I have not written for a while because so much of my time out of work is spent on appealing denial of payments by Novitas, the Medicare administrator for Texas.  They have denied care for patients who have had treatments that are considered as class 1 evidence for management by all the major vascular societies, including the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation, and Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).  In 25 years of doing this work, I have never encountered such nonsense.  I thought I was the only one going through this trouble.  Then I find out that a cardiology colleague of mine in South Dallas has the same issue.  By word of mouth, I talked to a cardiologist in Illinois who just went through the same  problem.  I bet there are more physicians that are being inappropriately denied payment for standard of care by Novitas.  Nothing against the profession, but I found out my cases were reviewed initially by a licensed vocational nurse (LVN).  Hell, even many physicians don’t fully understand what we do and why.  To add fuel to the fire, apparently Novitas keeps 12% of the amount of money that they recoup from physicians such as myself as a bounty.  When I reviewed a case with one of the Novitas nurses early in the course of this appeal, she told me “Well you know sometimes people need to have an amputation of their leg rather than an attempt at limb salvage.”  THERE IS SOMETHING GOING ON HERE, AND I WOULD LOVE TO HEAR FROM OTHER PHYSICIANS, BILLING PEOPLE, AND HEALTHCARE PROVIDERS ABOUT THEIR PROBLEMS WITH NOVITAS OR ANOTHER MEDICARE ADMINISTRATOR.

Carotid Artery Stenosis and Stroke, Part 2

Someone asked me to wrote more about carotid artery disease, so here goes.  We see a large number of patients with carotid artery stenosis.  Next to aneurysms, I don’t think that there is any other medical condition that raises more anxious feelings for patients.  The paired carotid arteries supply  the left and right side of the brain.  There are ale smaller arteries that supply the back of the brain named the vertebral arteries, and there is a communication between the 2 systems within the brain called the Circle of Willis.  But the dominant supply to each side of the brain is via the carotid artery.  Blockages in the carotid artery can lead to strokes.  The typical symptom of a stroke are loss of motor control on one side of the body versus the other, loss of speech ability, and loss of vision in one eye versus the other.  Stroke symptoms do not cause pain, and vague symptoms such as dizziness and vertigo are not typical of strokes (unless it occurs in a certain area of the brain that control balance).

The typical risk factors for carotid artery disease are the same as for other cardiovascular diseases, namely cigarette smoking, high blood pressure, high blood sugar, high cholesterol, age and family history. Age and family history you are stuck with.  If Dad or Mom had heart disease and strokes at an early age, then unfortunately you are probably at a higher risk.  But the other risk factors are able to be controlled with medication if needed, or diet and exercise and smoking cession.

Most people with carotid artery disease never have symptoms.  In general, the higher the degree of narrowing, the greater the risk of symptoms.  Sometimes, you can have what is called a Transient Ischemic Attack (TIA) or mini-stroke, and at other times you might have a full blown stroke.  The difference between the two is that a TIA resolves within 24 hours, while a stroke last greater than 24 hours.  We don’t know which event is going to occur, if it does occur. We just know if you have a TIA, and you have significant carotid artery narrowing, your risk for a full blown stroke is a lot higher.

Most patients with carotid artery stenosis do not need surgery.  We emphasize controlling the risk factors, as well as smoking cessation.  I advocate an anti-platelet agent such as Plavix or aspirin, and close follow-up.  We used to be much more aggressive with carotid stenosis in terms of surgical management years ago.  However, in the era of anti-platelet agents such as Plavix, as well as statin drugs to control cholesterol level, and much better management of diabetic patients by our family practice and medical colleagues, the role for carotid artery intervention has diminished.  The options for management of carotid stenosis include carotid surgery where the blockage is cleaned out versus carotid artery stenting where the blockage is essentially reopened with a stent.  There is an ongoing debate about which technique is better for patients.  I suspect the answer is going to be dependent on the patients age, and anatomy, as well as other cardiovascular issues such as heart disease.

I dont think there is any doubt that if you have a TIA or a stroke with good recovery, and you have severe carotid artery narrowing on the side of the stroke, that you would benefit from carotid artery intervention to reduce further strokes.  What is less settled to me in the modern era is what should be done for patients with moderate to severe carotid artery disease (greater than 60% narrowing) who do not have symptoms of TIA’s or strokes.  There are carotid stents or carotid surgeries being performed for that condition (so called asymptomatic carotid stenosis), but the data is not clear in my mind of the benefits of the intervention versus the risks.  Thats what this whole business is about, balancing the risks versus benefits of every intervention we do.

