Vascular Disease Foundation - Fighting Vascular Disease... Improving Vascular Health.

Interactive Learning : Ask the Doctor

 

Ask the Doctor Live Chat Transcript - October 5, 2010

Dr. Heather Gornik


Department of Cardiovascular MedicineThe Cleveland Clinic FoundationCleveland, OH

Vascular Disease FoundationBoard of Directors

 

 

Dr. Gornik generously donated her time to answer our patients general questions about vascular disease. The below transcript details all of the questions asked by our participants as well as her answers.

Moderator- VDF: Welcome and thank you for joining us today for VDF's Live Chat! I would like to introduce Dr. Heather Gornik from the Cleveland Clinic who will be taking your questions today. You may now go ahead and send Dr. Gornik your questions.


Susie: I want to understand my risks better - I have varicose veins and they are annoying!

Speaker- Dr. Gornik: Hi Susie. Yes, varicose veins can be very annoying. In terms of risk factors for varicose veins, this is an evolving area. Certainly previous blood clot, family history of varicose veins in relatives, age, and other factors contribute. For treatment of varicose veins, there are options ranging from elastic compression stockings to sclerotherapy or even laser ablation of large veins. A vascular specialist should be able to help out in terms of sorting through these options. For starters, elastic compression stockings are always very helpful... especially now that it's colder outside. Good luck!

Susie: What about the spider veins? Do they grow into varicose veins? I appreciate the thought on elastic stockings; I think that's the best way to start. Am I at a higher risk of getting a DVT because I have varicose veins? I've read about DVTs - yuck!

Speaker- Dr. Gornik: Spider veins can potentially grow, but usually they do not. Stockings can help progression of these veins and also new spider veins. Varicose veins are a risk factor for superficial phlebitis and possibly slightly increase risk of DVT too.

VDF Moderator: Hi Susie, you might like to visit VDF's Web site for more information on varicose veins: Christa S. http://www.vdf.org/diseaseinfo/varicose/


VDF Moderator: This first question was e-mailed to us ahead of time: Can the valves in one's lower leg that may have been damaged by a previous DVT (gone now)-be fixed by a surgeon?

Speaker- Dr. Gornik: This is a really good question. Unfortunately we do not have any clinically proven way to "fix" the vales in veins that have been damaged by previous DVT. This is called post thrombotic syndrome. Because of this, we mainly work on treating symptoms of leg swelling with graduated elastic compression stockings...and of course, work to prevent DVT. Most recently there have been efforts to prevent valve damage from DVT with use of thrombolytic therapy of thrombectomy to remove/break up the clot. Studies of this approach to DVT (versus standard anticoagulation) are ongoing.


Irene: First, thanks for providing this opportunity to ask questions.

VDF Moderator: You are most welcome Irene. Please feel free to type your questions for Dr. Gornik, she is happy to help!

Irene: I get ice cold hands and feet in the fall and winter months. They often turn very red and blue and will sting. Could this be a sign that I am not getting enough blood to both my hands and feet during the colder months? I also am diabetic and have FMD. Could this contribute to the problem I have with my hands and feet. Thanks

Dr. Heather Gornik: Hi Irene. Ice cold hands and color changes to the hands and feet in the cool months sound like Raynaud's phenomenon which is a benign condition in the overwhelming majority of cases due to "spasm" of the blood vessels in the fingers and toes. This is common among women and may be totally independent of your diabetes.  We are just starting to learn about what causes FMD. In the case of the patient with tears of all 4 arteries to the brain (again, uncommon and I don't want to alarm the people on the chat), we would do a thorough evaluation to be sure there is no other blood vessel wall problem that is leading to these tears.

VDF Moderator: Hi Irene, Dr. Gornik recorded an excellent HealthCast (a 20 minute audio podcast) on Raynaud's. It is episode 19 and can be found here: http://www.vdf.org/interactive/podcasts/ For more information on Raynaud's disease, please visit VDF's Web site: http://www.vdf.org/diseaseinfo/raynaud/

Dr. Heather GornikThe FMD research community is organizing itself in some research projects to understand the natural history and epidemiology of FMD. Please visit http://www.fmdsa.org for more information

Irene: Thanks I will ask the Vascular specialist I am now seeing about it. I have been told that is not Raynaud's because my hands and feet do not turn white but bright red and blue.

