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. ~ . ~ SOCIETY OF . '" INTERVENTIONAL"- FACT SHEET RADIOlOGY . Enhanced care through advanced techlZology~ Conta.ct: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 Suite 500 Fairfa x, Virginia st 22030 Interventional Radiology is 21 Century Medicine 703.691.1805 703.691.1855 fax Interventional radiology is a rapidly growing area of medicine. Interventional radiologists are www.sirweb.org physicians who specialize in minimally invasive, targeted treatments performed using imaging infoa>sirweb.org for guidance. Interventional radiology procedures are an advance in medicine that often replace open surgical procedures. They are generally easier for the patient because they involve no large incisions, less risk, less pain and shorter recovery times than open surgery.
What is Interventional Radiology?
Interventional radiology is the medical specialty devoted to advancing patient care through the innovative integration of clinical and imaging-based diagnosis and minimally invasive therapy.
Who Are Interventional Radiologists?
Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X-rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in minimally invasive interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training.
How Did Interventional Radiology Develop?
The improved ability of radiologists to see inside the body gave rise to interventional radiology (IR) -- minimally invasive targeted treatments performed under imaging guidance -- in the mid 1970s. Interventional radiologists invented angioplasty and the first catheter-delivered stent, which was first used in the legs, to save patients with vascular disease from amputation or other surgery. These advances pioneered modern medicine and gave rise to the state-of-the-art treatments that are common place today. Interventional radiology is a medical specialty recognized by the American Board of Medical Specialties and the American Medical Association.
What Are the Advantages of Interventional Radiology?
• Most procedures can be performed on an outpatient basis or require only a short hospital stay. • General anesthesia usually is not required. • Risk, pain and recovery time is Often significantly reduced. • The procedures are sometimes less expensive than surgery or other treatments.
Where Is Interventional Radiology Headed in the Future?
As technology advances and high-quality imaging equipment becomes more widely available, interventional radiology is able to offer patients and referring physicians a host of new treatment options.
Common Interventional Procedures
Angiography An X-ray exam of the arteries and veins to diagnose blockages and other blood vessel problems; uses a catheter to enter the blood vessel and a contrast agent (X-ray dye) to make the artery or vein visible on the X-ray.
BaHoon angioplasty Opens blocked or narrowed blood vessels by inserting a very small balloon into the vessel and inflating it. Used by IRs to unblock clogged arteries in the legs or arms (called peripheral vascular disease or PVD), kidneys (called portal hypertension), brain, or elsewhere in the body.
Biliary drainage and Uses a stent (small mesh tube) to open up blocked ducts and stenting allow bile to drain from the liver.
Central venous access Insertion of a tube beneath the skin and into the blood vessels so that patients can receive medication or nutrients directly into the blood stream or so blood can be drawn.
Chemoembolization Delivery of cancer-fighting agents directly to the site of a cancer tumor while depriving the tumor of its blood supply; currently being used mostly to treat cancers of the endocrine system and liver cancers.
Embolization Delivery of clotting agents (coils, plastic particles, gel, foam, etc.) directly to an area that is bleeding, or to block blood flow to a problem area, such as an aneurysm or a fibroid tumor in the uterus.
FaHopian tube Uses a catheter to open blocked fallopian tubes without surgery; catheterization a treatment for infertility.
Gastrostomy tube Feeding tube inserted into the stomach for patients who are unable to take sufficient food by mouth. ,. Hemodialysis access Use of angioplasty or thrombolysis to open blocked grafts for maintenance hemodialysis, which treats kidney failure.
Needle biopsy Diagnostic test for breast, lung and other cancers; an alternative to surgical biopsy.
Radiofrequency ablation Use of radiofrequency (RF) energy to kill cancerous tumors.
Stent A small flexible tube made of plastic or wire mesh, used to treat a variety of medical conditions (e.g., to hold open clogged blood vessels or other pathways that have been narrowed).
Stent-graft Reinforces a ruptured or ballooning sect}on of an artery (an aneurysm) with a fabric-wrapped stent, a small, flexible mesh tube used to "patch" the blood vessel. Also known as an endograph.
Thrombolysis Dissolves blood clots by injecting clot-busting drugs at the site of the clot. Treats blood clots in the brain to reverse the effects of stroke; treats deep vein thrombosis in the leg to prevent permanent disability (economy class syndrome).
TIPS (transjugular A life-saving procedure to improve blood flow and prevent intrahepatic portosystemic hemorrhage in patients with severe liver dysfunction. shunt)
Uterine fibroid Uterine fibroid embolization, also referred to as uterine artery embolization embolization, is a minimally invasive interventional radiology treatment that cuts off the blood supply to the fibroids, causing them to shrink.
Varicocele embolization A treatment for "varicose veins" in the scrotum, which can cause male infertility and pain.
Varicose Vein Treatment The saphenous vein is sealed shut through the use of a laser or radio frequency non-surgically.
Vena cava filter A tiny cage-like device that is inserted in a blood vessel to break up clots and prevent them from reaching the heart or lungs. Prevents pulmonary embolism.
Vertebroplasty A pain treatment for fractured vertebra in which medical-grade bone cement is injected into the vertebra. SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through advanced techn o !ogy ~ Contact: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 Suite 500 Fairfax, Virginia 22030 Interventional Radiology Treatments for Liver Cancer 703.69t.t805 703.691.1855 fax About Liver Cancer www.sirweb.org info Historically, chemotherapy drugs are generally ineffective at curing liver cancer. Radiofreguency Ablation For inoperable liver tumors, radiofrequency ablation (RFA) offers a non-surgical, localized treatment that kills the tumor cells with heat, while sparing the healthy liver tissue. Thus, this treatment is much easier on the patient than systemic therapy. Radiofrequency energy can be given without affecting the patient's overall health and most people can resume their usual activities in a few days. In this procedure, the interventional radiologist guides a small needle through the skin into the tumor. From the tip of the needle, a tiny umbrella shaped array of thin wires opens within the tumor. Then a mild radiofrequency energy (similar to microwaves) is transmitted to the tip of the needle, where it is converted into heat. The umbrella shape allows the RFA device to heat and kill a precise round "ball" of tumor with very little risk of damaging adjacent normal structures, The dead tumor tissue shrinks and slowly forms a scar. Efficacy Depending on the size of the tumor, RF A can shrink or kill the tumor, extending the patient's survival time and greatly improving their quality of life while living with terminal cancer. RFA is not a curative treatment. Because it is a local treatment that does not harm healthy tissue, the treatment can be repeated as often as needed to keep patients comfortable. It is a very safe procedure, with complication rates on the order of 2 to 3 percent, and has been available since the late 1990s. By decreasing the size of a large mass, or treating new tumors in the liver as they arise, the pain and other debilitating symptoms caused by the tumors are relieved. While the tumors themselves may not be painful, when they press against nerves or interfere with vital organs, they can cause pain. RFA is effective for small to medium-sized tumors and emerging new technologies