Tag: ENDOVASCULAR

BLOOD THINNING MEDICATIONS PART 1: ANTICOAGULANTS: WHAT ARE THEY AND HOW ARE THEY USED?

Posted on by Michael Kokinos

Over the next few weeks, I want to discuss the medications that vascular surgeons may prescribe.  These medications include anticoagulants, antiplatelets, statins, and other miscellaneous agents.  This week I will discuss anticoagulants!

Anticoagulation refers to agents that STOP the clotting of blood.  The clotting of blood starts with what is known as the coagulation cascade.  The cascade refers to a series of consecutive events each involving special proteins that are needed to occur for blood to form a clot.  Different anticoagulants block specific parts of the cascade.  The main reason we usually see patients with anticoagulants are for hypercoagulable states, certain heart arrhythmias like atrial fibrillation, and deep vein thromboses otherwise known as blood clots.  Hypercoagulable states are specific genetically inherited disorders that result in the blood being more likely to clot.  Atrial fibrillation and other arrhythmias can cause blood clots to form in the heart.

 

Anticoagulant agents are given to prevent the formation of clots in the heart that can then break off and go to the brain, hands, feet, kidneys, or any other part of the body and cause problems. 

 

Deep vein thrombosis or blood clots mandate the prescription of anticoagulant therapy to ensure that more blood clot does not form.

 

Anticoagulants can be broken up by many different classification schemes.  For the purposes of this blog, I will limit our discussion here to agents that are appropriate for the OUTPATIENT (Outside of the hospital) setting.  Please speak with you private physician to answer any additional questions you may have regarding Anticoagulation medication of feel free to reach out to me directions for more information on how anticoagulation is used. Anticoagulation agents that are used during hospitalization or in the IN-PATIENT setting in patients are outside the scope of this article.

 

Up until the 2010’s the mainstay of anticoagulation therapy was with a drug called warfarin (Trade name: Coumadin).  Warfarin, though effective, requires the weekly or biweekly measurement of a specific lab for the blood called the prothrombin time.  The active monitoring of the prothrombin time facilitates modulation of dosing to always allow for safe levels of effective therapeutic anticoagulation.  Since the beginning of the 21st century new agents have come to market that require only taking one or two pills a day.  They include Xarelto or Rivaroxaban and Eliquis or apixaban.

If you have a question about how your medications may be affecting your vascular disease, please do not hesitate to call and schedule an appointment today!

South Bay Vascular Center and Vein Institute is Silicon Valley’s largest and most trusted Vascular Surgery practice.  Serving South Bay communities for over 26 years, Dr Kokinos and her Colleague, Dr Ignatius Lau are the region’s foremost experts in advanced vascular care and provide innovative care for patients suffering from circulation relation problems. At South Bay Vascular Center and Vein Institute our job is to understand the “Why” so that you have real solutions to living a healthy life. Call us today at 408-376-3626 or visit our website at www.southbayvascular.com to learn about what makes us the most referred to vascular surgery clinic in Silicon Valley.

PART 3: WHY DO MY TOES, ANKLES AND FEET HURT AT NIGHT? PERIPHERAL ARTERIAL DISEASE

Posted on by Michael Kokinos

In part one- and two of our four-part series on “Why do my feet hurt at night”, I discussed Venous disease and Raynaud’s Syndrome. In today’s discussion I want to focus on an even more common reason for why patients may suffer from leg pain at night: Peripheral arterial disease (otherwise known as PAD.)

As we’ve discussed in our earlier blogs, there are two kinds of blood vessels: Arteries and veins.

  • Arteries bring blood from the heart to the foot and toes under high pressure while
  • Veins bring the blood back from the foot to the heart under low pressure.

Over the course of anyone’s lifetime, blockages may build up in the arteries between the heart and the feet, especially in the pelvis and the legs.  Risk factors that increase the risk of formation of these blockages include:

  • Obesity
  • High blood pressure
  • High cholesterol
  • Diabetes
  • History of smoking tobacco.

As you may imagine, the tissue within the foot needs a certain amount of blood to supply the nutrients and oxygen necessary to keep the cells within the foot living.  Though a single, short segment blockage of the arteries in the leg may not result in any problems, multiple blockages from the pelvis to the foot may can make it difficult or even impossible for the cells within the foot to survive this lack of nutrients and oxygen.

What Does PAD Feel Like?

