.: Unfortunately, because the aorta is in your abdomen, your aneurysm can grow quite large without any symptoms.

Ellen Beth Levitt: How would they normally diagnose that?

Rajabrata Sarkar, M.D.: Nowadays many people find out they have an aneurysm when they have imaging of their abdomen done for some other reason. May be for their liver or prostate. But many patients don't know. And that is why the American vascular association and the University of Maryland Medical Center have started screening programs to help find these aneurysm before they rupture.

Ellen Beth Levitt: Are there some people who are at greater risk of having an abdominal aortic aneurysm?

Rajabrata Sarkar, M.D.: Sure the most common risk factors include male, current or prior use of cigarettes, high blood pressure and generally age over 60.

Ellen Beth Levitt: So how do you screen for this?

Rajabrata Sarkar, M.D.: The first thing we do is examine the patient. If the aneurysm is large and the patient is not so large, sometimes you can feel the aneurysm as a mass with your fingers on their abdomen.

Ellen Beth Levitt: Really?

Rajabrata Sarkar, M.D.: But in many patients you cannot. The way we screen is with you'll extra sound, which is painless, safe, there is no incisions or invasive component. We can see inside the abdomen with the ultrasound and can easily and quickly tell if a patient has or does not have an aneurysm.

Ellen Beth Levitt: The aorta is the main blood vessel that goes up from the legs and so forth up into the heart, right?

Rajabrata Sarkar, M.D.: The blood flow is down the aorta from the heart to the kidneys, intestines, lower down it splits and gives blood supply to each leg.

Ellen Beth Levitt: So if somebody is screened with the ultrasound and you notice they have this ballooning out of the vessel wall, what do you recommend? Does having have to be done right away and.

Rajabrata Sarkar, M.D.: Well many people with aneurysms are not at risk for rupture. The risk for rupture goes up as the aneurysm gets larger. Fixing these aneurysms, like any procedure, carries certain risks. So if we have a patient with a small aneurysm, we have to balance the risk of rupture versus the risk of the repair. So, in general, vascular surgeons from large studies have agreed that most aneurysms need to be fixed when they are about five to 5.5 centimeters in diameter. That is about two to two and a half inches. For patients with aneurysms we find that are smaller than this, we generally follow them with ultrasound examinations every three to six months, and if they grow, which most of them do, quite slowly, if they reach the size I just mentioned. About approximate five centimeters, we recommend a repair. Many patients have small aneurysms that never grow and we never recommend repairing them but I think it is important if you have the risk factors for an aneurysm to get screened. If you do have an aneurysm get in the care of a vascular surgeon on who will follow it and only recommend a repair when it is necessary.

Ellen Beth Levitt: Are there some medicines that can help treat an aneurysm?

Rajabrata Sarkar, M.D.: The traditional medical therapy is smoking cessation and blood pressure control. At the University of Maryland Medical Center, we are going to be starting a new trial next year on an experimental medication that may actually prevent further weakening of the wall. That is a trial through the national institutes of health, and that is potentially a future medication. It is experimental now that would allow us to directly stabilize the wall of the blood vessel and potentially help prevent small aneurysms from getting bigger.

Ellen Beth Levitt: That would be a big advance.

Rajabrata Sarkar, M.D.: That would be a major advance.

Ellen Beth Levitt: If you have someone whose aneurysm has grown to the danger point, i guess you recommend doing something to kind of shore up that vessel, right?

Rajabrata Sarkar, M.D.: Yeah. The standard repair for decades, which is well established, was to open the abdomen, a fairly large operation, and to repair that segment of the aorta with a synthetic, either cloth or plastic, artificial artery. That was a large operation. Still is, we do that fairly often. And the recovery is about two to three weeks. There are serious risks. There is newer therapy for abdominal aortic aneurysms.

Ellen Beth Levitt: A less invasive approach?

Rajabrata Sarkar, M.D.: Right. We can repair an aneurysm you see in this diagram we put a guide wire up through the aneurysm and follow this with the same artificial artery. But it is rolled inside a stent. And here the stent is positioned inside the aneurysm and we can deploy the stent without opening up the patient. As that stent is deployed. What you are going to see is, it prevents blood flow from flowing in the aneurysm and the blood then only flows in the stent graft. We then come up the other leg as you see here with a wire and we put another extension on to that leg and this completes the repair. At the end of this repair, we are going to deploy another stent graft. Now there is only blood flow in the device and not in the aneurysm. Most patients are going home the next day, which is very different than a conventional repair.

Ellen Beth Levitt: So you insert the wire through a very tiny incision in the upper thigh?

