Preventing Vascular Disease
January 26, 2005
By Grace Cheung for Veins1
Dr. Enrico Ascher is a professor of Surgery at Mount Sinai School of Medicine and is also director of Vascular Surgery at Maimonides Medical Center in Brooklyn, New York. In the following interview, conducted on the first day of the Veith Symposium, Dr. Ascher shares advice for patients about how to prevent vascular disease. He also illuminates his ongoing research on how to make minimally invasive venous procedures even less invasive.
Veins1: Dr. Ascher, how are you enjoying the conference thus far?
Dr. Ascher: This is the best conference in this country, probably in the world. It is an excellent conference, covers every subject in vascular surgery, and is very exciting, actually to be here and to be part of the faculty.
Veins1: Excellent. What is your particular focus in research?
Dr. Ascher: We are interested in getting the minimally-invasive procedures to become even more minimally invasive, meaning, the least invasive as possible.
Veins1: Is your focus largely on reducing risk for the patient, then?
Dr. Ascher: Yes, and also reducing radiation. Because when you’re in a minimally-invasive procedure, there is radiation for the doctor who is performing the procedure, the nurse that’s helping him, the anesthesiologist in the room – so there’s a risk for everyone, limited but real. And there is also a risk for the patient in terms of the contrast material that is injected, to allow visualization of the arteries. So our clinical research is focused now on trying to eliminate the need to use contrast material and to diminish the amount of radiation that’s required for these procedures. And for this, we use state-of-the-art ultrasound machines called Duplex machines, where you have a visualization of the vessel in addition to a Doppler effect. The combination of what we call V-mode, a visualization of the vessel, and Doppler, those two allow us to actually perform these procedures, in many instances without any dye, and without radiation.
Veins1: What are these procedures that you refer to?
Dr. Ascher: Balloon angioplasties and stenting of the arteries in the lower extremities, to allow people to walk better, or to even save legs – for legs that are threatened, with what we call critical ischemia, meaning they don’t have enough circulation. So we open these arteries with a balloon, occasionally with a stent to keep them open, and we do these procedures now under ultrasound guidance, or Duplex guidance.
Veins1: Recently there was an article in The New York Times about a new kind of multidetector CT scan that enables you to see every single artery and vein and all the possible clots in the arteries and veins.
Dr. Ascher: Yes, I’m aware of this imaging modality, and I think it is going to revolutionize the way patients are worked up for coronary disease. Fortunately, in many of our patients with carotid disease and lower extremity disease, or even aortic problems, we are still using fairly widely the Duplex scan, which is cheaper, and in my opinion, is as effective. For coronary disease, you cannot use the Duplex scan, because of the chest wall. So this new modality, CT angiogram, is excellent, and the concern that it will be overused, I’m sure, is unfounded. Because, soon physicians are going to learn the proper indications, if they do not already know, and it is going to be much better for the patient because it is much less invasive than the coronary angiogram.
Veins1: For patients, how do you recommend they find out about these different technologies that apply to them?
Dr. Ascher: It depends on what issue we’re talking about. If the issue is related to the heart, then they should talk to their cardiologist. In terms of vascular diseases, the vascular surgeon is the vascular specialist.
Veins1: And that would include ...
Dr. Ascher: Stroke prevention for carotids; it includes people who cannot walk and present what we call claudication, meaning they have pain when they walk a block or two, or three or four, in their legs; for patients who have aneursyms, ballooning of the arteries that can rupture, and cause death in a significant number of patients. Unfortunately, these are silent and when they become symptomatic, often it’s too late. So usually they have to be screened, and we are working with the government and Congress now to get a bill approved, so patients over the age of 60 can be screened. So if a patient has any hint of an aneurysm, in the belly or the legs, he has to go to a vascular surgeon for evaluation. If the patient cannot walk, he has pain in the legs, he should see a vascular surgeon. If the patient wants to have an evaluation for stroke prevention, he should see a vascular surgeon. Because that’s what vascular surgeons do. They do the medical part of vascular diseases, the surgical part, and also the interventions, the minimally-invasives.
