clinical update publication

Diagnosing Vascular Disease at Deborah

Atherosclerosis affects the cerebral, renal and peripheral vasculature, as well as the coronary vessels of the heart. Just as is the case with coronary artery disease, if vascular disease can be caught in its early stages, preventive measures can be taken to help ward off further progression. Therefore, quick and accurate diagnoses of vascular disease is the first, and most important, step in fighting it.

Deborah Heart and Lung Center's Vascular Laboratory has been diagnosing and monitoringvascular disease since the early 1980s, and technical advances have significantly increased the accuracy of these tests. The Lab affords Deborah physicians the benefit of being able to diagnose vascular disease non-invasively, using ultrasound techniques such as continuous wave Doppler and duplex ultrasound, as well as invasively, using a top-of- the-line angiography lab.

Because they are noninvasive and harmless to the patient, ultrasound studies can be performed an unlimited number of times. Ultrasound studies have a wide range of functions for physicians, including confirming or dismissing the presence of vascular disease, pinpointing its location, following the progression of vascular disease over time, and monitoring vessels after an intervention or surgery.

Deborah's Vascular Lab is fully accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL), a non-profit organization providing a mechanism for accrediting facilities that perform comprehensive testing for vascular disease with non-invasive testing modalities. Deborah has been consistently recognized by the ICAVL for its steady adherence to industry standards in performing extracranial cerebrovascular, peripheral arterial and peripheral venous testing.

Extracranial cerebrovascular testing uses duplex ultrasound to survey the carotid and vertebrial arteries for disease. "Extracranial cerebrovascular testing assesses the velocity of blood flow and the diameter of the vessel," said Stephanie Flicker, MD, Chairperson of Deborah's Department of Radiology. "By calculating the speed of the blood flow in a particular vessel, we can determine the degree of narrowing or occlusion in that vessel, as severe narrowing may lead to stroke."

Peripheral arterial testing, utilizing Doppler techniques and segmental pressures, helps physicians ascertain arterial blood flow in the upper or lower extremities, as altered flow patterns and diminished pressures indicate a general area of narrowing and its severity.

Venous testing is employed to identify thrombus in the veins of both the upper and lower extremities. Physicians use duplex ultrasound to assess the veins using several techniques, including color flow, compression, and augmentation evaluation for deep vein thrombosis.

If further testing is warranted following an ultrasound study, patients will be referred for an angiogram in Deborah's Radiology Special Procedures Suite, where invasive, non-surgical vascular procedures are performed.

The Special Procedures Suite allows Deborah physicians to perform both diagnostic and interventional vascular procedures using a state-of-the-art Siemen's Multi StarTM unit. The Multi StarTM equipment supplies Deborah's physicians with digitally subtracted images in real-time, unlike older angiography equipment in which staff had to manually subtract images. When done manually, this process took a significant amount of time and manpower to perform. The Siemen's Multi StarTM unit, on the other hand, provides clearer images and significantly reduces patient examination time and the amount of manpower needed, and therefore ultimately reduces costs. In addition, the new unit measures flow patterns, so that physicians can evaluate the degree of a blockage, as well as its location.

"This digital technology is truly the last word in radiography," said Dr. Flicker, "Improvements in technology, both invasive and noninvasive, directly reflect the growing precision and sophistication of vascular diagnostic techniques and the confidence placed on the results by the ordering physicians." To make a referral to Deborah's Vascular Lab, call Deborah's Physician Referral Line at 1-800-214-3452.

Stephanie Flicker, MD., Chairwoman, Department of Radiology

Vascular Medicine and Prevention

It is estimated that 30 to 60 percent of the 12 million people affected with coronary artery disease have accompanying vascular disease. Because Deborah Heart and Lung Center is a tertiary referral center specializing in heart and lung care, a large population of its patients either currently have, or are at high risk for developing, vascular disease.

Deborah recently announced its Comprehensive Vascular Program, which provides patients the full spectrum of collaborative care for vascular disease. Armed with specially trained physicians, staff and equipment, the Program offers vascular patients thorough evaluations, collaborative diagnosis, in-depth patient education, individualized risk-management programs, and the ability to provide patients with cutting-edge interventional and surgical procedures.

We've tried to create a comprehensive and integrated model when developing Deborah's Vascular Program. We don't want to wait for people to be symptomatic with vascular disease before we begin to treat them. Of course, we will aggressively treat those who are already symptomatic, but if we can help manage risk factors for those in the beginning of the disease process, we will help these patients slow the progression of the disease, and avoid unnecessary procedures.

Because of the strong link between coronary artery and vascular disease, Deborah cardiologists are well acquainted with the issues associated with atherosclerosis. Clinical cardiologists with special interest and training in vascular medicine staff Deborah's Vascular Medicine Clinic, evaluating, diagnosing, and triaging vascular patients. These doctors are the patient's first line of defense against the development and/or further progression of vascular disease.

According to Maritza Cotto, MD, Attending Cardiologist at Deborah, nearly 70 percent of the patients who come through Deborah's doors with coronary problems will inevitably have some form of accompanying vascular disease. "Deborah's cardiologists concentrate on only one organ system," explained Dr. Cotto, "allowing us to more easily diagnose even the most subtle abnormalities. Once diagnosed, we can counsel patients on the best course of action for their particular case."

Dr. Cotto explained that patients enter Deborah's Vascular Program at various stages of the disease. Clinical cardiologists, radiologists, interventionalists, and surgeons collaborate on cases to determine the most appropriate method of treatment for each patient. Once a patient has been diagnosed and placed on an appropriate treatment track, physicians then focus on managing modifiable risk factors.

Managing risk for coronary artery and/or vascular disease can be challenging. We need to change behavior, and that is easier said than done. Despite a patient's readiness to change, however, we have an obligation as physicians to actively and aggressively address risk factors. These factors, including high blood pressure, elevated cholesterol, diabetes, and smoking, are all glaring predictors of atherosclerosis and, if managed assertively, can help slow, stop, or in even some cases, reverse the progression of the disease. Unfortunately, the medical community, as a whole, has not been doing a great job of this.

National studies reveal that only about 35 percent of people with high blood pressure, and only 13 percent of people with elevated cholesterol, are successfully treated to goal. Additionally, only about one percent of diabetics are known to effectively manage their diet, and according to the American Cancer Society's most recent statistics, 48 million Americans smoke.

Once we establish disease in a patient, they become much more motivated to change. Obviously, we'd rather see a change in behavior before a patient develops advanced disease. Deborah's risk factor management program currently includes monitoring cholesterol and blood pressure levels, helping diabetics control their diet and hemoglobin AIC levels, and counseling patients on the dangers of smoking. The Center's physicians also coordinate with referring physician to help manage risk factors over time. In addition, Deborah is in the process of implementing several long-term risk management methods, such as a tracking system that identifies at-risk patients who have failed to follow up on test results, regular smoking cessation programs, and a nurse-based program that allows Deborah nurses to help manage a patient's risk through regular telephone contact. Managing risk at a distance approach should prove highly effective, not to mention well received, as patients regularly acknowledge their appreciation of health-related follow up.

Realizing that not every patient is best served by any one approach, Deborah has really strived to create a comprehensive program that would offer its patients any possible combination of vascular treatment. Having all of the various disciplines working together allows us to make informed decisions about how to best care for each or our patients.

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