Rajabrata Sarkar, M.D.: Right in the femoral artery, the top of the thigh. There is one on either side. The recovery is much quicker than it is for a conventional aneurysm operation.

Ellen Beth Levitt: I can imagine. Can this also be used when the aneurysm is higher up in the chest area of the aorta?

Rajabrata Sarkar, M.D.: It can. The device is a little bit different but the approach is the same. As we discussed earlier aneurysms can occur throughout the body. In this diagram we see an aneurysm in the aorta up in the chest. A guide wire is put through. Here comes the stent graft, which will be positioned. And then once the device is deployed, it seals off the aneurysm so now there is only blood flow down the graft. This is a technique at the University of Maryland Medical Center we have a lot of experience with.

Ellen Beth Levitt: I guess these folks are lucky if they get the repair made, if there is a rupture, there is a very high mortality rate, is there not?

Rajabrata Sarkar, M.D.: Unfortunately the mortality rate once it is ruptured is high. Roughly 50% of patients will survive the operation.

Ellen Beth Levitt: That is if they make it to the hospital in time, right?

Rajabrata Sarkar, M.D.: That is only if they make it to the hospital in time?

So one of the most important things we try and do is find these before they rupture. Because they are fatal and fixable. There are very few things in medicine that are. So it is really a pleasure when you find one of these before it ruptures and you help a patient pre veep a catastrophe in the future.

Ellen Beth Levitt: Another problem that can occur in the arteries is peripheral arterial disease or P.A.D.?

Rajabrata Sarkar, M.D.: We have been hearing a lot about that in the news because there is a lot of new treatments for that. Many of which we are using every day at the University of Maryland Medical Center. What pad stands for is blockages in the arteries due to atherosclerosis or a hardening of the arteries. This can occur in the leg where plaque builds up. These patients usually present with difficulty walking. It limits their exercise and can eventually limit even their ability to get around. If this disease is allowed to progress, it can cause ulceration or loss of tissue, and then some in cases gangrene and even amputation.

Ellen Beth Levitt: I have heard it hurts when you walk and when you stop the pain goes away and once you walk again the pain comes back.

Rajabrata Sarkar, M.D.: That is a very good description of early stage P.A.D. the description that you give the medical term means it hurts when you walk. As I said, that is the early stage. That can be often treated with lifestyle changes and an exercise program. It can also be treat nowadays with many new treatments that involve less discomfort and disability to the patient. Pad is traditionally treated with surgery and we traditionally did open operations with incisions. They worked well and improved blood flow to the legs. The recovery time is quite long. What we do now, similar to what you see with aneurysms, is we use a catheter-base ad approach. We use things like stents which we can insert into the artery from far away. I happen to have one in my pocket. This is the stent we use to treat the blockage in the artery. This can be put in using a catheter, and is used to expand inside the blockage and to improve flow down the length of the stent to get more blood flow down the leg. So a patient can come in, I treated a woman two weeks ago who was in danger of losing her leg. And using some of this technology we were able to bring the blood flow in her leg almost back to normal without any incisions. She went home in a day or two which would be unheard of with bypass surgery.

Ellen Beth Levitt: I guess it is important for people to know if they have peripheral arterial disease. I would think if they have blockages in the artery in their leg, they also might have blockages in the arteries around their heart and so forth?

Rajabrata Sarkar, M.D.: That's correct. Atherosclerosis is a disease that generally affects all the arteries in your body. The same patients that have pad also have blockages in their heart.

Ellen Beth Levitt: Who is most at risk? Are they people who smoke or have diabetes?

Rajabrata Sarkar, M.D.: There is many risk factors. The two major risk factors are diabetes and cigarette smoking. Some of the other ones are listed in this chart and include high blood pressure, heart disease and high cholesterol, as well as kidney disease or stroke. But the big ones are diabetes and smoking.

Ellen Beth Levitt: We have to take a break. Whether we come back, we'll talk about minimally invasive techniques for problems in our veins. So stay with us. We'll be right back.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I’m Ellen Beth Levitt. My guest is Dr. Rajabrata Sarkar. He’s the chief of vascular surgery at the University of Maryland Medical Center and is also a professor of surgery and head of the division of vascular surgery at the University of Maryland School of Medicine. And before the break, we were talking about problems that occur in the arteries. Now let's switch gears and look at the veins.

Rajabrata Sarkar, M.D.: Sure.

Ellen Beth Levitt: I guess the first thing would be deep vein thrombosis, which is sometimes called D.V.T.?

Rajabrata Sarkar, M.D.: That is unfortunately a very common problem one or two million cases per year. Several hundred thousand deaths per year in America. It is a problem of major concern can occur in relatively healthy young people and is something we all need to be more aware of.

