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	Peripheral Vascular Disease: Diagnostic & Treatment Procedures Diagnostic Procedures

		Arteriogram/Aortogram Procedure During the procedure the physician will insert a catheter (a long, thin flexible tube) into a blood vessel in your groin or arm. Contrast, or dye, is then injected via these tubes to the vessel of concern while x-ray pictures are taken. This procedure can be performed on an outpatient basis. In preparation for your test, blood work will be ordered one to two days before the scheduled date. The day of the procedure, you will be asked to arrive early to the lab and someone should be able to drive you home. Before the procedure, an intravenous line will be started. You will remain awake throughout the procedure. It takes approximately 30-60 minutes to take the pictures. Once the procedure is complete, the catheter tube will be removed and firm pressure will be applied to the entry site for approximately thirty minutes; also a large, tight pressure dressing will be applied. You will return to your room or recovery area where you will need to lie flat in bed for 4 hours. When the dressing is removed, you will notice a small bruise at the catheter insertion site, no larger than the size of a quarter. You may also feel a hard lump. It is normal to expect the bruise to become slightly larger and darker the first few days you are home. They are the result of the body's normal healing process and should completely disappear in about two weeks. If you become uncomfortable or are experiencing any discomfort, please call your doctor.

	Interventional (Treatment) Procedures Preparation As in all catheterization procedures, you should arrive to the outpatient department at least 90 minutes prior to your scheduled procedure .This allows the nursing staff the time to become acquainted with you and your needs, prepare your intravenous fluid line and make you comfortable before the test. Most patients will be admitted to the hospital for a one night stay after the angioplasty/stent for patient safety. Percutaneous Transluminal Angioplasty Balloon angioplasty is now the most common method used for opening up a blocked artery in the heart, legs, kidneys, arms, or neck. The picture on the left shows a blocked Iliac artery. After the groin (arm) is washed with a sterile solution a sheath is placed in the access site (groin, arm) to allow passage of the entire catheter system to the site of intervention. A thin floppy wire is passed into the sheath system through the narrowed opening in the artery. A deflated balloon is passed over this wire to the obstructed area of concern. Under fluoroscopic (x-ray) guidance the balloon is inflated. This causes the obstruction to be compressed into the walls of the artery The picture on the right shows the blocked illiac artery after a successful angioplasty procedure. The blood then washes this area and allows for the natural healing process. This procedure is nearly 100% effective in eradicating the blockage. Sometimes regrowth of tissue in this region over the ensuing months (years) may necessitate a second intervention. The increased size of the arterial opening should allow for improved blood flow and thus lessen symptoms of discomfort in the affected limb.

Intravascular Stents

It has been shown that the use of an expandable device (stent) at the site of percutaneous transluminal angioplasty achieves a greater patency rate (artery remaining open) over time.

1. Balloon-expandable stents
Over the years the original Palmaz stent has under gone a facelift. No longer are these a bulky commodity but rather a thinstreamlines stainless steel or Nitinol wire mesh.

Palmaz-Schatz Stent: Placement and Expansion

The Palmaz-Schatz stent, illustrated at left, must be delivered to the obstructed site on a balloon catheter passed over a wire. After the balloon is inflated, the stent expands. The balloon catheter is then removed leaving the stent in place to keep the artery open.

2. Self-expanding stents
Over the years the oringinal Wallstent has under faced stiff competition from other new and improved devices These too are now stainless steel of Nitinol. There advantages are for use in tortuous blood vessels. A cover is removed from the stent which allows it to open like an umbrella, sealing itself into place.

The Wallstent, illustrated at right, is delivered to the obstructed site by traversing over a wire. The outer protective covering is then retracted allowing the stent to self expand to keep the artery open . A balloon is then passed over the wire to the affected site, where it is inflated for completion of the angioplasty procedure.

A second type of self-expanding stent is the Smart Stent, made of Nitinol material. This has an advantage of allowing a very small degree of shortening so as to allow the cardiologist to exactly place it in the proper position


	Stent-Grafts As recently as 1990, Dr. Juan Parodi of Argentina developed a method to place a covering over the stent to treat certain blockages, aneurysms and areas of traumatic injury. This Ultra thin PTFE covered graft (Viabahn) is used here to treat a 2.5 cm. aneurysm of the axillary (arm) artery located under the clavicle caused by previous surgery. .

Atherectomy

Rotaing catheter for Atherectomy
This procedure is normally reserved for the treatment of highly calcified areas in the arterial system.This specialized procedure involves the insertion of a rotating catheter at up to 180,000 rpm. The obstructing fibrous plaque is pulverized into minute micro particles and washed away into the bloodstream. Typically after removal of the device a balloon or stent procedure follows as previously stated.

Laser Assisted Angioplasty

This procedure is normally reserved for treating areas that cannot be opened with balloon technology as it exists today. A laser catheter, illustrated at right, produces a high intensity light beam which vaporizes the affected region without damaging the surrounding tissues. This then allows the passage of a balloon system to further open the obstruction. Balloon angioplasty /stent procedure follows to ensure that the artery remains open To date many laser systems exist however only the Excimer laser is FDA approved.

