Treatment for Vascular Disease
In recent years, an emphasis on prevention, enhanced detection using sophisticated imaging, and new minimally invasive surgical techniques have improved the treatment of vascular disease. According to Michael L. Marin, MD, Professor and Chair of the Department of Surgery, catching the disease early can make a big difference.
"Many of the vascular diseases that can lead to a person's death do not occur suddenly," Dr. Marin says. "There are many interventions that can be done to prevent the progression of disease."
Treatment includes the following procedures:
Aortic Aneurysm Stent Graft Surgery
Surgery to repair an aortic aneurysm involves replacing the damaged portion of the aorta with a mesh graft. Open surgery for aortic repair is riskier than other operations. It requires many hours of anesthesia, carries high potential for blood loss and infection, and entails a long, sometimes painful recovery. For older patients and those with complex medical conditions, it is often not an option at all. Timing is crucial.
"For many people, treatment consists of monitoring the aneurysm to see when it declares itself as dangerous," says Randall Griepp, MD, Professor of Cardiothoracic Surgery. "Surgery is an option only when the risk of the operation is lower than the risk of rupture or dissection. Gauging that is something Mount Sinai has focused on for many years."
The treatment of aortic aneurysms takes into account the following factors:
- Age and general health
- Likelihood that the aneurysm will rupture
- Location and size of the affected vessel
- History or predisposition for aneurysm
Faced with patients ineligible for open surgery, Dr. Marin created a new procedure: the endovascular stent graft. Rather than opening the abdomen or chest, the surgeon threads the stent through the groin, repairing the aneurysm more quickly and with considerably less trauma. Mount Sinai has the largest minimally invasive aortic endovascular stenting program in the United States.
Aortic Aneurysm and Dissection Repair Surgery
Patients who experience aortic dissection are at risk of further tearing. The first line of defense is to keep the patient's blood pressure under control to minimize stress on the artery. Then, through regular imaging surveillance, vascular physicians can keep an eye on the dissection's progress.
For aortic aneurysm cases in which rupture is unlikely, physicians often recommend nothing beyond close monitoring. Since 1985, the Mount Sinai Heart Surveillance and Registry Group has been keeping the world's largest database of people with aortic disease, maintaining records on more than 3,000 patients.
Patients at higher risk for rupture generally require surgery. The approach varies depending on the location of the tear and whether it impacts the aortic root, aortic arch, or aortic valve. The arch's position near the heart, aortic valve, and other important vessels requires especially strong surgical skills.
Randall Griepp, MD, Professor of Cardiothoracic Surgery, and the Mount Sinai Heart surgical team have extensive experience operating on aortic dissections and have developed a variety of methods to reconstruct the arch with artificial replacement vessels. The replacement vessels minimize complications and improve survival rates.
"We have tremendous experience with people coming to us with an aortic aneurysm," says Dr. Griepp. "Usually a small proportion of those people need immediate operations. We can put the majority of these patients with aneurysms of modest size into an organized follow-up program where the aorta is imaged regularly and the risk factors are tabulated."
Peripheral Arterial Angioplasty
Treatment options for coronary arteries have greatly improved in recent years, allowing for less invasive treatment and fewer open bypass surgeries. Likewise, peripheral arteries can now be widened through angioplasty, which speeds recovery, shortens hospital stays, and preserves arteries.
The procedure is highly successful in reducing symptoms such as painful walking, tissue damage due to poor blood supply (ischemia), muscle death, and limb loss. During peripheral angioplasty, a balloon catheter is threaded to the affected artery, where it presses the plaque against the wall to restore the flow of blood. A stent may also be placed inside the artery to shore up narrowed vessels.
Peter L. Faries, MD, Chief of Vascular Surgery and Professor of Surgery, was instrumental in developing a cerebral protection filter to catch the debris that comes loose during angioplasty, reducing the risk of stroke and death.
Prakash Krishnan, MD, Assistant Professor of Cardiology and Director of Endovascular Intervention, is a leader in peripheral arterial angioplasty in New York City, having performed more than 1,500 complex coronary and endovascular interventions with a success rate of over 99 percent.
Carotid Artery Stenting
Narrowing of the carotid artery is traditionally treated with a procedure called an endarterectomy. In this procedure, plaque is scraped off the carotid artery during surgery. For some patients, however, this surgery may carry an increased risk of heart attack or stroke. Because the carotid arteries are so close to the brain, critical nerve pathways could also be damaged. For those high-risk patients, a minimally invasive alternative is endovascular carotid artery stenting.
In endovascular carotid artery stenting, the narrowed vessel is identified during an angiogram and a wire mesh stent is threaded to the affected artery. The stent is then opened in the narrowed area, and an inflated balloon widens the narrowed segment of the vessel.