The area’s first and only vascular surgeon, Adonis J. Lysandrou, M.D., provides the full spectrum of care for those with arterial and venous disease to help them gain control of their health.
Dr. Lysandrou is board certified in vascular surgery. His practice at Vascular Associates of St. Cloud and St. Cloud Regional Medical Center brings to the region more than 10 years of experience in the diagnosis and management of arterial and venous disease.
“Vascular surgeons are usually called on to handle vascular conditions outside of the heart and brain that involve blood clots, injuries, trauma, dissection (of the artery walls) and uncontrolled bleeding,” says Dr. Lysandrou. “I treat everything from aneurysms and carotid artery blockages to peripheral vascular and venous diseases.”
Lifestyle changes that include a healthy diet and regular exercise are always advised, and Dr. Lysandrou urges smoking cessation. Often treatment requires medical management for as long as risk factors are present.
Consultation with a vascular surgeon often yields new options for patients with chronic and refractory disease. Dr. Lysandrou offers the latest in open and endovascular aneurysm repair, carotid endarterectomy, angioplasty with and without stenting, embolectomy, thrombectomy and vascular bypass grafting, among other procedures.
“New technology and advanced endovascular therapy are very nice for treating patients whose health is compromised because of diabetes, high blood pressure and cholesterol and worsened cardiac disease. Endovascular surgery decreases morbidity,” says Dr. Lysandrou. He performs endovascular procedures in St. Cloud Regional Medical Center’s state-of-the-art catheterization lab.
Dr. Lysandrou stresses the importance of experience, needed to determine when open or endovascular surgery is best for a patient, given the diagnosis. “As a vascular surgeon, it is very important to know when to do procedures and when not to do them. That’s when you’re going to save people’s lives and extremities. Sometimes it’s better to follow the patient, especially when the risks associated with the medical problem are low compared to the risks of surgery.”
Dr. Lysandrou’s specialized expertise extends to treatment of chronic venous insufficiency, venous thromboembolism, varicose and spider veins. He implants long-term venous access devices, such as Mediports for oncology and hematology patients and arteriovenous fistulas and catheters for dialysis access. He also works at the St. Cloud Regional Medical Center Wound Care Center once a week and provides hyperbaric oxygen treatments to patients.
Equal to his experience is Dr. Lysandrou’s depth of compassion. “My most important job as a physician and surgeon is to do no harm. It is the basis of the Hippocratic oath. And that’s why, when we see patients we take care of them like they are our family members and friends. We do for each patient what we would do for our family,” he says.
Dr. Lysandrou was attracted to vascular surgery during his general surgery residency because of the typically rapid results. “After a procedure, the difference is like day and night. Once healing occurs, patients are very happy and grateful to be able to do the activities of daily living that they used to,” he says.
The general public is not widely aware of the processes at work in cardiovascular disease beyond the heart and in other parts of the body that rely on oxygen- and nutrient-rich blood, such as the legs, feet and arms, kidneys, lungs and brain.
One of these processes is atherosclerosis. A form of arteriosclerosis, it is a slowly progressive disease that may begin as early as childhood.
The exact cause of atherosclerosis is unknown and thought to start with damage to the inner layer of the artery as a result of high blood pressure, cholesterol and/or triglycerides, smoking or other tobacco sources, insulin resistance or diabetes, obesity and/or inflammation as a result of such diseases as lupus or infections or unknown causes. Age and unhealthy diet also are risk factors.
The accumulation of fatty deposits and other cellular products at the site of injury is usually accompanied by hardening, and stenotic narrowing, of the artery. Plaque formations can grow large enough to significantly reduce the blood’s flow through an artery. When a plague formation becomes brittle or inflamed, it can rupture, producing a blood clot that can travel to other parts of the body.
Complications of atherosclerosis depend on the location of the affected arteries. Symptoms usually don’t occur until the artery is so narrowed or clogged it can’t supply adequate blood to organs and tissues.
