sign in sign up
<<
Home , Varicose veins

INFALL 2015 CIRCULATIONThe Official Publication for Center For Vascular Medicine™

volume 1 issue 4 PERIPHERAL ARTERIAL DISEASE - The Silent Debilitator Gaurav Lakhanpal, MD, FACC, RPVI

eripheral Arterial Disease (PAD) in the lower extrem- PAD Sanjiv Lakhanpal, MD ities is the narrowing or blockage of the vessels that The classic symptom of PAD is pain in the legs with exer- Pcarry blood from the heart to the legs. It is primar- tion, such as walking, which is relieved by resting. How- ily caused by the buildup of fatty plaque in the , ever, up to 40% of individuals with PAD have no leg pain. which is called . PAD (defined as plaque Symptoms: buildup in arteries other than coronaries or carotids) can • pain, ache occur in any blood vessel, but it is more common in the • with walking () can occur in the legs than the arms. buttock, hip, thigh, or calf Vinay Satwah, DO • muscle atrophy PAD Prevalence and Life Expectancy Data • hair loss Men and woman are equally affected by PAD; however, • smooth shiny skin certain races, such as African Americans, do have an in- • skin that is cool to the touch especially if creased risk of PAD. People of Hispanic origin may have accompanied by pain while walking similar to slightly higher rates of PAD compared to non- • decreased or absent pulses in the feet Hispanic whites. Approximately 8 million people in the • non-healing ulcers or sores in the legs or feet United States have PAD, including 12-20% of individuals • cold or numb toes Michael Malone, MD older than age 60. General population awareness of PAD is estimated at 25%, based on prior studies. PAD Diagnostic Options PAD is relatively easy to diagnose. The most common Life expectancy is reduced 10 years in patients with PAD. non- invasive diagnostic modalities are listed below. All The mortality rate data indicates patients with PAD will can be performed in an outpatient setting. expire at the following rates: 1. Ankle Brachial Index: • 25% at 5 yrs a. Very easy to perform in any • 50% at 10 yrs physician office setting Gaurav Lakhanpal, MD • 75% at 15 yrs b. Correlates with the severity of the disease In summary, 75% of deaths are caused by cardiovascular events. The same risk factors are responsible for develop- ing CV disease. Hence, early diagnosis and treatment of PAD is of vital importance to prevent future CV morbidity and mortality. Risk Factors for PAD All blood vessels’ Shekeeb Sufian, MD • Smoking combined length is • High • Atherosclerosis close to 100,000 km • Diabetes (60,000 miles). • High alone • Older than age 60 contribute for 85% • Younger than age 50 with diabetes of this length. and one additional risk factor Tom Militano, MD

C ENTER FOR Pelvic Pain of Vascular Origin ™ A Division of the Center for Vascular Medicine Krutiben Patel, PA-C PERIPHERAL ARTERIAL DISEASE - The Silent Debilitator (continued from page 1)

2. Pulse Volume Recording Treatment Options a. Useful in patients with non-compressible vessels and to • Risk Factor Modification correlate the anatomical level of disease • Smoking cessation • Increased exercise regimen • Dietary changes

• Medical Management • Lower blood pressure • Lower cholesterol • Close diabetic management • Antiplatelet therapy • Statin therapy 3. Arterial duplex ultrasound: a. Characterizes the plaque morphology, as well as, • Minimally Invasive Techniques quantifies severity based upon velocity of blood • flow in the vessel across the blockage • Stenting • • Thrombectomy are not blue. You need to consume a • Surgical Interventions They appear that way quart of water each day • Bypass as only blue light can for four months to equate • Amputation penetrate skin and reflect to the amount of blood back to your eyes your heart pumps in without being absorbed one hour. by skin.

4. CTA/MRA Blood has a long a. More expensive diagnostic modality road to travel: Laid end to b. Use of contrast dye and radiation is required end, there are about 60,000 Early Screening can Save Lives! miles of blood vessels in It is important for physicians to follow the screening recommenda- the human body. The tions by various societies and preventive task forces to reduce the hard-working heart pumps underdiagnosis of the disease and increase early intervention. about 2,000 gallons of blood Recent data suggests screening certain patients who normally would not be considered at risk by most physicians. According to through those vessels the 2011 ACC/AHA practice guidelines, patients who meet the fol- every day. lowing criteria are at high risk for developing PAD and hence should undergo screening for early detection and subsequent treatment: It is scientifically • Age <50 years with diabetes and one additional risk factor suggested that walking (smoking, dyslipidemia, , or homocysteinemia) • Age 50 to 69 years with history of smoking or diabetes at a fast pace for 3 hours or • Age ≥65 years more at least one time a • Known coronary, carotid, or renal atherosclerosis week can reduce your risk • The presence of abnormal lower extremity pulses, or symp- for heart disease by toms of claudication or ischemic rest pain up to 65%.