should allow the treatment of larger cancers in the future. RFA: • Is most effective when all the cancer is localized in the liver • Can be used to treat primary liver cancer and tumors that have metastasized (spread) from other areas in the body to the liver • Usually does not require general anesthesia • Is well tolerated. Most patients can resume their normal routine the next day and may feel tired for a few days • It can be repeated if necessary • It may be combined with other treatment options • It can relieve pain and suffering for many cancer patients Chemoembolization Chemoembolization is another minimally invasive treatment for liver cancer. Chemoembolization can be used when there is too much tumor to treat with RFA, when the tumor is in a location that cannot be treated with RFA, or in combination with RFA or other treatments. Chemoembolization delivers a high dose of cancer killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor. Using imaging for guidance, the interventional radiologist threads a tiny catheter up the femoral artery in the groin into the blood vessels supplying the liver tumor. The embolic agents keep the chemotherapy drug in the tumor by blocking the flow to other areas of the body. This allows for a higher dose of chemotherapy drug to be used, because less of the drug is able to circulate to the healthy cells in the body. Chemoembolization usually involves a hospital stay of two to four days. Patients typically have lower than normal energy levels for about a month afterwards. Chemoembolization is a palliative, not a curative, treatment. It can be extremely effective in treating primary liver cancers, especially when combined with other therapies. Chemoembolization has shown promising early results with some types of metastatic tumors. Prevalence of Liver Cancer Primary liver cancer: • According to the American Cancer Society, about 14,000 cases of primary liver cancer are diagnosed each year. The most common form is hepatocellular carcinoma (HCC). This is a tumor that begins in the main cells of the liver (hepatocytes). Primary liver cancer is twice as cornmon in men as in women. • HCC most frequently occurs in those who have a form of liver disease called cirrhosis. Cirrhosis occurs when the liver becomes diseased and develops scarring, usually over a period of years. The liver attempts to repair, or regenerate itself. This process can lead to the formation of tumors. In the United States, the most common causes of cirrhosis are chronic infection with the liver virus, Hepatitis B or C, or alcohol abuse. Gervais DA, Arellano RS, Mueller PR. Percutaneous radiofrequency ablation of nodal metastases. Cardiovasc lntervent Radiol. 2002 Nov-Dec;25(6):547-9 Callstrom MR, Charboneau lW, Goetz MP, Rubin l , Wong GY, Sloan lA, Novotny Pl, Lewis BD, Welch TJ, Farrell MA, Maus TP, Lee RA, Reading CC, Petersen lA, Pickett DD. Painful metastases involving bone: feasibility of percutaneous CT- and US-guided radio-frequency ablation. Radiology. 2002 lul;224(l):87-97. SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through advanced techll ology ~ Contact: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 Suite 500 Fairfa x. Virginia 22030 Interventional Radiology Offers Major Advances in Stroke Prevention 703.691.1805 and Treatment 703·691.1855 fax www.sirweb.org Stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is blocked infoa>sirweb.org by a clot or bursts, causing the brain to starve. If deprived of oxygen for even a short period of time, the brain nerve cells will start to die. Blood clots that block the artery are ischemic (is-KEM-ik) strokes and the most common type, causing between 70-80 percent of all strokes. I When a blood vessel ruptures, it causes a bleeding or hemorrhagic (hem o-RAJ-ik) stroke. j Once the brain cells die from a lack of oxygen, the part of the body that section of the brain controls is affected through paralysis, language, motor skills or .. 3 VISIon. Prevention As vascular experts, interventional radiologists treat atherosclerosis, "hardening of the arteries," throughout the body. In some patients, atherosclerosis, specifically in the carotid artery in the neck, can lead to ischemic stroke. Plaque in the carotid artery may result in a stroke by either decreasing blood flow to the brain or by breaking loose and floating into a smaller vessel, depriving a portion of the brain of blood flow. In patients at high risk of having a Jstroke, the narrowed section of artery may be re-opened by an interventional radiologist through angioplasty and reinforced with a stent, thereby preventing the stroke from occurring. Vascular stents are typically made of woven, laser cut or welded metal that permits the device to be compressed onto a catheter and delivered directly into the hardened artery. In addition to diagnosing and treating those at risk for stroke, interventional radiologists use their expertise in imaging, angioplasty and stenting to treat those having an acute stroke. Treatment Interventional radiologists are a critical part of the stroke team in hospitals. First it must be determined which kind of a stroke the patient has had so the proper treatment can be given. The interventional radiologist interprets the non-contrast CT (computed tomography) imaging to determine if acute stroke patients are candidates for clot-busting drugs. CT is quick, inexpensive and readily available. If the stroke is due to a blood clot, a clot-busting drug, tPA (tissue plasminogen activator), can be given intravenously if the patient is treated within three hours of the onset of symptoms. Currently, most patients arrive at the hospital too late, or make it through the emergency room, hospital processing and differential diagnosis too late to receive this standard treatment. However, interventional radiologists that specialize in neurological procedures are trained to thread a catheter to the tiny arteries in the brain to place the clot-busting drug directly on the clot or to break up the clot mechanically. When given locally this way, the tPA can be administered up to six hours after the onset of stroke symptoms. In many cases, the ambulance drivers will take a stroke victim past the three-hour window directly to the interventional radiology suite for assessment for this direct thrombolytic therapy. Often a significantly disabled stroke patient who receives this treatment can return to normal life with minimal or no after effects from the stroke. The interventional radiologist will also assess what caused the clot, such as a clogged carotid or other artery, and can correct the underlying problem to prevent future strokes from occurring. Unfortunately, many hospitals in this country do not have stroke teams that can rapidly assess patients and provide treatment within the three-hour window. Interventional radiologists are actively involved in creating more stroke teams across the country. Stroke teams generally consist of emergency room physicians, neurologists and interventional radiologists. Interventional neuroradiologists can also treat ruptured aneurysms inside the brain causing hemorrhage into the subarachnoid space, which can cause stroke or death. One recent study in the Lancet showed that the minimally invasive interventional technique substantially reduced the relative and absolute risk of subsequent severe disability or death compared to surgical repair, in those patients who were candidates for both procedures. 