Eating Right

I was trained the same way most physicians are trained in nutrition, and I suspect the same way that most other people in the health care industry are indoctrinated.  For years, I thought the equation for weight was simple.  Input equals output.  If your input in terms of calories are greater than your output, then you gain weight.  If your output was greater than your input, you lost weight.  Simple.  I recited the food pyramid to my patients diligently, and suspected that most people who thought they were following the correct diet and who did not lose weight were really not as strict as they thought.  If they only counted calories, they would lose weight.  I was the typical 35% cards, 35% protein, 30% fat diet guy.  When I started to hack my own diet and exercise, I discovered that at least for me, what I had been taught was all wrong.  Now I eat at least 50% of my calories from fat, and approximately 30-35% protein, with the rest being carbs.  I don’t eat bread or pasta.  I eat sweet potatoes only on a leg or back workout day (large muscle groups).  I have lost body fat, my waist size is less than 30 inches, and I am 56 years old (soon to be 57). Turns out there is new science validating some of this information.  As we get older, the body does not like to let go of fat.  You have to trick it into thinking there is lots of fat around.  It really works.  If you are a male in your 40’s or older, change the way you eat.  Combine it with variations of high intensity interval training.  You will feel better, and you will lose the body fat.  I should add I suspect the situation is more complex for women.

Peritoneal Dialysis

Another option that has been around for a long time, but is gaining increasing traction is peritoneal dialysis (PD).  PD is a method of cleaning the body of the toxins and waste products that are normally eliminated by the kidneys.  PD depends on diffusion, or the exchange of material along concentration gradients.  PD depends on the large surface area of the peritoneal cavity.  The peritoneal cavity is the space under your abdominal muscles and chest that hours the intestines and other organs.  In order for a patient to do PD, we have to insert a PD catheter into the peritoneal cavity and begin it out of the side of the abdomen.  This is an outpatient surgical procedure that takes about 45-60 minutes to perform and is not a very painful surgery.  The incisions are allowed to heal for about 2 weeks prior to the PD catheter being used or dialysis.

In essence, a large volume of dialysis fluid is placed into the abdominal (peritoneal) cavity, and allowed to dwell form some time, usually overnight.  During that time frame, due to the difference in the difference in concentration of electrolytes and other substances in the fluid as compared to the body, there is an exchange of products.  The fluid that was placed into the peritoneal saps a lot of the bad products that the kidneys would normally remove. This fluid is then drained out the next morning, resulting in “cleaning of the blood”, much like regular hemodialysis.

The good thing about PD is that is is much more physiologic than hemodialysis, meaning that it is gentler on your body because of the slower nature of the exchange.  The downside is that you have a piece of plastic tubing hanging out of your body, and you have to make adjustments to your lifestyle for it.  The other major risk of a PD catheter is the chance of infection.  An infection of the peritoneal cavity is called peritonitis, and can sometimes be treated with antibiotics in the dialysis fluid.  If the infection is severe, particularly if it s fungal infection, the catheter needs to be surgically removed in order to clear the infection.

PD requires  specialized training by peritoneal dialysis education centers, because it needs to be done correctly in order to reduce the chance of infection and other potential complications.  Patients who are significantly overweight, or who have had multiple pelvic or abdominal surgeries generally do not do as well with PD.

Dialysis Access, or What You Need To Be On Hemodialysis

Kidney failure that is permanent is called chronic renal insufficiency.  There are 6 stages to kidney failure,.  When you get to stage 5, you are much closer to ending dialysis. Your kidney doctor (nephrologist) will decide with you when its time to start dialysis.  When to start dialysis really depends on a constellation of your symptoms (shortness of breath, nausea and loss of appetite, leg swelling) as well as the lab work.  In general, when you kidney function is heading down below 10-12%, you are getting close to needing dialysis.

There are two ways of dialyzing, namely hemodialysis (blood dialysis) and peritoneal dialysis (dialyzing with a catheter that is placed in your abdominal cavity).  We are going to deal with hemodialysis today.  In order to have hemodialysis, you have to have a way to take the “dirty” blood out, pass it through the kidney machine, and then put the “clean” blood back into your circulation.  This can be achieved by wants called an arteriovenous graft (AVG) or an arteriovenous fistula (AVF).  Simply defined, an AVG is where we put a prosthetic material to connect an artery to a vein, and an AVG is when we connect one of your veins directly to an artery.  Essentially, we are creating a high flow conduit that can accessed for pulling blood out of the circulation, and retiring it after putting the blood through the kidney machine.

