American College of Cardiology

Vascular Medicine Specialists
Vascular Medicine specialists (vascular cardiologists & internists) provide special expertise in the diagnosis, treatment and prevention of blood vessel disorders. Individuals with transient ischemic attacks or stroke; exertional leg pain, claudication, or other manifestations of peripheral arterial disease; leg swelling or ulceration, and leg blood clots or other signs of acute or chronic venous disease can receive specialized care from a vascular medicine clinician. Vascular medicine specialists utilize the vascular laboratory to noninvasively diagnose vascular diseases, and provide expertise in the use of medications, exercise, and balloon angioplasty procedures to open blocked blood vessels. These vascular specialists also prevent blood vessel diseases via aggressive treatment of atherosclerosis risk factors (hypertension, high blood cholesterol, tobacco use, diabetes, etc.). Vascular medicine specialists also work closely with interventional radiologists, vascular surgeons, and vascular nurses in providing a team approach to care.

Peripheral Arterial Disease
Peripheral arterial disease, or "PAD", is a disorder that occurs when arteries supplying the legs and arms are narrowed or blocked by atherosclerotic plaque. Approximately 8-10 million individuals in the United States, the majority over the age of 60, are affected by peripheral arterial disease. The most common symptoms include aching, cramping, pain, or fatigue in the calf or thigh, which occurs with walking and subsides with rest. This symptom is called "intermittent claudication", or simply "claudication." In patients with severe circulatory impairment caused by peripheral arterial disease, persistent pain or numbness can occur in the feet, and also gangrene may develop. Patients with peripheral arterial disease may also have atherosclerosis of the arteries supplying the heart and brain. A physical examination can be useful in establishing the PAD diagnosis by demonstrating abnormal leg pulses. The diagnosis can also be more precisely established by the measurement of the systolic blood pressure in the ankles and the arms (the ankle-brachial index, or ABI, measurement). This test can be performed in the physician's office to substantiate the presence and severity of peripheral arterial disease. All patients with PAD should receive cholesterol lowering and antihypertensive medications if necessary, discontinue smoking and take antiplatelet agents such as aspirin or clopidogrel. Exercise conditioning has been shown to improve claudication symptoms, i.e., increase the distance patients walk before leg discomfort occurs. Several drugs approved by the Food and Drug Administration, such as pentoxifylline and cilostazol, are available also to treat this condition. In patients with disabling symptoms and those whose legs are in jeopardy (as evidenced by persistent pain, ulcers or gangrene), interventions to improve the blood supply should be considered. These include catheter-based procedures such as percutaneous transluminal angioplasty and stenting as well as surgery to bypass the arterial blockages.

Cerebrovascular Disease
Stroke causes damage to the brain and is the leading cause of intellectual and physical disability in the United States. Approximately 2/3 of all strokes are caused by blockages in the arteries that supply the brain and 1/3 by brain hemorrhage and bleeding. The brain receives the majority of its blood supply from arteries that brings blood from the heart, through the neck, to the brain. Two of these vessels, one on each side of the neck, are the "carotid arteries". Blockages in these arteries are called "carotid stenoses". They are usually caused by the accumulation of cholesterol plaque and are common in people who smoke, have high blood pressure, diabetes, high cholesterol levels, or family histories of stroke. These carotid stenoses are also more common in individuals who are known to have blockages in arteries that supply other vital organs, such as the heart, the kidney, or the leg arteries. There is very good evidence that treating these blockages can prevent stroke. Treatment includes risk factor reduction by aggressively lowering cholesterol and blood pressure levels, by stopping smoking, by use of antiplatelet agents (such as aspirin, clopidogrel, or persantine) and by removing the blockage by surgery or via a new approach using percutaneous angioplasty and stenting. The presence of these blockages can be easily detected by a simple external ultrasound examination of the neck.