4 The interventional neuroradiologist releases tiny coils at the site of the ruptured aneurysm to provide mechanical occlusion of the blood flow. The catheter is withdrawn and the coils remain to provide the occlusion. Surgery had been the primary treatment available until the platinum coil device was approved by the FDA in 1995. STROKE FACTS Prevalence • Stroke is third leading cause of death in United States behind high blood pressure and cancer • Every 45 seconds someone in the United States has a stroke • Every three minutes someone dies from a stroke • Nearly half of all stroke victims die before emergency medical personnel arrive • 1.1 million Americans live with disabilities caused by a stroke • 600,000 Americans will have a new or recurrent stroke each year - of them, 160,000 will dieS • Stroke is a medical emergency with a narrow time frame for treatment - people should call 911 immediately • Strokes can be treated intravenously with the clot-busting drug, tPA (tissue plasminogen activator), if it is given within three hours of the onset of symptoms. • Persons who have a transient ischemic attack (TIA), also known as a mini-stroke, are likely to have another one. Transient ischemic attacks cause brief stroke symptoms that go away. People often ignore these symptoms, but they are an early warning sign and 35 percent of those who experience a TIA will have a full-blown stroke if left untreated. • Stroke is not just an older person's disease - 28 percent of strokes occur in people under age of 656 • More men than women have strokes - although more women die from them • African Americans are at much higher risk. In part, this is because African Americans are at increased risk for obesity, high blood pressure and diabetes, which increase the risk of stroke. 7 • May is "Stroke Awareness" Month Stroke Symptoms • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordination • Sudden severe headache with no known cause Risk Factors • Obesity, high blood pressure and high cholesterol all increase the risk of stroke. These risk factors can be greatly reduced with healthy lifestyles or medication. • High blood pressure puts pressure on the arteries, making them more susceptible to rupture and more prone to clot formation, which can block the artery. • High cholesterol can lead to blockage in the carotid artery that takes blood from the neck to the brain. A piece of this plaque can break off and travel to the brain, causing a stroke. • Obesity can cause high blood pressure and high cholesterol. • Untreated atrial fibrillation causes the heart's upper chamber to beat irregularly, which allows the blood pool and clot. Ifa clot breaks off and enters the blood stream to the brain, a stroke will occur. 8 • Sickle cell anemia makes red blood cells less able to carry blood to the body's tissues and organ, as well as stick to the walls of the blood vessels that can block arteries to the brain causing a stroke. 9 • Family history • Smoking National Efforts to Improve Stroke Response Times Interventional radiologists are playing vital leadership roles in improving stroke diagnosis and treatment nationwide. SIR, along with other members of the STOP Stroke Coalition, is working with Congress to introduce legislation that would improve stroke care and access to reduce death and disability from our nation's third largest killer. What is an Interventional Radiologist Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in minimally invasive interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on stroke or interventional radiology, visit the SIR Web site at www.SIRweb.org. 1-3,5-9 American Heart Association, "Have You Heard the Latest" brochure 4. Molyneux, et a!. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. The Lancet, vol ume 360, October 26, 2002. SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enl.>allced care through advallced techllo l.ogy~ Contact: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 Suite 500 fairfax, Virginia 22030 Non-Surgical Vertebroplasty is Effective Pain Treatment for 703.691. 1805 Spinal Fractures Caused by Osteoporosis 703.691.1855 fa x www.sirweb.org Ve11ebroplasty is a pain treatment for vertebral compression fractures that fail to respond infoeVsirweb. org to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable. Vertebroplasty, a non-surgical treatment performed using imaging guidance by interventional radiologists, stabilizes the collapsed vertebra with the injection of medical-grade bone cement into the spine. This improves pain, and can prevent further collapse of the vertebra, thereby preventing the height loss and spine curvature commonly seen as a result of osteoporosis. Vertebroplasty dramatically improves back pain within hours of the procedure, provides long-term pain relief and has 1 a low complication rate as demonstrated in multiple studies. ,2,3,4,5,6,7 If the vertebra isn't shored up, it can heal in a compressed or flattened wedge shape. Once this occurs, the compression fracture cannot be treated effectively. It is very important for someone with persistent spinal pain lasting more than three months to consult an interventional radiologist, and people who require constant pain relief with narcotics should seek help immediately. About Vertebroplasty Vertebroplasty was first performed in France in 1984 to treat compression fractures caused by bone cancer or bone metastasis, and later to treat compression fractures caused by osteoporosis. Percutaneous vertebroplasty was introduced in the United States in 1994 and has become widely available since 1997 as a treatment for pain associated with compression fractures due to osteoporosis. The procedure has been shown to provide continued pain relief for osteoporotic compression fractures. A 1998 study by Dr. Deramond and colleagues reported on 80 patients with rapid and complete pain relief in more than 90 percent of osteoporotic cases. 2 The follow-up in this patient population ranged from one month to 10 years with evidence of prolonged pain relief. Vertebroplasty is likely to become a standard of care for treating osteoporotic compression fractures as more patients and physicians become aware of the new advances in interventional radiology. About the Procedure Vertebroplasty is an outpatient procedure using X-ray imaging and conscious sedation. The interventional radiologist inserts a needle through a nick in the skin in the back, directing it under fluoroscopy (continuous, moving X-ray imaging) into the fractured vertebra. The physician then injects the medical-grade bone cement into the vertebra. The cement hardens within 15 minutes and stabilizes the fracture, like an internal cast. About Osteoporosis Osteoporosis is characterized by low bone mass and structural deterioration of the bone resulting in an increased susceptibility to fractures. According to the National Osteoporosis Foundation, osteoporosis affects 10 million Americans and is responsible for 700,000 vertebral fractures each year. Multiple vertebral fractures can result in chronic pain and disability, loss of independence, stooped posture and compression of the lungs and stomach. Nearly all vertebral fractures in otherwise healthy people are due to osteoporosis, and can occur from a minor impact, such as a bump or a fall, in those who suffer from this bone weakening disease. People who have a spinal fracture often don't realize that they may have osteoporosis, because the disease is symptomless until a fracture occurs. About Interventional Radiologists lnterventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. lnterventional radiologists are board-certified and fellowship trained in minimally invasive interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on vertebroplasty or interventional radiology, visit the SIR Web site at www.SIRweb.org. 1. McGraw KJ, Lippert JA, Minkus KD, Rami PM, Davis TM, Budzik RF. Prospective Evaluation of Pain Relief in 100 Patients Undergoing Percutaneous Vertebroplasty Results and Follow-up. JVIR 2002: 13:883-886. 2. Deramond H, Depriester C, Galibert P, LeGars D. Percutaneous vertebroplasty with polymethacrylate. Technique, indications, and results. Radiol Clin North Am 1998; 36: 533-546. 3. Martin JB, Jean B, Sugiu K, et al. Vertebroplasty: clinical experience and follow-up results. Bone 1999: 25 (2 suppl): 11-15. 4. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous polyrnethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. Am J Neuroradiol 1997; 19:1897-1904. 5. Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilzation. Spine 2000; 25:923-928 6. Zoarski GH, Snow P, Olan WJ, et al. Percutaneous vertebroplasty for osteoporotic compression fractures: quantitative prospective evaluation of long-term outcomes. J Vasc Interv Radio12002; 13:139-148. 