Procedures

Angiography


What is an angiogram?

An angiogram is an exam that allows the doctor to look at your blood vessels (arteries or veins) by inserting a tube into the blood vessel and injecting dye.

If a blockage or narrowing of a vessel is found, the doctor may perform the following procedures:

Angioplasty:

  • This procedure opens up the blocked or narrowed blood vessels without surgery.
  • A tube with a deflated balloon on the end is inserted into your blood vessel.
  • The balloon is inflated in the area of blockage or narrowing.
  • Inflating the balloon stretches out the vessel, improving blood flow through the area.

Vascular Stent:

A small hollow tube made from wire mesh which is inserted into blockage or narrowing in the blood vessels that angioplasty alone cannot keep open.

Why do I need an angiogram?

Blockage or narrowing in your blood vessels.

Where is the angiogram performed?

It is performed in the Interventional Radiology Department, at JMCGH.

Who will perform the angiogram?

One of our specially trained Interventional Radiologists.

What can I expect before the angiogram?

  • You will be seen in our Clinic by one of our physicians and/or nurse clinicians. They will obtain a health history, perform a brief physical exam, explain the procedure and answer any questions you may have.
  • You will have blood drawn on your clinic day.
  • You may be required to have a CT (computed tomography) scan and/or ultrasound exam.
  • On the day of the procedure you will have an IV (intravenous) catheter started.
  • You will be requested to sign a consent form.

What can I expect during the angiogram?

  • You will be attached to a monitor so that IV (intravenous) medications can be given to relax you.
  • Your hip areas will be cleaned with special soap.
  • The doctor will numb the skin over the hip area.
  • After making a needle stick, the doctor will insert a small tube into the artery.
  • Through this tube, the doctor will inject x-ray dye and look at your blood vessels on a TV monitor. You will feel a warm sensation from the dye.
  • During the angiogram, the doctor will decide if you need angioplasty and/or a vascular stent procedure.

What can I expect after the angiogram?

  • You will be observed in the hospital for at least 6 hours. You will lie flat for up to 6 hours. This is to help your artery heal and prevent bleeding.
  • After 6 hours, the nurse will check for bleeding and help you walk.
  • You may have to remain in the hospital depending on the results of your angiogram.

What are the risks of an angiogram?

  • Bleeding at the puncture site.
  • Infection at the puncture site.
  • Injury to the artery resulting in the need for urgent surgery.
  • Reaction to the x-ray dye.
  • Damage to kidney function from the x-ray dye.

What are the benefits of an angiogram?

  • Repair of problem areas in your blood vessels without surgery.

What are the alternatives to having an angiogram?

  • An MRA (magnetic resonance angiogram) could be performed in special cases in which a person is not able to have an angiogram.
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Carotid Angiography


Carotid Angiography is an outpatient procedure that helps find problems in blood vessels leading to your brain. These vessels include the carotid arteries, which supply your brain with blood.

The procedure makes a "map" of your blood vessels. This map can show narrowing in your arteries. Narrowing can cause numbness, weakness, trouble with speech, or changes in vision. These symptoms may be warning signs of a stroke.

Before Angiography

Here's how to prepare for your Angiography: Tell your doctor what medicines you take, especially those for heart or blood sugar problems.

  • Tell your doctor about any allergies you may have.
  • Don't eat or drink after midnight the night before your angiography.
  • If your doctor says to take your normal medicines, swallow them with only small sips of water.
  • Arrange for a family member or friend to drive you home.

Risks and Complications

Carotid Angiography is safe. But it does have some risks and possible complications. These include:

  • Stroke
  • Changes in vision
  • Bleeding or bruising at the insertion site
  • Allergic reaction or kidney problems from the contrast dye.
  • Injury to the artery

During Angiography

You may receive medicine through an IV (intravenous) line to relax you. You'll also have an injection to numb the insertion site. A tiny skin incision is made near an artery in your groin. This is the insertion site. While viewing a monitor, your doctor inserts a catheter (thin tube) into an artery near the site and slides it up to one of the carotid arteries. A contrast dye is injected into the catheter. You may briefly feel warmth in your face. You lie still as x-ray images are taken. You may be asked to move your head a few times. The catheter is then removed. Pressure is applied to the incision by hand or with a special belt.

After Angiography

You'll be taken to a recovery area. A doctor or nurse will keep applying pressure to the site for about 10 minutes. You will need to keep your leg still and straight for a few hours. Your doctor will discuss the results with you soon after the procedure.

Back at Home

  • You'll have a small bandage over the insertion site. You can remove it in 1 or 2 days. On the day you get home: Please don't drive. Please don't exercise.
  • Avoid walking and taking stairs.
  • Avoid bending and lifting.

Your doctor may give you other care instructions. You can probably get back to your normal activities in a day or two.

Call Your Doctor If:

  • You notice a lump or bleeding at the insertion site.
  • You feel pain at the insertion site.
  • You become lighthearted or dizzy.
  • You have leg pain or numbness.
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Deep Venous Thrombosis Treatment


What is Deep Vein Thrombosis (DVT)?

A deep vein thrombosis (DVT) is a blood clot occurring in a deep vein. The clot forms in a valve cup and may grow big enough to completely block the vein. If part of the clot breaks off and travels to your lungs, the risk to your health can be serious. Hospital and home treatment for DVT both include medications to keep the clot from growing. Although the size of a clot can be controlled, some clots never fully go away.

Treating DVT

You may be hospitalized for 5 to 10 days. In the hospital, you'll be given anticoagulants, commonly called blood thinners. These medications control your blood's ability to clot. Anticoagulants are given by IV (intravenous) line, as well as in pill form. If bed rest is ordered, your leg may be elevated to prevent swelling. You may be fitted with prescription elastic support stockings before going home. By wearing these stockings, you may prevent ongoing leg swelling that could cause tissue damage.

Understanding Your Medication

To keep blood from forming clots, anticoagulants must be taken at the same time every day. Make this easier to do by always taking your medication at the same time each day. While taking anticoagulants, do not use over-the-counter or prescription medications without first checking with your doctor. The combined effect of the drugs may be dangerous.

Frequent Blood Tests

Your blood will be tested often to monitor how well your medication is controlling clotting. Don't miss these tests. Too much medication may cause bleeding, too little may cause clots. If you have bruising or your gums begin bleeding, have your blood tested. Your anticoagulant dosage may need to be changed.

What You Can Do

You can improve blood flow back to your heart by elevating your leg whenever it feels swollen or heavy. Return to normal activities gradually and talk with your doctor before going back to a strenuous exercise program, such as aerobics.

To help reduce leg swelling, follow the tips below:

  • Elevate the foot of your bed 5 to 6 inches if your leg is usually swollen when you wake up. This helps send blood back toward the heart.
  • Exercise both legs, even when you're sitting. Wiggle your toes and tighten your calves to keep blood moving. Walk around for a few minutes every hour.
  • Wear elastic stockings whenever you are out of bed.

Venous Thrombolytic Therapy

Deep vein thrombosis may not cause symptoms until the blockage severely interrupts blood flow. Then, you experience symptoms, such as:

  • Pain
  • Sudden swelling in the affected leg
  • Enlargement of the superficial veins
  • Reddish-blue discoloration
  • Skin that is warm to the touch
  • If you have symptoms like these, you should contact your doctor immediately. Untreated, DVT may cause serious problems.

    A clot can grow in size and block other veins. In addition, portions of the clot may break away from the vein wall and travel through the veins into the lung, where it can lodge in a pulmonary artery. This condition is known as pulmonary embolism, and the traveling clot is called an embolus. Pulmonary embolism can be life threatening if the embolus blocks the main pulmonary artery or if there are many clots. Pulmonary embolism can be treated with drugs that dissolve the clot and restore normal blood flow. You should get medical help immediately if you experience any symptoms of pulmonary embolism:

    • A feeling of apprehension
    • Shortness of breath
    • Sharp chest pain
    • Rapid pulse
    • Sweating
    • Cough with bloody sputum
    • Fainting

    Over time, untreated DVT may damage a venous valve so that it does not close completely. Consequently, blood flows back into the vein below the valve and collects in the lower leg veins. Pooling of blood in these lower leg veins causes swelling and tissue damage that may lead to painful ulcers. This condition is known as venous stasis disease.

    Fortunately, prompt treatment of DVT can prevent complications such as pulmonary embolism and venous stasis disease.

