sign in sign up
<<
Home , Ambulatory phlebectomy, Thrombophlebitis

APRIL 2011

Wake Minimally invasive experts of the Triangle

Also in This Issue Disease: Equal Opportunity Killer Treating Painful Spine Fractures On the Cover Wake Radiology excels with minimally invasive procedures Interventional radiologists lead the Triangle

Healthy looking legs may hide Wake Radiology Interventional Services offers valvular dysfunction patients a number of benefits, including It is estimated that by age 60, approxi- mately 50 percent of women and 25 to 30 combined experience that spans nearly a percent of men will have chronic venous insufficiency (CVI). Wake Radiology’s Susan century and close continuity of care, since the Weeks, M.D., a vascular and interventional who sees the patient typically also radiologist, has for over 5 years been treat- ing patients with CVI who suffer from performs the procedure. Patients benefit from a variety of symptoms that include aching, , heaviness, throbbing, tingling, itching, the convenience and individual attention or burning. CVI usually affects two main superfi- afforded by an outpatient setting at Wake cial including the Radiology’s Cary IR office. (GSV) and the small saphenous vein (SSV). When associated tributaries become af- Carroll Overton, M.D., director of interventional radiology services, leads a group of eight fected, varicosities may develop. In addition fellowship-trained interventional radiologists. “Whether it is by transvenous, transarterial, or other to varicosities, other visible signs include minimally invasive means, we offer patients alternatives to many surgical procedures,” Dr. Overton and lipodermatosclerosis (skin color says. Advances in image quality and speed of acquisition provide remarkable anatomic detail, and changes). It is important to note, however, innovative equipment allows high precision while sparing healthy tissue. “We work with micro- that some patients may have no visible signs catheters —they are no bigger than what you’d see coming off a fishing reel,” he says. of CVI and still have valvular dysfunction. “It is important to have CVI in your differ- ential, even if the person’s legs look perfectly healthy,” Dr. Weeks advises referring physi- cians. In addition to the more common su- perficial CVI, valvular dysfunction can also affect the lower extremity deep venous sys- tem, oftentimes secondary to prior deep vein (DVT). Doppler ultrasound is frequently used to identify the exact prob- lem. This painless examination uses a cuff (similar to a cuff) applied to the calf just above the . “We evaluate the deep and the superficial venous systems, including associated perforator and com- municating veins. We look not only for ap- propriate valve closure, but also for the pres- ence of , both chronic

PHOTO BY BRYAN REGAN PHOTOGRAPHY PHOTO BY BRYAN and acute.” Dr. Carroll Overton and Teresa Ball, IR technologist, prepare a patient for a treatment.

