APRIL 2011 Wake Radiology Interventional Radiology Minimally invasive experts of the Triangle Also in This Issue Heart 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 physician who sees the patient typically also radiologist, has for over 5 years been treat- ing vein patients with CVI who suffer from performs the procedure. Patients benefit from a variety of symptoms that include aching, pain, 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 veins including the great saphenous vein 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 edema 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 thrombosis (DVT). Doppler ultrasound is frequently used to identify the exact prob- lem. This painless examination uses a cuff (similar to a blood pressure cuff) applied to the calf just above the ankle. “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 venous thrombosis, 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 sclerotherapy 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 Therapy 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 varicose veins 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. deep vein thrombosis,” 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 artery 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 stent 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.