What is a "mini" stroke?
A "mini" stroke is also known as a TIA (transient ischemic attack). As with a stroke, there may be a decrease in blood flow to the brain; however, it is brief resulting in a temporary stroke which resolves usually within twenty-four hours.
Who is at risk?
Aging causes "hardening" of the arteries (atherosclerosis) which leads to a gradual narrowing, and thus decrease in blood flow to the brain. Occasionally, a tiny piece of plaque (atherosclerosis) can break away within the artery and block smaller arteries upstream in the brain or the eye leading to a TIA or fleeting blindness respectively. Approximately thirty percent (30%) of those who experience a TIA will develop a full stroke. High blood pressure and cigarette smoking also places one in a higher risk category as it leads to hemorrhage in the brain and accelerates the athersclerotic process.
What symptoms may I experience?
People who sustain a stroke or TIA may experience one-sided weakness, partial or complete paralysis, slurred speech and/or transient one-eyed blindness. Other symptoms can include lightheadedness, fainting, difficulty walking and/or brief memory loss.
What tests help to diagnose carotid artery narrowing?
Following a comprehensive examination by your family physician or vascular surgeon, they will arrange for an ultrasound (U/S) of your carotid arteries. The U/S is a painless, risk-free test which provides a preliminary picture of these arteries. It may be done in the office or outpatient hospital. Following interpretation of the U/S by your vascular surgeon, further tests may be required.
Who needs surgery?
Once all the tests have been performed, your vascular surgeon will discuss the extent of narrowing/blockage and the associated risks of future stroke. For those with significant narrowing (greater than 70%) and/or associated symptoms, surgery may be indicated. The surgical procedure is known as carotid endarterectomy. It involves the cleaning out of the narrowed portion of the artery. A two day hospital stay is usually all that is required.
How can I reduce my risk?
Avoid a high cholesterol and high fat diet. Limit your salt intake. Take your medications as prescribed. Stop smoking. If you have experienced any of the symptoms discussed in this article, a prompt examination is warranted.
Aneurysms can most often be found during a routine physical exam that includes palpation of the abdomen. Abdominal aortic aneurysms can be felt as a pulsating mass typically to the left of the midline at the level of the belly button (umbilicus). Various test modalities are available to evaluate the extent and size of aneurysms, these include: ultrasound (U/S), CT (computerized tomography) scan, MRI (magnetic resonance imaging), and arteriography. These tests vary in extent of resolution as well as pricing and although are very useful alone as a screening tool they are typically used in combination when preparing for surgical repair.
Abdominal aortic aneurysms can be surgically treated either with traditional (open repair) or with a minimally invasive procedure known as endovascular repair. Traditional (open technique) requires a large incision in the abdominal wall, extending from below the breastbone to the top of the pubic bone. The abdominal wall is divided longitudinally and the intestines and internal organs are pulled aside. The aorta is posteriorly located in the abdominal cavity, just in front of the spinal column. The aorta is then clamped and the aneurysm is opened to reveal any plaque and clot material contents inside. Following removal of this degenerative tissue an aortic graft is sewn to the healthy aorta above and below the weakened area. After the aortic graft has been sewn in place and the bleeding has been controlled, the aneurysm sac is sewn back loosely over the new graft. This prevents the new graft from rubbing against the intestines, which can damage the intestinal wall leading to complications. Following this the abdominal contents are allowed to return to their normal position. The abdominal wall is sewn back together and finally the skin is sewn or stapled closed. Endovascular repair requires two small groin incisions. With the aid of an x-ray imaging device (fluoroscopy), a delivery catheter containing a vascular graft is guided up through an artery in the groin (common femoral), advanced into the aorta, and positioned inside the aneurysm where it is released. The graft contains metal hooks at either end that are used to secure it to the inside of the aortic wall.
The Ancure Endograft® System is similar to grafts used in traditional open surgery. The graft is made from polyester cloth and has specially designed metal attachment hooks at either end that act like the sutures used to sew a conventional graft. Blood vessels (arteries) need to be of a certain size for the Ancure Endograft Vascular Graft to be properly inserted and fit into place. Your vascular surgeon will measure the size of the blood vessels during the examination of the aneurysm in preparation to assess for candidacy of the endovascular procedure. In some instances, patients (mostly women) are not considered candidates for endovascular repair and may require traditional surgery.