Arterial Disease: Prevalence and Risks
Coronary artery disease (CAD) is an effect of atherosclerosis. It is the most common form of heart disease and the leading cause of death in both men and women in the United States, according to the Centers for Disease Control and Prevention. Symptoms often include chest pain.
Those with CAD are at a higher risk for heart attack. Over time CAD can weaken the heart muscle and contribute to heart failure and arrhythmias. Individuals with CAD have a higher risk for other vascular diseases.
Treatment may include lifestyle changes and medications to lower heart attack risk. For those whose angina worsens, angioplasty with or without stenting and/or bypass surgery may be advised.
Peripheral arterial disease (PAD) is caused by atherosclerotic plaque that impedes blood flow in the legs, arms, abdomen, neck and brain. It is most common in the leg arteries. Approximately 8 million people in the United States have PAD, including 12-20 percent who are older than age 60. Individuals with PAD have a higher risk of developing CAD and cerebrovascular disease, which can lead to a heart attack or stroke.
Since PAD prevents muscles and organs from receiving the oxygen and nutrients to work properly, blockages can cause cramping, pain and tiredness in the affected area during activity. The pain resolves with rest. Left untreated, PAD can result in foot ulcers, infections and gangrene, which requires amputation.
In patients with symptoms of PAD in the legs, the ankle-brachial index is a non-invasive test to measure blood pressure in the ankles. Imaging tests such as ultrasound, magnetic resonance angiography and computed tomographic angiography can provide additional diagnostic information.
Most cases of PAD can be managed with lifestyle changes and medication. Severe cases may require surgery to bypass blocked arteries.
Atherosclerosis is a major cause of aneurysms. Symptoms depend on location and can result in life-threatening complications if left untreated. Often there are no noticeable symptoms, and the aneurysm is found incidentally to an imaging study for other medical reasons. Aneurysms may cause pain and throbbing at its location.
Aortic aneurysms, those that occur anywhere along the aorta, were the primary cause of 10,597 deaths and a contributing cause in more than 17,215 deaths in the United States in 2009, according to the Centers for Disease Control and Prevention.
Abdominal aneurysms are the most common along the aorta in people age 65 and older. In addition to atherosclerosis, risk factors include injury or infection, emphysema, family history, high blood pressure, high cholesterol, obesity and smoking. Less than 80 percent of patients survive a ruptured abdominal aneurysm, according to the American Heart Association (AHA)
When symptoms are present, they usually include throbbing or deep pain in the back or side and/or pain in the buttocks, groin or legs. The United States Preventive Services Task Force recommends that men age 65-75 who have ever smoked get an ultrasound screening for abdominal aortic aneurysms, even if they have no symptoms.
Thoracic aortic aneurysms are life threatening and cause significant short- and long-term mortality due to rupture and dissection. Fortunately they are rare, affecting approximately 6-10 out of 100,000 people. About 20 percent of those cases are linked to genetic syndromes, such as Marfan syndrome and Ehlers-Danlos syndrome. Symptoms, such as a sharp, sudden pain in the chest or upper back, shortness of breath and/or trouble breathing or swallowing, are subtle or non-existent.
Peripheral artery aneurysms commonly occur in the neck (carotid), groin (femoral) or behind the knees (popliteal). About 85 percent are popliteal, and most peripheral aneurysms occur in men older than 50. Risk factors include age, gender and diabetes.
It is estimated that about half of peripheral aneurysms are bilateral. Among these cases, about one-third of those with a popliteal aneurysm and one-half with a femoral aneurysm have an associated aortoiliac aneurysm.
While peripheral aneurysms are less likely to rupture or dissect than aortic aneurysms, they can form blood clots that break away and possibly block blood flow in an artery. Arterial thrombosis can be limb threatening when all outflow vessels are occluded.This can lead to amputation in up to 30 percent of patients.
