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When a patient is referred to a vascular surgeon, there are some questions that are commonly asked. This information is designed to help answer these questions and aid patients in understanding their disease process.

You are not alone

Whether you are reading this information to help you inform yourself about a specific problem or whether you are reading it simply to extend your knowledge, you are probably experiencing hardening of the arteries. But you are not alone. Everyone is, even your doctor. Hardening of the arteries, or arteriosclerosis, is an inevitable part of the aging process. No one is immune to some form of the hardening of the arteries. However, for some, this process is more rapid than for others. For these people, there are a variety of therapeutic choices that can be made. Your doctor can best describe these alternatives. This booklet is in no way a substitute for a thoughtful discussion with your doctor. It is, rather, a reference to be used to supplement what your doctor may have told you. As in almost every phase of life and health care, the more you know, the better off you are.

Understanding the basics

The circulatory system is responsible for providing nourishment to your body's cells, and removing wastes from them. The circulatory system is made up of the heart, arteries, veins, capillaries, and the circulating blood. The arteries take oxygenated blood from the heart to the cells, the veins return it from the cells back to the lungs for reoxygenation and recirculation by the heart. The largest artery leaving the heart is the aorta, which then subdivides into smaller arteries going to every part of the body. As the arteries narrow down, they are connected to smaller vessels called capillaries. In these microscopic tubes, oxygen and nutrients are released from the blood into the cells, and cellular wastes are collected for the return trip The capillaries, in turn, connect to veins, the vessels that return the blood to the heart. Obviously, a problem in the arteries or veins that restricts blood from completing its appointed rounds will rob an area of vital blood nutrients and oxygen.

Atherosclerosis, a problem leading to more problems

Arteriosclerosis (hardening of the arteries) can take on a number of forms, of which atherosclerosis (hardening of the innermost portion) is the most common. Atherosclerosis is thought to be an aging process which occurs with the constant passage of blood through the arteries. With atherosclerosis, fatty material containing cholesterol or calcuim is deposited on the innermost layer of the artery. The result is a narrowing of the inside diameter of the blood vessel - much like rust accumulating inside a water pipe. This can progress to the point where the artery becomes so narrow that a blood clot, or thrombus, forms and blocks blood flow to an entire portion of the body.

In another form of atherosclerosis, a rough area or ulcer forms in the diseased interior of the artery. Blood clots then tend to develop on this ulcer, break off, and travel further downstream, forming a blockage where the arteries get narrower. This kind of blockage resulting from a clot formed elsewhere in the body is called an embolism. Atherosclerosis can also take the form of a weakening of the artery wall, in which a bulge develops - much the same way as in a weak tire wall. The localized bulge is called an aneurysm and can cause several problems. It frequently ruptures, causing a leakage of blood, or it can also lead to thrombosis or embolism.

Diagnosing atherosclerosis

Your physician has many ways of feeling, hearing, measuring, and even seeing arterial blockages. Many arteries in the body can be felt or palpated. Your doctor can feel for a pulse in an area he or she believes afflicted. Usually the more advanced the arteriosclerosis, the less pulse in a given area.

As the artery becomes blocked, it can cause a noise very much like water roaring over rocky rapids. Your physician can listen to this noise, or bruit, directly, or can use special amplification systems to hear this noise. He or she can also use special equipment to measure the amount of blood going to a specific area of the body. Finally, he or she can perform an arteriogram, which enables him or her to take an x-ray picture of your artery. In this procedure a radiologist inserts a catheter - a needle or small tube - into the artery and injects an opaque dye that will show up on the x-ray film. The resulting picture serves as a perfect road map to any obstructions.

The symptoms of atherosclerosis depend on where they strike

The symptoms produced by atherosclerosis, thrombosis, embolism or an aneurysm depend on the particular artery affected. For instance, a diseased carotid artery leading to the brain can cause temporary or permanent strokes (stroke).

A coronary artery that fails to send enough blood to the heart muscle causes chest pain (angina pectoris). As the blockage increases, it can lead to a heart attack (myocardial infarction).

A blocked renal artery, leading to the kidney, can cause high blood pressure (hypertension).

Atherosclerosis in the mesenteric arteries leading to the bowel can cause abdominal pain, weight loss, or bowel death (mesenteric infarction).

Blockage in the arteries supplying the legs with blood can cause muscle discomfort after walking (claudication). This discomfort can be a tightness or aching pain in the calves, thighs, or buttocks, usually relieved by resting, As the blockage in the leg increases, it can cause pain at night or at rest, and can lead to leg ulcers and even gangrene.