0 The Triangle Physician | APRIL 2011 When venous insufficiency affects injury, Dr. Weeks cautions. Instead, cath- either the GSV or SSV, catheter directed eter directed sclerotherapy has proven more thermal heat ablation, including laser or useful for ablating this segment of the GSV. radiofrequency, offers a highly effective This is accomplished via the straightforward nonsurgical treatment. “Endovenous laser placement of a small-bore, end-hole catheter ablation (EVLA) is a one-hour procedure into the below-knee GSV under ultrasound Available 24/7 at wakerad.com performed in our office with local anesthe- guidance. A sclerosant is then gently in- Free Vein Consultations sia and an oral relaxant such as Xanax,” Dr. jected through the catheter as it is slowly Wake Radiology Interventional Services offers Weeks explains. Using ultrasound for guid- withdrawn, resulting in irritation, inflam- an initial vein consultation free of charge at the ance, a laser fiber is advanced up the vein to mation, fibrosis, and resorption of the vein. Wake Radiology Cary interventional office and WR Northwest Raleigh. Patients may request be treated, the surrounding soft tissues are Treatment timeframe is another con- an appointment online at wakerad.com or anesthetized with dilute local anesthetic, sideration. Patients with more acute medi- by calling 919-854-2180. A Wake Radiology and the dysfunctional vein is ablated with cal problems such as ulceration, hemor- Interventional Services scheduler will contact a gentle pullback of the catheter, allowing rhage, or recurrent thrombophlebitis can be the patient within one business day to set up a constant deposition of energy along the treated immediately. But for patients whose the appointment. length of the vein. This results in inflam- painful legs are interfering with activities of mation and fibrosis of the treated vein, with daily living, most insurers require a trial of of the variables involved!” eventual resorption by the body. conservative therapy: the use of 20mm to An important point to remember is “The EVLA procedure is 95-98 percent 30mm compression stockings, elevation, that CVI is a lifelong diagnosis. With the effective and does not carry with it the as- over-the-counter pain medications, and at- current technologies, CVI is not cured, and sociated morbidity seen in conjunction with tempted avoidance of activities that exacer- valves that were once functioning normally surgical stripping procedures,” Dr. Weeks bate symptoms. For some, the compression can become incompetent, which may or says. “Patients walk out of the room when stockings work well, Dr. Weeks says. For may not result in significant symptomatol- they are done, and the next day they are back others, symptoms recur when they take off ogy. Dr. Weeks emphasizes to her patients to normal activities as tolerated, except no the stockings, and with insurance company that once they have chronic venous insuffi- heavy exercise and no long travel for two approval, they proceed to treatment. ciency, they will always have it. “We tell our weeks. The most onerous part for many pa- While many patients with CVI are sig- patients to keep an eye on their legs for any tients is that we have them wear their com- nificantly symptomatic, others may be more changes in appearance as well as changes in pression stockings for two weeks following concerned solely with the appearance of their symptomatology, and we recommend they the procedure.” legs. In the latter patient population, sclero- continue to wear at least mild compression While EVLA effectively ablates long, therapy and microphlebectomy are also use- as frequently as they can in order to main- non-tortuous superficial veins, protruding ful. Both procedures have their advantages tain good leg health.” varicosities can be treated percutaneously as and disadvantages. Dr. Weeks notes, “Phle- well. After dilute anesthetic is administered, bectomy is an excellent minimally invasive Venous obstruction in the pelvis may cause leg symptoms tortuous are sequentially re- procedure, well tolerated by patients, and it moved via tiny (two millimeter) incisions results in the absolute removal of the vein Besides valvular dysfunction, another created along the length of the vein. A hook 99+ percent of the time. However, when cause of leg symptoms is venous outflow ob- instrument is used to gently extract the vein, compared with sclerotherapy, it is a bit more struction in the pelvis. “This can be seen es- segment by segment. This is known as an invasive, requires tiny incisions, and the pecially in patients who have had a history of ambulatory phlebectomy, and is often per- procedure is a bit longer than sclerotherapy. ,” Dr. Weeks notes. CT formed in conjunction with EVLA. Sclerotherapy involves straightforward in- or MRI is used for diagnosis, with a prefer- While symptoms resolve for most pa- jections with a tiny 30-gauge needle into the ence for MRI because it does not use radia- tients following EVLA with or without phle- vein. No prepping is required, there are no tion. One of the more common findings is bectomy, some patients may have persistent incisions, and it is usually a 30-minute pro- May-Thurner Syndrome, in which the right symptoms that can be due to untreated cedure. The disadvantage of sclerotherapy is common iliac is compressing the left venous insufficiency involving the GSV be- that it may require more than one treatment common iliac vein. Extrinsic venous com- low the knee. Currently, heat ablation is not to make the vein completely resolve, whether pression can result in scarring of the vein, commonly used in conjunction with below- it is a spider vein or a 5-millimeter varicos- with or without associated thrombosis. If knee GSV reflux because the saphenous ity. It is multi-factorial whether or not a single thrombosis is present, catheter-directed nerve runs in close proximity to the vein, sclerotherapy session will be successful, and thrombolysis may be indicated. Once the raising the possibility of significant nerve unfortunately, we still do not understand all vein is recanalized, a is usually required