Dr. Heather Gornik: There is a spectrum of Raynaud's clinical presentations, and yes there are some patients out there who don't have classic white, then blue, then red color changes, just 2 of the 3. The other features sound like Raynaud's, but again, it's tough without evaluating you clinically.


VDF Moderator: This next question was also e-mailed to us ahead of time: What does a Vascular Specialist do? Are they only surgeons as my GP have told me? I still have ongoing problems after a DVT in my leg last year, and wonder if one would be able to help me......

Dr. Heather Gornik: There are many specialists who care for patients with vascular disease. Of course, vascular surgeons who focus strictly on vascular care, but also vascular medicine internists, cardiologist, interventional radiologists also care for patients with vascular disease, among other specialties.


Akamoomoo: Hi, I am 55 and have PAD & CAD 7 yrs. I had a triple bypass with them taking most arteries from my upper left leg, nothing below the knee.  I am finally able to do more walking, walking 1.5 to 2 miles 6 days a week for 2 months now.  My left calf muscles hurt when I walk far and I have to stop and rest a few seconds. Is this from the removal of arteries or PAD? I s there anything I can do for it? Are there other exercises to help keep arteries open? I was told I have one artery in each leg. Do you think this is from a birth defect, artery dying off? Used for bypasses. Would you have any idea? Is it normal when you get over tired all your muscles hurt and seems you have to rest or sleep before they stop hurting?

Dr. Heather Gornik:Hi Akamoomo. Your question is really important. When they take the vessels from your legs to bypass the heart arteries, they take superficial veins out, not arteries. I don't think the leg symptoms you are having in your legs with walking are due to the bypass... Rather, I'd be worried that you have PAD due to clogging of the arteries of your legs, just as you had clogged arteries in your heart. I would recommend further evaluation for your PAD and also treatment options --- there are many in 2010 including supervised exercise rehabilitation, a medication called cilostazol, and also procedures to restore blood flow to the legs such as stenting and bypass.

Akamoomoo: I do have PAD from clogged arteries. I have stents in both legs

Dr. Heather Gornik:I'd check back with your vascular doc for routine re evaluation of your stents if you are having significant leg pains with walking.

Akamoomoo: are clogged arteries not reversible, is it possible clogged arteries in the leg are too small to bypass?

Dr. Heather Gornik: Yes sometimes arteries are indeed too small to take a bypass graft. In some of these cases, they can be treated with angioplasty and stents, as is done for the heart arteries.

Akamoomoo: can PAD just make you tired, and if over tired a sort of nausea feeling that only goes away with rest or sleep? Or would this be more towards the CAD?

Dr. Heather Gornik: Regarding your fatigue, I would recommend a thorough medical evaluation for all aspects of health, not just your vascular system. Fatigue as you describe is not a classic PAD or even coronary disease symptom. Please see your doctor.

VDF Moderator: Hi Akamoomoo, yes, VDF has a wonderfully supportive online community that you join. It is our Inspire Network and can be found here: http://www.vdf.org/interactive/support.php

Akamoomoo: is there a best time to take Plavix or Aspin mornings or night

Dr. Heather Gornik: I don't know of any data on best time to take these medications, mainly important to be sure to take them as your doctor prescribed (that is not missing doses).

Akamoomoo: thank you so much for allowing us this chat; I look forward to it each month.


VDF Moderator: This next question was also e-mailed to us ahead of time: I have 4 arterial dissections with pseudoanerysums. The doctors have concluded I have FMD. Please tell me if FMD is a progressive disease? Also, what are the chances of coronary involvement? One more thing, what exactly causes the "beaded like appearance", is it scar tissue? Thank you so much!

Dr. Heather Gornik: With regard to the question from the patient with FMD. This is a special interest of mine, but I will clarify to the group that this is an uncommon disorder relative to varicose veins, DVT, artery disease. It is a disorder with abnormalities of the blood vessel wall that lead to tears such as this patient had, narrowings, aneurysms.


Kay B:  71 yr old female, have pad, right ankle index 0.77 brachial 138, left ankle 0.80 brachial 12to 0.67 at 7 min left increased 0.41 at 1 mile and recovered to 0.72 at 7. 9 right ankles diminished to 0.3 at 1 mile and recovered, are these figures deadly serious or can I wait? I chose not to have surgery at this time so I am walking a lot

Dr. Heather Gornik: It sounds like you have what we would call mildly reduced ABIs with claudication that is not so bad as you can walk a mile. I think medical therapy for such a patient as you and holding off on surgery seems perfectly fine.