    Diagnosing DVT

    If DVT is suspected, additional tests will be needed to confirm the diagnosis. These tests may be performed by your doctor in his or her office. In some cases, they will be done in the hospital.

    The tests used most often to diagnose DVT do not involve any needles and are relatively painless. Your doctor may listen to blood flowing through the veins in your calf and thigh and behind your knee, using a special stethoscope placed on your leg.

    He or she can measure blood flow through your veins by placing a blood pressure cuff thigh and inflating. This way, the doctor can record the amount of blood flow through electronic sensors placed on your lower leg. A third method of diagnosing DVT is called a duplex scan. An ultrasound microphone is placed on the leg over the affected area, and sound waves measure the veins and blood flow on a screen.

    The duplex scan is very accurate for DVT because it shows the vein and any blood clots on the screen. If your doctor is unsure whether you have DVT after these tests, he or she may refer you to an interventional radiologist for a venogram. In a venogram, dye is injected into a vein in the foot and an x-ray is taken of the leg. In most cases, if a clot is present, it will be shown on the x-ray. In another type of venogram, a radioactive substance is injected into a vein in the foot and a special camera is used to record the concentration of radioactivity. Areas dense in concentration of radioactivity indicate sites of blockage.

    The Traditional Treatments

    Traditional treatments are bed rest, elevation of the affected limb, pressure stockings and drugs to prevent blood clotting. These drugs, called anticoagulants, keep the clot from increasing in size and help prevent pulmonary embolism. But, they do not dissolve clots that have already formed. Your body's own system for breaking down clots is needed for that.

    Catheter-directed thrombolysis is a new treatment that actually dissolves blood clots in veins. A clot-dissolving drug, called a thrombolytic agent, is placed directly into the thrombus through a long, thin plastic tube called a catheter. Catheter-directed thrombolysis is generally performed in a hospital radiology suite by an Interventional Radiologist. The Interventional Radiologist inserts the catheter into the jugular vein or femoral vein and threads it into the vein containing the clot.

    The catheter tip is placed into the clot, and the clot-dissolving drug is infused into the clot. It usually takes a few days for the clot to dissolve. During that time, the Interventional Radiologist monitors the progress of the treatment using venogram and duplex scans. Once the clot has been dissolved, any narrowing in the vein wall that might cause future clot formation can be seen on the venogram or duplex scan and may be treated.

    Balloon angioplasty may be used to widen the vein after catheter-directed thrombolysis. In this procedure, a catheter with a balloon on the end is threaded into the vein to the narrow area.

    The balloon is expanded and left in place. After a period of time the balloon is deflated and the catheter removed. The interior of the vein is wider than it was before treatment and blood flow is improved.

    A stent is a small mesh tube that may be inserted into a vein to keep the vein open if it tends to collapse. A stent is inserted into the vein using a catheter. Once it is in proper location, the stent is expanded. Some stents are inserted on a balloon, which is expanded once the stent is in place. Other stents are inserted without a balloon and expand by themselves. After the stent is expanded, the catheter and balloon, if used are withdrawn, leaving the stent behind to support the vein walls.

    After Your Treatment

    If you have no complications, you may stay in the hospital for a day or two after your vein has been reopened. Your doctor will want you to take an oral anticoagulant drug for a few months to prevent further clots from forming.

    He or she may order follow-up tests to make sure your veins stay open and monitor your anticoagulant dosage. Many patients go on to lead active, healthy lives after being treated for DVT. If you follow your doctor's instructions, so can you.

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    Dialysis Fistulagram


    What is a Dialysis Fistula And Fistula Maintenance?

    A dialysis fistula is a surgically created connection between an artery and a vein. This is done to provide enough blood flow at the appropriate pressure to make hemodialysis effective and possible.

    The blood vessels in the fistula are used frequently. Because of the rigors of hemodialysis, they are put through more trauma than other vessels in the body. The lining of these vessels are subjected to higher rates of blood flow and pressure, in addition to the trauma of multiple needle insertions. Often, the response to this repeated strain is the overgrowth of the lining of the vessel. This results in the narrowing of the fistula vessels. A fistulagram is designed to detect these narrowed areas by x-ray.

    What Is A Fistulagram?

    A fistulagram is a special procedure performed in the Radiology Imaging Department. With the use of x-ray dye, the blood flow through your fistula will be evaluated. The procedure can detect problems such as a clot or narrowing. Early detection and treatment of problems with your fistula can improve its performance and limit future complications.

    Who Will Perform My Fistulagram?

    An Interventional Radiologist, a doctor specially trained in the study of the vessels of the fistula, will perform the test.

    What Is Fistula Angioplasty?

    If a narrowed area is found in the fistula you may require balloon angioplasty. Angioplasty is the inflation of a balloon inside the blood vessel at the area in which it is narrowed. The inflation of the balloon redistributes the extra material inside the blood vessel against its walls. This makes the vessel opening bigger and allows for more blood flow.

    Angioplasty to the fistula is often performed immediately following the fistulagram portion of the test. Usually through the same needle, a small plastic tube with a balloon attached is positioned at the level of the narrowing. The balloon is inflated, sometimes repeatedly, and x-rays are taken. Most patients do not feel the balloon inflation. Others experience several seconds of pressure in the fistula. Sometimes a second needle must be placed in another part of the fistula in order to perform the angioplasty.

    When angioplasty is completed, the needle(s) are removed and pressure is applied to the fistula as it is after dialysis. A brief period of observation following fistula angioplasty may be required.

    Is There Any Preparation for the Test?

    There is usually minimal preparation before the test. Some patients may be asked to limit food or drink for a time before the test and/or make adjustments in their medications. Your dialysis staff will be able to help you with specific instructions.

    Points to remember:

    • Fistulagram detect narrowed areas in the blood vessels.
    • Narrowings are made wider with balloon angioplasty
    • A good thrill in your fistula is one sign of good blood flow through the exit portion or vein of your fistula.
    • A good pulse in your fistula is one sign of good blood flow through the entrance portion or artery of your fistula.
    • Monitor your fistula frequently.
  • You will be one of the best people to evaluate how well your fistula is working by knowing the characteristic thrill and pulse of your fistula. Note any changes to your physician and/or the hemodialysis staff.


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    Aortic Aneurysm Repair


    What is an aneurysm?

    An aneurysm is a weakened part of a blood vessel that expands like a balloon.

    What is an endograft?

    An endograft is a hollow tube made from wire mesh that is covered with strong fabric. The endograft is inserted into the aneurysm through two small incisions in the hips.

    Why do I need an endograft placed in my aneurysm?

    Aneurysm repair is required when the size of the aneurysm is at least double the size of the normal vessel and/or is causing symptoms. The shape of the aneurysm will determine whether an endograft will be placed.

    Where is the endograft placement performed?

    It is performed in the Interventional Radiology Department or the surgical suites of the hospital.

    Who will perform the endograft placement procedure?

    One of our specially trained Interventional Radiologists and your surgeon.

    What can I expect before the endograft placement procedure?

    • You will be seen in our clinic by one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure, and answer your questions.
    • You will have blood drawn on your clinic day.
    • You will have a CT (computed tomography) scan and an arteriogram of the aneurysm.
    • You will have an EKG (electrocardiogram) and chest X ray.
    • You will have an IV (intravenous) catheter started on the day of your procedure.
    • You will be requested to sign a consent form.

    What can I expect during the endograft placement procedure?

    • You will be attached to a monitor so that IV (intravenous) medications can be given by the anesthesiologist to make you sleep.
    • Your groin and abdomen will be cleaned with special soap.
    • After making an incision, a tube is inserted into the groin artery.
    • Through this tube, the doctor will inject x-ray dye to look at your blood vessels on a TV monitor. The endograft will be inserted through the tube into the aneurysm. This repairs the weakened wall of the aneurysm.

    What can I expect after the endograft placement procedure?

    • You will be observed in the hospital for 2 to 3 days.
    • You will return to our recovery area.
    • The length of stay is different for each person.
    • You will have several CT (computed tomography) scans to make sure the blood is flowing properly through your endograft.

    What are the risks of having an endograft placement procedure?

    • Bleeding at the puncture site.
    • Infection at the puncture site.
    • Small risk of blood vessel rupture causing the need for urgent surgery.
    • Damage to kidney function from the x-ray dye.

