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Lee Kirksey, MD  
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Cleveland , OH

Specialties: Peripheral Arterial Disease, PAD

Interests: vascular, specialist, treatment options
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Abdominal Aortic Aneurysm-treatable but underdiagnosed vascular disorder

Oct 04, 2014 - 6 comments
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penis spot aaah help

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abdominal aneurysm

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abdominal

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abdominal aortic aneurysm

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aortic

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aortic aneurysm

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aneurysm

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Lee Kirksey

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vascular surgeon

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Cleveland Clinic

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lee kirksey md

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thoracic aneurysm

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expert vascular surgeon



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Abdominal Aortic Aneurysm (AAA) is an abnormal enlargement of the aorta at a level below the blood vessels to the kidneys or renal arteries. AAA are generally without symptoms, or asymptomatic, until it arises to a size where its associated with abdominal or back pain. These symptoms arise from stretching of the sensory nerves within the wall of the enlarging aorta. As a general comment, a symptomatic aneurysm suggest impending rupture and merits immediate medical evaluation which frequently leads to surgery.

Unfortunately, because the aorta is located in the retroperitoneum , the blood vessel frequently reaches a large size when it remains asymptomatic. AAA that rupture are associated with an 80-90% out of hospital mortality. A patient who survives to make it to the hospital and to the operating room has a 50% mortality within 30 dys operation. This mortality is a reflection of the risk of heart attack, stroke, pulmonary infection, and renal failure.

Risk factors associated with AAA formation include a 20:1 M:Fdistribution, more common in Caucasians, non diabetics, smokers and first degree relatives (regardless of gender) of patients who have an AAA.

To this end, early diagnosis permits monitoring and planning for repair of the AAA when it reaches a threshold of 5.5cm. The rationale is that the risk of rupture before a patient reaches this threshold is quite low (but not zero). In a scenario of a patient with a AAA< 5.0 centimeters the aneurysm is usually monitored at 6-12 month intervals with US or CT imaging.

Currently 70% of AAA can be treated with a minimally invasive device called an aortic stent graft. This allows the aneurysm to be treated via small groin or puncture site. This approach is in comparison to the Open repair of an aneurysm. Open repair first done in the early 1950's is performed through a midline incision from the ribcage down to the bladder area.


The minimally invasive procedure or (EVAR) is associated with shorter lengths of hospitalization, decreased blood loss and high patient satisfaction. Improvements in technology have resulted in a greater number of abdominal aneurysms that can be treated with EVAR.  The drawback with EVAR is that 20-30%, will develop a secondary intervention that requires a secondary revision. Most revisions can be done via an endovascular route. However, a subpopulation of patients will require open repair of their AAA with explantation of the stent graft.

If you or your family member have been diagnosed with a AAA, seek an opinion on management options from a Board Certified Vascular surgeon





Treatment Resistant Hypertension and Renal Denervation

Dec 27, 2013 - 3 comments

Hypertension affects 78 million adults in the US. According to national data 82% of those with hypertension are aware that they have it. 75% are being treated but on 50% are under control. The degree of control is variable across different groups. Effective blood pressure control is essential to the successful reduction of heart attack, stroke and renal failure risks.

Importantly, of those control over 85% report having a usual source of health care and having insurance. Given the importance of this issue, the American Heart Association has made this a primary focus area of its 2014-17 campaign with a goal to reduce the death rate from heart attack and stroke by 20% in 2020.

Achieving this goal will require a mulipronged approach directed at systems changes, care provider education to ensure compliance with best evidence treatment approaches, and effective patient engagement to stimulate the highest level of patient education and participation.

http://millionhearts.hhs.gov/resources.html

Still, up to 20% of patients may have poorly controlled blood pressure despite being on three agents at maximally tolerated dosages, one of which is a diuretic. In this group of patients, the risk of heart attack, heart failure, stroke and renal failure are up to 3 times greater. Renal artery sympathetic ablation or renal denervation, represents a technology with potential benefit to better control blood pressures in this challenging group.

