Vascular surgery, says Saint Francis Hospital and Medical Center surgeon Kristofer A. Bagdasarian, MD, is a constantly evolving field. “New technologies keep improving our ways of doing things – and our outcomes,” he says.
Dr. Bagdasarian, who has been performing vascular surgery at Saint Francis since 2012, says he was attracted to the field because he liked the intricacy of the procedures and was excited by new endovascular techniques being introduced at the time he was training. “Endovascular surgery is a way of performing surgery through the blood vessels with little catheters, balloons, and stents under the guidance of x-ray,” he explains. “It is a much less invasive way of doing vascular procedures.”
Dr. Bagdasarian says his early exposure to surgery – both his father and his older brother are surgeons here in Connecticut – predisposed him toward that specialty. “I also enjoyed the immediacy of results that surgery offered patients,” he says.
After completing college and medical school at Tufts University in Boston, Dr. Bagdasarian did his general surgery residency in his home state of Connecticut, at the Hospital of St. Raphael/Yale University School of Medicine in New Haven. He then completed a vascular surgery fellowship at the Robert Wood Johnson University Hospital in New Brunswick, New Jersey (Rutgers).
“It feels good to be back and serving the population that I grew up with,” he says.
Dr. Bagdasarian treats a wide range of vascular conditions, spending about 80 percent of his time diagnosing, treating and managing conditions affecting the arteries, and about 20 percent on problems affecting the veins. His clinical interests include aneurysm repair, and surgical treatment of carotid artery disease, peripheral artery disease (PAD), and varicose veins.
Most people have heard of brain aneurysms, but an aneurysm – which is an enlargement of an artery – can also occur in other parts of the body, like in the arteries in the legs, or in the aorta, the main artery that carries blood away from the heart and to the rest of the body. “If an aneurysm gets too large, it can rupture,” says Dr. Bagdasarian. “A ruptured aortic aneurysm is probably the most deadly because it’s the body’s main – and largest – artery.”
Many people have aortic aneurysms, he notes, but vascular surgeons don’t typically fix them until they reach a certain size or become symptomatic. “For every one I fix, I am following 10 people because they have aneurysms that haven’t reached the threshold where they need to be fixed.” On the other hand, some patients come into the hospital with already-ruptured aneurysms. “That’s an absolute emergency,” he says.
Symptoms of a thoracic aortic aneurysm, that is, one that occurs in the upper part of the aorta, might include chest and back pain; patients with an abdominal aortic aneurysm would more likely experience abdominal or low back pain, he says. Risk factors for aneurysms include age (the older you are, the more likely you are to have an aneurysm), family history, high blood pressure, and smoking.
According to Dr. Bagdasarian, about 85 to 90 percent of aortic aneurysms can be fixed with an endovascular stent graft. A stent graft typically consists of an expanding frame that is covered with a flexible polymer material, and in effect, reinforces – and seals – the wall of the vessel.
“Instead of traditional open surgery, where we’d open someone’s chest or abdomen and surgically sew in a new aorta, this is a procedure through a little catheter where we can basically reline the aorta from inside the artery,” he says. “Obviously, this is much less invasive to the patient. You’re basically putting a new graft on the artery from the inside.”
Though Dr. Bagdasarian points out that endovascular aneurysm repair technically dates back to the 1990s, he says that the grafts continue to grow more and more advanced, allowing surgeons to treat complex aneurysms in locations that were previously not amenable to this treatment – like at a juncture where there are branch vessels coming off the aorta.
“I’m doing things now that just a few years ago we couldn’t do,” he says. Fenestrated endovascular repair, for example, allows surgeons to implant custom-built aortic grafts that are manufactured individually to fit a patient’s anatomy.
“My partners and I are still very adept at open aneurysm repair when that’s needed,” adds Dr. Bagdasarian, explaining that sometimes an aneurysm is not amenable to a graft because there are too many anatomical challenges for the current devices.”