    What are the benefits of having an endograft placement procedure?

    • Having one or two small incisions to repair the aneurysm instead of one large incision.
    • A short hospital stay with few complications.

    What are the alternatives to having an endograft placement procedure?

    • Surgical repair of an aneurysm
    • Not to repair the aneurysm and monitor it with periodic CT (computed tomography) scans.
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    IVC Filter placement


    What is an inferior vena cava (IVC) filter?

    Inferior vena cava (IVC) is a filter that is placed in the inferior vena cava (IVC), which is a large vein that connects your leg veins with your heart. The IVC filter traps blood clots.

    Why do I need an IVC filter?

    • Sometimes, clots develop in the veins in your legs, called deep vein thrombosis.
    • A clot, or a piece of it, can move out of your leg and flow towards your heart and lungs.
    • Clots in the lung can be life-threatening.
    • The filter protects the lungs from these life-threatening clots.

    Where is the IVC filter placement performed?

    It is performed in the Interventional Radiology Department.

    Who will perform the IVC filter placement?

    One of our specially trained Interventional Radiologists.

    What can I expect before the IVC filter placement?

    • You will see one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure and answer your questions.
    • You will have blood drawn.
    • You will have an IV (intravenous) catheter started if you do not have one already.
    • You will sign a consent form.

    What can I expect during the IVC filter placement?

    • You will be attached to a monitor so that IV (intravenous) medicines can be given to relax you.
    • Your hip or neck area will be cleaned with special soap.
    • The skin over the hip or neck area will be numbed with a special medicine through a needle.
    • After making a small incision, the doctor will insert a small tube into a vein.
    • Through this tube, the doctor will insert the filter into the large vein IVC in your belly.
    • X-ray dye will be injected through the tube to check the placement of the filter.
    • Once the filter is placed, it immediately begins filtering all the blood going to the lungs from the legs.
    • The tube in your neck or hip will be removed and light pressure will be held until the bleeding has stopped.

    What can I expect after the IVC filter is placed?

    • You will be on bedrest for 4 hours after the filter is placed.
    • You will return to your hospital room to continue to be observed.

    What are the risks of having an IVC filter placed?

    • Bleeding at the incision site.
    • Infection at the incision site.
    • Damage to the vein used to insert the filter.
    • Complete clotting of the IVC filter.

    What are the benefits of having an IVC filter placed?

    To protect your lungs from life threatening blood clots.

    What are the alternatives to having an IVC filter placed?

    You could be treated with bedrest and blood thinning medication.

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    Lung Biopsy


    What is a lung biopsy?

    A lung biopsy is an x-ray guided procedure in which samples of lung tissue are taken through a needle.

    Why do I need a lung biopsy?

    Your doctor has found an abnormal area on your chest x-ray.

    Where is the lung biopsy performed?

    It is performed in the Radiology Department.

    Who will perform the lung biopsy?

    One of our specially trained Interventional Radiologists.

    What can I expect before the lung biopsy?

    • You will be seen in our clinic by one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure and answer your questions.
    • You will have blood drawn.
    • You may be required to have a CT (computed tomography) scan.
    • You will have an IV (intravenous) catheter started the day of your procedure.
    • You will sign a consent form.

    What can I expect during the lung biopsy?

    • You will be attached to a monitor so that IV (intravenous) medication can be given to relax you.
    • An area on your chest or back will be cleaned with special soap.
    • The doctor will numb the skin and insert a needle into your lung to obtain some tissue. Three or four samples of tissue may be taken.
    • The sample(s) will be sent to Pathology for evaluation. You should get your results within 2 to 4 days.

    What can I expect after the lung biopsy?

    • You will receive a chest x-ray immediately, to look for air leakage into the lung space.
    • You will be observed in our department for 4 hours.
    • After 4 hours, you will receive a 2nd chest x-ray.
    • If this x-ray is unchanged, you will be discharged to home.
    • If you have an air leak, you will be admitted to the hospital to be observed for an increase in the air leak.
    • If your air leak is large or is causing you breathing problems, the doctor will insert a small tube in your chest or back to help stop the air leak and let your lung re-inflate.
    • You will be watched closely and get a few more chest x-rays before the tube is removed.
    • The doctor will remove the tube when your lung stays inflated by itself.

    What are the risks of having a lung biopsy?

    • Bleeding
    • Infection
    • An air leak in the lung (pneumothorax).

    What are the benefits of having a lung biopsy?

    Knowing what the abnormal tissue is made of.

    What are the alternatives to having a lung biopsy?

    • Open surgical biopsy
    • Discuss with your doctor the risks of not finding out what the abnormal tissue is made of.
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    Percutaneous Nephrostomy Tube Placement


    What is a nephrostomy tube insertion?

    Nephrostomy tube insertionis a procedure that uses x-ray to locate the kidney and then a tube(s) is inserted into the kidney to drain your urine.

    Why do I need a nephrostomy tube insertion?

    • The pathway that drains your urine from your kidney to your bladder is blocked or narrowed.
    • Stones in your kidney may be causing infection and/or blockage.
    • A previous attempt to pass a tube through the bladder to the kidney has failed.

    Where is the nephrostomy tube insertion performed?

    It is performed in the Interventional Radiology Department.

    Who will perform the nephrostomy tube insertion?

    One of our specially trained Interventional Radiologists.

    What can I expect before the nephrostomy tube insertion?

    • You will be seen by one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure and answer your questions.
    • You will have blood drawn and an IV (intravenous) catheter started.
    • You will receive IV (intravenous) antibiotics to help prevent infection.
    • You will be requested to sign a consent form.

    What can I expect during the nephrostomy tube insertion?

    • You will be attached to a monitor so that IV (intravenous) medications can be given to relax you.
    • You will be positioned on your abdomen and your back area will be cleaned with special soap.
    • The doctor will numb the skin with special medicine through a needle.
    • The doctor will insert the tube into your kidney and inject x-ray dye into the kidney. This gives him a clear picture of the kidney.
    • The tube will remain in your body and the end will be secured with a stitch where it comes out of your back.
    • A dressing will be put over the insertion site.
    • The tube(s) will be attached to a drainage bag outside your body to collect the urine.

    What can I expect after the nephrostomy tube insertion?

    • You will spend the night in the hospital to be observed for bleeding from the tube(s) and to monitor the urine output.
    • The nurse will teach you how to care for your nephrostomy tube(s) at home. An instruction sheet about how to care for your new tube will be sent home with you.
    • You will return for your follow-up x-ray. The doctor will tell you if you need to keep your tube(s) longer or if you need to return.
    • A home health nurse can come to your house to help you care for the tube(s).

    What are the risks of having a nephrostomy?

    • Bleeding at the insertion site.
    • Infection at the insertion site.
    • Urine leakage around the tube(s), the tube(s) coming out or becoming plugged.
    • Injury to the kidney.

    What the benefits of having a nephrostomy tube insertion?

    • It allows your body to get rid of the urine that isn't draining and is backed up in your kidney.
    • It will help with the health of your kidney.

    What are the alternatives to having a nephrostomy tube insertion?

    Surgical drainage of blocked urine.

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    Transjugular Intrahepatic Portosystemic Shunt (TIPS)


    What is a T.I.P.S.?

    T.I.P.S. is a procedure that uses a small hollow tube (shunt) to make a new pathway for the blood to flow from the liver to the large veins of the body.

    Why do I need a T.I.P.S.?

    • Your liver is severely scarred and cannot perform its normal job of clearing the blood of poisons.
    • Due to the scarring, blood backs up in the blood vessels that take blood to the liver.
    • The blood that is backed up causes bulging of the vein (varices). These varices can rupture and bleed.
    • Death can occur with bleeding from varices.
    • T.I.P.S. gives blood a pathway to prevent varices from bleeding.

    Where is the T.I.P.S. performed?

    It is performed in the Interventional Radiology Department.

    Who will perform the T.I.P.S.?

    One or our specially trained Interventional Radiologists.

    What can I expect before the T.I.P.S.?

    • You will be seen by one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure, and answer your questions.
    • You will have blood drawn and an IV (intravenous) catheter started.
    • You will receive IV (intravenous) medicine to help prevent infection and bleeding during the procedure.
    • You will be requested to sign a consent form.

    What can I expect during the T.I.P.S.?

