Arterial Disease
Abdominal Aortic Aneurysm
An aneurysm is an artery that has grown to more than one-and-a-half times the normal size. The aorta is the largest artery in the body, which begins at
the heart and gives off branches to all the major organs of the body. When the aorta has enlarged to greater than 3.0 centimeters in diameter, we
consider the aorta to be aneurysmal.
An estimated 1.7 million Americans have aortic aneurysms. Aneurysms grow mainly because of tobacco abuse, high blood pressure, high cholesterol,
genetic predisposition, and high fat diet. The risk of aneurysms increases after the age of 50, and are more common in men than women.
As aneurysms grow, the wall of the artery weakens and thins. When the aorta is larger than it should be, the aneurysm can cause pain, leak or burst. This
condition is responsible for 15,000 deaths per year in the United States. In order to prevent rupture, repair is recommended for abdominal aortic
aneurysms that cause pain, are rapidly growing or when they grow larger than 5.0-5.5 centimeters. Aneurysms of the chest are usually repaired when
they enlarge to 6.0 centimeters or grow rapidly. Although a few patients require open surgery for repair of aneurysms, most can be repaired through
small incisions in the groin with a stent graft (Endovascular Aortic Aneurysm Repair, EVAR)
Aneurysm Repair
Dr. Schmetterer will, through modification of your risk factors, work with your primary care physician to help minimize expansion of your aneurysm.
These risk factors include smoking, high blood pressure, high cholesterol, fatty diet and diabetes. If an aortic aneurysm grows rapidly, become
symptomatic, or over time, reaches 5-5.5 cm, repair may be indicated. The majority of abdominal aortic aneurysms are treated with endovascular stent
graft repair (EVAR) through a small incision in each groin. Most patients are discharged within 48 hours of surgery without significant restrictions. Some
aneurysms require open repair which increases hospital stay and recovery.
Carotid Artery Disease
The carotid arteries are the pulsatile structures on either side of the neck which supply the preponderance of blood flow from the aorta to the brain.
Narrowing or blockages of these arteries are a significant cause of strokes, and therefore prevention, diagnosis and treatment are very important.
Strokes are the third-leading cause of death in the United States, and patients who survive strokes often must live with permanent brain damage that
results in paralysis and loss of motor skills. Primary risk factors for these blockages (atherosclerosis) are tobacco abuse, high cholesterol and/or a high fat diet, uncontrolled hypertension, poorly regulated diabetes and a family history of atherosclerotic disease.
The diagnosis of carotid artery disease is often made by medical personnel either hearing an abnormal sound in the neck when listening with a
stethoscope (bruit) or by a non-invasive screening ultrasound scan of the carotid arteries. Additional testing by either a CAT scan or an angiogram is
usually required.
Mild or moderate blockages which remain asymptomatic can be treated with gentle blood thinners, medication and lifestyle modification to reduce the
underlying risk factors. Ongoing follow up is important to identify progressive narrowing before a stroke occurs. Symptomatic carotid artery stenosis may
present with mini strokes, or a transient ischemic attack (TIA) as temporary numbness of part of the body or vision or speech loss. Severe and
symptomatic blockages usually are best dealt with surgically or in certain cases with stenting.
Carotid Endarterectomy
Carotid Endarterectomy is a surgical procedure performed under general anesthesia, whereby an incision is made in a skin crease at the neck and the
carotid artery is cleared of all dangerous plaque. A shunt device is utilized to temporarily reroute blood flow to the brain during the procedure to prevent
stroke. The surgery takes about an hour, a drain is left in place, and the patient awakened in the operating room to confirm intact neurologic function.
Most patients stay overnight in the hospital and are discharged the following day. Post operative followup includes carotid ultrasound at 6 months and
then yearly.
Peripheral Vascular Disease
Hardening of the arteries (atherosclerosis), is associated with risk factors such as smoking, uncontrolled high blood pressure, high fat diet, diabetes, high
cholesterol, and family history. The disease also occurs in the carotid arteries causing strokes, and coronary arteries of the heart causing heart attacks.
When blockages occur in the legs patients experience symptoms of cramping and fatigue in the calves, thighs or hips with ambulation. This syndrome is
called intermittent claudication, and as the narrowing of the arteries (PVD, or Peripheral Vascular Disease) worsens, the distance that can be walked
without pain decreases. With severe PVD, patients may experience pain occurring at rest and ultimately ulcerations, tissues loss or eventually gangrene
can ensue. Patients are then at risk for amputations.
Early identification and control of the risk factors, coupled with a graded exercise program and medication can forestall or even improve this condition by enabling the body’s natural mechanisms to develop collaterals or side channels around the blockages in the arteries. Early detection, careful diagnosis, appropriate non-invasive testing and aggressive conservative management are crucial to managing this disease.
Vascular Disease Prevention
Prevention of Vascular Disease focuses on reducing or controlling certain key risk factors. These factors include tobacco use, diabetes, high cholesterol,
and hypertension. High fat diets and lack of exercise also contribute to the hardening of the arteries (arteriosclerosis) that causes blockages. These same
risk factors also contribute to heart disease and strokes. Dr. Schmetterer reviews these risk factors with patients and makes recommendations on
medical, nutrition and fitness aspects which may forestall or prevent the need for surgery, or speed healing and recovery when surgery is needed.
Arterial Bypass Surgery
When a blockage is encountered in an artery, the blood loses its direct path to an organ or extremity. In order to improve the circulation to the affected
area, a new and direct pathway must be created. This rerouting of the blood is called a bypass. This procedure is performed only in cases of severe
disease, and when more minimally invasive techniques or conservative management have failed.