7. Vasconcelos, C, Gailloud P, Beauchamp, NJ, Heck DV, Murphy KJ. Is Percutaneous Vertebroplasty without Pretreatment Venography Safe? Evaluation of 205 Consectuive Procedures. Am J Neuroradiol 23:913-917, June/July 2002. SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through advanced technology~ Contact: Diane Shnitzler Emily Oehler 10201 lee Highway 703-691-1805 Suite 500 Fairfax, Virginia 22030 V aricose Veins and Venous Insufficiency 703.691.1805 Non-Surgical Outpatient Procedure Treats Varicose Veins 703·691.1855 fax www .sirweb.org Venous insufficiency is an abnormal circulatory condition with decreased return of blood infOii)sirweb.org from the leg veins up to the heart, with pooling of blood in the veins. Normally, stop valves in the vein close to keep blood from flowing downward with gravity. When the valves in the vein become weak and don't close properly, they allow blood to flow backward, or reflux. Varicose veins are prominent veins that have lost their valve effectiveness and, as a result of dilation under pressure, become elongated, rope-like, bulged and thickened.3 A common cause of varicose veins is reflux within the greater saphenous vein in the thigh, which leads to pooling in the visible varicose veins below. Prevalence Chronic venous disease of the legs is one of the most common conditions affecting people. • Approximately half of the U.S. population has venous disease-50 to 55 percent of women and 40 to 45 percent of men. Of these, 20 to 25 percent of the women and 10 to 15 percent of men will have visible varicose veins.! • Varicose veins affect one out of two people age 50 and older, and 15 to 25 percent of all adults.! Risk Factors Risk factors include age, family history, female gender and pregnancy.l,2 Pregnancy, especially multiple pregnancies, is one of the most common factors accelerating the worsening of varicose veins. Symptoms Symptoms caused by venous insufficiency and varicose veins include aching leg pain, easy leg fatigue, and leg heaviness, all of which worsen as the day progresses. Many people find they need to sit down in the afternoon and elevate their legs to relieve these symptoms? In more severe cases, venous insufficiency and reflux can cause skin discoloration and ulceration which may be very difficult to treat. One percent of adults over age 60 have chronic ulceration.! People without visible varicose veins can still have symptoms. The symptoms can arise from spider veins as well as from varicose veins, because, in both cases, the symptoms are caused by pressure on nerves by dilated veins. Diagnosis and Assessment An interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use duplex ultrasound to assess the venous anatomy, vein valve function, and venous blood flow changes, which can assist in diagnosing venous insufficiency. The doctor will map the greater saphenous vein and examine the deep and superficial venous systems to determine if the veins are open and to pinpoint any reflux. This will help determine if the patient is a candidate for a minimally invasive treatment, known as vein ablation.3 Minimally Invasive Vein Ablation Treatment This minimally invasive treatment is an outpatient procedure performed using imaging guidance. After applying local anesthetic to the vein, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the vein and guides it up the greater saphenous vein in the thigh. Then laser or radiofrequency energy is applied to the inside of the vein. This heats the vein and seals the vein closed. Reflux within the greater saphenous vein leads to pooling in the visible varicose veins below. By closing the greater saphenous vein, the twisted and varicosed branch veins, which are close to the skin, shrink and improve in appearance. Once the diseased vein is closed, other healthy veins take over to carry blood from the leg, re-establishing normal flow. Benefits of Vein Ablation Treatment • The treatment takes less than an hour and provides immediate relief of symptoms. • Immediate return to normal activity with little or no pain. • There may be minor soreness or bruising, which can be treated with over-the-counter pain relievers. • No scar. Because the procedure does not require a surgical incision, just a nick in the skin about the size of a pencil tip, there are no scars or stitches. • High success rate and low recurrence rate compared to surgery. Surgical Treatment of Veins Traditionally, surgical ligation or vein stripping was the treatment for varicose veins, but these procedures can be quite painful and often have a long recovery time. In addition, there are high rates of recurrence with the surgical procedures. One study found a 29 percent recurrence rate after ligation and stripping of the greater saphenous vein, and a rate of 71 percent after high ligation. These recurrence rates are similar to those reported 3 in other studies. ,8 Efficacy The success rate ranges for vein ablation ranges from 93-95 percent,4,5 Insurance Many insurance carriers cover the vein ablation treatment, based on medical necessity for symptom relief. Other Treatments for Varicose Veins Ambulatory phlebectomy and injection sclerotherapy are also used. Ambulatory phlebectomy is a minimally invasive surgical technique used to treat varicose veins that are not caused by saphenous vein reflux. The abnormal vein is removed through a tiny incision or incisions using a special set of tools. The procedure is done under local anesthesia, and typically takes under an hour. Recovery is rapid, and most patients do not need to interrupt regular activity after ambulatory phlebectomy. Injection sclerotherapy can also be used to treat some varicose and nearly all spider veins. An extremely fine needle is used to inject the vein with a solution that shrinks the vein. About Interventional Radiologists Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in minimally invasive interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on varicose veins or interventional radiology, visit the SIR Web site at www.SIRweb.org. 1. Callam MJ. Epidemiology of variocose veins. Br. J Surg. 1994:81: 167-173. 2. Bergan, John, Kumins, Norman, Owens, Erik, and Sparks, Steven; Surgical and Endovascular Treatment of Lower Extremity Venous Insufficiency, JVIR 13:563-568 (2002) 3. Martinez, Hilario, Percutaneous interventions for varicose veins, Applied Radiology, supplement, August, 2002 4. Robert J. Min, MD, Neil Khilnani, MD, and Steven E. Zirnmet, MD. Endovenous Laser Treatment of Saphenous Vein Reflux: Long -Term Results, JVIR 2003; 14: 991-996. 5. RFA 2-year data as reported on the VNUS corporate Web site. 6. The Signet/Mosby Medical Encyclopedia 7. Dwerryhouse S. Davies B, Harradine K, Earnshaw JJ. Striping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: Five-year results of a randomized trial. J Vasco Surg. 1999: 29:589-592. ~ , SOCIETYOF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through advallceo techl1o"'gy~ Contact: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 5uite 500 Fairfax, Virginia 22030 Interventional Radiologists Treat Abdominal Aneurysms Non-Surgically 703 .691.1805 703 ·691.1855 fa x Abdominal Aortic Aneurysm www.sirweb.org infowsirweb.org In the past 30 years, the occurrence of Abdominal Aortic Aneurysms (AAA) has increased threefold. 3-5 AAA is caused by a weakened area in the main vessel that supplies blood from the heart to the rest of the body. When blood flows through the aorta, the pressure of the blood beats against the weakened wall, which then bulges like a balloon. If the balloon grows large enough, there is a danger that it will burst. Most commonly, aortic aneurysms occur in the portion of the vessel below the renal artery origins. The aneurysm may extend into the vessels supplying the hips and pelvis. Once an aneurysm reaches 5 cm in diameter, it is usually considered necessary to treat to prevent rupture. Below Scm, the risk of the aneurysm rupturing is lower than the risk of conventional surgery in patients with normal surgical risks. The goal of therapy for aneurysms is to prevent them from rupturing. Once an abdominal aortic aneurysm has ruptured, the chances of survival are low, with 80 to 90 percent of all ruptured aneurysms resulting in death. These deaths can be avoided if an aneurysm is detected and treated before it ruptures. Through its national screening program, Legs For Life®, the Society of Interventional Radiology (SIR) has offered free screening for early detection and monitoring of AAA. Of those screened, 25 percent have been found to be at