Ellen Beth Levitt: Is this the problem if you are on an airplane for a really long time or sitting still for a long time?

Rajabrata Sarkar, M.D.: Exactly. There are certain risk factors. The biggest ones are having surgery on your leg or in your abdomen or pelvis, being pregnant, having a broken leg, and lesser ones like airplane travel, and things like that. But the biggest one is surgery, having a previous DVT, and being pregnant. Those are the big ones.

Ellen Beth Levitt: Why? How could those things encourage the formation of blood clots in the veins?

Rajabrata Sarkar, M.D.: Well, when you have surgery, when you are under anesthesia, you are not moving. And the muscles, remember there is no pump on the vain side. There is no heart. The veins rely on the muscles of your body and their motion during the day to squeeze them and milk the blood back to your heart. So if you are under anesthesia for five or six hours, you are not moving and that is when as you see in this diagram the blood tends to get sluggish in the vain and form a clot, okay? Same thing in pregnancy you. Your blood volume goes up the pregnant uterus presses on the veins.

Ellen Beth Levitt: Why is there a concern about deep vein thrombosis? What can happen after that clot forms?

Rajabrata Sarkar, M.D.: Well the most feared complication is that the clot can break off. If it breaks off, it can go somewhere else in the circulation. And the veins travel back to the heart and the heart first pumps that blood to the lungs. So that piece of clot can end up in the lungs in the pulmonary artery. And that can cause respiratory problems and can be fatal.

Ellen Beth Levitt: So I guess it's important to know the symptoms or the signs. Are there some symptoms that you would have if you have deep vein thrombosis?

Rajabrata Sarkar, M.D.: Yes. There is almost nobody who has a deep vein thrombosis without symptoms. The simple symptoms are easy to understand. The leg is going to swell, and it is going to hurt and this is not a little bit of hurt, this is a lot of hurt. Many of the patients say I could barely walk on the leg it hurt so much.

Ellen Beth Levitt: Does it come on suddenly?

Rajabrata Sarkar, M.D.: It generally doesn't come on instantaneously. After surgery, or after a fracture of the leg or during a pregnancy, if one leg swells ask starts to hurt and usually occurs over a matter of hours to days, you need to seek some medical attention.

Ellen Beth Levitt: And what would the doctor do for you?

Rajabrata Sarkar, M.D.: Again, the diagnosis of DVT, can be made very quickly and painlessly with ultrasound. They would pass an ultrasound probe over the leg, and that can tell with near certainty whether there is or is not a DVT there. So it is a simple diagnosis that can be done in almost any hospital.

Ellen Beth Levitt: What is the treatment?

Rajabrata Sarkar, M.D.: The standard treatment is blood thinners. They prevent the close from growing and more importantly, they prevent the close clot from breaking off and causing a pulmonary embolism, which is the most feared and potentially fatal complication.

Ellen Beth Levitt: Are there some people who need invasive treatment?

Rajabrata Sarkar, M.D.: The blood thinners have done a phenomenal job of preventing death from DVT. They do not actually dissolve the clot, so the clot is there and then your body's own clot dissolving systems have to do that. In young patients, who have a large blood clot in the legs, because the clot will scar down and will destroy the valves in the veins, which we'll talk about a little later, what we'll do with a large clot in a younger patient is we will go in there and dissolve the clot to prevent future problems in the leg.

Ellen Beth Levitt: Another problem that can affect the veins is varicose veins and you called that earlier venous reflux. Should people be concerned or are they more a cosmetic issue?

Rajabrata Sarkar, M.D.: Varicose veins are a sign of the venous reflux. It is the medical term for backward flow in the veins. There is little valves inside the veins. As you see on the upper right of this diagram, when you stand up, those valves should close and keep the blood up in the vein. Varicose veins in and of themselves are not a health risk. They can cause discomfort, itching, swelling, a throbbing pain. They are a sign that you have some potential circulatory problems in the leg.

Ellen Beth Levitt: So then should people do anything about varicose veins?

Rajabrata Sarkar, M.D.: The primary treatment has been compression therapy, which helps the circulation of the legs.

Ellen Beth Levitt: Compression stockings?

Rajabrata Sarkar, M.D.: Usually just knee highs, in people who have varicose veins and tired, aching legs will help relieve the symptoms. And i think the most important thing is if you have varicose veins and you have associated symptoms, the leg aches, it throbs, it's tired at the end of the day, you stand a lot and your legs start to ache. We see a lot of nurses with this problem because they have been stand fog eight or ten hours, you need to go see a vascular specialist who has experience with veins whether who can do the kind of simple tests.