Veins1: If you could give advice to older patients about how to prevent the onset of vascular disease, what would you suggest?
Dr. Ascher:After 25 years of experience of dealing with vascular diseases, I have come to the conclusion that prevention is still the best way to avoid the complications. So I believe that patients over the age of 60 – particularly if they have high blood pressure, diabetes, or are smokers – should go for a vascular evaluation. It’s called a vascular check-up. The surgeon will look to see whether the patient has an aneurysm, carotid disease that can cause stroke, and whether the blood pressure in the legs is as good as the blood pressure in the arm. That can be not only a sign of vascular problems in the legs, but also in the heart. People who have lower blood pressure in the legs have a higher incidence of coronary disease. So the combination of non-invasive vascular tests, such as ultrasound screening, a physical examination and a carefully taken history – especially the family history of aneurysms – is very important. I think that that will be an exam that will satisfy our needs, as vascular specialists, to take care of vascular diseases.
Veins1: What are the basic signs and symptoms of an aneurysm that a patient might look out for? Dr. Ascher:Unfortunately, the symptoms are rare. When the symptoms begin, occasionally it may be too late, because it is a sign of rupture. The patient may faint, has abdominal pain, severe back pain, and that may mean that the aneurysm has ruptured or is ready to rupture, and the patient should immediately go to the emergency room. If the patient, however, has a history of aneurysms in the family, then the chance of this person having an aneurysm is significantly high, about 15 to 20 percent. So he should have [a screening of the aorta] to be sure he does not have an aneurysm. Not all aneurysms need to be fixed. Some aneurysms are small and they can safely be watched. Some aneurysms are large enough that they should be fixed. There are different ways to fix those aneurysms. One way is a minimally invasive procedure that we perform – two small incisions in the groin, and with the combination of stenting and grafts, we are able to fix these aneurysms without a big operation. Yet, a big operation is sometimes necessary, and the results are excellent, 95 percent good, and is better than watching a large aneurysm rupture. If it ruptures, the survival rate is, as best, 50 percent.
Veins1: In terms of stents, there are a bewildering number of various kinds of stents. Does a patient need to know the difference between different stent materials, or should that be left to the surgeon?
Dr. Ascher: Number one, there are indications for placing a stent, and there are indications for not placing a stent. So stents are not used in every case. Stents have a specific indication. Now, depending on the location of the vessel, and the type of vessel – whether it is an artery or a vein – the stents are different. And whether the obstructive lesion is long or short, they may require different stents, and depending primarily on the location in the body, we have hundreds of kinds of stents. That’s what makes our specialty interesting, because we keep learning more and more about what stent to place in what part of the body. Now there are coated stents, with medication that prevents scar tissue formation. For the heart, this has shown to be very effective, but for the peripheral arteries, the answer is not here yet. So there are ongoing studies where people try different medications to coat stents with, and hopefully these studies will come out and show a positive response in terms of preventing scar tissue. This is our major problem right now. In a balloon angioplasty, in a substantial number of patients, the lesion would not necessarily recur, but scar tissue would form and close this vessel again. So if we were able to stop this process, or at least minimize this process, we could have tremendous advantage over the disease.
Veins1: Great. So what are you excited about concerning this conference? Any particular research presentations, topic or technology?
Dr. Ascher: I think there are many, many interesting topics in this meeting. Certainly we were invited to present our work here, and I am very proud to present our work this afternoon – an advance in the minimally-invasive approach. Because not only are we now going to avoid an operation, but we are also going to avoid unnecessary radiation to the patient, to the doctor and the nurses, and we are going to avoid contrast material that can be harmful to the kidneys and can give severe allergic reactions. So that is the area that we are working on that we are most excited about.