risk for AAA. Prevalence • Approximately one in every 250 people over the age of 50 will die of a ruptured AAA • AAA affects as many as eight percent of people over the age of 605 • Males are four times more likely to have AAA than females 9 • AAA is the 13th leading cause of death in the United States, accounting for more than 15 ,000 deaths each year. • Those at highest risk are males over the age of 60 who have ever smoked and/or who have a history of atherosclerosis ("hardening of the arteries") • Those with a family history of AAA are at a higher risk (particularly if the relative with AAA was female) • Smokers die four times more often from ruptured aneurysms than nonsmokers • 50 percent of patients with AAA who do not undergo treatment die of a rupture5 Symptoms AAA is often called a "silent killer" because there are usually no obvious symptoms of the disease. Three out of four aneurysms show no symptoms at the time they are diagnosed. When symptoms are present, they may include: • abdominal pain (that may be constant or come and go) • pain in the lower back that may radiate to the buttocks, groin or legs • the feeling of a "heartbeat" or pulse in the abdomen Once the aneurysm bursts, symptoms include: • severe back or abdominal pain that begins suddenly • paleness • dry mouth/skin and excessive thirst • nausea and vomiting • signs of shock, such as shaking, dizziness, fainting, sweating, rapid heartbeat and sudden weakness Diagnosis In some, but not all cases, AAA can be diagnosed by a physical examination in which the doctor feels the aneurysm as a soft mass in the abdomen (about the level of a belly button) that pulses with each heartbeat. The most common test to diagnose AAA is ultrasound, a painless examination in which a device (a transducer) about the size of a computer mouse is passed over the abdomen. Sound waves are computerized to create "pictures" of the aorta and detect the presence of AAA. Other methods for determining the aneurysms' size are CT scan (computerized tomography), MRI (magnetic resonance imaging), and arteriogram (real time x-rays). Treatment Currently, there are three treatment options for AAA: Watchful waiting - Small AAA's (less than 5 centimeters or about 2 inches), which are not rapidly growing or causing symptoms, have a low incidence of rupture and often require no treatment other than "watchful waiting" under the guidance of a vascular disease specialist. This typically includes follow-up ultrasound exams at regular intervals to determine if the aneurysm has grown. Surgical Repair - The most common treatment for a large, unruptured aneurysm is open surgical repair by a vascular surgeon. This procedure involves an incision from just below the breastbone to the top of the pubic bone. The surgeon then clamps off the aorta, cuts open the aneurysm and sews in a graft to act as a bridge for the blood flow. The blood flow then goes through the plastic graft and no longer allows the direct pulsation pressure of the blood to further expand the weak aorta wall. Interventional Repair - This minimally invasive technique is performed by an interventional radiologist using imaging to guide the catheter and graft inside the patient's artery, rather than making a large incision. For the procedure, an incision is made in the skin at the groin through which a catheter is passed into the femoral artery and directed to the aortic aneurysm. Through the catheter, the physician passes a stent graft that is compressed into a small diameter within the catheter. The stent graft is advanced to the aneurysm, then opened, creating new walls in the blood vessel through which blood flows. This is a less invasive method of placing a graft within the aneurysm to redirect blood flow and stop direct pressure from being exerted on the weak aortic wall. This relatively new method eliminates the need for a large abdominal incision. It also eliminates the need to clamp the aorta during the procedure. Clamping the aorta creates significant stress on the heart, and people with severe heart disease may not be able to tolerate this major surgery. Stent grafts are most commonly considered for patients at increased surgical risk due to age or other medical conditions. The stent graft procedure is not for everyone, though. It is still a new technology and we don't yet have data to show that this will be a durable repair for long years. Thus, people with a life expectancy of 20 or more years may be counseled against this therapy. It is also a technology that is limited by size. The stent grafts are made in certain sizes, and the patient's anatomy must fit the graft, since grafts are not custom-built for each patient's anatomy. Recovery Time • Patients are often discharged the day after interventional repair, and typically do not require intensive care stay post-op • Once discharged, most return to normal activity within 2 weeks compared to 6-8 weeks after surgical repair Efficacy Interventional repair is an effective treatment that can be performed safely, resulting in lower morbidity and lower mortality rates than those of reported for open surgical repair. 1,6-8 Benefits of Interventional Repair • No abdominal surgical incision • No sutures, or sutures only at the groins 6 8 • Faster recovery, shorter time in the hospital • No general anesthesia in some cases • Less pain 6-8 6 8 • Reduced complications - Disadvantages of Interventional Repair • Possible movement of the graft after treatment, with blood flow into the aneurysm and resumption of risk of growth/rupture of the aneurysm • Probable life-time requirement for follow-up studies to be sure the stent graft is continuing to function About Interventional Radiologists Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in non-surgical interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on AAA or interventional radiology, visit the SIR Web site at www.SIRweb.org. 1. Kichikawa K, Department of Radiology, Nara Medical University, Kashihara, Nara, Japan. SIR Annual Meeting Plenary Session, "Comparative Study with Home-Made Stent Graft vs. Zenith Stent Graft for AAA". 2. Texas Heart Insitute Journal - Endovascular Exclusion of Abdominal Aortic Aneurysism: Initial Experience with Stent-Grafts in Cardiology Practice ... those source documents include: 3. Ernst CB. Abdominal Aortic Aneurysm. N Engl J Med 1993, 328: 1167-72 4. Parodi JC, Palmaz JC, Barone HD. Transfemoral Intraluminal Greaft Implantation for Abdominal Aortic Aneurysms. Ann Vasc Surg 1991 ;5:491-9. 5. Zarins CK,Harris EJ Jr. Operative Repair for Aortic Aneurysms: The Gold Standard. J Endovasc Surg 1997;4:232-41. 6. Zarins CK, White RA, Schwarten D, Kinney E, Diethrich EB, Hodgson KJ, et al. AneuRx Stent Graft Versus Open Surgical Repair of Abdominal Aortic Aneurysms: Multicenter Prospective Clinical Trial. J Vascular Surg 1999;29:292-308. 7. Blum U, Voshage G, Lammer J, BeyersdorfF, Tollner D, Kretschmer G, et al Endoluminal Stent Grafts for Infrarenal Abdominal Aortic Aneurysms. N Engl J Med 1997; 336: 13-20. 8. White GH, Yu, W, May J, Waugh R, Chaufour X, Harris JP, et al. Three-year Experience with the White-Yu Endo-vascular GAD Graft for Transluminal Repair of Aorticand Iliac Aneurysms. J Endovasc Surg 1997;4:124-36. 9. Sparks A, Johnson P, Meyer M. Imaging of Abdominal Aortic Aneurysms. Amer Family Physician April 15,2002 SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through ndvanced technoLogy'" Contact: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 Suite 500 Fairfax. Virginia 22030 Male Infertility Caused by Varicoceles Can be Treated Non-Surgically 703. 