Amanda Wilde (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today, we're speaking with vascular surgeon, Dr. Dale Coffey, about vascular conditions and treatments. I'm Amanda Wilde, your host. And Dr. Coffey, welcome.

Dale Coffey, DO: Thank you for having me. I appreciate it.

Host: Well, to start with, what are of main risk factors for developing a vascular condition?

Dale Coffey, DO: The main risk factors for vascular disease are risk factors that, you know, the primary care physicians and the cardiologists treat on a daily basis that are, you know, very commonplace in the United States. First being high blood pressure, hyperlipidemia, diabetes. And the biggest thing for us for many of the things that we treat is tobacco abuse.

Host: Can you explain a little bit about something we hear a lot about, aortic aneurysms?

Dale Coffey, DO: Yeah, there are different kinds. Aortic aneurysms are definitely probably one of the most frightening things that our patients have to deal with and one of the biggest things that we treat. We primarily treat in the abdominal segment, although we can treat some things in the thoracic segment as well.

I mean, these are most commonly seen in men and commonly seen in people in their 60s and 70s. And they kind carry a lot of the same risk factors. We break it down into modifiable and non-modifiable risk factors. So, you know, these non-modifiable risk factors that some people have, know, their age, their gender, their family history. Or some people have these things that we call collagen vascular disorders. So, these are things that are kind of these zebra conditions like Marfan's, Loeys-Dietz, or Ehlers-Danlos. Those are very rare, but those are certainly things that people are born with that they have no control over. And then, we have, you know, some of the risk factors that we already talked about. But in the aneurysm patient population, these are high blood pressure and tobacco abuse.

Host: What is the difference between an abdominal aneurysm and a descending thoracic? Or am even saying that right?

Dale Coffey, DO: No, you are, yes. Iit's merely location. Abdominal aortic aneurysms occur in the belly, below the level of the diaphragm. And then, you know, the descending thoracic aortic aneurysms occur above the level of the diaphragm. Primary descending thoracic aortic aneurysms are much less common for a number of reasons. The descending thoracic aorta has much more smooth muscle within the wall of the vessel as well as it has lot more blood supply the outside as well as the inside that the abdominal aorta lacks. And so, why people are much more prone to develop abdominal aortic aneurysms.

Host: What kind of treatment do you advise for both these kinds of aneurysms? Is it surgery or other treatment?

Dale Coffey, DO: I think a common theme that you'll kind of hear from me and is just kind of pushed forth by the rest of our team, I mean, the first we start with is medical management. And so, you know, it is this counseling on smoking cessation. It is blood pressure control. You know, our goal for people is to be less than 130/80, which are American Heart Association guidelines.

Past that, in terms of treatment, it really depends on size criteria. For men, we operate on aneurysms that are greater than 5.5 centimeters. For women, we operate on aneurysms that are greater than 5 centimeters. And this stuff has kind of been parsed out over time based upon numerous trials. And we're really going and operating at a time at which, you know, the risks of rupture outweigh risks of surgical intervention.

So, we can offer a number of different types of repairs for people. Whether it be an endovascular repair, which can be as little as two tiny poke holes in the groins in order to deliver a graft that goes in there and kind of excludes that aneurysm so it can no longer grow. Or in some patients, we think that the better repair for them is an open repair, which is a bigger open abdominal aortic operation, where we're reconstructing the aorta with our own hands.

Host: Just curious, what have you seen in terms of success rate for the surgeries, which sound like they're gold standard of treatment?

Dale Coffey, DO: Sure. The surgeries themselves are highly successful. I mean, we go into these cases looking at the CT scans and having a very good plan. There's some nuance that goes into creating these plans for repair. Not every exactly like the other. And so, that's an interesting part of the job. If it's sized appropriately and the case goes well, these are very good, durable repairs.

When we talk about the difference between endovascular and open repairs, the endovascular repairs, you know, they can be very easy to recover from in comparison to that of the open repair, which is certainly an advantage. But the caveat to that being these patients, it's imperative that they follow up with us, on an annual basis so that we can kind of monitor the graft and monitor for any growth. There can be these things that are called endoleaks that develop within the graft or around the graft that we need to go fix so that the aneurysm doesn't continue to grow. And so, you know, if there's any room for failure over the course of many years, it's that. It's not having people follow up with us.

When comes to open repair, that is a very durable repair. People get this surgery, it's certainly more difficult to recover from. It takes a stay in the ICU, which can be days and then, you know, up to a couple of weeks in the hospital to kind of recover from this. But in terms of durability, you see very good results from this. And over the course of many years, the need for re-intervention for these people is very, very low.

Host: And sometimes surgery is just necessary. And what said about follow-up and you keep an eye on patients long after a successful surgery, I think is very reassuring for those who are facing that option. Vascular conditions can impact areas throughout the body, as we know. This is one I have had and I have heard about plaque buildup in the carotid arteries the neck. How do you treat this one proactively?

Dale Coffey, DO: Yeah. So, the whole goal behind carotid artery management is that of stroke prevention. And, you know, again, like I said, a common theme of is medical management. So, you know, we're really not going and intervening on these people until they develop severe stenosis or severe narrowing, because, you know, the risks of surgery certainly do not outweigh the risks of medical management until you get to that point.

So from a medical management standpoint, you know, this is antiplatelet therapy with you baby aspirin. This is management your cholesterol, management of your blood pressure, smoking cessation. And when we talk about treating people, we kind of lump carotid arteries into the symptomatic patient as well as the asymptomatic patient. The symptomatic patient is somebody that to us in the hospital, typically. They've a stroke or a TIA, or mini-stroke. And, you know, we have no other identifiable cause for their stroke except for their carotid arteries. And if they have greater 50% narrowing, then we'll recommend revascularization to prevent a future stroke.

