[vc_row][vc_column][vc_tta_tabs][vc_tta_section title=”Abdominal Aortic Aneurysm” tab_id=”Abdominal_Aortic_Aneurysm”][vc_column_text]

What is it?

An abdominal aortic aneurysm (AAA) is a permanent local dilatation or bulge in the aorta greater than 1.5 times its normal diameter.

The aorta is the largest vessel carrying blood from the heart to the rest of the body. The aorta leaves the heart and descends through the chest and abdomen until it splits into two arteries to supply the legs.

The aorta is an elastic structure which is capable of loosing its elasticity as it gets further away from the heart. Therefore the most common site for an aneurysm is in the abdomen. Most aneurysms have a spindle shape, but the size, shape, and extent varies in patients.

When there is a weakening in the walls of the aorta, the high pressures within the vessel cause a bulge or sac. Further weakening of this sac and enlargement can lead to a rupture of this major blood vessel causing severe bleeding. A ruptured aneurysm requires emergency management.

Blood tends to collect within these sacs which may lead to clot (thrombus) formation. If this dislodges from the sac, it can travel to other areas of the body and obstruct circulation to a particular area.

What are the causes?

Abdominal aortic aneurysm is a degenerative process of the aorta that is often attributed to atherosclerosis; however, the exact cause remains unknown.

Other causes of an abdominal aortic aneurysm include:

What are the risk factors?

Risk factors of AAA share many of the same risk factors of atherosclerosis including:

Who needs to be screened?

Screening is done with an abdominal ultrasound used to view images of the aorta to detect any abnormalities.

Screening is recommended for the following groups of people:

Screening reduces the incidence of emergency repair and significantly reduced the mortality rate.

What are the symptoms?

Most abdominal aortic aneurysms are small and have no symptoms. Most people are unaware of it and are often discovered as an incidental finding during work-ups for other problems.

Symptoms are produced as aneurysms grow. The most common symptom of an abdominal aortic aneurysm is pain that may be felt in the abdomen, back, or groin.

A sudden and very severe abdominal, back, or groin pain may indicate a rupture of the aneurysm. A ruptured aneurysm requires emergency management.

How is it diagnosed?

Diagnosis is based around 3 parameters. These parameters include: Patient History, Physical Examination, and Imaging tests.

Patient History:

• Symptoms of pain in the abdomen, back, or groin

Physical Examination:

• During a physial examination, your vitals will be taken. Vitals include your pulse, blood pressure, and temperature. High blood pressure is an indication for further work up.

• An aneurysm may be felt in the abdomen as a small soft pulsating mass around the navel.

• Peripheral pulses will also be checked to determine if an associated aneurysm or occlusive disease is present.

• A stethoscope is placed over the abdomen to listen for a whooshing sound called a bruit.

Imaging tests

Imaging tests are performed to determine the size, location, and extent of an aneurysm. This also helps assess the risk of rupture and management.

 

 

• Computerized Tomographic (CT) Angiography: this test also involves the injection of a dye into the vein while pictures of the aorta are taken.

How is it treated?

Treatment includes preventing the progression of growth and preventing complications.

Treatment involves three separate parameters including: lifestyle changes, medications, and procedures.

Lifestyle changes

These lifestyle changes help maintain a normal blood pressure and also lower the risk of progression of growth of an aneurysm.

Medications:

Medications are used to prevent the progression and complications plus close monitoring. This does not treat an aneurysm.

Some medications used are:

Procedures:

Aneurysm repair is the primary treatment for symptomatic aneurysms and with a  high risk of rupture.

The goal of surgical management is to treat the aneurysm before it ruptures.

Two types of surgical procedures may be done for a large abdominal aneurysm.

These involve:

Open surgery- is a definitive treatment for symptomatic and high risk patients. This operation is done under general anesthesia and can last 4-6 hours. The abdomen is opened and a section of the aorta is removed. This section is replaced with a graft and the graft is covered by the artery wall and sutured into place.

Following this, normal blood flow is ensured. All surgeries carry a risk, although this holds a definitive treatment for aneurysm repair.