NEW LAUREL LOCATION! Center for Vascular Medicine is committed to providing the highest quality outpatient vascular services in convenient, friendly centers. 866-916-9202 Dr. Michael Malone, a vascular surgeon, will be seeing patients weekly in 7350 Van Dusen Road, #220 Laurel. He also will provide assessment and diagnostic services. Laurel, MD 20707 www.cvmus.com www.cvmus.com The Role of Outpatient-Based Vascular Laboratories in the Management of Complex Patients With Non-Healing Ulcerations Michael D. Malone, MD, FACS / Kruti Patel, PA-C s technologies improve in the management of non- Summary: healing ulcerations, the role of out-patient vascular The use of an outpatient vascular catheterization laboratory has revo- Alaboratories has become increasingly important in the lutionized the care of the complex vascular patient with non-healing management of complex patients. This article will focus on wounds. In the past, these patients would need to have an invasive three groups: open surgical procedure in the hospital setting with its prolonged perioperative recovery period. The longer period of recovery time 1. Patients with arterial insufficiency or inadequate blood flow negatively impacts patient satisfaction and healthcare costs. 2. Patients with venous insufficiency causing venous stasis and Case 1 tissue breakdown 3. Patients whose ulcerations are a result of a combination of 85 year old woman with ulceration of left ankle, lower arterial and venous disease. Physicians must address both extremity disease entities for healing to occur PMH/Risk Factors:

• Rheumatoid Arthritis • Hyperlipidemia The incidence of PAD, its early detection and appropriate man- • Post-thrombotic Syndrome • Peripheral Arterial Disease agement impacts the risk of ulceration formation and the preven- tion of amputations. In terms of the incidence of foot ulcers, ul- • History of Left Lower Extremity DVT cerations associated with diabetes mellitus are the most common • Procedures Performed: venogram, venoplasty, and venous cause of foot ulcers. Most of these ulcers are a direct result of loss stenting of left common iliac with wall stent of sensation secondary to (1). Approximate- Outcomes ly 15% of patients with diabetes will develop foot ulceration dur- Complete healing of venous stasis ulceration. In addition, the ing their lifetime (2). Venous leg ulcers are a prevalent and morbid patient underwent an arterial evaluation and was found to have disease that consumes considerable health care resources. In one initially asymptomatic occlusion of the right superficial femoral study, costs varied from $15,000 to $71,000 dependent on other . After the venous procedure was performed, the patient’s morbidities and duration of wound healing (3). ambulation improved. With increased walking, the arterial claudi- cation symptoms of the right lower extremity were unmasked and Treatment Options the right lower extremity occlusion was treated successfully with The goal in treatment of non-healing ulcers is to alter the anato- laser atherectomy, angioplasty and stenting of the right superficial my and correct any physiologic abnormalities. With arterial insuf- artery. ficiency, procedures attempt to improve and provide adequate arterial perfusion and oxygenation to allow for wound healing. Traditional open procedures include bypass surgeries (requiring autogenous or synthetic grafts) or procedures. These procedures are routinely performed in the hospital setting. Typically, they are more invasive and result in a prolonged post- operative course. In contrast, newer percutaneous procedures are minimally invasive and can be performed in the outpatient set- Pre Procedure Post Procedure ting. Some of these include: • Atherectomy: removes and debulks significant plaque Case 2 formation in the arterial circulation • Balloon angioplasty: alleviates narrowing in the arterial 66 year old woman with non-healing ulcerations to dorsum of left system foot and toes • Stenting: an option if there is still some residual narrowing PMH/Risk Factors: after the aforementioned procedures are performed • Arthritis • H/O CVA In terms of venous ulceration, procedures can be divided into • Diabetes Mellitus • Hypertension those which deal with superficial venous reflux and those which • deal with reflux of the deep venous system. • Procedures performed: diagnostic arteriogram; laser 1. Management of superficial venous reflux includes traditional atherectomy and balloon venous stripping, ablation procedures (laser or radio angioplasty of left popliteal frequency) or . artery 2. Deep venous insufficiency is a bit more complex. The goal Outcomes is to correct compression of the deep venous system either Complete healing of ulcerations from anatomical compression or scarring from posthrombot- to dorsum of left foot, left great toe and second toe. ic syndrome resulting after a DVT. Management includes the Pre Procedure Post Procedure use of (IVUS) to delineate the degree References: of compression. At this point, a plan can be devised and ve- 1. Allen, Gabriel and Molnar, Joseph. Medscape 11/6/2014 noplasty and/or stenting can be performed. 2. American Diabetes Assoc. Consensus development conference on diabetic foot wound care. 7-8 April 1999. Boston, MA. 3. Ma H, O’Donnell TF. The real cost of treating venous ulcers in a contemporary vascular practice.Oct2014 V2 Issue 355-361.