Research has shown that patients with this problem suffer from higher circulating levels of norepinephrine levels which are regulated by the nerves to and from the kidney. These nerves are also responsible for regulating salt and water absorption and blood vessel tone. Increased salt absorption and increase vascular constriction both elevate blood pressure.

Selectively interrupting these nerve pathways causes a reduction in blood pressure. The SimplicityI 1 Trial showed a reduction of 30/17 at one year which continued out to 3 years in a subset of patients followed out that far.
84% of patients responded.

The next level of studies will be better controlled with a placebo arm (patients not receiving the treatment to reduce the impact of the "placebo affect"). The trial will also have larger numbers.  The questions that remain to be answered include who it works in and just as important, who doesnt it work in. Are there any mid and long term side affects on artery integrity.

For a patient group that has limited options and significantly elevated stroke and heart attack risk--denervation trial enrollment represents an important immediate and future treatment option.



Renal Denervation for Severe Drug Resistant Hypertension

Dec 12, 2013 - 2 comments
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hypertension

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drug resistant

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renal denervation

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atrial

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Cleveland Clinic



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High blood pressure or Hypertension is a leading cause of heart attack and stroke in the US and worldwide. The World Health Organization has identified hypertension as the most important risk factor for all cause mortality accounting for about 12% of the attributable hazard for death in the world. Currently, one third of American adults suffer from hypertension with that number expected to increase to one in two over the coming decade. Beyond the cardiovascular risks, end organ injury to the heart and kidneys can also result in systolic heart failure, chronic kidney disease and even end stage renal disease requiring dialysis.

It is estimated that up to 50% of those suffering hypertension have inadequate control. The causes of poorly controlled hypertension range from lack of access to healthcare, to patient noncompliance or physician noncompliance.

Other causes of poorly controlled hypertension are related to correctable secondary issues including:
Pheochromocytoma, Hyperaldosteronism, Cushing Syndrome, Hyperparathyroid, Hyperthyroid, Coarctation, Aortic Coarctation, Sleep apnea, NSAIDS, OCP.

Finally, an important and sometimes overlooked cause of hypertension is “white coat phenomena” in which patients experience high blood pressures while in the providers office only.  Typically, the patient can be evaluated with an ambulatory monitor for 24 hours which will verify that the blood pressure is normalized outside of the office.
As secondary causes of hypertension are evaluated and ruled out, most patients are placed on a heart healthy low sodium diet and optimized on a medication regimen if necessary. Despite these efforts a subgroup of hypertensive patients, from 5-20%, will continue to have suboptimal control of their blood pressure while maintained on 3 antihypertensive agents of different classes at maximal tolerable doses.  Studies suggest that this group of patients carries a long term higher risk of cardiovascular complications.

A growing body of recent research suggests that selective renal artery denervation using radiofrequency ablation causes reductions in blood pressure which may over time translate to fewer cardiovascular complications in affected patients.  Renal artery denervation is currently not FDA approved for use in the United States. Ongoing investigational trials (See ReduceHTN, Boston Scientific) hope to confirm earlier studies suggesting that the procedure is safe with a low rate of complication and the earlier data showing that reductions in blood pressure are consistent, reproducible and sustained.

Current renal denervation systems involve the catheterization performed from the groin region. Angiographic images are obtained of the renal arteries. A wire is then inserted into the renal artery and an ablative catheter threaded over that wire and carefully positioned with XRAY guidance in the blood vessel. The procedure is identical to commonly performed angioplasty.  

The catheter then delivers a safe degree of heat through electrodes positioned on the balloon at carefully selected locations.  The heat is able to destroy nerves that course along the outside and within the mid wall of the blood vessel-without causing any damage to the artery wall. The heat is delivered over 2 minutes. Because heat is applied, the patient is given intravenous sedation to minimize discomfort during the procedure.