    • You will be attached to a monitor and you will be given IV (intravenous) "sleeping" medications by the Anesthesiologist.
    • Your neck area will be cleaned with special soap.
    • The doctor will numb the skin over your neck area with special medicine through a needle.
    • The doctor will insert a small catheter into your neck vein.
    • Through this catheter, smaller catheters will be inserted to reach the veins in your liver.
    • With these catheters, a small hollow tube (shunt) will then be inserted into the liver veins making a new pathway for your blood to flow around the scarred liver.

    What can I expect after the T.I.P.S.?

    • You will return to your hospital room to be closely observed for bleeding. Also, close supervision of the shunt will be necessary because scar tissue can close off the shunt.
    • Because the blood will now bypass the liver, poisons in your blood may make you sleepy or disoriented.
    • You may have to take medicine to correct this. This usually doesn't last long. If the medications don't work, the shunt may have to be closed.

    What are the risks of having a T.I.P.S.?

    • Bleeding
    • Infection
    • A tear in the liver
    • Becoming sleepy or disoriented.

    What are the benefits of having a T.I.P.S.?

    • To relieve the back up of blood in your body.
    • To make you more comfortable.
    • To relieve life-threatening bleeding from the varices.

    What are the alternatives to having a T.I.P.S.?

    • Having a shunt put in surgically.
    • Varicele sclerosis or banding.
    • Peritoneal shunt insertion.
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    Uterine Artery Embolization


    What is a Uterine Fibroid?

    Fibroid tumors are non-cancerous (benign) growths that develop in the muscular wall of the uterus.They can cause pain and heavy bleeding for some women.

    What is a Uterine Artery Embolization?

    Uterine artery embolization is a procedure in which the doctor injects tiny plastic or gelatin sponge particles the size of grains of sand, into the arteries that supply the blood to the fibroid tumor. This blocks the blood supply and causes the tumor to shrink.

    Why do I need a uterine artery embolization?

    • The reasons for this procedure are:
    • Heavy prolonged menstrual periods.
    • Pelvic pain.
    • Bladder pressure that causes a constant urge to urinate.

    Where is the embolization performed?

    It is performed in the Interventional Radiology Department.

    Who will perform the embolization?

    One of our specially trained Interventional Radiologists.

    What can I expect before the embolization?

    • You will be seen in our clinic by one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure and answer your questions.
    • You will have blood drawn and an IV (intravenous) catheter started.
    • You may have an ultrasound exam.
    • You will be requested to sign a consent form.

    What can I expect during the embolization?

    • You will be attached to a monitor so that IV (intravenous) medications can be given to relax you.
    • Your hip areas will be cleaned with special soap.
    • The doctor will numb the skin over the blood vessel with special medicine through a needle.
    • After making a needle stick, the doctor will insert a small tube into the artery and inject x-ray dye to look at your blood vessels on a TV monitor. You will feel a warm sensation from the dye.
    • Through this tube, the doctor will inject the particles.

    What can I expect after the embolization?

    • You will be admitted to the hospital overnight for observation.
    • You will lie flat up to 6 hours.
    • You will be given medicine that controls pain and swelling.
    • Pain, cramping and fever, are common side effects. You will need to take Tylenol (acetominephin) 2 to 3 tabs (regular strength) every 4 hours for 48 hours.
    • Total recovery time is 1 to 2 weeks, but can take up to 6 to 8 weeks.

    What are the risks of having an embolization?

    • Most women experience moderate to severe pain and cramping immediately following the procedure.
    • There is a small chance of injury to the uterus.
    • There is a chance of bleeding or injury to the hip artery.
    • A small number of women will enter into menopause.

    What are the benefits of having an embolization?

    • This procedure is an alternative to surgical methods used to treat uterine fibroids.
    • This procedure allows a woman to keep her uterus, possibly preserving the ability to have children.

    What are the alternatives to having an embolization?

    Surgical removal of the fibroid and/or the uterus.

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    Vertebroplasty / Kyphoplasty


    What is Vertebroplasty & Kyphoplasty?

    Vertebroplasty and kyphoplasty are minimally invasive procedures for the treatment of vertebral compression fractures (VCF), which are fractures involving the vertebral bodies that make up the spinal column.

    When a vertebral body fractures, the usual rectangular shape of the bone becomes compressed, causing pain. These compression fractures may involve the collapse of one or more vertebrae in the spine and are a common result of osteoporosis. Osteoporosis is a disease that results in a loss of normal bone density, mass and strength, leading to a condition in which bones are increasingly porous, and vulnerable to breaking. Vertebrae may also become weakened by cancer.

    In vertebroplasty, physicians use image guidance to inject a cement mixture into the fractured bone through a hollow needle. In kyphohplasty, a balloon is first inserted into the fractured bone through the hollow needle to create a cavity or space. The cement is injected into the cavity once the balloon is removed.

    What are some common uses of the procedures?

    Vertebroplasty and kyphoplasty are used to treat painful vertebral compression fractures in the spine, most often the result of osteoporosis.

    Typically, vertebroplasty is recommended after less invasive treatments, such as bed rest, a back brace or pain medication, have been ineffective, or once medications begin to cause undesired side effects, such as stomach ulcers or changes in mental status. Vertebroplasty can be performed immediately in patients with problematic pain requiring hospitalization or for conditions that limit bed rest and pain medications.

    Vertebroplasty is also performed on patients who:

    • are too elderly or frail to tolerate open spinal surgery, or whose bones are too weak for surgical repair
    • have vertebral compression due to a malignant tumor
    • are younger, with osteoporosis due to long-term steroid treatment or a metabolic disorder

    Vertebroplasty and kyphoplasty should be completed within eight weeks of the acute fracture for the highest probability of successful treatment.

    How should I prepare?

    • A clinical evaluation including diagnostic imaging, blood tests, a physical exam, spine x-rays and a radioisotope bone scan or magnetic resonance (MR) imaging will be done to confirm the presence of a compression fracture that may benefit from treatment with vertebroplasty or kyphoplasty.
    • You may be given bone-strengthening medication during treatment.
    • You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or a blood thinner for a specified period of time before your procedure.
    • Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.
    • You will need to have blood drawn for tests prior to the procedure to determine if your blood clots normally.
    • On the day of the procedure, you should be able to take your usual medications with sips of water or clear liquid up to three hours before the procedure. You should avoid drinking orange juice, cream and milk.
    • In most cases, you may take your usual medications, especially blood pressure medications. These may be taken with some water in the morning before your procedure.
    • You may be instructed to not eat or drink anything for several hours before your procedure.
    • You should plan to have a relative or friend drive you home after your procedure.
    • You will be given a gown to wear during the procedure.

    What does the equipment look like?

    • For vertebroplasty and kyphoplasty procedures, x-ray equipment, a hollow needle or tube called a trocar, orthopedic cement, and a solvent are used. In addition, barium or another substance may be added to the cement to make it radiopaque (appear on x-ray).
    • For kyphoplasty, a device called a balloon tamp is also used to make room for the balloon catheter.
    • The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room or in a nearby room. When used for viewing images in real time (called fluoroscopy), the image intensifier (which converts x-rays into a video image) is suspended over a table on which the patient lies. When used for taking still pictures, the image is captured either electronically or on film.
    • The orthopedic cement includes an ingredient called polymethylmethacrylate (PMMA). Its physical appearance resembles toothpaste.
    • Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.
    • A Foley catheter may be placed in your bladder.

    How does the procedure work?

    • Vertebroplasty involves injecting a cement mixture into the empty spaces within weakened vertebrae to strengthen them and provide pain relief.
    • Using image-guidance, a hollow needle called a trocar is passed through the skin into the vertebral body for injection of the cement mixture into the vertebra.
    • In kyphoplasty, a balloon is first inserted through the trocar, into the fractured vertebra where it is inflated to create a cavity for cement injection. The balloon is removed prior to injecting cement into the cavity that was created by the balloon.

    How is the procedure performed?

