VEIN SERVICES: VARICOSE VEINS AND VENOUS INSUFFICIENCY TREATMENT:

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The VNUS Closure procedure is a minimally invasive treatment alternative with less pain and less bruising when compared to traditional vein stripping surgery and laser treatment. Using the Closure system, physicians close the diseased veins by inserting the Closure catheter into a vein and heating the vein wall using temperature-controlled RF energy. Heating the vein wall causes collagen in the wall to shrink and the vein to close. After the vein is sealed shut, blood then naturally reroutes to healthy veins.

Venous reflux or venous insufficiency develops when the valves that usually keep blood flowing out of your legs become damaged or diseased.

 

The Closure procedure provides the following benefits for patients and physicians:

  • Minimally Invasive Outpatient Procedure. Closure catheters are inserted into the vein via a tiny incision in the lower leg, eliminating the need for groin surgery and general anesthesia. The Closure procedure can be performed using local anesthesia in a physician’s office, as well as in an outpatient hospital setting or surgicenter.
  • Clinically Proven Less Post-Operative Pain. The Closure procedure does not involve pulling the diseased vein from the thigh as with vein stripping surgery, or using 700° C laser energy which boils blood to occlude a vein as with endovenous laser (EVL)12. In the RECOVERY Trial, a multi-center head-to-head comparative randomized trial comparing the Closure procedure with EVL, the Closure procedure was found to have less patient pain and less patient bruising than EVL for the best patient recovery experience available from a minimally invasive vein treatment.10 Additionally, in other randomized comparative studies have shown that patients receiving the Closure procedure return to normal activity and work significantly faster than those receiving vein stripping.3
  • Excellent Clinical Outcomes. The ClosureFAST catheter, which represents the latest advancement in the Closure procedure, has been shown in a multi-center study to have a 97.4 efficacy rate at one-year.11  This shows that the treatment is highly effective and, as proven in the RECOVERY trial, is gentle on the patient.10
  • Cosmetically Appealing. Because treatment with Closure is minimally invasive and is catheter-based, it results in little to no scarring. As with any medical procedure, you are encouraged to review all safety information associated with the procedure by consulting your physician.


ELECTROCARDIOGRAM (EKG):

An EKG is a record of the electrical activity of the heart. During this test, electrodes are placed on each arm and leg and at 6 points on the chest. If the EKG is abnormal, it may mean or suggest different types of heart problems. The EKG can provide important information about the heart rhythm, a previous heart attack, increased wall thickness of the ventricles, signs of insufficient oxygen delivery to the heart muscle or an ongoing heart attack, and problems with conduction of the electrical signals from one part of the heart to another. A normal EKG does not exclude heart disease.

SIGNAL-AVERAGED ELECTROCARDIOGRAM


This test is done in a manner similar to a standard EKG. The electrical data is acquired for a little longer time and the computer processes the information, averages it and amplifies it. The data obtained will identify any instability of the heart’s electrical system, thus providing information of the risk of potentially fatal arrhythmias.


TREADMILL TEST (EXERCISE STRESS TEST)


The treadmill test is basically a continuous EKG monitoring during physical exertion with close attention to the blood pressure and heart rate. Its' major use is to detect significant coronary artery disease (blockages in the coronary arteries). Frequently is used as part of the evaluation of patients with chest pain and arrhythmias (irregular heartbeats). It also provides assessment of the exercise capacity, circulation to the legs, and blood pressure and heart rate response to exercise. The test is performed according to standard protocols. The most commonly used is the Bruce protocol. It consists of three-minute stages at increasing speed and slope. This allows physicians anywhere in the world communicate and compare test results. One of the end-points of the exercise test is to achieve at least 85% of the age-predicted maximum heart rate. If a patient has a significant narrowing in the coronary arteries, the exercise may elicit chest discomfort (angina pectoris) or changes in the EKG. Although the regular treadmill test is extremely useful, it can occasionally miss coronary artery disease. Nuclear imaging done in conjunction with exercise testing will improve the overall accuracy of the test and provide useful information in regard to the location and severity of the blockages.