Ellen Beth Levitt: Are there people whether or not need invasive treatment for this?

Rajabrata Sarkar, M.D.: It works well at relieving symptoms and there are patients in whom if leaf untreated, it can lead to worse problems. Such as skin changes, swelling of the legs and those patients really benefit from invasive treatment. The treatments have gotten a lot simpler these days.

Ellen Beth Levitt: I know in the past there was something called vain stripping.

Rajabrata Sarkar, M.D.: The problem is you have valves that don't work. This involved removing the segment of the vein. What I have here in my hands is a we made an incision, we attach a round piece to the other end.

Ellen Beth Levitt: That looks pretty large.

Rajabrata Sarkar, M.D.: We have to catch it and then we pull quite hard on this handle and we rip it out of the leg. That is stripping it. And frankly, it causes a fair amount of bruising a fair amount of trauma and discomfort. That's largely been replaced with newer treatments.

Ellen Beth Levitt: That is been called closure catheter

Rajabrata Sarkar, M.D.: This is the name of the treatment we use.

Ellen Beth Levitt: Okay.

Rajabrata Sarkar, M.D.: This is an example of such a device. This again is still a treatment a procedure has some risks. We put this inside the vain with the radio frequency catheter. What we do is sequentially apply microwave energy to the vein. As you see in this diagram on the screen, the closure catheter is being shown here treating different segments as it is pulled back through the leg.

Ellen Beth Levitt: So this just collapses?

Rajabrata Sarkar, M.D.: It collapses it and seals it off. There is no incision. There is just a tiny skin puncture and people are back on their feet in a day or two. Since there is backward flow you do not need it to help your circulation. It can also help with varying koas veins as you see in these before and after pictures.

Ellen Beth Levitt: What can we do to prevent varicose veins?

Rajabrata Sarkar, M.D.: I think if you have a family history of varicose veins or leg swelling and you are starting to have either signs of varicose veins or symptoms at an early age where just wear knee high compression stockings. I tell my patients wear them under your pants so no one can see them. Particularly if you are standing, if you are a nurse, or you are in sales or some other job where you are going to be standing for most of the day, wear the compression stockings. Then if you develop symptoms, find a vascular specialist who can treat them and get you back to your normal activity.

Ellen Beth Levitt: I guess varicose veins are different from spider veins?

Rajabrata Sarkar, M.D.: Spider veins are the fine lines on the skin. Varicose veins actually bulge through the skin.

Ellen Beth Levitt: People might be reluctant to come to a vascular surgeon because you have the word surgery in the description of what you do.

Rajabrata Sarkar, M.D.: Sure.

Ellen Beth Levitt: It sounds like you have a lot of minimally invasive techniques now.

Rajabrata Sarkar, M.D.: Vascular surgeons have been treating vascular disease for about 50 or 60 years. Traditionally we did conventional operations. We have also been at the forefront both nationally and at the University of Maryland Medical Center at developing minimally invasive treatments. There are a lot of people who are treating vascular disease out in the community now. Frankly, the vascular surgeons have the most experience. There are still some patients in whom regular surgery is the best option, particularly if they have end stage problems. But for many patients, we can treat them with an operation. We still call it an operation. It has no incisions and minimal recovery and give them excellent results. So I think people should be comfortable coming to see a vascular surgeon and asking about the different options.

Ellen Beth Levitt: With all the of the high-tech equipment now to allow you to see inside the body without actually making an incision and looking in, that has really helped with the minimally invasive approaches, right?

Rajabrata Sarkar, M.D.: Yes it certainly has.

Ellen Beth Levitt: Great. We have ten seconds left. Give us a couple of tips to keep our arteries and veins healthy.

Rajabrata Sarkar, M.D.: Don't smoke. Exercise regularly. If you have the symptoms we have talked about, ask your doctor to send you to a vascular specialist.

Ellen Beth Levitt: Thank you very much.

Rajabrata Sarkar, M.D.: Thank you, Ellen Beth, for having me on the program.

Ellen Beth Levitt: My guest has been Dr. Rajabrata Sarkar. He’s the chief of vascular surgery at the University of Maryland Medical Center and is also a professor of surgery and head of the division of vascular surgery at the University of Maryland School of Medicine. If you have any comments about this program, contact me. Call 1-800-492-5538. Or visit the website where you'll find a great amount of health information and be able to see other Maryland Health Today shows. That web address is www.umm.edu. Take good care of yourself. We'll see you next time for Maryland Health Today.

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This page was last updated on: June 25, 2009.

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