    • Image-guided, minimally invasive procedures such as vertebroplasty and kyphoplasty are most often performed by a specially trained interventional radiologist in an interventional radiology suite.
    • This procedure is often done on an outpatient basis. However, some procedures may require admission. Please consult with your physician.
    • You will be positioned lying face down for the procedure.
    • You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure.
    • A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia.
    • You may be given medications to help prevent nausea and pain, and antibiotics to help prevent infection.
    • The area through which the hollow needle, or trocar, will be inserted will be shaved, sterilized and covered with a surgical drape.
    • A local anesthetic is then injected into the muscles under the skin, near the fracture.
    • A very small nick is made in the skin at the site.
    • Using x-ray guidance, the trocar is passed through the spinal muscles until its tip is precisely positioned within the fractured vertebra. An examination called intraosseous venography may be performed to confirm safe needle placement within the fractured bone. Many interventional radiologists proceed directly to vertebroplasty or kyphoplasty without intraosseous venography.
    • In vertebroplasty, the orthopedic cement is then injected. Medical-grade cement hardens quickly, typically within 20 minutes.
    • In kyphoplasty, the balloon tamp is first inserted through the needle and the balloon is inflated, to create a hole or cavity. The balloon is then removed and the bone cement is injected into the cavity created by the balloon.
    • X-rays and/or a CT scan may be performed at the end of the procedure to check the distribution of the cement.
    • The trocar is removed after the cement is injected.
    • Pressure will be applied to stop any bleeding and the opening in the skin is covered with a bandage. No sutures are needed.
    • This procedure is usually completed within one hour. It may take longer if more than one vertebral body level is being treated.
    • Your intravenous line will be removed.

    What will I experience during the procedure?

    • Devices to monitor your heart rate and blood pressure will be attached to your body.
    • You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected.
    • If the case is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated.
    • The treatment area of your back will be cleaned, shaved and numbed.
    • During the procedure you will be asked questions. It is important for you to be able to tell your doctor whether you are feeling any pain.
    • The longest part of vertebroplasty and kyphoplasty procedures involves setting up the equipment and making sure the needle is perfectly positioned in the collapsed vertebral body.
    • You may not drive after the procedure, but you may be driven home if you live close by. Otherwise, an overnight stay at a nearby hotel is advised.
    • Bed rest is recommended for the first 24 hours following vertebroplasty and kyphoplasty, though you may get up to use the bathroom. You will be advised to increase your activity gradually and resume all your regular medications. At home, patients may return to their normal daily activities, although strenuous exertion, such as heavy lifting, should be avoided for at least six weeks.
    • If you take blood thinners, check with your doctor about restarting this medication the day after your procedure.
    • Pain relief is immediate for some patients. In others, pain is eliminated or reduced within two days. Pain resulting from the procedure will typically diminish within two weeks.
    • For two or three days afterward, you may feel a bit sore at the point of the needle insertion. You can use an icepack to relieve any discomfort but be sure to protect your skin from the ice with a cloth and ice the area for only 15 minutes per hour. Your bandage should remain in place for several days (even during showers).

    Who interprets the results and how do I get them?

    • Approximately one hour after the procedure, you should be able to walk. The interventional radiologist is often able to advise you as to whether the procedure was a technical success at that point. In some cases, it can take a few days for the doctor to be able to make this assessment.
    • Your interventional radiologist may recommend a follow-up visit after your procedure or treatment is complete.
    • The visit may include a physical check-up, imaging procedure(s) and blood or other lab tests. During your follow-up visit, you may discuss with your doctor any changes or side effects you have experienced since your procedure or treatment.

    What are the benefits vs. risks?

    Benefits

    • Vertebroplasty and kyphoplasty can increase a patient's functional abilities, allow return to the previous level of activity without any form of physical therapy or rehabilitation and stabilize the vertebra.
    • These procedures are usually successful at alleviating the pain caused by a vertebral compression fracture; many patients feel significant relief almost immediately. Many patients become symptom-free.
    • Following vertebroplasty, about 75 percent of patients regain lost mobility and become more active, which helps combat osteoporosis. After the procedure, patients who had been immobile can get out of bed, reducing their risk of pneumonia. Increased activity builds more muscle strength, further encouraging mobility.
    • Usually, vertebroplasty and kyphoplasty are safe and effective procedures.
    • No surgical incision is needed—only a small nick in the skin that does not have to be stitched closed.

    Risks

    • Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
    • A small amount of orthopedic cement can leak out of the vertebral body. This does not usually cause a serious problem, unless the leakage moves into a potentially dangerous location such as the spinal canal.
    • Other possible complications include infection, bleeding, increased back pain and neurological symptoms such as numbness or tingling. Paralysis is extremely rare.
    • There is a risk of allergic reaction to the contrast material used for intraosseous venography or to help visualize the balloon as it inflates on the x-ray image.

    What are the limitations of Vertebroplasty & Kyphoplasty?

    Vertebroplasty is not:

    • used for herniated disks or arthritic back pain.
    • generally recommended for otherwise healthy younger patients, mostly because there is limited experience with cement in a vertebral body for longer time periods.
    • a preventive treatment to help patients with osteoporosis avoid future fractures. It is used only to repair a known, non-healing compression fracture.
    • used to correct an osteoporosis-induced curvature of the spine, but it may keep the curvature from worsening.
    • ideal for someone with severe emphysema or other lung disease because it may be difficult for such individuals to lie facedown for the one to two hours vertebroplasty requires. Special accommodations may be made for patients with these conditions.
    • for patients with a healed (chronic) vertebral fracture.

    Kyphoplasty is not appropriate for:

    • patients with young healthy bones or those who have suffered a fractured vertebra in an accident.
    • patients with spinal curvature such as scoliosis or kyphosis that results from causes other than osteoporosis.
    • patients who suffer from spinal stenosis or herniated disk with nerve or spinal cord compression and loss of neurologic function not associated with a VCF.
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    Acute Stroke Treatment


    Strokes fall into two categories:

    • Those disorders leading to ischemia, which is a lack of blood flow in the brain. Ischemic disease can be caused by stenosis (extracranial or intracranial), thrombosis or embolism.
    • Those disorders leading to hemorrhage, which is too much blood in the brain, such as brain hemorrhage or subarachnoid hemorrhage.

    Who is at risk for a Stroke?

    Factors that increase the risk for a stroke include:

    • Age (people over 65 are at increased risk)
    • Family or personal history of stroke
    • Certain conditions like uncontrolled diabetes, high cholesterol and high blood pressure
    • Smoking
    • Lack of exercise
    • Poor diet
    • Obesity

    What are the Symptoms of a Ischemic Stroke?

    Ischemic stroke often has no symptoms. In some cases, patients present with temporary stroke-like events called transient ischemic attacks (TIAs). Receiving treatment with tissue plasminogen-activator (tPA) at the first signs of a TIA or stroke may prevent brain damage if it is administered within three hours of the initial symptoms. Patients should seek immediate medical attention if they experience the following symptoms:

    • Difficulty seeing
    • Loss of strength, coordination or feeling on one side of the body
    • Confusion
    • Dizziness
    • Seizures
    • Severe headache similar to a migraine
    • Slurred speech
    • Difficulty eating or swallowing

    What are the Symptoms of a Hemorrhagic Stroke?

    Hemorrhagic stroke that results from a slow accumulation of blood can show early symptoms, including:

    • Headaches
    • Lethargy
    • Nausea or vomiting

    Hemorrhagic stroke that results from a blood vessel rupture presents with serious, immediate and life-threatening symptoms, including:

    • A very severe headache that starts suddenly and is often located near the back of the head. Even if a patient is prone to headaches or migraines, this headache will feel very different from the normal pattern. It is often described as the “worst headache of your life.”
    • Losing consciousness
    • Inability to move or feel
    • Confusion and irritability
    • Muscle pain in neck and shoulders
    • Nausea and vomiting
    • Sensitivity to light
    • Seizure
    • Problems with vision
    • Eyelid drooping
    • Eye pupils are different sizes

    How Do Doctors Diagnose a Stroke?