Endovascular repair offers several advantages when compared to traditional (open) surgery including a significant reduction in medical complications and length of hospital stay. Endovascular repair has been shown to significantly reduce the occurrence of myocardial infarction (heart attack), cardiac arrhythmia (irregular heartbeat), congestive heart failure and blood loss during surgery. Hospital length of stay for traditional surgery averages six (6) days, with at least 24-48 hours in an intensive care unit. The hospital recovery for endovascular repair is usually 1 or 2 days and fewer patients require time in the intensive care unit. Prior to discharge, a CT scan, ultrasound, or abdominal x-ray will be performed to ensure that the endovascular graft is working properly. Once discharged, most people return to a normal level of activity by 2 weeks compared to 6-8 weeks for traditional repair. Follow-up visits thereafter will be approximately biannually based on an individual situation.
As with any medical device or procedure, endovascular repair of aneurysms has risks in addition to benefits. Associated risks and benefits should always be discussed with your surgeon prior to undertaking any procedure. Risks associated with aneurysm repair can include infection, blood clots, bleeding, kidney failure, pneumonia, loss of blood supply to the colon, erectile dysfunction, spinal cord injury, heart attack, stroke, or death. These risks are usually far outweighed by the risk of dying from an acute aneurysm rupture. Elective surgical mortality is approximately 5% compared to as high as 90% for emergency repair.
What is a hemorrhoid?
Hemorrhoids are swollen blood vessels that are located either in the anal canal or around the outside of the anus. The veins in the anal canal are present from birth and act as "cushions" to help in the passage of stool during regular elimination. If there is too much pressure on these veins, they can bleed, clot, enlarge and become inflamed. Veins that swell inside the anal canal form internal hemorrhoids. Veins that swell near the opening of the anus form external hemorrhoids. You can have both types at the same time, but the symptoms and treatment depend on which type you have.
How do I know that I have hemorrhoids?
The most common symptom of internal hemorrhoids is painless rectal bleeding. You may see bright red blood in the toilet bowl after you have a normal bowel movement or bright red streaks of blood on the toilet paper. There also may be blood on the stool. Internal hemorrhoids may also cause nighttime burning and itching. External hemorrhoids can occur suddenly and usually cause rectal itching and burning, as well as pain around the anus. Generally, external hemorrhoids are painful while internal hemorrhoids are not painful unless they are clotted.
What causes hemorrhoids?
Hemorrhoids are rarely symptomatic before the fourth decade of life, except during pregnancy. The most common causes of problematic hemorrhoids are straining to move stool, chronic constipation, diarrhea, low-fiber diet, genetics, sitting for long periods of time, obesity, and aging. Pregnancy can lead to hemorrhoids because of increased pressure from the fetus on the blood vessels in the pelvic area. Hormonal changes also contribute to the enlarging to hemorrhoidal vessels. Straining to deliver the baby can make hemorrhoids worse.
Hemorrhoids have degrees of severity. With first degree hemorrhoids, there is an increase in the number and size of the anal canal veins, but there is no protrusion. Second degree hemorrhoids occur when the veins protrude during a bowel movement, but retract on their own once the patient is finished straining. When the veins protrude and have to be pushed back in by the patient, the condition is third degree and can involve both internal and external hemorrhoids. The most severe type of hemorrhoids is fourth degree, which occurs when the patient has both internal and external hemorrhoids that do not reduce in size and therefore have to remain outside the body.
Is there anything to help prevent or relieve hemorrhoidal attack?
For early hemorrhoids, avoid constipation by increasing the fiber in your diet and increasing fluid intake to 6-8 glasses a day. A psyllium product (such as Citrucel or Metamucil) may also be used. Avoid straining or sitting and reading on the toilet. These habits contribute to the downward pressure on hemorrhoidal veins. You may find relief with sitz baths. Add a few tablespoons of Epsom salts to three to four inches of warm (not hot) bath water and sit in this water for brief periods. Ice packs or topical ointments may also be used to provide relief.
When should you see a surgeon?