Dr. Bagdasarian also uses endovascular stent grafts to treat aortic dissections, a tear in the wall of the aorta that results in bleeding between the layers of the blood vessel walls and can eventually lead to an aneurysm.
Treating carotid artery disease; preventing stroke
The carotid arteries are the two main vessels that carry blood and oxygen to the brain. They are located on either side of the neck. “Carotid artery disease, which refers to the build up of plaque within the carotid arteries, is one of the leading causes of strokes,” says Dr. Bagdasarian. “If patients have a severe narrowing in one of these arteries, or if they actually have a stroke, we oftentimes have to operate.”
The gold standard for this surgery, according to Dr. Bagdasarian, is still an open surgery called a carotid endarterectomy, in which the surgeon cuts open the vessel, literally cleans out the plaque, and then, instead of just sewing the two pieces of the artery back together, sews in a flexible patch made of bovine heart tissue to widen the vessel. Newer endovascular approaches can be used to put stents in the carotid arteries of patients who are not candidates for open surgery, such as older patients, or people who have had previous neck surgery or radiation to the neck.
Risk factors for carotid artery disease are the same as those for atherosclerosis, or narrowing, of the coronary arteries: age, smoking, high blood pressure, high cholesterol, diabetes, family history, and obesity.
“Just as with aortic aneurysms,” says Dr. Bagdasarian, “we manage the majority of these patients medically (i.e. with statins), and only operate when the condition becomes very severe or symptomatic.” That is, if a patient has a stroke or a ministroke, also known as a transient ischemic attack, or TIA. Unlike a stroke, where blood flow to the brain is restricted for long enough that an area of brain tissue dies off, a TIA occurs when there is temporarily reduced blood flow, but circulation returns to normal.
Problems in the peripheral vessels
In contrast to carotid artery disease, peripheral artery disease (PAD) occurs when plaque builds up in the arteries leading to the arms and legs. The result: poor circulation to the limbs, which can ultimately lead to ulcers, decomposition, and even amputation. Risk factors are the same as for carotid artery disease. Diabetics are especially susceptible, and because they often have decreased feeling in their fingers and toes, might not realize that they have poor blood flow or ulcers until the problem is at an advanced stage.
Surgical options for PAD include bypass surgery, which is the traditional open technique, and newer endovascular approaches, in which surgeons can open arteries with a balloon or stent. Dr. Bagdasarian and his partners are currently participating in an international trial comparing endovascular surgery to open surgery in certain PAD patients.
Dr. Bagdasarian also performs surgery to repair varicose veins, enlarged and swollen veins that can cause pain and swelling. “Years ago, doctors did something called vein stripping, where they surgically removed – or stripped – the veins out,” he says. “But this has been replaced by a technique called endovenous ablation, a technique where through a series of catheters and small endovascular surgery, we can close the veins off with no incision and no major surgery,” he says. “The advantage is that postoperative pain and recuperation is much, much less.”
Saving – and improving – lives
Other surgical procedures in Dr. Bagdasarian’s arsenal include arterial and venous thrombolysis, in which clot-dissolving medication is guided through a catheter using x-ray imaging to the site of a blood clot to eliminate the blockage, and the creation of arteriovenous fistulas in patients with kidney failure, which widens a vein in the arm by connecting it to a nearby artery, improving blood flow and making it easier for doctors to insert a needle for dialysis.
“The most rewarding thing about vascular surgery is being able to do these surgeries that save people’s lives or improve their quality of life,” says Dr. Bagdasarian, “and the results oftentimes are immediate, so it’s very satisfying.” The challenging part, he says, is that “despite your best efforts, patients can have bad outcomes, because these are very sick patients, most of whom have heart disease, high blood pressure, and diabetes.”
When Dr. Bagdasarian isn’t working, he, his wife Jenny, a pediatrician, and their daughter Isabelle enjoy travelling, skiing, swimming, and visiting with nearby family.
Lori Miller Kase is a freelance writer living in Simsbury.
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