An AVF is the best way of creating a dialysis access.  When we create an AVG, we don’t put any prosthetic material into your body.  We connect a vein in your arm to an artery, and create a low resistance pathway for blood to flow.  Remember arteries bring blood down to the hand and veins take blood back up.  When we sew a vein onto an artery, part of the blood flow that is going down the artery goes immediately back up the vein. In time, the vein gets bigger, and develops a stronger thrill (a “buzzing” feeling or vibration that you feel when you put your fingers over that area due to the rapid flow of blood in an elastic vessel).  Fistulas can be created in the forearm at the wrist or in the upper arm.  We always perform a preoperative ultrasound evaluation of the veins to assess the ideal site for creating the AVF, and I usually repeat the ultrasound at the time of surgery to conform the preoperative evaluation.  The surgery itself takes about an hour to perform as an outpatient, and is not particularly painful. Once you recover from the surgery discomfort, you can use your arm like normal, including weight lifting and exercising.  The advantage of the fistula is that is tends to last longer without clotting, and has a very low risk of getting an infection.  The downside of an AVF is that is takes 6-8 weeks to “mature” or get ready to use, and sometimes needs a revision because of narrowing in the fistula, or development of large side branches that steal blood from the main body of the fistula.

If your veins are small or scared up from previous blood draws or I.V’s we sometimes will use prosthetic material to create the connection between the artery and vein.  The most commonly used prosthetic material is polytetrafluoroethelene (PTFE).  In essence, we create a pathway for dialysis by tunneling the PTFE under the skin in a straight line o a loop to connect an artery that supplies blood to the vein that takes blood back.  The surgical site has to heal for 2-3 weeks before it can the used.  In this situation, blood is taken out of the PTFE on the “arterial side” and returned after passing through the dialysis machine on the “venous side”.  The advantage of an AVG is that is can be used within 2-3 weeks.  the disadvantage is that it tends to clot more often and may have to  be declotted, and it has a higher risk for infection.

The reason your nephrologist refers you to us as vascular surgeons before you might need to start dialysis is so that we can create an AVF or AVG well ahead of time. If you don’t have an AVF or AVG ready to use, and you need to start dialysis, we have to place tunneled catheters that hang out of your skin to use for dialysis immediately.  It has 2 openings or ports, one to pull blood out and put it into the kidney machine, and the other to return the cleaned blood back to the circulation.  Remember, there is nothing hanging out of you with an AVG or AVF.  Tunneled catheters are what we would like to avoid if at all possible.  First of all, its a nuisance having a piece of plastic tubing having out of your chest area.  you can’t shower properly, and it hangs up on your clothes, and can sometimes be accidentally pulled out.  But the bigger concern is that it is a piece of plastic tubing that is tunneled under your skin that ultimately ends up inside one of the main veins that drains towards the heart.  It is an invitation to getting an infection. If we place these tunneled catheters (sometimes called permacaths), we would like to remove them as soon as possible to avoid the potential complications.  That why it is far better to have an AVF created way ahead of time, even if you don’t need dialysis for 6 months, so that it will be ready for you when you need to start hemodialysis.

One final word on hemodialysis.  Typically, you need to go to the dialysis center 3 times a week for 4 hour sessions of dialysis.  However, more and more patients are able now to get dialysis machines at home, and so home hemodialysis is becoming a good option. I will discuss peritoneal dialysis at a later time.

Maktub-Air of Resignation or Sound Advice?

One of the words that really interested me in The Alchemist by Paulo Cuehlo was the Arabic word “Maktub” which apparently means “so it is written.”  I think it really loses it full flavor when translated from the Arabic.  Even the pronunciation of the word gives it more meaning than you can get by literal translation, but I guess thats what you lose when you translate one language to another.  All the pronunciations of the word I can find on the internet sound like an American or European reading the word MACK-TUB.  I would love to hear it from an Arabic speaking person to get the full flavor.

Does the word mean “so it is written” as in “there’s nothing you can do about it” or does it imply “young man or women, take life one step at a time.”  I would prefer it to imply the latter, but thats probably my own personal bias.  Life seems much more hectic than it used to be.  Every event and statement has taken on an air of so much importance and relevance.  But perhaps as Charlie Munger might ask “what is the incentive for these peoples motivation and behavior?” I tell my kids there are only 3 or 4 really important things or events in life, kind of like the 10X inflection points that Andy Grove wrote about.  These include controlling your mind and thinking, when and to whom you get married, and when and if you have children.  A loving atmosphere at home is the foundation for your life.  The rest of it is probably nonsense.  The other thing I tell my kids is what my Dad told me years ago, and it has always stuck in my mind.  He said “I can tell you about a man by the people he hangs out with.”  Thanks Dad, that was good advice.