A bypass can be constructed using either the patient’s own vein or a synthetic tube called a graft. Dr. Schmetterer will evaluate the areas of blockage with a CT Angiogram, and determine the best way to re-route the blood. The procedure typically involves general anesthesia and one or more incisions on the leg. The recovery time varies depending on the extent of the bypass and the patient’s other medical conditions. Oftentimes, bypass surgery is combined with minimally invasive techniques to create a hybrid procedure, maximizing results and minimizing invasiveness.
Balloon Angioplasty
An alternative to bypass surgery is balloon angioplasty. Angioplasty consists of accessing a blood vessel, usually the femoral artery in the lower extremity or the brachial artery in the upper extremity, with a device called a sheath. Through the sheath, various wires, catheters and devices may be inserted into the arteries under x-ray guidance.
Once the diseased area in the artery is identified, a small, flexible wire is used to cross the blocked or narrowed vessel followed by a catheter (with a
balloon attached to the tip) that is tracked over the wire. The balloon is inflated within the diseased artery compressing the plaque in the artery so that
the blood will flow more easily through the vessel. Balloon angioplasty can also be performed in diseased veins and dialysis grafts or fistulas. The
procedure is typically done on an outpatient basis.
Atherectomy
One of the more recent innovations in the minimally invasive treatment of arterial blockages is the technique of atherectomy performed by Dr.
Schmetterer. Atherectomy means cutting out the plaque. With a similar technique as that involved in stenting and balloon angioplasty, a special catheter
with a diamond coated burr at the tip is passed through the diseased arterial segment rotating at high speed, reducing plaque and creating a more
supple vessel. Usually, this allows for balloon angioplasty alone, without the need for stent placement. This is especially important in areas near joints
where stents may kink.
Arterial Stenting
Occasionally after balloon angioplasty, the diseased artery will recoil or shows signs of a crack (dissection) within the vessel wall. In these cases, stents
are used to hold the artery open, acting as a scaffold. Stents are either mounted on a balloon or packaged within a specially designed catheter that
allows the stent to self-expand and conform to the artery. Stents can be placed in almost any artery in the body. Stents also come “covered” with a
Gortex wrap allowing the device to be used to close a leaking vessel or trap dangerous plaque from traveling through the body (embolism).
Advanced Minimally Invasive Limb Salvage Surgery
Often times, patients are looking for a less invasive means of resolving a complex vascular problem and choose an approach that provides complete
repair, resulting in improved circulation. Some patients have many risk factors which prevent long open bypass operations, or are lacking their own
saphenous veins which are commonly used for bypass procedures. The indication for the procedure may be for relief or claudication (pain while
walking), pain occurring at rest, or to assist in wound healing. In most cases the procedure is completed through a single needle stick on an outpatient
basis in Youngstown, Ohio and the surrounding areas, including Warren, Boardman, Salem, Austintown, Ohio.
Dr Schmetterer has developed a minimally invasive approach utilizing a variety of endovascular devices to reopen closed vessels (contact atherectomy),
and remove plaque (orbital atherectomy) with a device patients call a Roto-rooter. A new drug coated balloon is used to treat the vessel wall with
medication in order to prevent plaque regrowth. Complex blood vessel disease is often treated with the aid of intravascular ultrasound to guide therapy.
Small diffusely diseased lower leg arteries are treated with specialized balloons to score plaque with a Focal Force balloon.
Dr. Schmetterer also employs the newest techniques for saving legs felt to be non bypassable or non-operable at other institutions. These advanced
techniques include gaining access to small blood vessels in the leg or foot utilizing a special ultrasound guidance probe. Combined with the above
devices, limb salvage surgery is possible for most patients who would otherwise undergo amputation of the extremity.
Dialysis Access
When kidney failure, or end stage renal disease develops, patients require dialysis, a means of cleansing the blood of waste products. Patients may
undergo hemodialysis through a connection between the body’s blood vessels and a dialysis machine. The connection may be a temporary or long term
catheter or an arteriovenous fistula or graft.
Patients are often referred by their nephrologist for creation of an arteriovenous fistula, which is a connection between an artery and vein. Ideally, this is
accomplished several months prior to the start of dialysis so that the fistula has time to mature before the patient needs to begin treatment. Some
patients do not have adequate veins for fistula creation. In this situation the patient receives an arteriovenous synthetic Gortex graft. Occasionally, a
patient’s dialysis access requires treatment to maintain optimal function. This is usually a short outpatient procedure which may involve angioplasty or
stent placement.
Renovascular Hypertension
If your doctor is struggling to control your blood pressure on multiple medications you may have blockages in the arteries that supply blood to your
kidneys. When the kidneys do not get enough blood, they release substances into the blood stream that cause elevated blood pressure. Most such
blockages can be fixed by passing a small catheter through the groin, with a balloon and stent to treat the renal artery blockage. Typically, this is an
outpatient procedure in Dr. Schmetterer’s practice. Restoring blood flow to the kidneys can improve blood pressure control, decrease the need for
medication and prevent permanent damage to the kidneys.
Temporal Artery Biopsy
The temporal arteries are the small arteries in front of each ear and running up onto the forehead. In cases of severe headaches without a clear cause,
and in certain inflammatory conditions diagnosed by blood tests, a biopsy of a temporal artery may reveal that the cause is Temporal Arteritis. This
condition is frequently very responsive to steroid treatment. Biopsy of the temporal arteries is an outpatient procedure with quick recovery which these
procedures are performed in Youngstown, Austintown, Boardman, Warren and Salem, Ohio.