Following the procedure, the patient is monitored and able to go home the following day.  The effect is not immediate. Over time however, the blood pressure begins to lower. Early studies show a reduction of 27/17 over 12 months and this reduction appears to be sustained in patients followed out to 3 years.
The important implication of this study is that in patients most severely affected by hypertension in which few options were previously available, an option now exists for reducing blood pressure. We know that reducing the blood pressure 20/10 can reduce that risk of heart attack and stroke by 50%.

In summary, renal artery denervation holds significant promise for reducing morbidity in drug resistant hypertensive patients. Further research is needed to determine in which patients the intervention works best in.






























Do medical innovations always improve patients outcomes-Controlling healthcare costs

Jul 27, 2013 - 1 comments
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Lee Kirksey

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vascular surgery

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Cleveland Clinic

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Holistic Health

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Stroke

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Heart Attack

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limb salvage



The Medical device and healthcare industry like other industries in a capital market are driven by profit.  In the ideal scenario, the techology, provider and financial backer for a product or technology would be rewarded for  innovation which improves patient outcome. Unfortunately, that is increasingly less common and a new New York Times article suggests that up to 40% of established medical practices when studied show no benefit and may even be harmful.

In vascular surgery, one example is the use of arterial stents. It makes intuitive sense that if a patients has a study performed which reveals a blood vessel to be blocked--the blockage should be opened to make the patient better.  The reality is, that it requires clinical judgment. Merely the presence of the blocked blood vessel is less important than eliciting a careful history which discerns the symptoms, if any, that a patient is experiencing.

For example, a patient with none or very mild symptoms might be better off with serial monitoring and no procedure.  What's known is that the performance and durability of stents varies depending upon what blood vessel they are placed within.  In some vessels the risk for restenosis of occlusion of the stent within 12-24 months approaches or exceeds 50%. In some cases when this occurs, the patient may actually get worse symptoms than they started with. So in many cases it requires prudent judgment by the physician to determine if this procedure is actually warranted.  And in a situation where there is a perverse incentive for the physician to do more, the set up can predictably lead to more procedures. Especially as procedures become less invasive and less risk to perform, the threshold for doing them may be lowered.

In some areas, we see a rapid escalation in the number of procedures done as new technology is introduced and patient demand begins to drive the utilization. Many times before long term studies are performed in different patient types. This can lead to significant increased and wasteful healthcare expenses. All with no real long term benefit to the patient.

Unfortunately, sometimes referring physicians actually feed into this process by telling patients that they need a treatment or surgery without the referring physician necessarily understanding the nuances of the decision making process. The patient shows up saying " I trust my doctor and he said that I need this procedure"

One major benefit of the Cleveland Clinic physician compensation model is that all physicians are employed and not compensated on a per case productivity scale. In theory, I make as much money if I dont do a procedure so I dont have pressure to produce. I don't have to persuade myself subconciously that because something is minimally invasive, it should be done.

From the NY Times:

We usually assume that new medical procedures and drugs are adopted because they are better. But a new analysis has found that many new techniques and medicines are either no more effective than the old ones, or worse. Moreover, many doctors persist in using practices that have been shown to be useless or harmful.

Scientists reviewed each issue of The New England Journal of Medicine from 2001 through 2010 and found 363 studies examining an established clinical practice. In 146 of them, the currently used drug or procedure was found to be either no better, or even worse, than the one previously used. The report appears in the August issue of Mayo Clinic Proceedings.

More than 40 percent of established practices studied were found to be ineffective or harmful, 38 percent beneficial, and the remaining 22 percent unknown. Among the practices found to be ineffective or harmful were the routine use of hormone therapy in postmenopausal women; high-dose chemotherapy and stem cell transplant, a complex and expensive treatment for breast cancer that was found to be no better than conventional chemotherapy; and intensive glucose lowering in Type 2 diabetes patients in intensive care, which not only failed to reduce cardiovascular events but actually increased mortality. source