NUCLEAR IMAGING STRESS TEST:

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This test uses the IV injection of a small amount of a radioactive substance called "Cardiolite" (in certain situations "Thallium" is used instead). A special camera ("gamma camera") is used to take pictures of the heart at "rest" and after "stress" (usually in two different days). This medication gets to the heart muscle through the coronary arteries. Normally there is uniform uptake of this radioactive substance. However, if there is a blockage in one or more of the coronaries, there will be a "spot" or "defect". The size, number and degree of "darkness" of these spots will correlate with the number, location, and severity of the coronary artery disease. Therefore, these nuclear techniques provide more accurate and detailed information than that provided by a regular treadmill test. This test is frequently used to evaluate patients with chest pain or after an angioplasty to detect re-blockage of the dilated artery and after coronary bypass surgery to assess the integrity and function of the bypass grafts done.

If the patient cannot exercise, a "chemical stress test" will be used. This involves the use of an IV medication (instead of exercise) that increases the blood flow to the heart (coronary vasodilators, such as adenosine or persantine). Other IV medications such as dobutamine simulate the effects of exercise (by increasing the heart rate and making each heart beat more forceful) can also be used. These types of stress tests are used in patients who cannot exercise such as those with severe lung disease, arthritis, prior leg amputation or stroke, etc.

We have in place state-of-the-art equipment and computer software, which is operated with the strictest quality control.



ECHOCARDIOGRAM:


This is a simple office test that uses ultrasound to image the heart (image is formed by bouncing sound waves off the heart). It is painless and entirely non-invasive. This test provides a detailed analysis of the structure and function of the heart. The information provided includes: size and thickness of the walls of the heart, the strength of the heart muscle as a pump (extremely important after a heart attack), congenital anomalies of the heart, detailed assessment of the heart valves for narrowing or leakage and presence of tumors or clots. It allows initial assessment and follow-up of prosthetic heart valves. In essence an echocardiogram provides vital information that is necessary in most patients with known heart disease or patients with symptoms that suggest it.




STRESS ECHOCARDIOGRAM:


This test combines the treadmill test and the echocardiogram. A resting Echo is done and repeated immediately after the exercise. Both digitized studies are compared side by side. Patients with blocked coronary arteries have transient abnormal motion of part of their heart muscle after exercise, which can be seen with the echocardiogram. If patients cannot exercise, a chemical stress test (as described above) may be substituted for the treadmill exercise.



24-HOUR HOLTER MONITOR and EVENT MONITORS:


The Holter monitor is continuous EKG recorded on audiotape over 24 hrs. The patients are sent home with the attached monitor to record the heart rhythm for 24 hrs. The patient is encouraged to perform their usual daily activities while wearing the monitor. A "diary" is given to the patients to write down any symptoms experienced during that period. The cardiologist then will be able to match the symptoms with abnormal heart rhythms. This test is used to detect and document any cardiac arrhythmias or simply to determine the patients’ heart rate over a 24-hour period. If the heart rate becomes too slow, a permanent pacemaker may be indicated.

If the patient experiences cardiac arrhythmias only every 2 or 3 weeks, a 24 hr-Holter may not "catch" the problem. In those cases,  different types of monitors are used ("event recorders" or "event monitors") that will record and save the EKG strip only when patients press a button.




VASCULAR STUDIES – ULTRASOUND AND DOPPLER (DUPLEX)


Ultrasound provides 2-dimensional images of the blood vessels and doppler assesses the velocities of blood flow. Color flow imaging is basically doppler data represented in color on a 2-dimensional real-time image. Vital information about the severity of the blockages and composition of the plaques can be obtained. Therefore, it is not surprising that duplex ultrasound studies have become the technique of choice to detect, quantify and follow the progression of vascular disease in different areas:

Carotid arteries: neck arteries that supply blood flow to the brain, (blockages may result in strokes),
Peripheral (leg) arteries: blockages may cause exertional leg pain (intermittent claudication),
Renal arteries: arteries that supply blood to the kidneys, (blockages may result in severe hypertension and renal failure) and,
Aorta: the gradual dilatation or "ballooning" of an artery is called aneurysm, the most common of which is the aneurysm of the abdominal aorta. Growth rate of the aneurysm varies but a mean rate of enlargement of 0.4 cm/yr have been reported. Yearly examinations are necessary to measure the aneurysm size. Surgical treatment is necessary in large aneurysms (greater than 4.5-5 cm in diameter) to prevent rupture and internal bleeding, sometimes fatal. Also first-degree relatives of patients with abdominal aneurysms should probably be screened.



PACEMAKER OR DEFIBRILLATOR (ICD) FOLLOW-UP


Regular follow-up checks of your pacemaker or implantable cardioverter-defibrillator (ICD) are an important part of your implanted device care. Some of the objectives of the pacemaker follow-up clinic include: 1) optimize the settings of the pacemaker to match your present needs, 2) maximize the battery life of your pacemaker and detect early signs of battery depletion, 3) monitor the underlying electrical disease process and accommodate changing pacemaker/ICD needs, 4) re-programming around pacer related problems, 5) stay abreast of pacemaker advisories and alerts, and 6) educate patients and family members.