    If the Emergency Department physicians suspect a stroke, they will perform a thorough personal and family history and a medical examination. The Center's physicians will also perform additional tests that might include:

    • Cerebral angiography. X-rays are taken of the brain after a dye is injected into it through a catheter threaded through the groin. Aneurysms are often seen on this X-ray.
    • Carotid duplex ultrasound. Ultrasound technology provides images of the carotid arteries.
    • A CTA (computed topography) scan. CT scans can confirm hemorrhagic cerebrovascular disease and give detailed information about vascular anatomy and blockages.
    • A lumbar puncture spinal tap. If the spinal fluid has traces of blood or is yellow signs this is an indication of bleeding in the brain.
    • Magnetic resonance imaging (MRI). These scans can detect both blockages and aneurysms.
    • Magnetic resonance angiography. This test can detect unruptured aneurysms and screen high-risk patients. Similar to cerebral angiography, images are taken of the brain after a dye is injected into it through a catheter threaded through the groin.
    • Patients presenting with symptoms of hemorrhagic stroke that indicate a ruptured aneurysm are treated in a life-preserving way to stabilize their condition.
    • What are the Stroke Treatment Options for Hemorrhagic Stroke?
    • Neurosurgeons treat hemorrhagic stroke by one or more of the following strategies:
    • Locating the source of the bleed and then surgically clipping it.
    • Placing a drainage device in the skull to decrease pressure in the brain.
    • Follow-up care, which may require medications to reduce blood pressure, pain, anxiety, headaches and/or seizures.

    What are the Stroke Treatment Options Ischemic Stroke?

    Our physicians treat ischemic stroke by one or more of the following strategies:

    • Intravenous tPA (tissue plasminogen activator) may improve clinical outcome if a patient presents with stroke or TIA symptoms within three hours of onset of symptoms. Intravenous tPA is usually administered via the Emergency Department.
    • Administering antiplatelet and anticoagulation agents
    • Intra-arterial tPA
    • Balloon angioplasty
    • Extracranial and intracranial stenting
    • Clot retraction with MERCI and PENUMBRA devices
    • Bypass, including techniques using laser bypass technology
    • Medications may be prescribed to reduce blood pressure, prevent embolism and/or control cholesterol
    • Lifestyle changes may be recommended such as smoking cessation and nutritional and exercise counseling
    • When a stroke has resulted in loss of function, physical therapy and stroke rehabilitation is recommended
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    Abscess Drainage


    What is an abscess?

    • An abscess is a collection of pus in an area of the body.
    • An abscess can cause fever, infection and/or pain.

    Why do I need an abscess drainage?

    This will help relieve your symptoms of fever, infection and/or pain.

    Where is the abscess drainage performed?

    It is performed in the Radiology Department.

    Who will perform the abscess drainage?

    One of our specially trained Interventional Radiologists.

    What can I expect before the abscess drainage?

    • You will be seen by one of our doctors and/or nurse clinicians, who will obtain a health history, perform a brief physical exam, explain the procedure and answer your questions.
    • You will have blood drawn and an IV (intravenous) catheter started before your exam.
    • You will receive IV (intravenous) antibiotics to prevent infection.
    • You may be required to have a CT (computed tomography) scan.
    • You will be requested to sign a consent form.

    What can I expect during the abscess drainage?

    • You will be attached to a monitor so that IV (intravenous) medications can be given if needed.
    • The skin over your abscess will be cleaned with special soap.
    • The doctor will numb the skin with special medicine.
    • Using the CT (computed tomography) scan to guide him, the doctor will insert a tube into the abscess through a needle in the skin.
    • The tube will remain in your body and the end will be secured in place.
    • The tube will be attached to a drainage bag outside of your body.
    • More than one tube may be required depending on the condition of the abscess.

    What can I expect after the abscess drainage?

    • You will be admitted to the hospital at least overnight to monitor and treat your pain and observe the amount of drainage from your tube.
    • The nurse will instruct you how to care for your tube at home.
    • The doctor or nurse clinician will discuss with you a follow-up CT (computed tomography)scan and the anticipated duration for your drainage tube.
    • A home health nurse can come to your home to help you care for your tube(s).

    What are the risks of having an abscess drainage?

    • Bleeding
    • Worsening of infection
    • Plugged tube or the tube may fall out.

    What are the benefits of having an abscess drainage?

    • An abscess drainage rids the body of infection so that you can heal faster.
    • Usually you will feel better the next day.

    What are the alternatives to having an abscess drainage?

    • Antibiotic therapy by itself may or may not be effective.
    • Surgical removal of abscess.
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    Percutaneous Treatment of Varicose Veins


    Varicose Vein Information

    The visible varicose veins in the legs both large and small are most often a result of problems elsewhere in the leg. Veins carry blood from the tissues back eventually to the heart. They are thin walled tubes which get squeezed by the surrounding muscles as they contract. This squeezing forces blood along the veins and a series of non-return valves ensure the flow is only in one direction.

    If these valves become faulty and fail to close the blood can run backwards (or reflux) and will gather or pool in the legs.

    Where this extra blood is sitting in veins close to the surface of the skin, the veins will swell up and become visible and 'refluxed'.

    There is one major vein (the greater saphenous vein), which connects to many of the surface superficial veins. Failure of the valves in this vein is quite common and is therefore a major cause of vein reflux disease. This vein runs down from the groin to the lower leg and the faulty valves are often up near the top.

    Hence reflux veins disease in the lower thigh, around the knee and in the calf are often caused by a problem much higher up.

    Symptoms

    • The symptoms associated with varicose vein disease fall into three categories: Physical symptoms
    • Tiredness
    • Heaviness in the leg
    • Pain - aching or burning sensations

    Visual symptoms

    • The tortuous blue vein disease seen running down the leg
    • Areas of small red/blue blood vessels in the skin known as spider veins
    • Swelling in the lower leg

    Long term consequences

    • Eczema
    • Pigmentation
    • Ulceration
    • Bleeding

    EVLT Procedure

    The EVLT Procedure deals with the incompetence of the greater saphenous veins. Unlike surgical stripping, EVLT permanently closes off the vein while leaving it in place. It uses the energy from an 810 nm diode laser delivered by a fine fiber-optic probe.

    As it is only the probe and a slim sheath which need to enter the vein the whole procedure is performed via a tiny skin nick, so there will be no post operative scarring. The probe is guided into place using ultrasound and the procedure is performed under strictly local anesthetic of a similar type used by dentist to numb the treatment area.

    As blood flows through your veins to the heart, stop valves are supposed to prevent the blood from flowing backwards as gravity pulls it down. If the valves don't close properly, blood pools in the vein, forcing the walls to enlarge and bulge out. EVLT uses targeted laser energy to seal the vein shut and help you look and feel better fast.

    EVLT (Endovenous Laser Treatment) effectively and safely treats vein disease through the use of a diode laser fiber to close the Greater Saphenous Vein. The procedure is easy to perform and gets patients back on their feet in only 45 minutes.

    The key benefits of EVLT:

    • Simple procedure
    • Performed under local anesthetic
    • Can be performed in the doctor's office
    • Immediate relief of symptoms
    • Minimally invasive, so minimal risk of scarring and postoperative infection
    • Less than one hour examination and treatment time
    • Rapid recovery with reduced postoperative pain
    • Normal activities can be resumed immediately
    • Excellent clinical and aesthetic results

    EVLT Frequently Asked Questions

    Q. How does the EVLT work?

    A. The laser energy damages the vein walls, shrinking them and closing flow through it. This eliminates vein bulging at its source.

    Q. Is loss of this vein a problem? A. No. After treatment, the blood in the faulty veins will be diverted to the many normal veins in the leg.

    Q. What are the complications of this procedure? The only minimal complications experienced with EVLT have been a small number of cases of numbness that passes quickly.

    Q. Am I at risk from the laser? No. Just as a precaution against accidental firing of laser energy outside the body, you will be given a pair of special glasses to protect your eyes.

    Q. How successful is EVLT? Published clinical studies show that EVLT has a 98% initial success rate with excellent long-term results.

    Venous Treatment-Sclerotherapy

    The spider veins and small varicosities are treated in 15-minute sessions, and it usually requires four to ten sessions. We use multiple dilutions of the most effective sclerosant, sodium tetradecyl (Sotradecol ), for optimum results and minimum side effects and complications. Although painful, almost all patients tolerate the procedure. We typically inject 0.1 to 0.2 mm of solution at a time using the smallest needles possible (30-gauge). Pain is common during the procedure, but occasionally it can last for a few hours up to a few days after treatment. However, most patients describe the pain as mild and not require more than a few analgesic tablets for pain relief. We require post-treatment compression usually by means of a class 2 support stocking. Normal physical activities are not restricted and exercising can be resumed after a day. It is recommended that the patients wear the stockings daily throughout the scheduled sessions and for several weeks afterward. Besides pain, there can be bruising and dark pigmentation of the treated veins. This will gradually resolve over time. Clearing of the treated spider veins can continue for up to 12 months. However, new varicosities can develop which is why we recommend periodic re-evaluation and re-treatment.