Kay B: also is there a medication to clean arteries


Speaker- Dr. Gornik: To answer Kay B and Akamoomoo questions: Unfortunately, there's not "draino" in 2010 for the lower extremity arteries. We have a lot of drugs that have shown to stabilize plaque, prevent plaque from growing, and prevent clots in arteries. These include the statins, platelet blocking medications/blood thinners (aspirin and clopidogrel), and certain blood pressure medications (such as ace inhibitors).
Katie M:  Good Afternoon, I have a varicose vein on my right leg and when it is that time of the month it is very painful, why is that?

Speaker- Dr. Gornik: Hi Katie - some patients to report more discomfort of their varicose veins around the time of their periods. It's a very interesting observation I've heard from some of my patients, but I am afraid I do not have a good scientific explanation for you!

Katie M:  ok thank you...it has become more bothersome now that I'm older. I've just begun to wear compression stockings more regularly so maybe that will help.

VDF Moderator: We also published a nice article last year on varicose veins and treatment options: http://www.keepingincirculation.org/articl…


Maria B: Earlier in the year, I began to experience severe pain in both legs (worse in the right leg), swelling, cramping at night, extreme fatigue and an open sore on the back of my right calf. My legs felt as if they weighed 100 lbs each. I was referred to and saw a local vascular specialist. My right leg measured 3/4cm larger than the left leg. The two tests he had done revealed that the circulation was limited in the right leg - not bad enough to do surgery, and recommended compression stockings. He said I would just have to live with my medical condition, which does not seem to be getting better. The stocking have helped with some of the pain, but the swelling is still present.  Do you think my symptoms have anything to do with PAD? Thank you.

Speaker- Dr. Gornik: Hi Maria so sorry to hear about your problems. It's tough to say without seeing the results of your evaluation. It sounds like you may even have combination artery and vein disease with swelling and blood flow impairment. If you symptoms are persisting despite the stocking and if the wound has not healed, please do check back with your doctor for re-evaluation.


VDF Moderator: This next question was also e-mailed to us ahead of time: How often should a patient have a vascular evaluation with an ABI between 0.90 and 0.80? Regardless of Symptomatic or Asymptomatic.

Speaker- Dr. Gornik: With regard to the question on ABI follow-up frequency, I don't know of any published guidelines. In my own practice, I do periodically re-check the ABI for people known to have PAD, generally once a year to be sure there is not rapid asymptomatic progression. Of course, I also re evaluate sooner if the patient starts to have worsening leg symptoms.


Dennis N: My aunt has diabetes and "blue toe" syndrome. The condition of her feet seems to be getting worse with time. Is there anything besides aspirin that might help her?

Speaker- Dr. Gornik:Hi Dennis. Great question…"blue toe" syndrome refers to discoloration, sometimes blue, sometimes purple, sometimes a lacy like pattern called livedo reticularis that happens on one or more of the toes. Many vascular problems can cause it, some potentially serious, such as an abdominal or leg artery aneurysm, shower of plaque from the aorta to the toes, or PAD. The blue toes, need to figure out the cause first (PAD, aneurysm) vs. just Raynaud's/chilblain's to figure out the best treatment. A vascular specialist should hopefully be able to evaluate her and make some suggestions. There are also some more benign causes of blue toes, especially if this involves all of the toes and reverses, such as Raynaud's which Irene mentioned and also something called "chilblains" which can flair up in cold weather.

Dennis N: Some sites talk about Chelation therapy as if it were "draino for arteries". What's your opinion?

Speaker- Dr. Gornik:Chelation was studied for coronary disease and was not an effective treatment and also there were major concerns regarding some side effects. This is not a proven or recommended treatment for PAD.  I would emphasize that for PAD, though, a major risk to your health is not necessarily your legs, but the fact that PAD puts you at high risk for a heart attack or stroke.

VDF Moderator: This next question was also e-mailed to us ahead of time: Does the High Thigh Index (HTI) have a future in assessing PAD as much as the ABI?