Endovascular repair- is a less invasive procedure which involves the placement of a stent within the abdominal aorta. A catheter is inserted into the groin through a small incision and advanced up to the aorta. A contrast dye is given to view the aorta and seen under x-ray guidance. A metal stent is positioned in the aorta which acts as a scaffolding for the artery.

Although this is less invasive, this is not a definitive treatment.

Who is not eligible?

The following people may be contraindicated for an open surgical repair of an abdominal aortic aneurysm:

What are the risks of surgery vs. the risk of rupturing?

The risk of rupture of a small (<4 cm) aneurysm is less compared to a large (>6 cm) aneurysm. A small aneurysm if asymptomatic must be closely monitored every 6 months. The risk of rupture also depends on the rate of growth of the aneurysm.

The average rate of growth of an aneurysm is about 0.3-0.4cm per year. A large aneurysm has an increase risk of rupture and grows faster in smokers.

The decision of surgical intervention depends on the associated risks as well as the surgical risks.

Most small, asymptomatic, aneurysms do not require surgical intervention and only need monitoring every 6 months. Whereas patients who have an asymptomatic aneurysm close to 5.5 cm along with a rapid growth, are advised for repair.

Factors that need to be considered include:

What are the complications?

Complications of AAA include:

*Rupture of an abdominal aortic aneurysm is a true medical emergency and can cause the following:

What is the prognosis?

Most abdominal aortic aneurysms grow slowly. If the aneurysm is slow growing, the prognosis is good.

Increasing size on an aneurysm increases the chance of rupture. The prognosis is good for patients who undergo aneurysm repair.

However, a ruptured abdominal aortic aneurysm holds a bad prognosis. Less than 80% of patients survive a ruptured aneurysm of such a major vessel.

How can I prevent this?

Risk factor modification slows the rate of progression as well as prevents complications.

Some ways to prevent these risk factors include:

 

FOOD ITEM	GI	FOOD ITEM	GI
White bread	71	Broad beans	79
Golden Grahams	71	Jelly beans	80
Millet	71	Pretzels	81
Watermelon	72	Rice Krispies	82
White rolls	73	Potato, microwaved	82
Puffed wheat	74	Cornflakes	83
Corn chips	74	Potato, instant	83
Chips	75	Potato, baked	85
Waffles	76	Rice pasta, brown	92
Doughnut	76	Baguette	95
Wafer biscuits	77	Parsnips	97
Rice cakes	77	Dates	103
Weetabix	77

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Aortic Dissection” tab_id=”Aortic_Dissection”][vc_column_text]

What is it?

Aortic dissection is a condition in which a tear develops in the inner layer of the aorta.

The aorta is the largest and main blood vessel branching off the heart. Blood flows through this tear into the middle layer of the aorta, causing the inner and middle layer to separate or dissect.

This weakening in the wall of the aorta is prone to rupture which is often fatal.

What are the causes?

The most common cause of aortic dissection is due to chronic or long standing hypertension (high blood pressure).

Chronic hypertension causes stress in the aortic vessel wall making it more susceptible to tearing.

Other causes include:

How does it occur?

Deterioration of the inner layer of the aorta is said to be a prerequisite in the development of non-traumatic aortic dissection. Following deterioration, tearing of the inner layer or aortic intima may occur.

Blood passes into the middle layer or aortic media through the tear, separating the intima from the media and dissects the blood vessel.

The dissection can spread both proximal (before) and distal (after) to the tear, involving major branching vessels of the aorta and aortic valve and filling blood around the heart.

Spread of this nature is responsible for many of the symptoms including ischemia (decrease in blood supply) to vital organs, aortic regurgitation, and cardiac tamponade.

Who is at risk?

Those at potential risk of developing aortic dissection include:

What are the symptoms?

Symptoms if aortic dissection includes:

What are the types?

Aortic dissection is classified by the site of dissection.

The most widely used classification is the Stanford system which classifies dissection into two types.

Type A – dissections involving the ascending aorta, regardless of the site of tear

Type B – all other dissections

What are the complications?

Complications of aortic dissection include:

How is it diagnosed?

The diagnosis of aortic dissection is based on three parameters including patient history, physical examination, and tests.