Often peripheral aneurysm is asymptomatic. Disabling claudication and/or acute limb ischemia are often the result of arterial thrombosis, peripheral embolization or compression of adjacent structures with resultant venous thrombosis or neuropathy.
Surgery is recommended for all asymptomatic popliteal aneurysms larger than 2 centimeters and for all that are symptomatic regardless of size. Large aneurysms that compress the popliteal vein or nerve are resected in addition to grafting.
Aortic Aneurysm: Diagnosis & Treatment
Life-threatening internal bleeding is likely when aneurysms rupture or dissect. As a result, timely diagnosis and treatment, including open or endovascular surgery to replace or repair the damaged artery, are critical.
Medication to lower blood pressure may be prescribed for those whose aneurysm doesn’t appear to be at imminent risk of rupture. Studies have shown likelihood of rupture is directly related to the size of the aneurysm. A small aneurysm may be monitored by ultrasound every six months or annually.
The standard surgical treatment for aneurysms has been open surgery. In 2003, endovascular aneurism repair (EVAR) surpassed open aorta surgery as the most common repair of abdominal aortic aneurysms.
Symptomatic aneurysms mandate endovascular or open repair regardless of size.
During EVAR, long, thin catheters are inserted through small incisions in the femoral artery. Using X-ray guidance, the stent graft, or “scaffold,” is delivered to the aneurysm site. The stent graft provides a snug, new artery lining, relieving the diseased tissue from direct stress of blood pressure. This often results in the aneurysm shrinking over time.
The benefits of endovascular repair are generally less pain, a shorter hospital stay, lower risk of complications and speedier recovery than traditional surgery. Potential risks include endoleak around the graft, migration of the graft and stent fracturing. Other complications that are serious but rare include paralysis, delayed aneurysm rupture and infection.
The long-term durability of endovascular stent grafting is not yet known, because it is a fairly new procedure. For this reason, patients who have endovascular repair should be monitored on a regular basis.
Venous Disease: Diagnosis & Treatment
Leg health problems and vein disease affect approximately 80 million Americans.
A properly functioning vein relies on tiny valves that open and close to move oxygen-depleted blood up from the feet and back toward the heart. While the exact cause of vein disease is unknown, the following factors may contribute to chronic inflammation that results in overstretched and dilated veins, functional valvular failure and reflux:
- Heredity, which includes congenital absence of venous valves
- Excess weight
- Female gender
- Standing occupations
- Previous damage or inflammation of the venous system
Venous thrombosis includes superficial thrombophlebitis, which does not pose as much health threat as deep-vein thrombosis, which is life threatening.
Superficial thrombophlebitis can occur after an injury, in a varicose vein or after the introduction of irritating fluids into the vein. It responds well to warm, moist heat, non-steroidal anti-inflammatory medication and elevation.
Deep-vein thrombosis (DVT) can occlude one or more of the major leg veins, impairing blood return to the heart and causing significant leg swelling. There also is a risk that the blood clot or a piece of it will break loose and travel to the heart and lungs, where it can cause a fatal pulmonary embolism.
Factors that cause blood flow to become sluggish and clot include smoking, use of female hormones, prolonged bed rest, surgical procedures, injuries and prior episodes of DVT, to name a few. If DVT is suspected, anticoagulation therapy is promptly initiated and aggressively managed.
Post-thrombotic syndrome is the result of scarred valves and vein linings that prevent the valves from closing properly, causing blood to leak into surrounding tissue. Swelling, heaviness and aching in the leg tends to increase by day when the patient is upright. There is no cure and lifelong use of elastic stockings may be required to control symptoms.
Untreated venous insufficiency in the deep or superficial system causes chronic venous insufficiency (CVI). This complex, progressive condition affects 2-5 percent of the population and comes with a high potential for serious complications, such as phlebitis, deep-vein thrombosis and venous stasis ulcers.