APRIL 2011 | The Triangle Physician 0 These two images demonstrate a solid complex nodule with shadowing macrocalcifications. Although this lesion is smaller than the dominant nodule, the irregular appearance of the macrocalcifications raised our concern. This was proven to be a papillary carcinoma on the biopsy. to maintain patency. Stent placement is per- is a concern, he adds, and the recurrence formed under mild IV sedation and local formed under fluoroscopic guidance, using rate is less than 10 percent. anesthetic, and it takes approximately two catheter as a roadmap. “You al- hours. Nonsurgical embolization relieves ways have to keep in the corner of your mind women’s pelvic pain Thyroid nodule biopsies help that venous obstruction in the pelvis is anoth- Another minimally invasive procedure diagnose cancer er possible cause of leg symptoms,” she says. that benefits women is embolization to treat In the diagnostic arena, image-guided Minimally invasive UFE offers pelvic congestion syndrome, also referred to biopsies increasingly provide definitive an- alternative to hysterectomy as pelvic venous insufficiency. This painful swers without the pain, long recovery, and Of the 600,000 hysterectomies per- condition, which can last for years and af- expense of . This is the case for thy- formed each year, perhaps half are due fect every element of a woman’s life, is caused roid nodules that frequently are incidental to leiomyomatous disease. As the nation by reflux of blood in the ovarian vein. The findings on chest CT, cervical spine MR, strives to reduce this number, Wake Radiol- malady primarily affects women during their or carotid ultrasounds. One in ten thyroid ogy’s interventional radiologists team with childbearing years. “This is a source of dis- nodules is cancerous, and need to gynecologists to offer patients a nonsurgical comfort that is very much under-diagnosed,” know how concerned they should be. option: uterine fibroid embolization (UFE). explains vascular and interventional radiol- “The imaging evaluation begins with The procedure is performed in a hospi- ogist Michael Kwong, M.D. “But it is a very a high-resolution ultrasound to assess the tal and includes an overnight stay for pain well-known, well-documented entity, and physical nature of the nodule,” Dr. Kwong ex- management. Approximately 90 percent of we have a nonsurgical treatment for it.” For plains. “If a nodule is confirmed to be solid women receive relief from symptoms, and this image-guided outpatient procedure, a and has indeterminate characteristics, then a the complication rate is a low 0.2 percent. tiny nick is made at the groin, a small cath- nuclear scan may be performed to Candidates are women with uterine eter is inserted, and the ovarian vein is per- assess the physiological nature of the lesion.” leiomyomata who no longer desire fertility. manently occluded using coils and either a How large should a nodule be before For their diagnostic imaging, Dr. Overton sclerosant or an embolic agent. This forces it is appropriate to biopsy it? That’s a fre- explains, “If they have a high-quality ultra- venous blood return to seek normal collater- quent and important question, Dr. Kwong sound that gives us the answer, that is good al veins that have competent valves, thereby acknowledges. “The consensus statement enough. If they do not have prior imaging, resolving the problem. from the Society of Radiologists in Ultra- or if the ultrasound shows something that is sound provides size criteria and scientific, Variococele embolization can unclear, we will proceed to MRI for diagnos- improve infertility in men data-driven recommendations on that.” (See tic imaging prior to treatment.” chart.) Similar to pelvic congestion syndrome, “This is a transarterial procedure, very The biopsy is performed in Wake reflux in the testicular veins can produce much like heart catherization, with the same Radiology’s Cary IR office, where the inter- in men. Nonsurgical emboliza- access in the top of a leg as a heart catheter, ventional suite provides a sterile operative tion can also be used to treat men suffering but we stop in the pelvis,” he explains. “This setting. A repeat high-resolution ultrasound from varicoceles, abnormally enlarged veins can be challenging, but the success rate of is performed to confirm the diagnostic find- in the scrotum that can cause pain, testicular completing the procedure is about 98 per- ings prior to the procedure. “If I see there are atrophy, or infertility. emboliza- cent in the United States.” Follow-up does tiny calcifications or an area that is more vas- tion is also an outpatient procedure per- not involve additional imaging unless there cular, I specifically target the most suspicious