1. Patient history

 

• Sudden severe tearing or ripping pain in the chest or back

• Disorientation or confusion

• Profuse sweating

2. Physical Examination

 

• Delay in pulse between arms and legs

• Hypertension or hypotension

• Blood pressure difference between right and left arms

• Auscultation over the chest may reveal a “blowing” murmur

• New stroke symptoms and signs like decreased sensation or movement

3. Tests

 

• Chest X-ray: reveals widening of the mediastinum                   X-ray of an aneurysm

• Transesophageal echocardiogram (TEE) – a test that uses high pitched sounds to produce images of the heart by passing a probe down the esophagus to view the heart

• Computerized tomography (CT) scan: injection of a contrast dye is used to  visualize the aorta

• Magnetic resonance angiogram (MRA) – uses magnetic fields to form images of the body

 

How is it treated?

Aortic dissections are treated according to the type of dissection presented.

Type A

Type A aortic dissections are considered surgical emergencies. This is the more common and dangerous type of dissection. Surgery is preferred in this type of dissection.

During the surgical procedure, surgeons remove as much of the dissected aorta as possible and make a blockade so blood does not enter into the aortic wall any longer.

The aorta is then reconstructed with a synthetic tube using a graft.

Some patients may have their aortic valve replaced at the same time if a leaky valve is present.

 

Type B

Type B aortic dissections may be treated medically unless the patient demonstrates progressive dissection with ischemia (decreased blood supply) or continued bleeding into the lung or abdominal space.

Medical treatment is used to reduce symptoms and prevent progression of the disease.

Medications include beta blockers (i.e. esmolol; labetalol; metoprolol) to reduce the action of adrenaline on the heart and blood vessels, vasodilators (i.e. sodium nitroprusside) to reduce the heart rate and blood pressure and nitrates (i.e. nitroglycerin) to dilate the blood vessels to decrease blood pressure.

Surgical repair is curative and is similar to the surgical procedure for Type A.

Sometimes a small wire mesh stent is inserted which acts as a scaffolding for the aorta.

What is the prognosis?

Aortic dissection is life threatening. The condition can be managed with surgery if it is done before the aorta ruptures. Less than half of the patients with ruptured aorta survive.

For Type A aortic dissection, the mortality rate remains high, with up to 30% deaths after surgery.

For Type B, when treated medically, the mortality rate is less with a death rate of 10%.

In both types, the ten year survival rate is more than 60%.

How can I prevent this?

The most important way to prevent aortic dissection is to control your blood pressure.

Prevention is enforced in patients who are at risk of dissection.

Some ways to reduce your risk is by:

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Aortic Stenosis” tab_id=”Aortic_Stenosis”][vc_column_text]

What is it?

Aortic stenosis is a condition in which the aortic valve narrows and prevents the valve from completely opening. This restricts blood flow out of the aorta and heart. Restriction of blood flow exiting the aorta diminishes the body’s potential to receive the maximum amount of oxygen rich blood.
Over time the pressure increases in the left ventricle forcing the left ventricular wall to work harder and eventually become thicker and weaker. Weakening of the heart muscle can lead to the development of symptoms including weakness and fatigue.

 

What are the causes?

Narrowing of the aortic valve may be caused by the following:

Rare causes include:

How does a normal heart work?

The heart consists of four chambers. The top two chambers (atria) receive blood while the bottom two chambers (ventricles) pump blood out.

Deoxygenated venous blood returns to the right atrium of the heart. Blood flows from the right atrium to the right ventricle by the opening of the tricuspid valve. Blood is prevented from going backwards into the atrium by the closure of the tricuspid valve. The right ventricle then contracts and pumps blood out through the pulmonary valve into the pulmonary artery. The pulmonary valve is closed and the blood is sent to the lungs where it picks up oxygen.

Oxygenated blood returns from the lungs by the pulmonary veins and enters the left atrium. From the left atrium, blood enters the left ventricle by the opening of the mitral valve. Blood is prevented from flowing back into the left atrium by the closure of the mitral valve. Blood is then pumped out the left ventricle to the aorta by the opening of the aortic valve. Blood is prevented from flowing back into the left ventricle by the closure of the aortic valve. From the aorta, oxygenated blood is pumped out to the entire body.

 

What happens in aortic stenosis?