If you have bleeding, painful, or swollen hemorrhoids that are not relieved by over-the-counter treatments or if your hemorrhoids are recurrent, you should see a surgeon. The diagnosis of hemorrhoids is fairly simple and begins with visual inspection. A rectal exam will follow to determine the extent of the hemorrhoids and to rule out other more serious problems. The exam will take place in the surgeon’s office.
What types of treatment are available?
Thrombosed (clotted) hemorrhoids can be surgically removed using a local anesthetic and a small incision to remove the clot.
For more extensive or severe hemorrhoids, a hemorrhoidectomy may be necessary. This surgical removal of the enlarged veins is performed under general anesthesia on an outpatient basis. Healing time following this may be from five weeks to two months, but you may return to work before this.
Rubber band ligation is a simple and painless office procedure in which elastic bands are applied onto an external hemorrhoid to cut off its blood supply. For a few days the patient may feel pressure at the procedure site, but within 5-7 days the withered hemorrhoid falls off. Ligation may have to be repeated a few times over a period of weeks if the hemorrhoids are plentiful.
The Transanal Hemorrhoidal Dearterialization-Hemorrhoidopexy (THD-HP) is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then “tied off” and the prolapsed tissue is sutured back to its normal position without any removal of tissue. Clinical results have shown patients encounter less pain and have less risk of complications with the THD-HP procedure. Additionally, patients are able to resume normal activities within 24-48 hours.
HOW DO VEINS FUNCTION?
Veins have cup-like flaps within the walls called valves. These valves are equally spaced throughout the veins and open upward to allow blood to move up the vein. The valves open when muscle contracts (thus squeezing the blood upward) and close when muscle relaxes, keeping blood from falling back down the vein.
HOW DOES CIRCULATION BECOME IMPAIRED?
When a vein becomes damaged, blood flow back to the heart is diminished. Weak or injured valves are not able to support the blood when muscle relaxes, thus resulting in a pooling of blood within the vein. This leads to increased pressure on the valves, which further distends the vein wall causing more separation of the valve leaflets and thus increased blood pooling (vicious circle). This results in the condition known as varicose veins.
WHAT ARE VARICOSE VEINS?
Varicose veins are damaged veins in which blood flows in both directions resulting in increased pooling (venous distention), causing veins to bulge and/or twist like a rope. The tiny superficial reddish or purple bursts seen at the ankles, knees, and thighs are known as spider veins (telangiectasias).
WHO IS AT RISK?
Venous disease can affect men and women of all ages. Certain health conditions and lifestyle habits increase the chances of developing a problem. Heredity, surgery, injury, and pregnancy are risk factors that may not be under direct control. Other factors, however, may be controlled such as being overweight, not exercising, and prolonged standing.
WHAT SIGNS AND SYMPTOMS MAY I EXPERIENCE?
Varicose veins are often hereditary and inevitably become larger and more numerous over time (especially with pregnancy). As a result, symptoms may progress to swelling (edema) of the legs and ankles, causing heavy, tired, aching legs. They may also cause localized tenderness, burning, itching and pressure-like sensation to the area of the varicosity. In addition, you may experience increased warmth, redness, (erythema), and pain as a precursor to formation of a blood clot (superficial phlebitis). Chronically untreated varicose veins associated with recurrent bouts of phlebitis may lead to irreversible leg discoloration, swelling, and ulcer formation.
WHAT CAN I DO?
You can usually decrease the burden on your veins and reduce your symptoms by increasing exercise and by losing any excess weight. The association of leg swelling and prolonged standing may be alleviated by elevating as frequently as possible and by wearing prescribed graduated compression stockings. Exercise itself without adequate stocking support will aggravate the condition. Prescription stockings should be worn during the second and third trimester of pregnancy if the condition is pre-existing.
WHAT TREATMENTS ARE AVAILABLE?
Two procedures can be used to treat superficial varicose veins - sclerotherapy and surgery. Sclerotherapy (chemical injection) is very effective for the treatment of spider veins. Larger veins can also be successfully treated with sclerotherapy, either alone or in combination with surgery. A vascular surgeon with an interest and training in venous diseases performs both sclerotherapy and surgery.
WHAT CAN I EXPECT?