www.cvmus.com Vulvar varicosities: a private condition often under recognized Vinay Satwah, DO, FACOI, RPVI

he presence of vulvar varicosities is atic varicosities. With each subsequent not an easy topic to discuss with , symptoms typically present T female patients. The condition earlier in the course of gestation and can be a source of unnecessary anxiety are more significant. The majority of and embarrassment. The good news is varicose veins of the vulva are caused by that there may be a permanent solution reflux in the pelvic veins termed ovarian to these unsightly veins that the Center vein reflux and/or iliac vein reflux. Exten- for Vascular Medicine (CVM) can offer in sion of varicosities into the medial thigh the outpatient setting. is also a common finding in patients with varicosities of the vulva. Vulvar varicosities are dilated veins found in the labia majora and minora After a thorough history and physical, a and are more commonly in pregnant painless transcutaneous pelvic venous the patient returns for a follow-up pelvic women as opposed to the non- duplex ultrasound is the method of ultrasound at six weeks to evaluate her pregnant population. While as many as choice for non-invasive diagnostic response to interventional therapy. If the one in ten pregnant women experience evaluation of the pelvic and vulvar intervention has been successful, there these troublesome veins, spontaneous venous system. The symptomatic patient is resolution of the pelvic vein reflux by improvement in the appearance of vulvar may then undergo further invasive ultrasound and the vulvar varicose veins varicosities is typically seen within six to evaluation including a venogram, where may begin to decrease in size. A period eight weeks post-partum. However, in contrast dye is injected into the veins of observation (six to twelve months) is some women these dilated veins may under fluoroscopy. typically warranted prior to moving on never resolve and only worsen with With the diagnosis of ovarian vein re- to as many vulvar varicosi- time and further . When flux, a coil or chemical sclerosant can ties will improve significantly after cor- persistent and symptomatic, they may rection of the pelvic vein reflux. When present with pelvic discomfort during indicated, sclerotherapy may be inject- walking, a sense of swelling, vulvar ed either directly into the vulvar varicose pressure, pruritis, pain, and dyspareunia veins or under ultrasound guidance (painful intercourse). pending their visibility. The ovarian vein dilates due to valve Anatomically, normal veins of the vulva failure or Many women are hesitant to initiate a have a rich network of communicating Normal obstruction to flow conversation on vulvar varicosities. This anatomy branches with veins arising in the wall of This causes issue is often discovered in the course of varicose veins the pelvis, which also communicate and After pregnancy, the around the discussing symptoms of pelvic pain, pel- veins open up anastomose with the vasculature of the ovary which vic congestion syndrome or varicosities between the ovarian then can spread female organs. The venous drainage of varices and the leg, to the pelvis. through the vagina of the legs. Soliciting this information is the vulva is via the pudendal and peri- and vulva vital in order to properly direct a wom- neal veins which then depend on com- an’s evaluation and treatment. As with petence of the ovarian, iliac and great be placed selectively into the ovarian venous insufficiency and varicosities of saphenous veins. During pregnancy, vein resulting in closure of the vein with the lower extremities, this is a medical the rise in estrogen and progesterone eradication of reflux in this vessel. Once problem, not simply a cosmetic con- production causes venous dilatation. the faulty pelvic vein is closed, the ve- cern. Presenting the condition in such a Furthermore, the increasing physical nous blood will be re-directed naturally manner can reassure a patient that her load of the enlarged uterus on the pel- into the healthier veins and improve the issue is not simply an embarrassment, vic floor contributes to pelvic venous in- pelvic venous drainage. Following treat- but a medical disorder that warrants at- sufficiency and the resultant symptom- ment of the pelvic venous insufficiency, tention.

For every To lose one pound of pound gained, you add Call today to make a referral: of fat, a person has seven miles to burn roughly of new blood 866-916-9202 3,500 calories. vessels. www.cvmus.com

Immediate Appointments Available Annapolis – Glen Burnie – Greenbelt – Laurel – Prince Frederick – Silver Spring