The aortic valve consists of three leaflets (cusps) which connect to the aorta by a ring called the annulus. Heart valves only open in one direction. Once all of the blood has emptied out of the left ventricle, the aortic valve tightly closes to ensure no backflow of blood.

In aortic stenosis, the leaflets become thickened or calcified preventing the valve to completely open. The thickening of the leaflets make the valve opening narrowed. The ejection of blood from the left ventricle struggles to get through the narrowed opening. The complete emptying of oxygenated blood from the left ventricle is limited, increasing pressure in the ventricle and eventually thickens the wall of the left ventricle.

The limiting of blood flow into the aorta results in symptoms of breathlessness, dizziness, and loss of consciousness.

What are the risk factors?

Aortic stenosis is not considered a preventable disease, yet some risk factors include:

What are the symptoms?

Patients with aortic stenosis may have no symptoms at all.

Aortic stenosis ranges from mild to severe. Symptoms typically develop in severe aortic stenosis.

Symptoms include:

How is it classified?

Aortic stenosis is classified as:

 Normal valve area: 3.0- 4.0cm2 with no transvalvular gradient

What are the complications?

Complications of aortic stenosis include:

Call your doctor immediately if you have any of the following:

• Chest pain or shortness of breath

• Weakness in the muscles of your face, arms, or legs

• Difficulty in speaking

• Rapid or bounding heartbeat

• Fainting or dizziness

How is it diagnosed?

Aortic stenosis is usually diagnosed during a routine visit with your physician.

Diagnosis is based around three parameters including patient history, physical examination, and tests.

1. Patient history

Patients may complain of symptoms in severe aortic stenosis.

Symptoms of:

2. Physical examination

During a routine physical examination, your health care provider will notice the following:

3. Tests

The following tests may be performed:

How is it treated?

Lifestyle changes are implemented in patients diagnosed with aortic stenosis to stop the progression of the disease.

Treatment of aortic stenosis is primarily done with surgical intervention, although medications can be used to relieve symptoms of aortic stenosis.

Lifestyle modifications

Lifestyle modifications help reduce the work load on the heart.

Lifestyle modifications include:

Medications

Medications are used to reduce symptoms and control heart rhythm disturbances associated with aortic stenosis.

Medications may be used to lower blood pressure or cholesterol.

Surgical Procedures

Surgical valve repair or valve replacement is preferred in patients who develop symptoms; even if symptoms are not bad, surgery is still recommended.

Aortic valve replacement offers substantial improvement of symptoms and life expectancy. The only effective treatment for severe aortic stenosis is aortic valve replacement.

Therapies to repair or replace the aortic valve include:

• Transcatheter aortic valve implantation (TAVI) – this is a less invasive approach for aortic valve replacement with a prosthetic valve. The approach can be transfemoral (femoral artery in leg) or transapical (apex of heart). TAVI approach is reserved for patients who are at an increased risk of complication from aortic valve surgery.

What is the prognosis?

Without treatment, an individual with aortic stenosis with symptoms or complications may do poorly.

Aortic stenosis can be cured with surgery although there is a risk for arrhythmias (irregular heart rhythm) which may cause sudden death. There is also a risk that the new valve will stop working and may need to be replaced.

How can I prevent this?

Aortic stenosis itself often can not be prevented, although some of the complications may be prevented.

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Deep Vein Thrombosis” tab_id=”Deep_Vein_Thrombosis”][vc_column_text]

What is deep venous thrombosis?
Deep venous thrombosis (DVT) affects mainly the veins in the lower leg and the thigh. It involves the formation of a clot (thrombus) in the larger veins of the area. This thrombus may interfere with circulation of the area, and it may break off and travel through the blood stream (embolize). The embolus thus created can lodge in the brain, lungs, heart, or other area, causing severe damage to that organ.

Risks include prolonged sitting, bedrest, or immobilization; recent surgery or trauma, especially hip surgery, gynecological surgery, heart surgery, or fractures; childbirth within the last 6 months; obesity; and the use of medications such as estrogen and birth control pills. Risks also include a history of polycythemia vera, malignant tumor, changes in the levels of blood clotting factors making the blood more likely to clot, disseminated intravascular coagulation (DIC), and dysfibrinogenia.