Deep Vein Thrombosis
Deep vein thrombosis (DVT) is a disorder in which a blood clot forms within a vein. Another term for this problem is "thrombophlebitis". The most common veins to be affected are those of the leg. Leg swelling, particularly of the ankle and calf, may occur when deep vein thrombosis develops in the legs because blood return to the heart is impeded by the blockage. This tendency for ankle swelling, or for the development of varicose veins or calf pain, can occur for many years after the development of a DVT. Some patients may also experience discomfort in the calf or thigh, which is aggravated by standing or walking. The greatest risk of deep vein thrombosis is if the blood clot leaves the leg and travels to the lung. This is called a "pulmonary embolus", an event that may be fatal. The diagnosis of deep vein thrombosis is typically made by ultrasound. Occasionally, a more sophisticated x-ray procedure, called a venogram, is required. Once the diagnosis is made, patients are treated with anticoagulant medications. The initial anticoagulant is usually heparin, which is available in several forms and given either intravenously (by IV) or subcutaneously (by injection). Thereafter, patients are usually given an oral anticoagulant medication called warfarin, which is usually continued for at least three months and sometimes longer. Patients who cannot receive anticoagulants because of bleeding problems may require percutaneous placement of a filter in the inferior vena cava, the major venous vessel that takes blood from the legs to the heart. Once a deep vein thrombosis has occurred, patients are at risk for chronic leg swelling and occasionally ulcer formation near the ankles. This risk is reduced by periodic leg elevation and the use of compressive stockings.

Chronic Venous Disease
The major function of veins is to return blood back to the heart. Veins in the legs have one-way valves that allow blood to flow from the legs toward the body and eventually, to the heart. When these valves are functioning properly, they prevent blood from pooling in the legs. When veins become blocked (as with a blood clot—see "Deep vein thrombosis"), or when the valves fail to work properly, blood will pool in the leg. Pooling of blood in the leg can cause swelling and pain, particularly when standing. These are the first symptoms that occur with chronic venous disease (also know as chronic venous insufficiency). As time goes on, the increased pooling of blood (and increased pressure in the veins) may cause the veins to become enlarged and tortuous ("varicose veins"). Also the high pressures in the veins can cause blood to leak out of the vessels and into the tissues. The blood becomes trapped in the skin, and turns brown. This brownish pigmentation typically occurs around and above the ankles. Over the course of years, the leakage of blood and fluid into the leg can cause damage to the skin. Ulcers of the skin can occur, usually in the ankle area. To prevent the progression of this disease, the most important therapy is good compressive support. There are a variety of compressive stockings that are useful. In more severe cases, the Circ-Aid device (a form of inelastic compression composed of lightweight fabric and velcro straps) is very helpful. If you have chronic venous disease, you may need to have your blood thinned so as to prevent further clot formation. This is particularly true if you become hospitalized or immobilized for any reason. Ask your doctor. Also, if you are going on a long trip, don't sit without moving your legs for long periods of time. If you are in a plane, get up and wallk every half-hour. If you are in a car, flex your leg muscles, and take frequent rest stops. Exercise is beneficial, particularly swimming or walking in water (because the veins are supported by the hydrostatic pressure of the water). Walking is good, so long as you are wearing compressive support. A new over-the-counter medicine is now available in the United States, that can reduce pain and swelling of chronic venous disease. Venastat is an extract of horse chestnut seed that is used widely in Europe, and has been shown to reduce the leaking of veins. It is taken as one pill (50 mg standardized extract) twice daily. Chronic venous disease is very responsive to simple measures that you can initiate with the help of your physician. Prevention can reduce your risk of developing more swelling, pain and varicosity of your veins.

Lymphedema
Lymphedema is an illness that causes swelling of an arm or leg due to obstruction of the lymphatic vessels. The lymphatic vessels are tiny, thread-like vessels that carry fluid out of the body's tissues, back to the circulation. When the lymphatics are blocked, fluid builds up in the region of the body served by those lymphatics. The most common cause of lymphedema in women is surgery or radiation for breast cancer. In 10-30% of women having treatment for breast cancer, lymphedema (swelling) of the arm may occur. The most common cause of lymphedema in men is prostate cancer, which can cause swelling of a leg. Sometimes lymphedema occurs at birth (congenital lymphedema), in the teen years (lymphedema praecox) or later in life (lymphedema tarda). In this case, lymphedema is usually due to inadequate development of the lymphatics. There are now various treatments for lymphedema, including many forms of compressive support, and manual lymphatic drainage and bandaging. When properly diagnosed and treated, the patient can usually enjoy improved health of the limb and an improved quality-of-life, while occasionally avoiding severe adverse events, such as recurrent skin infections.