0 The Triangle Physician | APRIL 2011 area—even if the nodule is only a centimeter Less invasive techniques aid Outpatient port placement at patients Wake Radiology saves time, in size,” Dr. Kwong notes. reduces stress He adds, “We are meticulous about our Wake Radiology Interventional Services To help ease the pain and stress of can- technique. We take a minimum of three to has a well-established record of helping can- cer treatment, Interventional Services offers four passes each time, although only one may cer patients. “Our skills in doing image-guided outpatient placement of ports and catheters. be needed. 85 to 90 percent of the time, we procedures match up well with oncology,” says Some allow access to veins for lab work, get diagnostic results.” In addition to thyroid Philip Pretter, M.D., a vascular and interven- medications, or chemotherapy, and the nodules, the interventional radiologists also tional radiologist. “Referring physicians realize newer power-injectable ports can accom- perform biopsies of lymph nodes and the pa- there is a lot of value in less-invasive techniques, modate the injection of contrast for follow- rotid gland. and the ability to do some procedures as an out- up CT scans. Port placement, which takes We call or fax all reports to the referring patient is quite beneficial to the patient.” about an hour or slightly less, is performed physician to make sure all reports One strength is image guidance for non- in the Cary IR office. “We use ultrasound are received. If the diagnosis is cancer, we are surgical biopsies. “If the tumor is very small, you and fluoroscopic guidance to place ports ac- sure to make a doc-to-doc phone call as well. may only see it with a CT scan, an ultrasound, curately, so that they function well for long Dr. Kwong phones the referring physician to or an MRI. Being able to direct a needle under periods of time,” says Dr. Pretter. “Many out- discuss the findings, and a faxed copy of the the guidance of that machine taking pictures al- patients come in, have the port placed, and pathology report is forwarded to the referring lows you to precisely target that lesion. oftentimes start chemotherapy the same office. Even if the biopsy is nondiagnostic, he “This is something we can do with an 18- day.” adds, “We often call the referring doctor to or a 20-gauge needle that requires no stitches, discuss what we think, in terms of imaging. just a tiny nick in the skin, local anesthesia, and Techniques help relieve Sometimes the imaging strongly favors a be- a little bit of conscious sedation,” he says. complications of cancer nign process. Even though it technically falls Interventional techniques play a role in treat- A number of interventional procedures into the category of nondiagnostic, the imag- ment as well. treats help oncology patients with complications ing along with a biopsy that shows no malig- liver or kidney tumors and has even been used such as ascites or pleural effusions. “We are nant cells may provide enough information to on tumors, Dr. Pretter notes. For pal- often asked to do a paracentesis to remove help make a decision.” liative care, interventional radiologists can treat the fluid from the abdomen or a thoracentesis metastatic liver disease with radioactive micro- to remove excess pleural fluid from around spheres or with chemoembolization, which di- the . These procedures can be both di- rectly deposits a high concentration of chemo- agnostic and therapeutic as the fluid can be therapy to the target location. sent for laboratory analysis. Higher volume

Society of Radiologists in Ultrasound Recommendations for Thyroid Nodules 1cm or Larger in Maximum Diameter

ULTRASOUND FEATURE RECOMMENDATION

Solitary nodule – microcalcifications Strongly consider ultrasound-guided FNA if > 1 cm

Solid (or almost entirely solid) or coarse calcifications Strongly consider ultrasound-guided FNA if 1.5 cm

Mixed solid and cystic or almost entirely cystic with solid mural Consider ultrasound-guided FNA if > 2 cm component

None of the above, but substantial growth since prior ultrasound Consider ultrasound-guided FNA examination

Almost entirely cystic and none of the above and no substantial Ultrasound-guided FNA probably unnecessary growth (or no prior ultrasound)

Multiple nodules Consider ultrasound-guided FNA of one or more nodules, with selection prioritized on basis of the criteria (in order listed) for a solitary nodule*

*The panel had two opinions regarding selection of nodules for FNA. The majority opinion is stated here.

APRIL 2011 | The Triangle Physician 0 PATIENT CASE: GASTRIC HEMORRHAGE

Patient is a 40-year-old male with acute hemorrhage into the stomach from a gastric ulcer that could not be stopped by endoscopy. A catheter was threaded into the left gastric artery, and the artery was temporarily blocked with gelfoam embolization.

This case stands as an example of how interventional radiologists can address problematic bleeding in various locations. Often patients have significant hemorrhage in locations that surgeons have great difficulty accessing, the patients are in poor health, or are anti-coagulated. Embolization may be a viable treatment for these cases.