Deep venous thrombosis occurs in approximately 2 out of 1,000 people. The condition is most commonly seen in adults over age 60.

Prevention:
Anticoagulants may be prescribed as a preventive measure for high-risk people. Minimize immobility of the legs.

Symptoms:

Signs and Tests:
An examination may reveal a red, swollen, tender area of the leg. The Homans sign is positive, there is sharp pain when the foot is flexed upward.
The presence of deep venous thrombosis may be seen on:

Treatment:
The clot itself usually will resolve through the natural healing processes. Treatment is also aimed at relieving symptoms and preventing the clot from traveling to the lungs, heart, brain, or other areas. Treatment usually requires hospitalization, at least initially.

Anticoagulants or antiplatelet medications are prescribed to prevent further clotting. Analgesics may be needed to control pain. Thrombolytics (clot dissolving medications) are rarely needed.

Bedrest may be recommended until the symptoms are relieved. The leg may be elevated to reduce swelling. Avoid prolonged sitting. Warm, moist heat to the area may help relieve pain.

After returning home, the patient may continue oral anticoagulants or antiplatelet medications for a prolonged period of time. Warm compresses may also be continued. Continue to avoid prolonged sitting or standing in one position.

Expectations:
Most DVT’s disappear without difficulty. Complications may be life threatening.
Complications:

It is recommended that you call your health care provider if symptoms suggestive of DVT occur. With proper attention and care, a person with DVT can still live a long and productive life.

[/vc_column_text][/vc_tta_section][vc_tta_section title=”EECP” tab_id=”EECP”][vc_column_text]

Enhanced External Counterpulsation (EECP)

 

What is EECP?

EECP is a non-invasive, FDA approved, outpatient therapy for patients having coronary artery disease with persistent symptoms of angina or heart failure who have already had the standard treatments for revascularization or those who are not eligible for surgical intervention.

EECP stimulates the formation of collaterals to help create a natural bypass around narrowed or blocked arteries to improve coronary perfusion.

This increases the amount of oxygen-rich blood to the heart and reduces the symptoms of chest pain, shortness of breath, and fatigue.

Who needs EECP?

• Patients with coronary artery disease who do not require surgical intervention.
• A patient with chronic angina and medical therapy alone does not provide satisfactory relief.
• Patients who have already undergone one or more invasive procedures who have persistent chest pain.
• Patients who are seeking to lower the requirements for medications.

What are the benefits of EECP?

• Lowers the requirement of medications.
• Decrease the onset and frequency of chest pain.
• Enhance the quality of life and the ability to return to daily activities.

 

How does EECP work?

EECP affects the dynamics of cardiovascular blood flow. A series of inflatable cuffs sequenced from the calves, thighs, and hips rapidly inflate and deflate.

The timing of the inflation will be during the exact resting phase of each of your heartbeats. This timed compression in the lower extremities pushes the arterial blood backward into the aorta and increases the coronary perfusion pressure causing stress in the coronary arteries facilitating the development of collaterals.

EECP also increases the venous return during the sequential compression of the lower extremities with a “milking” effect at the same time as the arteries, which further increases cardiac output.

Since collaterals take time to develop, EECP is given for about 1 hour a day, for 7 weeks, with a total of 35 sessions. 80% of patients usually notice improvement of symptoms with this therapy.

Patients may be ordered a nuclear stress test after the course of therapy is complete to confirm the improvement of coronary blood flow.

Can anybody with chest pain try this?

Patients who do not qualify for EECP include patients with:

• Uncontrolled congestive heart failure
• Uncontrolled arrhythmia
• Severe pulmonary or systemic hypertension
• Mild to moderate aortic insufficiency
• Significant coagulopathy- patients on heparin or warfarin
• Severe peripheral vascular disease
• Thrombophlebitis- Inflammation in the veins due to a clot

 

What are the risks of EECP?

EECP is a non-invasive procedure and risks are very low. Although risks are rare, patients may feel discomfort or minor pain in their legs or back.

Other effects may include bruising, blistering, or skin abrasions from the inflatable cuffs.[/vc_column_text][/vc_tta_section][vc_tta_section title=”Pulmonary Hypertension” tab_id=”Pulmonary_Hypertension”][vc_column_text]

What is it?