Thrombolysis - Angiojet

Thrombosis in leg artery Many arterial blockages may also contain a blood clot at the site of obstruction. Your physician may deem it necessary to instill a clot buster at that site either before, during or after the interventional procedure. Various agents are available to your physician, including r-TPA (Alteplase) and r-PA (Retavase), TNKase and Urokinase. All of the available agents function by dissolving clots in the vascular system. Because of the powerful nature of these medications it will be necessary for your physician to closely monitor you for signs of excessive bleeding. This may require monitoring in the Intensive Care Unit overnight.

Recently a catheter has been approved for the direct removal of blood clots from arterial vessels by means of catheter techniques rather than by surgery. Such a device, the Angiojet by Possis Medical, is pictured here showing the 100% removal of a blood clot from the Poplipteal leg artery in an individual with the acute onset of a cold leg secondary to a blood clot. The AngioJet system design is based on the Bernoulli principle to quickly, thoroughly, and safely remove thrombus using normal saline to accomplish its task. The Drive Unit and Pump Set deliver high-pressure saline to the tip of the Catheter where it is transformed into high-velocity jets. The saline jets create a near perfect vacuum in a 360º radius around the tip. This vacuum pulls the thrombus into the jet stream where it is broken into microscopic fragments and propelled out of the patient's body.

Non-Surgical Abdominal Aneurysm Repair

With the advancing age of our patients aided by the excellence of present day health care, we are also finding improved methods to repair the enlarged abdominal blood vessel "Aortic Aneurysm" created by high blood pressure (hypertension) and hardening of the arteries (atherosclerosis). Many patients with this problem are totally without any symptoms and are discovered either by their local physician during check-up or during an ultrasound screening that is offered widely throughout the country.
Because of the high risk of surgery in these individuals with severe heart, lung or medical problems, we are now able to use various different covered stents (Endovascular Stent-Grafts) to avoid a potentially life threatening surgery and replace it by a less invasive procedure to remove the aneurysm from the circulation. (See photos)
Dr. Neil E. Strickman MD also has FDA approval for the use of future devices related to not only abdominal aortic aneurysm (AAA) but also thoracic aortic aneurysm (ADTA). Likewise, almost any blood vessel in the entire body can be treated with stents or covered stent-grafts today. Many however are still under investigation (also shown below).
Patients accepted by our Cardiology practice for this procedure will spend only 1 or 2 nights in the hospital with immediate recovery, rather than 1-2 weeks in the hospital followed by 4-12 weeks of recovery at home. If you or your physicians feel that you can be helped with this disorder, please feel free to contact our office for a full evaluation or send an e-mail to hallgar@hgcardio.com


	Implanting a stentgraft in an Abdominal Aortic Aneurysm

The AneuRx
stentgraft
being implanted

The AneuRx
stentgraft
implanted

Gore Excluder

The Talent
stentgraft

The Zenith
stentgraft

Carotid Artery Stent Angioplasty

Many patients are just too high risk for a carotid artery bypass operation. Some may have had a previous Carotid Endarterectomy which has failed to remain open and this can be a new life-threatening problem. Indeed, they may not have symptoms of severe blockage but can be categorized as having a blockage with a high chance of impending stroke. Patients who already have had one such operation, who have had radiation therapy, or have severe heart and lung disease, may be candidates for this stent procedurel.

They will be carefully screened by a team of physicians prior to being accepted into this program. At the present time this procedure is under investigation by the FDA of which Dr. Neil E. Strickman MD is the leading certified physician. Acceptance for this procedure requires strict guidelines which must be followed. It is anticipated that the FDA will approve this procedure for Medicare as well as all insurance companies before 2005.

We are now investigating various filter devices for use in patients with diseased Carotid arteries that capture any debris liberated during the non-surgical balloon/stent procedure. Shown here is a Precise Nitinol self expanding Stent implanted in a carotid artery stenosis yielding an excellent angiographic appearance. This stent has the property to expand fully with time after initial deployment. Please contact us if you feel that you may be a potential candidate for this fast rising non-surgical treatment of this disorder.

After the Procedure/Discharge

Upon completion of the procedure you will return to your room where a nurse will monitor your vital signs and progress. She will continuously check the catheter insertion area (groin or arm) for any signs of bleeding and all the pulses from the arms to the toes. As with the arteriogram procedure, you will remain flat in bed for a few hours before the doctor allows you to get up and move around. A Doppler measurement of your pulses may be performed prior to your discharge in the peripheral vascular laboratory. This will be repeated at 6 monthly intervals to keep a close watch on blood flow in your upper or lower extremities. After discharge home it will be advisable to perform minimal exertional activities for 24 hours to allow healing of the puncture site. A follow-up examination will be scheduled with your physician in the coming weeks as a completion to your personalized percutaneous transluminal angioplasty . Any localized swelling or swelling of the extremities should be reported to your physician at once..




		a severely narrowed carotid artery in a 70 yo female with an impending stroke




	a perfectly implanted stent in the carotid artery which not onlly prevented a major stroke but was completed in < 60 minutes without the use of general anesthesia, surgery or pain

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