This image shows the circulation This image shows the blood to the stomach before treatment. vessel after embolization. thoracenteses also help patients breathe more easily and more com- “The patients for whom this treatment is most appropriate are fortably, while higher volume paracentesis typically decreases the pain usually in their fifties or older, have osteoporosis, and have developed a and discomfort from excess peritoneal fluid. fracture from weakened bones,” Dr. Leuchtmann explains. Indications “Using ultrasound, we can, in a few minutes, direct a small tube for treatment include acute or subacute onset of back pain, most often into the fluid and drain it out over a period of 20 minutes to an hour. with point tenderness, and pain that interferes with normal daily activi- The patient goes home shortly after that, and usually feels much better ties without medication. Wake Radiology interventionalists also treat immediately. Occasionally, we put in a PleurX® catheter so the patient vertebral fractures in cancer patients, typically those with advanced- can drain the fluid at home.” stage cancer or cancer with bone metastases. “Imaging studies to demonstrate compression fracture should Vertebroplasty/Kyphoplasty show 75% to 90 % success rate in relieving pain always begin with radiographs,” Dr. Leuchtmann says. Most patients undergo an MRI during their workup to determine the acuity of the The skilled hands of experienced interventional radiologists pro- compression fracture. For patients who cannot undergo an MRI, a vide vital help in relieving the severe pain of vertebral compression bone scan and CT scan combination can be performed. These find- fractures. These fractures are most frequently caused by osteoporosis, ings are crucial in determining which patients will most likely benefit. a widespread and costly disease. “There are 10 million Americans with “Optimal results are obtained in patients with active bone edema on osteoporosis and another 34 million at risk of developing the disease,” MRI, usually within two to six weeks of their fracture,” he says. notes Pete Leuchtmann, M.D., a joint and spine interventional spe- Numerous factors affect the interventional radiologist’s choice of cialist who is fellowship trained in both interventional and musculo- vertebroplasty or kyphoplasty, among them the fracture location. “We skeletal radiology. “The annual cost for fractures due to osteoporosis is are not able to treat fractures in the highest portion of the thoracic on the order of $20 billion. In the United States, there are an estimated spine because of the smaller size of the vertebra at those levels. Typi- 700,000 vertebral compression fractures each year.” cally, the highest level we treat with Balloon Kyphoplasty is T7. We For the appropriate patient population, Dr. Leuchtmann says, may go up to the T5 level with vertebroplasty.” minimally invasive vertebral augmentation procedures—vertebro- Vertebroplasty is performed as an outpatient procedure at plasty or kyphoplasty—are the most effective therapy. “Some 75 to WakeMed in Raleigh. It requires only conscious sedation and local 90 percent of patients show significant relief, typically within the first anesthesia, and it takes about 40 minutes. Using c-arm fluoroscopy days after the procedure.” as a guide, the interventional radiologist inserts a needle/cannula into Vertebroplasty involves a fluoroscopically guided injection of the fractured vertebral body and infuses it with surgical bone cement, bone cement into the fractured vertebra. Kyphoplasty utilizes a bal- polymethyl methacrylate. The cement hardens within 15 minutes, sta- loon to create a void and correct the deformity, restoring some height bilizing the fracture and preventing further collapse. to the fractured vertebra. A similar procedure, sacroplasty, is used to treat sacral fractures.

0 The Triangle Physician | APRIL 2011 The overwhelming majority of patients dures have provided dramatic relief for count- “Those are particularly gratifying because report no pain from the procedure itself. If less patients with debilitating pain,” Dr. Leucht- the injuries are life-threatening. A surgical ap- necessary, more than one vertebral level can be mann says. “No longer suffering from the proach is felt to be dangerous by the surgeons, performed in a single setting. Post-procedural fractures, these individuals can avoid the side and that’s why they’ve asked us to look at them. fluoroscopic images are obtained for docu- effects (deconditioning, pulmonary complica- In some cases, it’s one of the few alternatives a mentation. After a vertebroplasty, patients re- tions, etc.) of being bedridden or on narcotic patient may have,” Dr. Presson says. main in bed for two hours. pain medications, and they can return to their WAKE RADIOLOGY Patients often report improvement im- normal activities and enjoy their lives.” INTERVENTIONAL SERVICES mediately, and most report pain relief or sig- Saving the lives of trauma VENOUS ACCESS nificant improvement over the next 48 hours. patients • Chest Ports Vertebroplasty has a typical success rate of • PICCs Quite often a Wake Radiology interventional • Hickmans greater than 80 percent for patients with osteo- • Catheter Removals radiologist gets a call and heads for WakeMed’s • Dialysis Access porosis and greater than 50 to 60 percent for • Shuntgrams/Fistulagrams with emergency department, one of the busiest treatment of neoplastic fractures. in the state. Thomas Presson, M.D., a vascu- Vertebroplasty has been shown to be safe VARICOSE VEIN lar and interventional radiologist, describes • Laser Ablation of Superficial Venous system when performed in the appropriate setting by a • Microphlebectomy the typical situation. “Acute hemorrhage in a • Sclerotherapy well-trained physician. The incidence of com- trauma patient is a typical emergency case. • Topical Laser for Spider Varicosities plications is less than 1 percent in osteoporotic THYROID BIOPSIES Bleeding may be caused by penetrating trauma patients and less than 5 percent in the neoplas- or blunt trauma, such as a car accident. Bleed- PARACENTESIS / THORACENTESIS tic population. ing from small vessels, or vessels within organs Balloon Kyphoplasty, a slightly more inva- BONE THERAPIES such as the liver or spleen, may be particularly • Balloon Kyphoplasty sive procedure, is also performed at WakeMed • Vertebroplasty hard to approach surgically due to the risk of in Raleigh. This procedure, like vertebroplasty, • Facet Injection further disturbing the damaged organ. In that • SI Joint Injection is usually performed on an outpatient basis, case, we do an embolization where you run a CONSULTATIONS FOR although there are times when inpatients need little catheter right up into the bleeding vessel • Vein Therapies the procedure as well. With kyphoplasty, a bal- • Vertebral Compression Fractures (Kyphoplasty/ and block it off.” Vertebroplasty) loon introduced into the center of the vertebral • Uterine Fibroid Embolization (UFE/UAE) “If a trauma patient is particularly un- • Tumor Therapy (Radiofrequency Ablation) body is used to create a cavity in the bone and stable, our objective is to immediately find the • Peripheral Arterial Disease to increase the height of the fractured vertebra. bleeding vessel and stop the bleeding. Some- The space is then filled with bone cement. Pain Long-term ascites/pleural effusion drainage times you embolize the bleed site without even catheter placement (PleurX®) relief can be dramatic and nearly complete in seeing exactly which vessel is disrupted, be- more than 80 percent of patients. cause you have to do something before it’s too “Overall, vertebral augmentation proce- late. PATIENT CASE: LIVER BRACHYTHERAPY TREATMENTS