Pulmonary hypertension is an increase in blood pressure within the arteries of the lungs and the right side of the heart.

When the blood vessels of the lungs become narrowed, pressure builds up in these arteries, therefore called pulmonary hypertension (high blood pressure).

When the heart begins to work harder, over time the right side of the heart becomes enlarged leading to right heart failure or cor pulmonale.

 

 

What are the causes?

Pulmonary hypertension may be caused by the following:

 

 

What are the risk factors?

The risk factors for pulmonary hypertension include:

 

 

What are the symptoms?

Symptoms of pulmonary hypertension include:

 

 

How is it classified?

Pulmonary hypertension can be classified into:

Unknown cause of high blood pressure in the lungs; Uncommon

High pulmonary pressure due to other medical problems; Common

Causes include:

 

 

What are the complications?

Pulmonary hypertension can lead to complications including:

 

Call your doctor immediately if you have any of the following:

Call your doctor if you develop symptoms such as:

 

 

How is it diagnosed?

Pulmonary hypertension is diagnosed in three different parameters including patient history, physical examination, and tests.

 

 

Patient history

Patients may complain of symptoms in severe pulmonary hypertension. Including symptoms of:

 

Physical examination

During a routine physical examination, your health care provider will notice the following:

 

Tests

The following tests may be performed:

 

How is it treated?

The treatment of pulmonary hypertension is aimed at early recognition, controlling symptoms, treatment of the underlying disease, and the prevention of more lung damage.

Treatment depends on what type of pulmonary hypertension is present and the severity.

 

Lifestyle modification:

• Rest

• No smoking

• Exercise: Ask your physician which exercise routine is best for you. Exercise for at least 30 minutes a day, 5 days a week. This can improve symptoms of shortness of breath and fatigue

• Avoid pregnancy and birth control pills

• Avoid traveling at high altitudes

• Control weight: maintain a healthy weight with a BMI less than 25. Extra weight makes the heart work harder. By reducing your weight you can reduce the strain on your heart.

• Nutrition: Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas

• Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food

• Reduce stress

 

 

Medications:

• Prostacydinces
• Vasodilators: Vasodilators dilate the blood vessels. Epoprostenol (Flolan) is the most commonly prescribed vasodilator for pulmonary hypertension. Another medication that can be prescribed is Iloprost (Ventavis), which can be inhaled and taken directly to the lungs.

• Endothelin receptor antagonist: These medications reverse the effect of endothelin (vasoconstrictor) which makes vessels narrower. Bosentan (Tracleer) helps to improve energy and symptoms.

• Sildenafil (Viagra) and Tadalafil (Cialis): These medications are used to treat pulmonary hypertension by opening up the blood vessels in the lungs to allow more blood flow.

• Calcium channel blockers: Calcium channel blockers may be given in high dosage to help relax the muscles surrounding the arteries and cause the vessels to open. This increases blood flow to the lungs and lowers blood pressure. Calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem), and nifedipine (Adalat, Procardia)

• Ambrisenten (Lentairis): helps dilate the blood vessels

• Anticoagulants: help prevent clot formation

• Diuretics: these are sometimes referred to as ‘water pills’ that is used for patients with leg swelling or fluid in the lungs. This helps excrete excess water in the body

• Oxygen: breathing in pure oxygen can help treat pulmonary hypertension

 

 

Surgical Procedures:

Surgery is required if medications are unable to control your pulmonary hypertension.

 

What is the prognosis?

 

The long term outlook for pulmonary hypertension is poor, yet new treatments may lead to better results.

Death can result in patients with associated heart failure.

Pregnancy is not encouraged for patients with this condition.

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Renal Artery Stenosis” tab_id=”Renal_Artery_Stenosis”][vc_column_text]What is it?

Renal artery stenosis is the narrowing of one or both of the arteries that carry blood to the kidneys.

This may cause high blood pressure and reduced kidney function.

What are the causes?

The most common cause of renal artery stenosis is atherosclerosis due to the formation of fatty plaques on the inner lining of the arteries.

 

 

How does it occur?