    Ambulatory Phlebectomy

    Ambulatory phlebectomy is a method of removing varicose veins on the surface of the legs. It is done in the office under local anesthesia. This procedure involves making tiny punctures or incisions through which the varicose veins are removed. The incisions are so small no stitches are required. Veins are very collapsible such that even large veins may be removed through the tiny incisions used in this technique. The patient is able to walk following the procedure.

    After treatment, a compression bandage and/or compression stocking are worn. Your physician will advice you how long to wear any bandages or hose. Many physicians recommend that you walk or bike after treatment. This reduces pressure in the veins, increases the flow in the veins and reduces the risk of forming a blood clot.

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    Chemoembolization


    What is Chemoembolization?

    Chemoembolization is a combination of local delivery of chemotherapy and a procedure called embolization to treat cancer, most often of the liver.

    In chemoembolization, anti-cancer drugs are injected directly into the blood vessel feeding a cancerous tumor. In addition, synthetic material called an embolic agent is placed inside the blood vessels that supply blood to the tumor, in effect trapping the chemotherapy in the tumor.

    What are some common uses of the procedure?

    Chemoembolization is most beneficial to patients whose disease is predominately limited to the liver, whether the tumor began in the liver or spread to the liver (metastasized) from another organ.

    Cancers that may be treated by chemoembolization include:

    • Hepatoma or hepatocellular carcinoma (primary liver cancer)
    • Metastasis (spread) to the liver from:
    • colon cancer
    • breast cancer
    • carcinoid tumors and other neuroendocrine tumors
    • islet cell tumors of the pancreas
    • ocular melanoma
    • sarcomas
    • other vascular primary tumors in the body

    Some success has been demonstrated with patients whose cancer has spread to other areas of the body.

    Depending on the number and type of tumors, chemoembolization may be used as the sole treatment or may be combined with other treatment options such as surgery, chemotherapy, radiation therapy, or radiofrequency ablation.

    How should I prepare?

    • Several days before the procedure, you will have an office consultation with the interventional radiologist who will be performing your procedure.
    • Prior to your procedure, your blood may be tested to determine how well your liver and kidneys are functioning and whether your blood clots normally.
    • You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or a blood thinner for a specified period of time before your procedure.
    • Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page (www.RadiologyInfo.org/en/safety/) for more information about pregnancy and x-rays.
    • You will receive specific instructions on how to prepare, including any changes that need to be made to your regular medication schedule.
    • If you are going to be given a sedative during the procedure, you may be asked not to eat or drink anything for four to eight hours before your exam. If so, you may want to have a relative or friend accompany you and drive you home afterward.
    • You should plan to stay overnight at the hospital for one or more days.
    • You will be given a gown to wear during the procedure.

    What does the equipment look like?

    • In this procedure, x-ray equipment, a catheter and embolic agents are used.
    • The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room or in a nearby room. When used for viewing images in real time (called fluoroscopy), the image intensifier (which converts x-rays into a video image) is suspended over a table on which the patient lies. When used for taking still pictures, the image is captured either electronically or on film.
    • A catheter is a long, thin plastic tube, about as thick as a strand of spaghetti.
    • Various materials called embolic agents are used to occlude or block off blood vessels, but the most common are oil or plastic particles made from polyvinyl alcohol (PVA).
    • Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.

    How does the procedure work?

    Chemoembolization attacks the cancer in two ways. First, it delivers a very high concentration of chemotherapy, or anti-cancer drugs, directly into the tumor, without exposing the entire body to the effects of those drugs. Second, the procedure cuts off blood supply to the tumor, trapping the anti-cancer drugs at the site and depriving the tumor of the oxygen and nutrients it needs to grow.

    The liver is unique because it has two blood supplies—an artery (the hepatic artery) and a large vein (the portal vein). The normal liver receives about 75 percent of its blood supply through the portal vein and only 25 percent through the hepatic artery. But when a tumor grows in the liver, it receives almost all of its blood supply from the hepatic artery.

    Chemotherapy drugs injected into the hepatic artery reach the tumor very directly, sparing most of the healthy liver tissue. Then, when the artery is blocked, the blood is no longer supplied to the tumor, while the liver continues to be supplied by blood from the portal vein. This also permits a higher concentration of the anti-cancer drugs to be in contact with the tumor for a longer period of time.

    How is the procedure performed?

    • Image-guided, minimally invasive procedures such as chemoembolization are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room.
    • X-ray images will be taken to map the path of the blood vessels feeding the tumor.
    • You may be given a medication called Allopurinol, which may help protect the kidneys from the chemotherapy and the byproducts produced by the dying tumor cells.
    • You may be given medications to help prevent nausea and pain, and antibiotics to help prevent infection.
    • You will be positioned on the examining table.
    • You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure.
    • A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia.
    • A very small nick is made in the skin at the site.
    • Using x-ray guidance, a thin catheter is inserted through the skin and into the femoral artery, a large groin vessel, and advanced into the liver. Then a contrast material is injected through your IV and another series of x-rays will be taken.
    • Once the catheter is positioned in the branches of the artery that are feeding the tumor, the anti-cancer drugs and embolic agents are mixed together and injected.
    • Additional x-rays will be taken to confirm that the entire tumor has been treated.
    • At the end of the procedure, the catheter will be removed and pressure will be applied to stop any bleeding. The opening in the skin is then covered with a dressing. No sutures are needed.
    • You can expect to stay in bed in the recovery room for six to eight hours.
    • Chemoembolization is usually completed within 90 minutes.

    What will I experience during and after the procedure?

    • Devices to monitor your heart rate and blood pressure will be attached to your body.
    • You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected.
    • If the case is done with sedation, the intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated.
    • You may feel slight pressure when the catheter is inserted but no serious discomfort.
    • As the contrast material passes through your body, you may get a warm feeling.
    • Most patients experience some side effects called post-embolization syndrome, including pain, nausea, vomiting and fever. Pain is the most common side effect that occurs because the blood supply to the treated area is cut off. It can readily be controlled by medications given by mouth or your IV.
    • You should be able to leave the hospital within 48 hours after the procedure, once your pain and nausea have subsided.
    • You will be sent home with prescriptions for oral antibiotics, pain medicine and medicine for nausea. It is normal for you to run a fever up to a week following the procedure. Fatigue and loss of appetite are also common and may last two weeks or longer. In general, these are all signs of a normal recuperation.
    • If your pain suddenly changes in degree or character, if your fever becomes suddenly higher or you notice any other unusual changes, you should contact your physician.
    • Your nurse will instruct you on how to use a breathing apparatus called an incentive spirometer. The purpose of this is to help you inflate your lungs so that you will not develop pneumonia.
    • You should be able to resume your normal activities within a week.

    During the first month following the procedure, you should check in routinely to let your physician know how your recovery is progressing. You will return for a CT scan or MRI and blood tests to determine the size of the treated tumor.

    If there is a tumor on both sides of the liver, commonly only part of the liver will be treated at first and after one month, you will return to the hospital for additional chemoembolization.

    CT scans or MRI will be performed every three months thereafter to determine how much the tumors ultimately shrink, and to see if and when any new tumors arise in the liver. The average time before a second round of chemoembolization is necessary (because of new tumor) is between 10 and 14 months. Chemoembolization can be repeated many times over the course of many years, as long as it remains technically possible and you continue to be healthy enough to tolerate repeat procedures.

    Who interprets the results and how do I get them?

    • The interventional radiologist can advise you as to whether the procedure was a technical success when it is completed.
    • You will also be scheduled for additional CT or MRI exams and blood tests to determine the size of the treated tumor.

    What are the benefits vs. risks?

    Benefits

    • In about two-thirds of cases treated, chemoembolization can stop liver tumors from growing or cause them to shrink. This benefit lasts for an average of 10 to 14 months, depending upon the type of tumor, and usually can be repeated if the cancer starts to grow again.
    • Other types of therapy (tumor ablation, chemotherapy, radiation) may be used in combination with chemoembolization to control the tumor.
    • When cancer is confined to the liver, most deaths that occur are due to liver failure caused by the growing tumor, not due to the spread of cancer throughout the body. Chemoembolization can help prevent this growth of the tumor, potentially preserving liver function and a relatively normal quality of life.