Typically, patients notice a gradual onset of pain in the forefoot and toes over the course of a few weeks to months.  As their blockages worsen, their pain becomes more severe.  Pain from PAD occurs in the forefoot and toes because those parts of the body are the furthest away from the heart and thus any blockage along the way from the heart to the toes can contribute to the lack of blood flow. One classic symptom of PAD pain is a burning, tingling, or numb sensation that can be partially relieved by hanging your foot off the bed or a chair.  In this position with the foot hanging down, gravity assists the flow of blood to the foot and toes and relieves the pain.  Typically, patients complain that when they lay flat at night, the pain in the forefoot and toes or just the foot in general will wake them up.  I always specifically ask patients if they are woken up at night by the pain.  If they are woken up by the pain, then I know the PAD must be very severe.

In some patients, the lack of blood flow is so diminished that there is also the development of ulcers, or defects in the skin with exposure of underlying fatty tissue, bone, and muscle or gangrene, the death of the tissue itself.

Even though PAD is a very severe and life limiting disease, specially trained vascular surgeons have many tools to combat it!  We can do a minimally invasive procedure called an angiogram that I described in an earlier blog post that you can access here!  Essentially, I access the diseased blood vessel with a needle and through that needle use contrast and x-ray to see where the blockages are.  Then, using balloons, stents, or self-expanding metal tubes, it is possible to re-open the blockages to re-establish blood flow to the impacted area.  For severe blockages, I also use a device called atherectomy that allows me to cut through and to remove the plaque responsible for blocking this vessel.  The procedure on average takes 1.5 to 2.5 hours and most patients can go home the same day.

Does foot pain wake you up at night? If you are experiencing pain in your foot or toes, please do not hesitate to contact my office at 408-376-3626 to schedule a clinic appointment today!

We Can Help!

Dr. Ignatius H. Lau

Vascular Surgeon

Dr. Ignatius Lau grew up in Portland, Oregon. He attended the University of Washington in Seattle for college and Stony Brook University in Long Island for medical school. He then went on to train in vascular surgery at Mount Sinai Hospital in New York City. During his time in New York, he performed over 1600 cases involving aortic, peripheral, venous, and carotid surgery. He has a special interest in limb salvage and treating patients with peripheral arterial disease and has extensive training and experience in treating the full spectrum of vascular diseases. Dr Lau was also very active in medical research during his training, ultimately finishing with twelve peer reviewed manuscripts. During his training in New York he met his wife, Lisa, who is a practicing endodontist. Together they love to hike, try new restaurants, and travel.

FIXING BLOCKED ARTERIES

Posted on by Michael Kokinos

The most common disease that I treat as a vascular surgeon is a medical problem called peripheral vascular disease.  Specifically, peripheral refers to the legs, and vascular disease refers to blockages of the arteries.

Because peripheral vascular disease is the most common disease that I treat, I want to talk today about what I can do as a vascular surgeon to fix these kinds of blockages in the arteries!

First though, let me explain why blockages to the arteries of the legs are bad.  When not enough blood flow reaches the legs, patients can have pain in their calves or buttocks that limits their ability to walk longer than a city block.  When the blockages are very severe, they can also have pain in their feet and toes even when they are not moving or develop non-healing ulcers and gangrene.  When I open blockages in patients’ legs, I allow them to walk again, or I give them the ability to heal their ulcers and gangrene pain free.  The improvement in patient lives is the most exciting aspect of my job!

There are two main approaches to performing what we call revascularization. Revascularization refers to the opening of old passageways or creation of new passageways to bring blood directly from the heart to the foot without any obstruction.

  • Open Surgery: In the early decades of vascular surgery, namely the 1980s and 1990s the primary way to treat peripheral vascular disease was to perform an open surgical bypass.  If there was a blockage in the thigh, I would surgically expose above and below the blockage and take a synthetic tube or the patient’s own vein and then sew it above and below the blockage.  This would allow the flow of blood to bypass the blocked segment, hence, the reason we call this surgery a bypass!  Though this procedure does produce robust flow, it necessitates large surgical incisions that cause significant pain and are susceptible to poor wound healing and/or infection.

 

  • Endovascular Surgery: In the 2000s, an innovative approach called endovascular surgery started to become more widely used and is now actually standard of care today.  Indeed, I prefer to treat patients with peripheral vascular disease with endovascular surgery whenever possible.  We access the arterial system of the leg with a needle in the groin.  Through that needle we put in a strong wire and over that wire we can then advance several different instruments over catheters.  In general, there are three different techniques I can employ in my efforts to re-establish blood flow to an area that is no longer receiving blood due to some type of arterial blockage.
    • Balloons: The most basic instrument is a balloon that expands and breaks up the narrowing or blockage.
    • Stents: If the balloon does not work, we can use a self-expanding tube called a stent.
    • Atherectomy: If the stent does not work, we can use a special device called atherectomy.  Atherectomy involves the use of a device that can literally cut the plaque out of the artery and aspirate all the debris.