In the asymptomatic patient population, you know, somebody who's not had a stroke, TIA, or or visual disturbances that might be secondary to their carotid arteries, we'll generally wait until they get be at least 70% stenosis or more.

Host: You mentioned revascularization treatment for those whose arteries are intensely blocked. What is that?

Dale Coffey, DO: Yeah. I mean, these are our surgical options that we're talking about. You know, we offer three different kinds of surgical options for people. And there's some nuance that goes into decision as well. You know, these decisions are upon the patient's age, the patient's anatomy, the patient's current quality of life and their lifespan or their projected lifespan rather.

And so, the things that we would offer for surgical revascularization would be something called a carotid endarterectomy, endarterectomy, which is a larger incision on neck. We go down and basically clamp the carotid artery, open it up, clean out the inside, and sew a patch over top in order to, you know, make sure that that area is wide open now and there's no risk of it clotting off or throwing any bits of calcium up into the brain causing a stroke. That's option number one.

Option number two that we offer people is something called a TCAR, otherwise known as a transcarotid revascularization. I know that's a mouthful, but really what that is, in short, is ballooning open the carotid artery and then stenting stenting it, but it's doing so in a very particular way in which we make a small incision in the neck, and we introduce a sheath in the carotid artery. We then put a sheath in the femoral vein in the leg, we connect those two sheaths with a cannula. So, blood is therefore going from the high pressure carotid system down into the femoral system. So, you're kind of reversing flow, flow that otherwise would have going up into the brain is now going through this cannula. And the importance of that is we can then feel free to go and balloon the carotid artery and place stent there, and any debris that otherwise may have gone up into the brain will kind of be shunted through that cannula that has a filter in it to catch anything.

And the last thing we offer people is a transfemoral carotid stent. That's where we go through the artery in the groin in order to deliver a stent up into the neck. That's kind the thing that we offer as a vascular surgery practice last for multiple reasons that I think are beyond the scope of this podcast. But we typically reserve that for patients that have had, you know, extensive neck dissections for for head and neck cancer or radiation. So, it's a fairly hostile surgical area.

Host: Right. Gotcha. So, there are these three options for revascularization as we've just learned. Before that, you hope to treat it in the ways that you outlined. I also want to ask about peripheral artery disease, which can affect the legs. Can you describe some of the hallmark symptoms, and then we'll talk about treatment options?

Dale Coffey, DO: This exists on a spectrum. You know, there no role for asymptomatic peripheral arterial disease. So for example, if someone ever got a a CT scan or an ultrasound of their legs, and someone noted calcium within their blood vessels, but these people are asymptomatic, there's no role for treatment, just kind of medical optimization, which falls in kind of a category that we talking about antiplatelet therapy, statin therapy, so on and so forth. And like you said, we'll get into that in a second.

But so, on one end of the spectrum, you have this asymptomatic patient. And then, as we move along, patients develop claudication, which is when they walk, they can get pain in their calves or their thighs because their muscles are asking for more oxygenated blood than their body can provide.

And so, the hallmark symptom of that is pain with ambulation, but it gets better when they stop. This can progress to something we call rest pain, which is when the blood flow is so bad that they're hurting all the time, in particular in kind of the distal aspect of the feet, and more specifically when they're lying in bed at night and they put their legs up. And when that happens, they've kind of taken gravity out of the equation, and they can develop some significant pain that then improves once they dangle their legs off the bed again.

And then, on the far end of the other spectrum is tissue loss. So, people can develop ulcers or, you know, wounds that they're unable to heal.

Host: Dr. Coffey, as we prepare to close, want to ask you, the things you describe do are very complex and delicate, what drew you to focus on vascular surgery?

Dale Coffey, DO: From kind of an academic surgical perspective, there's a lot of variety in vascular surgery. I mean, we touched on three kind of pathologies that we treat. But, you know, there's a number of other things that we also treat that are kind outside of the scope of this discussion. So, that variety to be able to do multiple different things. Also, kind of the variety of options for repair, you know, between open and endovascular. And when you're doing things endovascularly, this is requiring technology, and this technology is ever-evolving, and I think that really promotes this or allows for this room for creativity when you're talking about repairing a certain issue. You know, you can do things open or endovascular. You can do a little bit of both in order to make sure that you give the patient the best outcome.

And so, you know, when you're talking about all this stuff, and I think, you know, the same sentiment is shared by my partners, it's kind of an opportunity to make a difference, and you're able to see that difference, you know, as soon as you get done or over time longitudinally, whether it be saving someone's leg or, you know, preventing them from having a stroke or, you know, preventing an aneurysm rupture.

And I think these things are the kind of the crux of vascular surgery, is to maintain patient's quality of life, at least that they deem to be acceptable. So, I think that that's our goal as well. And so, you know, working with the patient and giving the best option for repair is certainly a challenging but rewarding part of the job.

Host: Yes, it is challenging, and it's comforting to know that you're on the case. I really appreciate you sharing your knowledge and expertise today.

Dale Coffey, DO: Absolutely. Thank you so much for having me. I really appreciate it.

Host: That was vascular surgeon Dr. Dale Coffey. To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. Thanks for listening to Meaningful Medicine, a Novant Health podcast. If you enjoyed this podcast, please share it on your social channels and check out the entire Meaningful Medicine library for topics that matter to you.