CVI’s earliest manifestation may include lower-extremity edema, lipodermatosclerosis and/or discomfort, such as the signature pain that comes with ambulation. Varicose or spider veins and ulceration may occur above the superficial fascia.
Diagnosis is often performed on an outpatient basis. The most common noninvasive test is a venous duplex scan that assesses reflux, venous valve function and venous clot formation. Magnetic resonance angiography is often used if venous clots or vessel narrowing is suspected in the pelvis or abdomen.
A contrast venogram, using X-ray fluoroscopy, is an invasive examination that is occasionally necessary to investigate venous disease more thoroughly. Intravascular ultrasound uses a catheter with an ultrasound probe in the vein to obtain the most accurate measurement of venous obstruction.
Once venous insufficiency syndromes begin, the damage cannot be reversed, only treated. Treatment is designed to alleviate the symptoms and correct the underlying abnormality when possible.
Graduated compression is the cornerstone of treatment, as oral medication has not proven useful. Surgical and endovenous therapy is commonly reserved for those with discomfort or ulcers that are refractory to medical management. Valvuloplasty is occasionally successful, but the risk of postoperative deep-venous thrombosis is high. Venous bypass is successful in select patients.
About one percent of the population in developing countries suffers from venous ulcers, which may be caused by inflammatory processes associated with leukocyte activation, endothelial damage, platelet aggregation and intracellular edema. Many patients with venous ulcers have had a history of deep-vein thrombosis.
The ulcers are generally irregular in shape, shallow and located over bony prominences. Venous ulcers are often recurrent and can persist for weeks to many years, significantly impacting patient quality of life. Severe complications include cellulitis, osteomyelitis and malignant change.
Antibiotics won’t heal ulcers and should only be used for short courses in cases of clinical infection. Large ulcers that are refractory to conservative measures may benefit from surgical management. In addition to advanced expertise in valvular dysfunction, Dr. Lysandrou provides a coordinated multidisciplinary approach that is critical to effective treatment and prevention.
Varicose veins affect at least 15 percent of the population in the United States. Varicose veins do not pose a serious health threat, so therapy for asymptomatic varicose veins is unnecessary unless removal is for cosmetic purposes. While elevating the legs and/or wearing elastic compression stockings usually control discomfort, Dr. Lysandrou offers more aggressive therapy.
Most spider veins can be treated in the office using sclerotherapy, in which a very thin needle is used to inject a sclerosant directly into the veins. This causes the vein lining to seal.
Nonsurgical endovascular laser therapy (EVLT) uses heat under ultrasound guidance to close varicose veins. The body then naturally reroutes the blood to healthy veins. After the office procedure, patients notice an immediate and significant improvement in appearance, and there is little-to-no recovery time.
Vein stripping is a more invasive procedure in which the saphenous veins are removed and the major side branches are ligated. The outpatient surgical procedure is performed under general anesthesia. The incisions are not sutured and elastic compression is applied. Recovery varies from two to four weeks, depending on the number of veins removed and their location.
Radiofrequency ablation is a minimally invasive alternative to vein stripping. Under ultrasound guidance, a radiofrequency catheter inserted into the abnormal vein emits heat to close the vein. This procedure can be performed in the office using local anesthesia and a mild sedative. Recovery is in a matter of days, with strenuous activity restricted for two weeks.
Recognizing that many vascular diseases go undiagnosed or misdiagnosed, Dr. Lysandrou urges early intervention with a specialist at the earliest signs.
“If you see anything in the feet or legs – discoloration or ulcerations that are not healing – leg pain or numbness, that’s when it’s really important to think about a vascular cause and a bigger problem,” he says.
Prevention is always better than treatment after a medical emergency. “Once an artery closes in the leg, it can be difficult to open it up again, and irreversible damage may already be done.”
For more information on Vascular Associates of St. Cloud visit StCloudPhysicians.com. To schedule an appointment with Dr. Lysandrou, call (407) 891-2930.
By Heidi Ketler