 

These three technologies allow the reopening of arteries from the toes to the pelvis and only necessitate a 2 mm puncture site in the skin of the groin to be used.  There is little to no risk of infection and the procedure can be performed several times over the course of the patient’s life.  On the other hand, surgical bypass can only be performed twice—three times—during the patient’s life due to the development of dense scar tissue after each operation.

 

If you have trouble walking because of pain in your buttocks or calves or have pain in your feet and toes or ulcers that will not heal, please do not hesitate to call my office today at 408-376-3626 to schedule an appointment.  The chances are that I will be able to help take your pain and ulcers away! We Can Help

www.southbayvascular.com

WHAT IS “ENDOVASCULAR” SURGERY?

Posted on by Michael Kokinos

As a vascular surgeon, I perform two very different types of surgery: Open Surgery and Endovascular Surgery.

  • Open surgery is just as you might think!  It involves making an incision with a scalpel and using various tools like forceps, scissors, electrocautery, and needle drivers to expose and then repair specific structures.  Since the beginning of surgery itself, all surgeons, not just vascular surgeons, have been practicing open surgery.
  • Endovascular surgery is a recent development that only began in the 1990s.  Motivated by the desire to perform minimally invasive and less harmful interventions on the most sick and highest risk patients, pioneers in vascular surgery developed endovascular techniques.

Though the concept is simple, endovascular surgery now allows vascular surgeons to solve a multitude of problems with blood vessels very differently than they have in the past. Using advanced minimally invasive surgical techniques, vascular surgeons can treat many forms of vascular disease without the need to “cut-open” their patients to treat extraordinarily complex and in some cases life threatening diseases.

Endovascular surgical techniques utilize ultrasound (sound waves) to place the tip of a hollow needle into a blood vessel.  Once these hollow needles have been placed through the needle, we place a very stiff wire that allows us to advance large tubes called catheters into the vessel.  Catheters have many different functions depending on the situation and are used to re-establish blood flow in vessels that are diseased and or blocked.

For peripheral vascular disease, there are blockages in the legs of a patient that prevent blood flow from reaching the foot.  For peripheral vascular disease we can use balloons on the end of the catheter that are inflated to open a blockage.  If balloons do not work, then we can put a self-expanding metal mesh tube on the end of a catheter and then deploy it inside the blockage, thereby keeping it open.  There is also a technology called atherectomy which literally means cutting out plaque.  The atherectomy device has a cutting edge that sands down the plaque and then a suction function that removes all the debris.

For aneurysms, which are dilations of a blood vessel that can rupture, we use stent grafts, which are self-expanding metal mesh tubes that are lined with an impermeable fabric.  We place the stent graft above and below the aneurysm, thereby sealing it from the pressure created by the heart and preventing rupture.

At the end of these endovascular cases, the patient only has one or two 1 mm in size punctures over the arteries that were accessed.  Contrast this to the classic open surgeries where patients could have incisions up to 10 to 20 cm!  As a contemporary vascular surgeon, I take pride and joy in being able to offer both types of surgical interventions to my patients.  If you or your loved one may be suffering from vascular disease, please do not hesitate to call our office at 408-376-3626 to schedule an appointment today!

TRANSCAROTID ARTERY REVASCULARIZATION: THE FUTURE OF CAROTID SURGERY

Posted on by Michael Kokinos

One of the most gratifying problems we help treat for patients is carotid artery disease.  The carotid arteries supply the brain with blood.  In patients with high blood pressure, high cholesterol, diabetes, and a history of smoking, the carotid arteries can become narrowed and form blood clots that then go into the brain and cause strokes.  Traditionally, vascular surgeons have fixed this carotid artery narrowing’s with a surgery called a carotid endarterectomy.  The carotid artery is dissected out and cut open.  The plaque is then removed, and the carotid artery is sewn back together.

Over the past five years, however, I have had the opportunity to perform a new technique involving carotid stenting called trans carotid artery revascularization or TCAR.  Stents are self-expanding metal tubes that we can use in the carotid artery to stop clots from forming in narrowed areas.  TCAR uses a suction machine to reverse flow in the carotid artery during the placement of a stent to minimize the risk of inadvertent stroke during the procedure itself.  After having performed over 20 of these procedures in the past two years, I can say with confidence that the flow reversal and stenting that TCAR provides is a highly safe and successful way to treat carotid artery disease.  Furthermore, the length of the incision, postoperative pain, and risk of nerve damage and bleeding are all much less with TCAR than with CEA.