ENHANCED EXTERNAL COUNTERPULSATION (EECP)

EECP therapy is a non-invasive outpatient treatment for coronary artery disease patients with angina pectoris refractory to standard medical therapy or surgical intervention. Following successful trials, Medicare coverage for this treatment modality has been granted. In simplest terms, EECP involves sequential inflation and deflation of compressive cuffs wrapped around the patient’s legs. These events are timed to the cardiac cycle and provide both an increase in the blood flow to the coronary arteries (inflation when heart is relaxed) and a reduction in the workload to the heart (deflation at the beginning of the ventricular contraction). In addition to improving the performance of the heart, it is possible that EECP may promote the development of collateral blood vessels ("natural bypasses"). The MUST-EECP trial reported that 1-hour sessions once or twice daily for total of 35 hrs (course of therapy 7 weeks, if used 1 hour/day Mon-Fri) decrease the frequency of angina and nitroglycerin usage. Some patients do not qualify for EECP such as those with valvular heart disease, recent heart attack or bypass surgery, deep vein thrombosis, severe PVD, bleeding problems, certain cardiac arrhythmias, pregnant women among others.

TILT TABLE TESTING


This simple test involves the placement of an IV, taking frequent blood pressure readings and continuous EKG monitoring, both lying down flat and with the table at 80o (almost standing up). If normal, an IV medication (isuprel) or nitroglycerin are given and the tilt is repeated. This test provides an assessment of the neural reflexes, which when abnormal, may cause patients to faint.


CARDIAC CATHETERIZATION (Coronary Angiography)


Cardiac catheterization is an X-ray test that uses radiographic contrast (‘dye") to visualize the coronary arteries and pinpoint the presence and severity of blockages and, more importantly, to determine the best treatment available. If the test revealed blockages, you will be offered one of three treatment modalities: medications only, angioplasty or bypass surgery.

The test is done on an outpatient basis. The patient is mildly sedated but awake during the procedure. A local anesthetic is used to numb the area (usually the right groin). Soft plastic tubes ("catheters") are inserted into the artery and then advanced under X-ray guidance. The dye is injected into the heart chambers and coronaries and pictures are taken from different angles. This is the best test available to find and visualize the blockages.

 A non-threatening environment, caring nurses and skillful technologists will make this experience more comfortable for you.

It is not uncommon to have blockages in more than one artery. These tests are sometimes done simultaneously.



Transesophageal Echocardiography (TEE)

  Transesophageal Echocardiogram is a type of echocardiogram test that allows a physician to record images of the heart from the inside of the patient's esophagus by using an ultrasound transducer, positioned on an endoscope. The endoscope is a long, thin, flexible instrument that is guided down the patient's throat into the esophagus to provide close-up images of the heart's valves and chambers without interference from the ribs or lungs.


Permanent Pacemaker Implantation


If the heart rate is too slow, a pacemaker may be necessary to electrically stimulate the heart. Placement of a permanent pacemaker requires overnight hospital stay. This is done under local anesthetic. A small incision is made in the shoulder level (usually on the left side in right-handed patients), below the clavicle. A pocket is performed under the skin and one or two tiny wires ("leads") are advanced through a vein into the right heart chambers. These leads are connected to the pacemaker battery can and are sutured in place. The pacemaker will only pace the heart when the heart rate is below the pacer set rate. The battery lasts 3 to 12 years with an average of 5-7 years. Replacement of the pulse generator (can that contains the battery and electronics) is easy requiring only a few hours in the hospital.



DEFIBRILLATOR IMPLANTATION

An implanted defibrillator or AICD is an electronic device that is placed in your body to help control the speed and pattern of your heart rate by constantly monitoring your heart rate and rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle. This causes the heart to beat in a normal rhythm again. The AICD is made up of two parts, a generator and leads.The generator houses the battery and a tiny computer. Energy is stored in the battery until it is needed. The computer receives information from the leads which are tiny wires that monitor the heart’s rhythm and delivery energy from the generator to determine what rhythm is occurring. for pacing, cardioversion and/or defibrillation. The AICD normally works as a pacemaker and prevents slow heart beat until a potentially "killer rhythm" emerges and then it delivers the shock energy to the heart automatically.