Patient is a 74-year-old woman with metastatic carcinoma of the pancreas, progression despite conventional therapy, and prior Whipple procedure. The patient was referred for liver brachytherapy with radioactive microspheres.

This case shows an end-stage malignancy that has failed to respond to first-line therapy. The malignancy is widespread in the liver, which precludes surgical removal of a portion of the liver. Brachytherapy can treat the whole liver while preserving liver function, often significantly slowing the progression of disease, and it is sometimes curative. Our physicians support local radiation oncologists with arterial procedures for their liver brachytherapy patients.

This image shows one of the hepatic lesions Numerous hepatic metastases on an Hepatic following microsphere Distribution of the test dose of radiation concentrated on the CT scan. angiogram. infusion. in the liver.

APRIL 2011 | The Triangle Physician 0 MEET OUR INTERVENTIONAL RADIOLOGISTS CARROLL C. OVERTON, MD THOMAS L. PRESSON JR., MD Vascular & Interventional Radiologist Vascular & Interventional Radiologist Director of Interventional Services • | Bowman Gray School of Medicine, Wake Forest Univer- • Medical School | University of North Carolina School of Medicine, Chapel Hill sity, Winston-Salem • Residencies | Diagnostic Radiology, Mercy Hospital of Pittsburgh; Diagnostic • Residency | Diagnostic Radiology, Duke University Medical Center, Durham Radiology, University of Pittsburgh Medical Center; Surgical Residency, Mercy • Fellowship | Vascular and Interventional Radiology, Duke University Hospital of Pittsburgh Medical Center • Fellowship | Interventional Radiology, Alexandria Hospital, • Certification | American Board of Radiology – Diagnostic Radiology Alexandria, VA • Appointments | Radiation Safety Officer – Wake Radiology, WakeMed Raleigh, WakeMed Cary Hospital • Certification | American Board of Radiology – Diagnostic Radiology • Memberships | American College of Radiology, Society of • Appointments | Director of Interventional Services, Wake Radiology; Chairman, Credentials Committee, Interventional Radiology, North Carolina Medical Society, Wake County Medical Society WakeMed (2010) • Joined practice in 2001 • Membership | Society of Interventional Radiology, North Carolina Medical Society, Wake County Medical Society MICHAEL D. KWONG, MD • Joined practice in 1998 Vascular & Interventional Radiologist • Medical School | University of Texas School of Medicine, San Antonio ALAN B. FEIN, MD Vascular & Interventional Radiologist • Residency | Diagnostic Radiology, Boston Medical Center • Fellowship | Vascular and Interventional Radiology, University of California • Medical School | Columbia University College of Physicians and Surgeons, New York San Diego Medical Center • Residencies | , Emory University Affiliated Hospitals, Atlanta; • Certification | American Board of Radiology – Diagnostic Radiology Diagnostic Radiology, Duke University Medical Center, Durham • Memberships | Society of Interventional Radiology, Radiological • Fellowships | Mini-fellowship Vascular Interventional Radiology, Duke University Society of North America, American College of Radiology, North Carolina Medical Society, Wake County Medical Center; Vascular IR and Abdominal Imaging, Mallinckrodt Institute of Radiol- Medical Society ogy, Washington University School of Medicine, St. Louis, MO • Joined practice in 2003 • Certifications | American Board of Radiology – Diagnostic Radiology, American Board of Internal Medicine, National Board of Medical Examiners PETER L. LEUCHTMANN, MD • Memberships | ACR, Society of Interventional Radiology, North Carolina Medical Society Vascular & Interventional Radiologist • Joined practice in 1986 Musculoskeletal Radiologist