I am so happy to be able to offer this revolutionary, safe, and effective therapy to all my patients at South Bay Vascular Center.  Should you or anyone you know have any problems with your carotid arteries or a stroke, please do not hesitate to call us today at 408-376-3626 to schedule a consultation.

https://youtu.be/O32nDoovMPY]

DR. POLYXENE KOKINOS…AN INDEPENDENT COMMUNITY VASCULAR SURGEON SERVING SOUTH BAY RESIDENTS FOR 24 YEARS

Posted on by Angelica Rodezno

For 24 years, Dr. Polyxene (Polly) Kokinos has worked in the greater San Francisco Bay Area community as an independent vascular surgeon, dedicating her time to serving patients suffering from vascular disease.

With offices in both Campbell, CA and Gilroy, CA Dr. Kokinos has worked with over 25,000 patients helping them as they suffer from circulatory illnesses and the impact of their disease. From the most delicate to the most complex surgical care, Dr. Kokinos’ and her staff have remained independent community physicians, offering patients an alternative to the “Big Box” medical systems of Santa Clara, San Mateo and Alameda Counties (Kaiser, PAMF, Sutter, Stanford) by offering unmatched personalized care and innovative surgical techniques to advance the care and treatment of her patients.

“We offer hope when others say there is none” is more than a simple message crafted by a marketing agent. It is at the core of everything we do and is the reason why we our facility operates in the most personal way available…

One Patient, One Doctor, One Nurse

South Bay Vascular Center and Vein Institute, located in Campbell, CA is the only fully accredited privately owned state of surgery center in the South Bay dedicated entirely to the practice of Vascular Surgery. Here, Dr. Kokinos provides unmatched vascular surgical care using cutting edge imaging and device technology that no other vascular surgeon or institution in the area can offer as she continues her pioneering work in the treatment of vascular disease.

Recognized by her peers as a national expert in the care of complex vascular disease, Dr. Kokinos is highly sought after as a speaker at national and international vascular surgical conferences and educational symposia. On March 4 2020 as part of her ongoing commitment to her community, Dr. Kokinos spoke in San Mateo, CA. addressing a large group of her peers as an invited guest of Global Education Group and Educational Awareness Solutions under a grant from Philips Image Guided Therapy. Her topic was “The Essential Role of the Primary Community Care Team in the Management of Lower Extremity Arterial and Venous Disease”

Her talk focused on Vascular diseases, “Including peripheral arterial disease (PAD) and venous thromboembolism and their prevalence in the US. When unrecognized or inadequately treated, these disorders may be life threatening and disabling. The therapeutic an diagnostic landscape for vascular conditions is rapidly evolving; yet there remains an unmet need for more awareness among healthcare professionals and patients.” As a recognized expert in her field, Dr. Kokinos was asked to address these topics with her peers, offering solutions and answering questions and was honored to present at this event.

As an independent community surgeon, Dr Kokinos isn’t forced to achieve the “productivity” targets or revenue targets that are by design a part of “Big Box” Medicine. Her practice has always been one of service to her community and as such continues taking emergency vascular call at Good Samaritan Hospital, O’Connor and El Camino Hospital’s in the Silicon Valley. She has served as the chair of vascular surgery at Good Samaritan Hospital in San Jose, Headed the wound care clinic at Good Samaritan, O’Connor and St Louis hospitals and continues to treat patients at the O’Connor Wound Care Clinic.

As an independent community physician Dr. Kokinos focuses her work on providing cutting edge care in the treatment of the most difficult vascular problems. Free from “corporate” medicine Dr Kokinos’ practice is dedicated to finding the “Why” you are suffering so that you have “real” solutions to living a healthy life. At South Bay Vascular, our first job is to listen. We take the time to fully understand your symptoms so that we can provide the best possible solutions to get your legs and your life back…and that’s what she has been doing for over 24 years.

Unlike Big Box medical practices where doctors see the patients on their “list” every morning, Dr. Kokinos must earn the trust and respect of everyone she sees. She’s knows each and every one of her patients by name and everyone who comes in to see Dr. Kokinos gets her cell phone to call if they ever have a problem. It’s what she does and what she’s always done, building her practice patient by patient, referring physician by referring physician for the past 24 years.