A blockage of 50-70% of the renal artery is considered significant. As a result of decreased blood flow to the kidneys, the kidney cells falsely presume that blood flow throughout the entire body is reduced.

As a normal defense mechanism, the kidney activates a hormonal system known as the renin-angiotensin system. This response expands blood volume and elevates blood pressure throughout the entire body.

 

 

What are the risk factors?

Renal artery stenosis shares the same risk factors as atherosclerosis.

These risk factors include:

 

 

What are the symptoms?

Renal artery stenosis is generally not associated with any specific symptoms. Most patients commonly present with high blood pressure (hypertension).

Renal artery stenosis may be suspected in patients:

 

 

What are the complications?

Complications of renal artery stenosis include:

• Aortic Aneurysm

• Heart attack

• Congestive heart failure

• Kidney failure

• Stroke

 

 

How is it diagnosed?

Diagnosis is based around 3 parameters. These parameters include: Patient History, Physical Examination, and Testing.

 

 

Laboratory investigations:

 

• Blood Analysis- this includes a complete blood count (CBC), electrolytes, renal function tests (urea and creatinine).

• Urine Analysis- to search for the presence of any blood in the urine.

 

 

Imaging Studies:

 

• Renal Ultrasound or Doppler- is a simple office procedure done to screen renal artery stenosis in high risk patients. The advantage of this test is that it is able to measure the size of a narrowing and measure the blood flow through the vessel.

 

 

How is it treated?

The goal of treatment is to prevent the progression of renal artery stenosis, treating high blood pressure, and relieve blockages within the renal arteries.

Treatment involves 3 separate parameters including: lifestyle changes, medications, and procedures.

Life style changes

 

• First line of treatment is to reduce the risk factors by diet changes, exercise, and weight management.

• Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas.

• Lower your salt intake

• Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food.

• Maintain a healthy weight with a BMI below 25

• No smoking

• Limit alcohol to one glass a day if you chose to drink

• Be more physically active

• Relax and reduce stress

 

 

Medications:

Renal artery stenosis is associated with high blood pressure. The first and safest approach to treatment is with medication.

Medications used to treat high blood pressure include:

These drugs may cause worsening of renal function. Medications and renal function will need to be closely monitored.

 

 

Procedure:

Intervention is required in arterial narrowing of 50-70%, uncontrolled blood pressure with medication, and worsening renal function. Interventions done to treat renal artery stenosis include:

How can I prevent this?

Healthy lifestyle habits can prevent renal artery stenosis from developing. Taking action in leading a healthy lifestyle can help keep your arteries strong, elastic, and free of plaque build-up to ensure maximum blood flow.

These healthy habits include:

[/vc_column_text][/vc_tta_section][vc_tta_section title=”T Wave Alternans” tab_id=”T_Wave_Alternans”][vc_column_text]What is it?

T wave alternans refers to a noninvasive diagnostic test to help identify patients who are at risk of life threatening heart rhythm disturbances that can lead to cardiac death.

This test refers to a beat to beat variability in the timing or shape of T waves on the surface electrocardiogram (ECG) which is not visible to the human eye. Therefore high resolution sensors are used to detect subtle changes in the ECG.

Sudden cardiac death is the nation’s number one cause of death. Most people who suffer a cardiac arrest have an underlying, pre-identifiable, electrical disorder that puts them at risk. A good way to identify this is through the measurement of TWA, a beat-to-beat alternation of a patients ECG.

 

Who needs it?

Patients who need a TWA are those who are at risk of sudden cardiac death (SCD). Sudden cardiac death occurs in patients who have abnormal heart rhythms or arrhythmias.

Risk of SCD typically focuses on the presence of a few factors:

Reduced left ventricular ejection fraction is currently the primary determinate of Implantable Cardioverter Defibrillators (ICD’s), however; reduced ventricular ejection fraction lacks sensitivity.

TWA is a tool to help clarify the overall risk of arrhythmias, especially in patients who have known risks, but who fall into this ‘gray area’ in ICD eligibility.

 

How is it done?

TWA is performed during a treadmill stress test. The standard stress test can only identify the presence of clogged arteries, while the TWA test will identify subtle changes in electrical disturbances.