The exact cause of atherosclerosis is unknown. However, there are many factors that seem to play a role. These factors include a strong family history of vascular disease, levels of fats in the blood (high cholesterol or serum triglyceride levels), smoking, diabetes, and hypertension.

Treating atherosclerosis

Medically

Currently there are no medicines available that cure the disease. Medicines are sometimes used to dilate smaller arteries or to help lower blood cholesterol. Medicines are also used to control diabetes and hypertension if they are present.

If you have atherosclerosis, you can take steps to improve it. If you smoke, stop. Get regular exercise. Lose weight, if you need to. Keep a close check on blood cholesterol and triglyceride levels and maintain them within normal limits through diet control. If you suffer from diabetes and/or high blood pressure, pay strict attention to your treatment programs and take your medications regularly.

If you take these steps, nature itself will sometimes improve the blood supply to a blocked area by developing detours around the problems. This happens when small arteries enlarge to accept more blood and become alternate pathways. These enlarged pathways are called collaterals.

Surgically

While there is no known cure for atherosclerosis, surgery is used to treat specific diseased arteries and help prevent strokes or heart attacks, improve or relieve angina, or hypertension, remove aneurysms, improve claudication, and save legs that would otherwise have to be amputated. Modern surgical techniques are constantly changing, materials improving, techniques evolving. Basically, the choices involve either repairing the artery, bypassing it, or replacing it.

Embolectomy

In this technique, an embolic clot on the wall of the artery is removed, using an inflatable balloon catheter.

Thromboendarterectomy

In this technique, the inner diseased layers of the artery are removed, leaving the relatively normal outer coats of the artery.

Bypass

In this technique, the diseased artery is left in place and a new artery is constructed around the area of the blockage. Larger arteries are usually bypassed with Dacron grafts. Smaller arteries are usually bypassed using a vein of the patient's own leg as a substitute. For small arteries, synthetic materials and specially processed umbilical veins can also be used.

Resection

When a diseased artery has experienced an aneurysm, or weakening of its wall, the artery is surgically removed and a bypass is created with a synthetic graft.

Living with your problem

Should surgery be recommended for your atherosclerotic condition, your concerns will focus first on immediate prospects and then, on your long term expectation. Surgical treatment of atherosclerotic diseases is commonplace. With the currently available operating techniques and materials and modern anesthesia-support abilities, you can anticipate reasonable degrees of success. However, atherosclerosis may become symptomatic in other parts of the body, and can actually reoccur in the repaired area.

Your physician can best explain individual risk factors, and can help determine the advisability of surgery. He or she will also offer counsel on post-operative symptoms and stress the urgency of regular checkups and the importance of following his or her suggestions for improving lifestyle management.

A glossary of terms - simplified

Aneurysm
A weakening of the artery wall, due to atherosclerosis, causing a bulge. An aneurysm can rupture. It can lead to thrombosis or embolism.

Aorta
A large, elastic artery beginning at the upper part of the left ventricle of the heart that becomes the main trunk of the arterial system.

Artery
A blood vessel conveying blood in a direction away from the heart.

Arteriosclerosis
A hardening of the arteries taking a number of forms.

Arteriogram
An x-ray picture of an artery achieved by injecting an opaque dye with a needle or tube into the affected artery.

Atherosclerosis
A form of arteriosclerosis affecting the innermost area of the artery; a series of calcified deposits that can close down the vessel.

Bruit
A roaring sound created by a partially blocked artery.

Capillary
Smallest extremity of the arterial vessel, where oxygen and nutrients are released from the blood into the cells, and cellular waste is collected.

Carotid Artery
Major artery leading to the brain, blockages of which can cause temporary or permanent strokes.

Cholesterol
The most abundant fatty substance in animal tissues. High levels in the diet are a factor in the cause of atherosclerosis.

Claudication
Attacks of lameness of pain chiefly in the calf muscles, brought on by walking. It is caused by a lack of oxygen reaching the muscle.

Collaterals
Alternate pathways for arterial blood.

Embolism
Obstruction or occlusion of a vessel by a transported clot of foreign matter.

Heart
Hollow muscular organ which receives the blood from the veins and propels it into the arteries.

Palpation
Examination by feeling with the hand.

Thromboendarterectomy
An operation involving the opening of an artery and the removal of atherosclerotic material and an occluding thrombus.

Thrombus
A blood clot that may form in a blood vessel or in one of the cavities of the heart.

Ulcer
A lesion or rough spot formed on the surface of an artery.

Vascular
Relating to the blood vessels.

 
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