Speaker- Dr. Gornik: With regard to the very sophisticated question re: the high thigh brachial index, I do not know of data showing its use in assessing outcome in PAD. I do know a low high thigh brachial index sometimes suggests that the PAD is located in the aorta or pelvic arteries. A very sophisticated question from a health care provider, no doubt!


Frances N:  I have heard that oxygen in your arteries is needed for good circulation. Is there any help from taking a product called nitrogen oxide that you can buy from health food stores?

Speaker- Dr. Gornik:HI Frances. What an awesome question. Nitric oxide is a molecule that regulates blood vessels and is felt to be perturbed in patients with plaque/atherosclerosis and PAD. Some supplements that are felt to boost nitric oxide availability such as L-Arginine in the body were studied for PAD, but unfortunately were not helpful, so no, I would not recommend this.

Frances N: I read an article about a new artificial vein being studied in England. It help makes the blood flow,

Speaker- Dr. Gornik: I know there is some research ongoing in terms of ways to treat severely leaking veins, and perhaps this is one of these projects.


Sally J: Is there a connection between headaches and Coumadin?

Speaker- Dr. Gornik: Headache is listed as a potential side effect to Coumadin, but it is not common. Of course, bleeding is a side effect of Coumadin and a very, very severe headache could be caused by bleeding into the head. IF you are having severe headaches on Coumadin, please report this to your doctor.

Sally J: Thanks. I wasn't aware of that. Since I do get headaches when taking Coumadin, would another drug for clots work as well (like Plavix)?

Speaker- Dr. Gornik: Good question. In this case, really depends on your specific problem. Clopidogrel (Plavix) is very good for some conditions, like coronary artery disease, PAD, but would be inadequate for blood clots in the legs or atrial fibrillation... this is a discussion that varies by individual patient and you should discuss this very specifically with your own doctor. For DVT, clopidogrel is not adequate therapy.


Chai T: Dr. Heather, given the international stature of the Cleveland, is there any evidence that vascular disease is more prevalent based on ethnicity?

Speaker- Dr. Gornik: Good question about ethnicity and PAD. Dr. Criqui and others have shown that African Americans are at increased risk of PAD.

Chai T: I understand that cancer patients have a higher risk of DVT/PE. My brother has prostate cancer - is he more at risk for DVT?

VDF Moderator: Yes cancer and its treatment are risk factors for DVT. While we wait for Dr. Gornik's answer, I thought I would send you this link to a patient education piece on DVT and cancer: http://www.venousdiseasecoalition.org/reso…


Angeline: I am 50 years old and was diagnosed with FMD of carotids (severe) and also vertebrals, renals and subclavians. This is non-operable and my management is with antihypertensives. I recently developed paroxysmal AF and had a vertebral TIA. I am due to start Warfarin/Coumadin this week. Is AF common in FMD?

Speaker- Dr. Gornik:Hi Angeline. In my relatively large FMD practice, I have not seen a significant overlap with atrial fibrillation.

Angeline: Secondly, I have severe left sided neck and shoulder pain- present since diagnosis but worse lately. I also have cervical spondylosis. Docs aren’t sure if the pain is related to the spondylosis alone or if the FMD is partly to blame. Would acupuncture be safe, since pain killers and physio haven’t worked? Any other thoughts on management?

Speaker- Dr. Gornik:Regarding your FMD and neck and shoulder pain. It's tough for me to answer the question without really looking through things. I'd want to be sure your shoulder pains aren't due to inadequate blood flow, an aneurysm, or dissection. If this has been ruled out and your problem is musculoskeletal truly and your doctor thinks acupuncture might help, I see no obvious reason why you can't have this done as an FMD patient as long as you see a licensed practitioner and he/she knows you have a vascular disease. I would recommend avoiding aggressive manipulation of your head/neck.

Angeline: The site of my pain is posterior neck and also under lateral part of left clavicle but the intensity and site can vary. Activity does not worsen it and there is no coldness or apparent gross arterial insufficiency to see. Thank you very much for this opportunity to ask questions directly.


Speaker- Dr. Gornik: Thanks to everyone for the great questions and lively interaction! I really enjoyed this.
Moderator- VDF: Thanks to everyone for joining us today, we appreciate your time! Thank you Dr. Gornik for taking the time to answer everyone's questions. We wish you a great day!

Disclaimer

The material provided on VDF's Web site and Live Ask the Doctor chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.