691.1805 Highly Effective, Widely Available IntervelltiOllal Radiology Treatment is Underutilized 703.691.1855 fax www.sirweb.org A varicocele is a varicose vein of the testicle and scrotum that may cause pain, testicular infoiVsirweb.org atrophy (shrinkage) or fertility problems. Veins contain one-way valves that work to allow blood to flow from the testicles and scrotum back to the heart. When these valves fail, the blood pools and enlarges the veins around the testicle in the scrotum to cause a varicocele. Open surgical ligation, performed by a urologist, is the most common treatment for symptomatic varicoceles. Varicocele embolization, a non-surgical treatment performed by an interventional radiologist, is a highly effective, widely available technique to treat symptomatic varicoceles that is greatly underutilized in this country.5 Prevalence • Approximately 10 percent of all men have varicoceles - among infertile couples, the incidence of varicoceles increases to 30 percent.s • Highest occurrence in men aged 15-35 • As many as 70-80,000 men in America may undergo surgical correction of varicocele annually.s Varicocele Symptoms Pain - aching pain when an individual has been standing or sitting for long periods of time and pressure builds up on the affected veins. Typically, painful varicoceles are prominent in size. Fertility Problems - There is an association between varicoceles and infertility. The incidence of varicocele increases to 30 percent in infertile couples,S Decreased sperm count, decreased motility of sperm, and an increase in the number of deformed sperm are related to varicoceles. Some experts believe these blocked and enlarged veins around the testes cause infertility by raising the temperature in the scrotum and decreasing sperm production. Testicular Atrophy - Shrinking of the testicles is another sign of varicoceles. Often, once the testicle is repaired it will return to normal size. Efficacy Embolization is equally effective in improving male infertility and costs about the same as surgical ligation. 1 Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. Sixty percent conceived who were treated for infertility.4 In one study, sperm concentration improved in 83 percent of patients undergoing embolization compared to 63 percent of those surgically ligated. Patients who underwent both procedures expressed a strong preference for embolization.2 Diagnosis • Typical on left side of scrotum • Physical exam - visible - scrotum looks like a "bag of worms" • Testicle can shrink in size I atrophy • When varicoceles are not clearly present, the abnormal blood flow can often be detected with a non-invasive imaging exam called color flow ultrasound or through a venogram-an X-ray in which a special dye is injected into the veins to "highlight" blood vessel abnormalities Treatment Currently, there are two treatment options for men with varicoceles: catheter directed embolization or surgical ligation. Catheter directed embolization is a non-surgical, outpatient treatment performed by an interventional radiologist using imaging to guide catheters or other instruments inside the body. Through mild IV sedation and local anesthesia, patients are relaxed and pain-free during the approximately two-hour procedure. For the procedure, an interventional radiologist makes a tiny nick in the skin at the groin using local anesthesia, through which a thin catheter (much like a piece of spaghetti) is passed into the femoral vein, directly to the testicular vein. The physician then injects contrast dye to provide direct visualization of the veins so s/he can map out exactly where the problem is and where to embolize, or block, the vein. By using coils, balloons, or particles, the interventional radiologist blocks the blood flow in the vein which reduces pressure on the varicocele. By embolizing the vein, blood flow is re-directed to other healthy pathways. Essentially, the incompetent vein is "shut off' internally by preventing blood flow , accomplishing what the urologist does, but without surgery. Recovery Time • Average of one to two days for complete recovery for embolization compared to two to three weeks for surgery'S • 24 percent of surgical ligation patients required overnight hospital stay, compared to none for embolization5 Surgical Treatment of Varicoceles After receiving anesthesia, an incision is made in the skin above the scrotum, cutting down to the testicular veins, and tying them off with sutures. Although patients leave the hospital the same day, there is a two to five week recovery period. Benefits of Embolization • No surgical incision in the scrotal area5 • Effective as surgery, as measured by improvement in semen analysis and pregnancy rates? • Less recovery time-able to return to normal daily activities immediately and without hospital admittance2 • A patient with varicoceles on both sides can have them fixed simultaneously through one vein puncture site compared to surgery, which requires two separate open incisions • No general anesthesiaS s • No sutures s • No infections • Cost-effective About Interventional Radiologists Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in non-surgical interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on varicoceles or interventional radiology, visit the SIR Web site at www.SIRweb.arg. 1. Dewire DM, Thomas AJ Jr, Falk RM, Geisinger MA, Lammert GK. Clinical Outcome and Cost Comparison of Percutaneous Embolization and Surgical Ligation of Varicoceles. J Androl 1994, Nov Dec, 15 Suppl: 38S-42S. 2. Feneley MR, Pal MK, Nockler lB, Hendry WF. Retrograde Embolization and Causes of Failure in the Primary Treatment of Varicocele. British Journal of Urology. 1997 Oct; 80 (4 ):642-6. 3. Nieschlag E, Behre HM, Schlingheider A, Nashan D, Pohl J, Fischedick AR. Surgical Ligation vs. Angiographic Embolization of the Vena Spermatica: A Prospective Randomized Study for the Treatment of Varicocele-related Infertility. Andrologia. 1993 Sept-Oct; 25(5):233-7. 4. Zuckerman AM, Mitchell SE, Venbrux, Trerotola SO, Savader SJ, Lund GB, White RI Jr, Osterman FA Jr. Percutaneous Varicocele Occlusion: Long-term Follow-up. JVIR. 1994 March-April; 5(2):315 9. 5. Smith SJ, White R JR. Nonsurgical Treatment of Variococele Monograph www.varicoceles.com SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through ndvanced techllology ~ Contact: Diane Shnitzler Emily Oehler 10201 lee Highway 703-691-1805 SLiite 500 Fairfax, Virginia 22030 Peripheral Arterial Disease and Interventional Radiology 703. 691.1805 703.691 .1855 fax Peripheral arterial disease (PAD), also known as peripheral vascular disease (PVD), is a www.sirweb.org very common condition affecting 12-20 percent of Americans age 65 and 01der. 4 PAD infoiVsirweb.org develops most commonly as a result of atherosclerosis, or "hardening of the arteries," which occurs when cholesterol and scar tissue build up, forming a substance called plaque inside the arteries that narrows and clogs the arteries. This is a very serious condition. The clogged arteries cause decreased blood flow to the legs, which can result in pain when walking, and eventually gangrene and amputation. Because atherosclerosis is a systemic disease, people with PAD are likely to have blocked arteries in other areas of the body.2 Thus, people with PAD are at increased risk for heart disease, aortic aneurysms and stroke. PAD is also a marker for diabetes, hypertension and other conditions. This is a major public health issue and the Society of Interventional Radiology recommends greater screening efforts through the use of the ankle brachial index (ABI) test. This simple, painless test compares the blood pressure in the legs to the blood pressure in the arms to determine how well the blood is flowing and if further tests are needed. Each September, during Peripheral Vascular Disease Month, interventional radiologists participate in Legs For Life®, a nationwide screening program sponsored by the Society of Interventional Radiology. PAD Symptoms • The most common symptom of P AD is called claudication, which is leg pain that occurs when walking or exercising and disappears when the person stops the actIVIty.. . 