To obtain an accurate diagnosis and treatment for a possible venous disorder you should undergo a complete vascular examination. Upon evaluation by a vascular surgeon, he will describe your exact venous condition. Depending on the extent of your venous disease the surgeon will recommend supportive treatment, sclerotherapy, surgery, or a combination of these.
If sclerotherapy alone is recommended you can expect to undergo injection of a medicine directly into the varicosity. The medicine helps to close the damaged veins. The blood is then directed to other nearby healthy veins. The doctor will perform the injections and advise you with post injection instructions. Following the procedure you may drive yourself home.
Should surgery be recommended it might be one of several types, ranging from minimally invasive, which limits scarring, to complete vein stripping. Rarely is the latter necessary. All of these surgeries are performed on an outpatient hospital basis. Usually recovery time is several days (depending on the surgery required). For some conditions your surgeon will recommend a combination of surgery and sclerotherapy. In this situation surgical intervention will be carried out first, followed by sclerotherapy at a later time. This treatment modality speeds recovery time (return to normal activity in 24-hours) and minimizes scarring.
The results of sclerotherapy will occur in anywhere from two to twelve weeks. The vessels, after being closed off, will gradually fade away. Some bruising may initially occur but shall clear. The degree to which your particular veins "fade" depend on such factors as size, chronicity, sclerosing agent, and the individuals' own healing ability. Upon completion of the sclerotherapy course you should not experience any further discomfort from the once varicosed veins.
When surgery is the course of treatment you should expect immediate results. The degree of bruising following surgery is proportionate to the extent of surgery. Postoperative discomfort is readily controlled with medication and usually lasts a couple of days following surgery.
It is usually easy to recognize a hernia. Often there is a painful bulge under the skin that becomes symptomatic when lifting heavy objects, coughing, or straining during urination or bowel movements. This pain is described as sharp and immediate. Other people may describe the pain as more of a dull ache or burning discomfort that gets worse toward the end of the day or after standing for long periods of time. Hernias can occur at the navel, in the groin, or along a previous abdominal incision.
A hernia develops when the abdominal wall weakens, often to the point of tearing. A loop of intestine (or fatty tissue) pushes against the inner lining of the abdomen and a hernia sac forms. Most hernias bulge and cause pain as the intestine pushes into this sac.
If you think you have a hernia, see your physician for an evaluation that will include obtaining a medical history and physical examination. With accurate diagnosis surgical repair should be performed before the hernia enlarges or complications arise. If the hernia bulge flattens out when you lie down or push (with gentle pressure) against it, it is termed a reducible hernia. Although not of immediate danger, this hernia should be surgically repaired. Should the intestine become trapped or incarcerated and the hernia bulge cannot be flattened it is termed a non-reducible hernia. This is often a painful condition and prompt surgical repair is required. An uncommon, but nevertheless dangerous, complication may arise when the intestine is tightly trapped in the hernia sac. This strangulated intestine eventually loses blood supply and dies. Strangulated intestine can block digestion and cause severe pain. Emergency operation is required to relieve the blockage and repair the hernia.
Advances in technology have led to various successful methods in the treatment of hernias. Laparoscopic surgery can decrease operative time although it is typically more expensive than the standard repair. Furthermore, not all hernias can be repaired using laparoscopic techniques. The Kugel Hernia Patch repair, on the other hand, is quick, decreases postoperative disability as well as maintaining a low risk of hernia recurrence. The Kugel Hernia Patch, designed by Dr. Robert D. Kugel, is a patented design, which reduces recurrence rate by covering the entire inguinal floor. The Kugel repair is a minimally invasive procedure that combines the best features of the open hernia repair and the Laparoscopic hernia repair. The Kugel procedure is a tension free near "suture-less" repair. Post operatively, patients are released to "common sense" activities. Best of all, the repair is performed quickly through a single small incision, usually under local or regional anesthesia.
A careful evaluation by a qualified surgeon is necessary prior to all surgical repairs. Non-surgical treatment is only a temporary solution. Hernias should be repaired before complications arise. Because hernia repair is safe and effective, I recommend prompt surgical treatment. A hernia need not keep you from doing your work or enjoying your life.