GP Information

Carotid Surgery

Stroke is one of the afflictions most feared by patients. A significant proportion of strokes is due to embolic events which may be potentially preventable. Carotid stenosis is one potentially preventable cause and where present management depends on the presence or absence of symptoms and the degree of narrowing together with an assessment of the individuals overall health status.

For symptomatic stenoses presenting with recovering stroke, TIA, or Amaurosis, the situation is fairly clear. The classic European and North American trials data both demonstrated clearly that for symptomatic stenosis over 70% diameter loss on ultrasound surgery carried a clearcut advantage over best medical therapy in the form of statin, antiplatelet drugs, and BP control. There is some suggestion that between 50-69% there may also be a benefit for surgery especially where symptoms recur despite good medical treatment.

For the asymptomatic patient the position is less definite but given the low rates of serious complication associated with surgery a case can often be made to support endarterectomy, more so in the male patient.

Where total occlusion of an internal carotid has occurred it is rare to be possible to offer intervention as reopening is unlikely to be possible or safe. More controversial is the place of carotid stenting. Most recent data suggests this is still less safe than surgery with higher stroke rates (8% vs 1-2%) although the use of better devices for stenting may improve this. Most clinicians however feel stenting is unlikely to match the excellent results of endarterectomy in the near future and reserve carotid stenting for specific situations of "hostile" neck due to previous radiation, surgery, or infection.

At Vascular Surgical we welcome referrals for assessment of these sometimes difficult cases.

 

Aneurysms

In greater Auckland over 120 Abdominal Aortic and Iliac Aneurysms are treated each year and with the increasing older population this will inevitably continue to rise.

Current criteria for repair of AAA suggest maximal diameter of 50mm in females and 55mm in males, based on the extremely low risk of rupture at these levels. While these are the accepted standards, with improved results from Endoluminal stenting ("EVAR") there may well be a downward revision of these standards in future. World standards for open AAA repair are a mortality rate with surgery of 2-3% and risk of rupture reaches this level at around the 55mm mark. For EVAR the rate is about 1%. We are comfortably in line with these rates in Auckland.

At Vascular Surgical we offer treatment of AAA by either method. About half of patients presenting with AAA are anatomically suitable for EVAR. We welcome referrals of patients with AAA to discuss the management of any AAA either to arrange a surveillance programme or to discuss appropriate repair.

Thoracic Aortic Aneurysm (TAA) in the descending aorta are now largely repaired using EVAR technology, while those in the ascending aorta remain the province of the Cardiac team. Again we would be pleased to see referrals to assist with management if required.

 

Claudication

The main cause of claudication is likely to be vascular insufficiency at aorto-iliac level or in the femoro-popliteal segment. The usual differential is spinal stenosis and while in most cases the cause is apparent there are times where the two conditions co-exist.

At Vascular Surgical we use a sophisticated computerised doppler to help sort this out. Where the claudication is interfering with lifestyle MR Angiography is used to plan treatment. Initially this is in the form of smoking cessation, lipid lowering, anti-platelet drugs, BP control, and exercise. Where the claudication is more advanced we use balloon angioplasty, stents, and if necessary surgery.

 

Varicose Veins

A large part of vascular surgical practice, Varicose Veins can be managed in several ways and we are Affiliated Providers to Southern Cross for this, as well as working with all other health insurers including ACC. While surgical treatment remains the "gold standard" for VVs other options have their place. Of these Endovenous Radiofrequency or Endovenous Laser (EVLT) offer the most rapid outpatient procedure under local anaesthetic. In many cases different treatment options need to be combined for best results and we can offer a comprehensive plan within the practice.

 

Hyperhidrosis

This poorly understood affliction is more common than usually realised. It affects young women more than men in a ratio of about 4:1 and is capable of causing extreme distress. Most often it involves localised areas of the anatomy such as face, hands, axillae or feet.

Young persons present with numerous difficulties in social contact, handling paper, keyboards, sporting equipment, musical instruments, steering wheels etc. Mild control can be achieved with strong anti-perspirants but skin reactions are common and control imperfect.

Face and hand sweating is not suited to these strong products and Botox is painful, unreliable, temporary and expensive. It should be used with great caution in most sites if at all.

Sympathectomy is very effective and offers a permanent cure but is controversial for this very reason and because compensatory trunk sweating can result. Patients presenting for consideration of sympathectomy are very carefully counselled before proceeding with this as the operation is not reversible. The results are often described as "life changing" by grateful patients. As performed currently the operation is keyhole, rapid, and involves a single night in hospital.