2 • Other symptoms of PAD include: numbness and tingling in the lower legs and feet; coldness in the lower legs and feet; and ulcers or sores on the legs or feet that don't heal. • Many people simply live with their pain, assuming it is a normal part of aging, rather than reporting it to their doctor. Prevalence • Peripheral Arterial Disease (PAD) is a disease of the arteries that affects 10 million Americans. l • P AD can happen to anyone, regardless of age, but it is most common in men and women over age 50.2 • PAD affects 12-20 percent of Americans age 65 and 01der. 4 Risk Factors • Smoking • High blood pressure (hypertension) • High cholesterol • Diabetes • Family history of heart or vascular disease • Being overweight • Lack of exercise or physical activity • Age over 503 PAD Treatments • Lifestyle Often PAD can be treated with lifestyle changes. Smoking cessation and a structured exercise program are often all that is needed to alleviate symptoms and prevent further progression of the disease. • Angioplasty and stenting Interventional radiologists pioneered angioplasty and stenting, which was first performed to treat peripheral arterial disease. Using imaging for guidance, the interventional radiologist threads a catheter through the femoral artery in the groin, to the blocked artery in the legs. Then the interventional radiologist inflates a balloon to open the blood vessel where it is narrowed or blocked. In some cases this is then held open with a stent, a tiny metal cylinder. This is a minimally invasive treatment that does not require surgery, just a nick in the skin the size of a pencil tip. About Interventional Radiologists Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in minimally invasive interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on PAD or interventional radiology, visit the SIR Web site at www.SIRweb.org. 1. Weitz JI, Byrne J, Clagett GP, Farkouh ME, Porter JM, Sackett DL, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996;94:3026-49. 2. De Sanctis J. Percutaneous Interventions for Lower Extremity Peripheral Vascular Disease. American Family Physician. 2001 :December. 3. Sacks D, Bakal C, Beatty P, Becker G, Cardella J, Raabe R, Wiener H, Lewis C. Position statement on the use of the ankle-brachial index in the evaluation of patients with peripheral vascular disease. JVIR 2002;13:353. 4. Becker G, McClenny T, Kovacs M, Raabe R, Katzen B. The importance of increasing public awareness of peripheral arterial disease. JVIR 2002; 13:7-11 SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through advallced lechno/Qgy~ Contact: Diane Shnitzler Emily Oehler 10201 Lee Highway 703-691-1805 Suite 500 fairfax, Virginia 22030 Deep Vein Thrombosis 70 3691.1805 Interventional Radiology Clot Busting Treatment Prevents Permanent Leg Damage 703.691.1855 fax www.sirweb.org The formation of a blood clot, known as a thrombus, in a deep leg vein can be a very infowsirweb.org serious condition that can cause permanent damage to the leg, known as post-thrombotic syndrome. Early treatment with blood thinners is important to prevent a life-threatening pulmonary embolism, but does not treat the existing clot. Post-Thrombotic Syndrome Post-thrombotic syndrome is an under-recognized, but relatively common sequela, or aftereffect, of having DVT if treated with blood thinners (anticoagulation) alone, because the clot remains in the leg. Contrary to popular belief, anticoagulants do not actively dissolve the clot, they just prevent new clots from forming. The body will eventually dissolve a clot, but often the vein becomes damaged in the meantime. A significant proportion of these patients develop permanent irreversible damage in the affected leg veins and their valves, resulting in abnormal pooling of blood in the leg, chronic leg pain, fatigue, swelling, and in extreme cases, severe skin ulcers. Many patients have to plan their daily activities around their leg, knowing that if they stand or exercise too long, their legs will swell or be painful. While irreversible damage use to be considered an unusual, long-term sequela, it actually occurs frequently in as many as 60-70 percent of people and can develop within two months of developing DVT. 1,2 There is increasing evidence that clot removal via interventional catheter-directed thrombolysis in selected cases of DVT can improve quality of life and prevent the debilitating sequela of post-thrombotic syndrome. Treatments Catheter-Directed Thrombolysis: Catheter-directed thrombolysis is performed under imaging guidance by interventional radiologists. This procedure, performed in a hospital's interventional radiology suite, is designed to rapidly break up the clot, restore blood flow within the vein, and potentially preserve valve function to minimize the risk of post-thrombotic syndrome. The interventional radiologist inserts a catheter into the popliteal or other leg vein and threads it into the vein containing the clot using imaging guidance. The catheter tip is placed into the clot and a "clot busting" drug is infused directly into the thrombus (clot). The fresher the clot, the faster it dissolves-one to two days. Any narrowing in the vein that might lead to future clot formation can be identified by venography, an imaging study of the veins, and treated by the interventional radiologist with balloon angioplasty or stent placement. In patients in whom this is not appropriate and blood thinners are contraindicated, an interventional radiologist can insert a vena cava filter, a small device that functions like a catcher's mitt to capture blood clots but allow normal liquid blood to pass. People with symptoms of DVT should first go to an emergency room to seek help, to receive initial treatment with blood thinners to prevent a pulmonary embolism. After treatment with blood thinners, if symptoms such as leg pain and swelling continue, patients should obtain a consult with an interventional radiologist for further evaluation. DEEP VEIN THROMBOSIS FACTS The deep veins that lie near the center of the leg are surrounded by powerful muscles that contract and force deoxygenated blood back to the lungs and heart. One-way valves prevent the back-flow of blood between the contractions. When the circulation of the blood slows down due to illness, injury or inactivity, blood can accumulate or "pool," which provides an ideal setting for clot formation. One in every 100 people who develops DVT dies. Recently, it has been referred to as "Economy Class Syndrome" due to the occurrence after sitting on long flights. Prevalence of DVT In the United States alone, 600,000 new cases are diagnosed each year. Symptoms Some of these include: • Discoloration of the legs • Calf or leg pain or tenderness • Swelling of the leg or lower limb • Warm skin • Surface veins become more visible • Leg fatigue Efficacy Clinical resolution of pain and swelling and restoration of blood flow in the vein is greater than 85 percent with the catheter-directed technique. Risk Factors • Previous DVT or family history of DVT • Immobility, such as bed rest or sitting for long periods of time • Recent surgery • Above the age of 40 • Hormone therapy or oral contraceptives • Pregnancy or post-partum • Previous or current cancer • Limb trauma and/or orthopedic procedures • Coagulation abnormalities • Obesity Preventing "Economy Class Syndrome" Sitting in one position for a long period of time can increase one's chances for DVT. Preventative steps on long trips include: • Drink lots of water, and avoid beverages that dehydrate (coffee, tea, alcohol) • Get up and move around the aircraft cabin occasionally (aisle seats make this easier) • Exercise your feet and legs four to five minutes every hour when seated. • Wear support socks that apply the proper amount of compression to the lower legs • If you have circulation problems or a history of blood clots, consult your physician prior to flying. PULMONARY EMBOLISM FACTS Left untreated, a deep vein thrombosis (OVT) can break off and travel in the circulation, getting trapped in the lung, where it blocks the oxygen supply, causing heart failure. This is known as a pulmonary embolism, which can be fatal. With early treatment, people with DVT can reduce their chances of developing a life threatening pulmonary embolism to less than 1 percent. Blood thinners like heparin and coumadin are effective in preventing further clotting and can prevent a pulmonary embolism from occurring. • It is estimated that each year more than 600,000 patients suffer a pulmonary embolism. • PE causes or contributes to up to 200,000 deaths annually in the United States. • One in every 100 patients who develop DVT die due to pulmonary embolism. • A majority of pulmonary embolisms are caused by DVT. • If pulmonary embolism can be diagnosed and appropriate therapy started, the mortality can be reduced from approximately 30 percent to less than 10 percent. Symptoms of Pulmonarv Embolism Some symptoms of a pulmonary embolism are: • Shortness of breath • Rapid pulse • Sweating • Sharp chest pain • Bloody sputum (coughing up blood) • Fainting The symptoms are frequently nonspecific and can mimic many other cardiopulmonary events. What is an Interventional Radiologist Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments perfonned using imaging for guidance. They use their expertise in reading X rays, ultrasound, MRI and other diagnostic imaging, to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board-certified and fellowship trained in minimally invasive interventions using imaging guidance. The American Board of Medical Specialties certifies their specialized training. For Further Information For more information on DVT, pulmonary embolism, or interventional radiology, visit the SIR Web site at www.SIRweb.org. I. Comerota AJ, Throm RC, Mathias SD. Haughton S. Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg. 2000 July; 32(1): 130-7. 2. Saarinen et al. Prospective study of anticoagulated DVT. J Cardiov Surg 2000;41 ;441-6. 3. Anderson F. Jr. Auden AM. Best Practices: Preventing Deep Vein Thrombosis and Pulmonary Embolism. Univ Mass Medical School. 1998. 4. Barloon T. Bergus G. Seabold J. Diagnostic Imaging of Lower Limb Deep Venous Thrombosis. Am Family Physician. 1997 September;56(3). SOCIETY OF INTERVENTIONAL FACT SHEET RADIOLOGY Enhanced care through advanced techlZol.ogy ~ Contact: Diane Shnitzler Emily Oehler 10201 lee Highway Suite 500 703-691-1805 Fairfax, Virginia 22030 Uterine Fibroid Embolization, a Minimally Invasive Treatment for 703.691.1805 Uterine Fibroids 703.691.1855 fax www.sirweb.org Highly Effective, Widely Available Intervelltional Radiology Treatment is Underutilized infoiVsirweb.org Uterine fibroids are very common non-cancerous (benign) growths that develop in the muscular wall of the uterus. They can range in size from very tiny (a quarter of an inch) to larger than a cantaloupe. Occasionally, they can cause the uterus to grow to the size of a five-month pregnancy. In most cases, there is more than one fibroid in the uterus. Prevalence Twenty to 40 percent of women age 35 and older have uterine fibroids of a significant size. African American women are at a higher risk for fibroids: as many as 50 percent have fibroids of a significant size. Uterine fibroids are the most frequent indication for hysterectomy in pre-menopausal women and, therefore, are a major public health issue. Of the 600,000 hysterectomies performed annually in the United States, 113 of these are 1 due to fibroids. ,4 ,JO Symptoms Most fibroids don't cause symptoms-only 10 to 20 percent of women who have fibroids require treatment. Depending on size, location and number of fibroids, they may cause: • Heavy, prolonged menstrual periods and unusual monthly bleeding, sometimes with clots. This can lead to anemia. • Pel vic pain and pressure • Pain in the back and legs • Pain during sexual intercourse • Bladder pressure leading to a frequent urge to urinate • Pressure on the bowel, leading to constipation and bloating • Abnonnally enlarged abdomen About the Procedure Uterine Fibroid Embolization (UFE), also known as uterine artery embolization, is performed by an interventional radiologist, a physician who is trained to peIiorm this and other types of embolization and minimally invasive procedures. It is perfonned while the patient is conscious, but sedated and feeling no pain. It does not require general anesthesia. The interventional radiologist makes a tiny nick in the skin, less than a 14 of an inch, in the groin and inserts a catheter into the femoral artery. Using real-time imaging, the physician guides the catheter through the artery and then releases tiny particles, the size of grains of sand, into the uterine arteries that supply blood to the fibroid tumor. This blocks the blood flow to the fibroid tumor and causes it to shrink. Recovery Time Fibroid embolization usually requires a hospital stay of one night. Pain-killing medications and drugs that control swelling typically are prescribed following the procedure to treat cramping and pain. Many women resume light activities in a few days and the majority of women are able to return to normal activities within seven to 10 days. Efficacy • On average, 90 percent of women who had the procedure experience significant or total relief of heavy bleeding and other symptoms. 2 • The procedure is effective for multiple fibroids?·16.17 • Recurrence of treated fibroids is very rare. Short and mid-term data show UFE to be 7 11 12 very effective with a very low rate of recurrence. . . Long-term (10 year) data is ongoing and not yet available, but in one study in which patients were followed for six years, no fibroid that had been emboli zed regrew. 1O Other UFE Facts • At least 25,000 UFE procedures have been performed worldwide, at least half of them in the United States. • The embolic particles are approved by the FDA specifically for UFE, based on comparative trials showing similar efficacy with less serious complications compared to hysterectomy and myomectomy (the surgical removal of fibroids). • Embolization of the uterine arteries is not new. While embolization to treat uterine fibroids has been performed since 1995, it has been used successfully by interventional radiologists for more than 20 years to treat heavy bleeding after childbirth. • Embolization of fibroids was first used as an adjunct to help decrease blood loss during myomectomy. To the surprise of the initial users of this method, many patients had spontaneous resolution of their symptoms after only the embolization and no longer needed the surgery. • UFE is covered by most major insurance companies and is widely available across the country. • Most women with symptomatic fibroids are candidates for UFE and should obtain a consult with an interventional radiologist to determine whether UFE is a treatment option for them. An ultrasound or MRI diagnostic test will help the interventional radiologist to determine if the woman is a candidate for this treatment. • Many women wonder about the safety of leaving particles in the body. The embolic particles most commonly used in UFE have been available with FDA approval for use in people for more than 20 years. During that time, they have been used in thousands of patients without long-term complications. Effect on Fertility There have been numerous reports of pregnancies following uterine fibroid embolization, however prospective studies are needed to determine the effects of uterine fibroid For Further Information For more infOlmation on UFE or interventional radiology, visit the SIR Web site at www.SIRweb.org. I . Vollenhoven B: Introduc ti on: the epidemiology of uterine leiomyomas. Baillieres Clin Obstet Gynaecol 1998: 12 : 169-176. Greenberg MD, Kazamel TIG: Medical and socioeconomic impact of uterine fibroids. Obstet Gynecol C lin North Am 1995; 22:625-636. 2. Spies J, Ascher S, Roth A, Kim J, Levy E, Gomez-Jorge 1. Uterine artery embolization for leiomyomata. Ohstet & Gyneeol 200 I ; 98: 29-34. 3. McLucas, B, Goodwin, S, Adler, L, Rappaport, R. Reed and Perrella, R. Pregnancy following uterine fibroid embolization. IntI. J. of Gynecol & Obstetrics 200 I Jul;74(l): 1-7. 4. Broder MS, Kanouse DE, Mittman BS, et a\. The appropriateness or reconunendations for hysterectomy. Obstet Gynecol2000: 95: 199-205. 5. Subramanian S., Spies JB: Uterine artery embolization for leiomyomata: resource use and cost estimation. J VascoInterv Radiol 2001: 12:571-574 6. Spies lB, Sealli AR, Jha RC, et al: Initial results from uterine fibroid embolization for symptomatic leiomomata. J Vase Imerv Radiol. 1999;10: 1149-1157 7. Hutchins FL, Worthington-Kirsch R, Berkowitz RP: Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri. J Am Assoc Gynecol Laparosc 1999, 6:279-284 8. Ravina JH, Bouret JM, Ciraru-Vigneron N, et al: Recourse to particular arterial embolization in the treatment for some uterine leiomyoma Bull Acad Natl Med 1997; 181: 233-236. 9. Ravina, J, Ciraru-Vigernon N, Aymard, A, LedreffO, Herbreteau D, Merland J. Arterial embolization th of uterine myomata: results of 184 cases. Presentation at 10 Anniversary International Conference for the Society for Minimally Invasive Therapy; September 4, 1998: London, England. 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