Mr C. Kyriakides MBChB, MD, FRCS, FRCSEd, FRCS(Gen)
Consultant Vascular and Endovascular Surgeon

1. Carotid disease and stroke:

Stroke is the third commonest cause of death in the western world. It usually presents as an either permanent or transient weakness of the limbs on one side of the body or with speech disturbance. In its milder form also known as transient ischaemic attack (TIA) it can also present with a fleeting visual disturbance known as amaurosis fugax. Stroke occurs as a result of a disturbance in the blood flow through the brain. The carotid artery is the main blood vessel that carries blood from the heart to the brain. Disturbance in the blood flow through this vessel can result in a stroke or any of its milder forms as already mentioned. Most commonly this means that a narrowing has occurred in the carotid artery secondary to cholesterol, calcium and other factors depositing in its wall, also known as atherosclerosis. This can result in debri being carried off to the brain, often described as an embolic event, or less commonly subtotal or total occlusion of the carotid artery lumen thus depriving the brain of its oxygen supply. There are a number of predisposing factors to carotid disease and stoke, including undiagnosed or poorly controlled blood pressure or hypertension, smoking, diabetes, and hyperlipidemia or high cholesterol. The commonest tests used to diagnose carotid disease and stroke include ultrasound scan of the neck known as carotid duplex and CT scan of the brain which is a specialised X-ray scan. Blood tests are also important to check for high blood sugar and cholesterol. Long-term treatment measures include risk factor management such as control of blood pressure, diabetes, smoking cessation and diet modification. Low dose aspirin therapy and similar other drug-therapy that reduces clot formation may be of benefit as well as cholesterol lowering drug therapy. A proportion of patients will benefit from surgery to the carotid artery referred to as carotid endarterectomy, to remove the debri from its wall. This will primarily be dictated by the severity of narrowing in the carotid artery. Carotid endarterectomy is a very safe procedure and is considered the gold standard which can be performed either under full general anaesthesia or under local anaesthesia. Currently the role and safety of carotid stenting is being evaluated. This is a procedure whereby the narrow carotid artery is crossed by a wire over which an expandable metallic cage (stent) is deployed to open up the lumen of the vessel.

2. Peripheral vascular disease:

Peripheral vascular disease (PVD) manifests itself primarily as atherosclerotic narrowing of the arteries that supply oxygen and blood to the muscles in the legs. It mainly affects the arteries in the legs such as the superficial femoral artery but also the abdominal aorta and iliac arteries in the pelvis. It is more likely to occur with increasing age and men are more frequently affected than women. Patients usually complain of calf and occasionally buttock pain on walking which improves with rest, known as intermittent claudication. Depending on the severity of the disease patients may be limited to the extent whereby they experience pain after only a few steps or even describe pain in their toes whilst in bed at night, known as nocturnal rest pain. If left untreated this may result in ulceration or gangrene of the feet also known as critical limb ischaemia. The most important risk factor for developing peripheral vascular disease is smoking. Others include diabetes, hypertension, obesity and hyperlipidemia. Blood tests are important to check for high blood sugar and cholesterol, as well as anaemia (low red blood cell count) or polycythemia (high red blood cell count). More specialist tests used to help in the management of peripheral vascular disease include treadmill testing, ultrasound scan of the peripheral arteries known as peripheral arterial duplex scan and angiography, an X-ray investigation which involves injection of a special dye in order to take pictures of the circulation. The most important aspect in the management of peripheral vascular disease involves risk factor modification. This includes stopping smoking usually with the help of smoking cessation clinics, control of blood pressure, diabetes, weight loss, and cholesterol lowering drug therapy. Low dose aspirin therapy has been shown to reduce the risk of heart attack and stroke in patients suffering from peripheral vascular disease. Supervised exercise programmes can improve walking distance over the course of weeks and months. In patients who experience debilitating symptoms that may significantly interfere with daily activity or if there is evidence of critical limb ischaemia, surgical intervention should be considered. This may be in the form of balloon angioplasty, stent insertion, or open bypass surgery. The type of intervention performed will to a large extent depend on how extensive the blockages in the arterial circulation are.

3. Arterial aneurysms:

The term aneurysm refers to a permanent significant localised expansion of a blood vessel. The aorta is most commonly affected although other vessels can be affected as well. It is the main artery that originates from the heart and runs a long course through the chest and into the abdomen giving off branches along its course to every organ in the body. Depending on the anatomical location of the aortic aneurysm it is either described as thoracic when it is in the chest or abdominal. If it affects both sections then it is described as thoraco-abdominal aortic aneurysm. The abdominal aortic aneurysm also referred to as “triple A” is by far the commonest. There is an increased incidence with age and men are up to five times more commonly affected than women. Other predisposing factors include hypertension, smoking and positive family history. By end large they tend to cause no symptoms (asymptomatic) and are picked up as an incidental finding during abdominal examination or following an abdominal X-ray or scan. The few that do cause symptoms usually manifest with abdominal or back pain. Depending on the size of the aneurysm surgical repair may be indicated as there is an increased risk of rupture. Similarly if the aneurysm is causing symptoms surgical repair is indicated irrespective of size as again there is an increased risk of rupture. An abdominal ultrasound scan will accurately diagnose an aortic aneurysm and an abdominal CT scan will provide useful information with regards to its shape and extent. Standard open surgical repair requires an abdominal incision under general anaesthesia. The aneurysm sac is then isolated opened and replaced with a synthetic tube known as graft which is sutured onto the healthy aorta. There are a number of modifications of this technique including performing the procedure through a very small abdominal incision, otherwise known as mini-laparotomy. In recent years a new technique has been developed, known as endovascular aneurysm repair or EVAR, which can be performed if necessary under local or epidural anaesthesia. No abdominal incision is required and the aortic aneurysm is treated through a small incision in each groin. The new aortic graft is incorporated within a sheathed device that is pushed over a wire under X-ray control and passed up the groin arteries and into the segment of the aorta that contains the aneurysm. The aortic graft is then deployed through its sheath thus bridging the aneurismal aortic segment. In a recent multi-centre clinical trial this new technique has been shown to be at least as good as the standard open repair. However, at present only one third of all patients with abdominal aortic aneurysm are suitable for treatment using this technique. Patients should discussed treatment options with their vascular surgeon.

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