If you or anyone you love suffers from vascular disease, we would be honored to meet with you to discuss your symptoms. Please call our office at 408-376-3626 to schedule an appointment.

PERIPHERAL VASCULAR DISEASE (PVD)

Posted on by Angelica Rodezno

Peripheral vascular disease, sometimes referred to as PVD, in the legs or lower extremities is the narrowing or blockage of the vessels that carry blood from the heart to the legs.

Dr. Polyxene G Kokinos, founder of San Jose’s South Bay Vascular Center and Vein Institute is a board certified general and vascular surgeon who specializes in treating patients who suffer from this condition. For 24 years, Dr. Kokinos has dedicated her practice to helping South Bay patients regain their circulatory health by bringing advanced surgical solutions to complex vascular problems. Having treated over 20,000 Varicose Vein patients, Dr. Kokinos understands both the aesthetic as well as the complex side of her field and is recognized one of the regions most respected surgeons.

Recent advances in both imaging and medical device technology has revolutionized the practice of Vascular Surgery. Of particular interest to Dr. Kokinos is treating vessels in the deep venous systems, as well as the treatment of peripheral vascular disease. Having performed hundreds of these procedures, Dr. Kokinos has found that many of her patients, being properly treated and educated are able to make great strides to regaining their health and quality of life.

Recently, the US Centers for Disease Control and Prevention published a patient educational bulletin that Dr. Kokinos shares with her patients as part of re-educating them to live a healthier life and to recognize the symptoms of Peripheral Vascular Disease. As part of her continuing efforts to educate her patients, she wanted to share this handout, written and published by the CDC for patients following her blog to read.

Please click on the link below to receive this CDC authored bulletin in the hopes that you too can begin to live a healthier life and become aware of the signs of peripheral vascular disease.

https://www.cdc.gov/heartdisease/pad.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdhdsp%2Fdata_statistics%2Ffact_sheets%2Ffs_pad.htm

If you or anyone you know suffers from peripheral vascular disease call today to schedule an appointment at 408-376-3626.

LEG SWELLING FOLLOWING COSMETIC VEIN OR BACK SURGERY

Posted on by Angelica Rodezno

Every year thousands of patients in the US undergo cosmetic vein procedures in the hope of getting rid of their swollen legs and unsightly varicose veins. In like manner, many patients having back surgery also suffer from swollen legs following their surgery. Unfortunately, in a large percentage of these patients, a well known but often unrecognized and undiagnosed condition know as Iliac Vein Compression is the cause of this unexpected complication. Further complicating this issue is that even when the procedure is successful, patients complain of on-going leg swelling, heaviness, and pain in their legs.

Internet searches for, “Why do my legs continue to swell following my varicose vein or back surgery?” are everywhere on the internet and lead many patients to simplified, incomplete answers. Confused, patients return to their primary care or specialist seeking answers to their questions and are told that leg swelling is a known complication of this kind of procedure and that they must learn to live with this complication. Patients are left in a difficult position where they continue to suffer and have no answers for what to do next

Over the past 5 years, significant advances in medical imaging and device technology have given Vascular surgeons new ways to treat leg swelling. Today, with the help of this new technology, trained vascular surgeons are able to restore normal blood flow to the lower legs in a straightforward, outpatient procedure that has led to significantly better outcomes than ever before possible.

Dr. Kokinos, a board certified vascular and general surgeon, is a nationally recognized expert in treating a medical condition known as iliac-vein compression or May Thurner’s disease. In her nationally accredited ambulatory surgery center located in Campbell, CA. Dr Kokinos has performed over 250 IVUS procedures (a specialized intravascular ultrasound scan) to evaluate for and to treat this disease. Dr. Kokinos is a highly sought after expert in this area of vascular surgery and has has presented her findings at pre-eminent vascular surgery conferences in Miami, Fl. OEIS, San Francisco Vascular Surgery meetings and in Cypress, Greece where she has spoken to global audiences about her work in the care and treatment of patients suffering from swollen legs.

If you or anyone you know suffers from swollen legs, especially left leg swelling, have been diagnosed with a DVT (blood clot), or experiences leg swelling, excessive pain following a cosmetic vein procedure (EVLT, Laser Sclerotheraphy etc.) or back surgery ask your physician to speak with you about May-Thurner’s disease and Iliac Vein Compression.

At South Bay Vascular Center and Vein Institute we can help fix your swollen, achy legs and can help you “Get Back Your Life”.

If you or anyone you know suffers from a swollen leg following a cosmetic vein or back surgery, give us a call at 408-376-3626 to schedule an appointment.