ANDREW WU, MD • Medical School | Indiana University School of Medicine, Indianapolis Vascular & Interventional Radiologist • Residency | Diagnostic Radiology, University of Maryland School of Medicine, Baltimore • Medical School | Washington University School of Medicine, St. Louis • Fellowships | Cardiovascular/Interventional Radiology, The Johns Hopkins • Residency | Diagnostic Radiology, Mallinckrodt Institute of Radiology, Wash- Hospital, Baltimore; Musculoskeletal Radiology, University of North Carolina ington University School of Medicine, St. Louis Hospitals, Chapel Hill, NC • Fellowship | Interventional Radiology, University of Michigan Medical School, • Certifications | American Board of Radiology – Diagnostic Radiology, International Society for Clinical Ann Arbor Densitometry • Certification | American Board of Radiology – Diagnostic Radiology • Memberships | American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, Society of Interventional Radiology, International Spine Intervention Society, North Carolina • Appointments | President, NC state chapter of ACR (2010), Fellow of American Medical Society, Wake County Medical Society College of Radiology (5/2011) • Joined practice in 2006 • Memberships | American College of Radiology, Society of Interventional Radiology, North Carolina Medi- cal Society, Wake County Medical Society SUSAN M. WEEKS, MD • Joined practice in 1991 Vascular & Interventional Radiologist

PHILIP C. PRETTER, MD • Medical School | University of North Carolina School of Medicine, Chapel Hill Vascular & Interventional Radiologist • Residency | Diagnostic Radiology, University of North Carolina Hospitals, Chapel Hill • Medical School | University of Pittsburgh School of Medicine, Pittsburgh • Fellowship | Vascular and Interventional Radiology, University of North • Residency | Diagnostic Radiology – Chief Resident, University of Pittsburgh Carolina Hospitals, Chapel Hill Medical Center • Certification | American Board of Radiology – Diagnostic Radiology • Fellowship | Interventional Radiology – Fellow of the Year, Department of Radiol- ogy, University of Pittsburgh School of Medicine • Memberships | American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, Society of Interventional Radiology, North Carolina Medical Society, Wake County Medical Society • Certifications | American Board of Radiology – Diagnostic Radiology • Joined practice in 2006 • Appointments | Vice Chairman, Department of Radiology, WakeMed Raleigh Hospital • Memberships | American Roentgen Ray Society, Radiological Society of North America, Society of Interventional Radiology, NC Medical Society, Wake County Medical Society • Joined practice in 2000

WAKE RADIOLOGY EXPRESS SCHEDULING STREAMLINE YOUR SCHEDULING With Wake Radiology’s Express Scheduling, scheduling patients throughout the region takes only one call or fax to order any service. As an additional feature, Wake Radiology Express Schedulers will contact referring physicians’ patients to coordinate the best date, time, and location for their procedures. Wake Radiology Interventional Radiology & Vein Therapy Center WR Express Scheduling 300 Ashville Avenue Ste 160 Cary, NC 27518 919-232-4700 Interventional Radiologist Physician Hotline 919-854-2180 wakerad.com PleurX is a registered trademark of CareFusion Corporation or one of its subsidiaries. All rights reserved. Balloon Kyphoplasty is a registered trademark of Kyphon Inc. 0 The Triangle Physician | APRIL 2011