    Risks

    • Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
    • Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection.
    • There is always a chance that embolization material can lodge in the wrong place and deprive normal tissue of its blood supply.
    • There is a risk of infection after embolization, even if an antibiotic has been given.
    • Because angiography is part of the procedure, there is a risk of an allergic reaction to the contrast material.
    • Because angiography is part of the procedure, there is a risk of kidney damage in patients with diabetes or other pre-existing kidney disease.
    • Reactions to chemotherapy may include nausea, hair loss, a decrease in white blood cells, a decrease in platelets and anemia. Because chemoembolization traps most of the chemotherapy drugs in the liver, these reactions are usually mild.
    • Serious complications from chemoembolization occur after about one in 20 procedures. Most major complications involve either infection in the liver or damage to the liver. Reporting indicates that approximately one in 100 procedures result in death, usually due to liver failure.

    What are the limitations of Chemoembolization?

    Chemoembolization is not recommended in cases where severe liver or kidney dysfunction, abnormal blood clotting or a blockage of the bile ducts. In some cases—despite liver dysfunction—chemoembolization may be done in small amounts and in several procedures to try and minimize the effect on the normal liver.

    Chemoembolization is a treatment, not a cure. Approximately 70 percent of the patients will see improvement in the liver and, depending on the type of liver cancer, it may improve survival rates.

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    PICC Line Placement


    What is a PICC Line?

    A Peripherally Inserted Central Catheter, or "PICC line," is a thin, soft plastic tube — like an intravenous (IV) line — that allows you to receive medicines and fluids. A PICC line stays in place for as long as needed.

    A doctor places a PICC line into a large vein in your arm and guides the catheter up into the main vein near your heart where blood flows quickly. The doctor sutures (stitches) the PICC line in place and covers the site with a sterile bandage. An x-ray is done to make sure that the catheter is in the right place. It takes 1 - 1 ½ hours to place the PICC line. Most patients feel little or no discomfort during this procedure. A local anesthetic may be used.

    Before Your PICC Line Insertion

    • Usually, the Radiologist inserts the PICC line in the Radiology Department.
    • You sign a consent form stating that you understand the procedure.
    • The medical and nursing staff reviews the risks and benefits of this procedure with you. This is a good time to ask any questions you have.

    Understanding the Risks and Benefits of PICC Line Insertion

    Risks During Insertion

    • There may be slight discomfort when the introducer needle is put into your vein.
    • If your veins have scars or are partly clotted from many IV's, this type of IV catheter may not be able to be used.
    • Sometimes, the doctor cannot use the vein in one arm and may place the line in the other arm.
    • Puncture of a blood vessel, nerve or tendon near the insertion site.
    • You may have an irregular heartbeat because the catheter was put too far into the heart.

    Risks After the Insertion

    • The catheter can move out of position in the vein if you cough or move a lot or have severe vomiting. The catheter may need to be removed or repositioned.
    • The PICC line can move out of position if it is not secured in place (with sutures).
    • There is a risk of vein clotting (thrombosis) or vein inflammation (phlebitis).
    • You may get an infection at the insertion site or in your bloodstream. The catheter may need to be removed and you may need antibiotics.
    • The PICC line can get blocked with a clot. This can usually be cleared.
    • A piece of catheter may break off and travel into the bloodstream.

    Benefits

    • A PICC line can be cared for at home and can stay in place for many weeks, or months, if needed.
    • The risk of infection is low.
    • You can get fluids to hydrate you and give you nutrition, blood transfusions, and medicines, like chemotherapy or antibiotics.
    • A PICC line can be used to get blood tests, without another needle "stick."
    • There is a smaller chance of irritation and damage to your veins and blood vessels from many blood draws, IV insertions, and IV medicines.

    Options

    • You can have a regular IV placed in a vein in your arm or hand. This requires changing every 3 days.
    • A doctor can place a central line into a vein in your neck, upper chest or groin area. This type of catheter is for short-term use (less than two weeks) and requires you stay in the hospital.
    • There are other types of catheters that are placed under your skin for long-term use.

    How is the PICC Line Inserted?

    • A doctor will use an ultrasound machine to find the veins in your upper arm.
    • The nurse cleans your arm and covers it with a sterile cloth to prevent infection.
    • The nurse places a tourniquet on your arm.
    • You get a numbing medicine.
    • The doctor puts a small needle into the vein, inserts the introducer needle, and guides the PICC line into the vein near your heart.
    • You have a chest x-ray afterwards to make sure that the PICC line is in the right place.
    • After numbing the skin, the technician places sutures to hold the PICC line in place.
    • The technician covers the insertion site with a clear, sterile dressing and a pressure bandage. The dressing is changed after 24 hours or twice a week.

    Your Care at Home

    • DO NOT take a bath in a bathtub. Cover the insertion site with clear, plastic wrap and tape to keep it dry before showering.
    • No swimming. No hot tubs.
    • Avoid a lot of arm movement and coughing. Avoid lifting weight. Check with your doctor about activity limitations with your PICC line.
    • Your arm may be tender and a little uncomfortable for 1-2 days. Rest your arm for one day after the insertion.
    • It is normal to see a small amount of blood leaking from the insertion site the day after the procedure. There may also be some bruising.
    • When you are home, your PICC line is cared for by a nurse from a home care agency, your doctor's office or an infusion center. You can also learn to take care of the line yourself.

    Call your Health Care Provider Immediately if You Have:

    • Pain
    • Fever
    • A large amount of bright red bleeding (soaking the dressing with blood)
    • Warmth, redness, or swelling along the arm or PICC line insertion site
    • A tear or break in the PICC line catheter or tubing
    • The IV pump continues to alarm, even after flushing the catheter
    • Any leakage of IV fluid from around the PICC line insertion site

    More Ways to Learn

    If you go home with a PICC line, you get a booklet on how to care for your PICC line at home.

    If you are a patient in the hospital, your Case Manager (Discharge Planner) makes arrangements for you before you go home.

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    Tunneled Dialysis Catheter Placement


    General Information:

    Your physician has requested that you have a long-term dialysis catheter placed. A tunneled dialysis catheter is a synthetic catheter that can be used for hemodialysis until a more permanent access is placed.

    How is the Catheter placed?

    • A Radiologist or Physician Assistant using an ultrasound device to locate a suitable vein, and x-rays to guide placement of the introducer device, the catheter is placed in a large vein in the lower neck (jujular vein) or upper chest (subclavian vein). Rarely, a vein in the groin may be used.
    • The catheter is then advanced through the tissues beneath the skin to exit 2-3 inches from where it enters the vein.
    • Generally, only local anesthesia (Xylocaine) is used, although under unusual circumstances a small amount of intravenous pain medicine or sedation may be given.

    What are the alternatives?

    Your kidney specialist (nephrologist) has determined that you need dialysis. Until a more permanent approach to dialysis can be established (arteriovenous graft or fistula, or peritoneal dialysis) the only method is through a catheter.

    It is your option to decline dialysis however, if you do so, you must understand the consequences.

    What are risks and/or complications?

    There is generally only a very small risk of significant complications with dialysis catheter insertion.

    These include:

    • Inadvertent puncture of the lung with lung collapse (pneumothorax). When x-rays and an ultrasound are used to guide catheter placement this is uncommon (less than one in a hundred). If it does occur a chest tube may be required.
    • Injury to a large vein or artery possibly with bleeding into the chest. This is very uncommon (less than one in five hundred) when ultrasound and x-ray are used for catheter placement.
    • Air embolus or air drawn into the venous system. This is potentially a very serious complication and it is the reason that it is unsafe to perform this procedure in patients who are not awake and alert.
    • Localized bleeding.

    Infection is very unusual during the initial placement of a dialysis catheter but over time there is a risk of the catheter tract “tunnel” becoming infected and of bloodstream infections. If these occur, removal of the catheter and antibiotic treatment is usually required.

    How long can the catheter stay?

    There is no absolute limit as to how long a catheter may stay in place, however these catheters should not be regarded as a permanent access device in most patients. The longer the catheter is in place, the greater the likelihood that there will be injury to the entry vein or that a catheter related infection may occur. Over time, all vein access sites may be used up and there will be no reasonable sites for dialysis. You are urged to follow-up with your nephrologist (kidney doctor) or vascular surgeon to establish a long-term plan for dialysis access.

    Choose the least invasive option first.