For TWA to be detected and measured at this microscopic level, the patient’s heart rate must be raised, usually by means of exercise on a treadmill.

This test is painless, noninvasive, and done on an outpatient basis.

Prior to the test, sensors are attached to the patient’s chest.

The patient begins to walk on the treadmill.

Once the patient’s heart rate reaches 90 beats per minute, the TWA test will begin.

After 2.5 minutes, the test is complete.

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Stroke” tab_id=”Stroke”][vc_column_text]What is it?

A stroke is a medical emergency causing neurological injury to the brain due to ischemia or hemorrhage. Ischemia to the brain means a portion of the brain is not receiving blood and oxygen. Hemorrhage means there is bleeding in the brain due to a ruptured blood vessel.

A stroke is due to a cardiovascular cause, yet causes neurological disorders. A stroke is a medical emergency.

 

What are the types?

The two types of stroke include:

 

How does it occur?

A stroke occurs when blood flow to the brain stops for more than a few seconds depriving the brain of oxygen. Without oxygen for an extended period of time, permanent brain damage can occur.

Ischemic stroke may occur due to blocked or clogged arteries. A blocked artery can be due to a blood clot. A blood clot may form in an already narrowed artery (thrombotic stroke). A clot may also dislodge from another site of the body and travel to the brain (embolic stroke). Clogged arteries are due to a collection of fat, cholesterol, calcium and other substances in the interior wall of an artery.

A hemorrhagic stroke occurs in weak vessels which can rupture causing blood to leak into the brain. (i.e. aneurysm)

 

 

What are the risk factors?

A number of risk factors are present for stroke.

These factors include:

Precipitating factors:

 

 

What are the symptoms?

Stroke symptoms depend on what part of the brain has suffered from the lack of blood supply. Some people may be asymptomatic and may never know they have had a stroke.

Symptoms usually occur suddenly without any warning and can even occur while you are sleeping.

Symptoms are typically more severe when the stroke first happens, but can get worse.

Hemorrhagic stroke symptoms (bleeding within the brain) typically appear with a sudden and severe headache that can happen when lying down or while sleeping. The headache can get worse while straining, coughing, or with change of position.

Other symptoms of stroke include:

 

 

What are the complications?

A number of complications may occur with stroke. A stroke can cause temporary or permanent disabilities, depending on how long the brain has suffered without oxygen and which part of the brain was affected.

Common complications include the following:

 

 

How is a stroke diagnosed?

• F – Facial Drooping
• A – Arm Weakness
• S – Speech Difficulty
• T – Time to call 911

Anyone who has signs or symptoms of stroke needs immediate medical attention in an emergency department or hospital.

Several tests may be used to determine your risk of stroke including:

 

How is it treated?

A stroke is a medical emergency. Immediate treatment can save lives and reduce disability.

Call 911 or seek urgent medical care at the first sign of a stroke.

 

Ischemic Stroke

The goal of treatment in ischemic stroke is to restore blood flow to the affected area of the brain as quickly as possible.

Medicines used for the early treatment of stroke are used to break down clots (i.e. aspirin, anticoagulants, etc).

Results are best seen within the first 3 hours of symptoms.

 

Hemorrhagic stroke

The treatment of a hemorrhagic stroke depends on the cause of bleeding (i.e. high blood pressure, use of anticoagulant medications, head trauma, blood vessel malformation).

Surgical blood vessel repair may be needed in cases of aneurysms or arteriovenous malformation (AVM) rupture.

Surgical options include:

Once the bleeding within the brain stops, treatment usually involves bed rest and supportive medical care.

 

 

What is the prognosis?

The outlook depends on:

Some patients may recover completely or some may remain with permanent loss of function.

Over half of the patients are able to function and live at home. Others may not be able to care for themselves.

If treatment with clot dissolving drugs is successful, the symptoms of stroke may go away. However, patients who do not receive treatment soon enough may not get the same results.

Patients who have ischemic stroke (due to blood clot) have a better chance of surviving than those with hemorrhagic stroke (bleeding).

Risk of a second stroke is highest during the weeks or months after the initial stroke.

 

How can I prevent this?

Know your stroke risk factors. Identifying your risk factors makes prevention of stroke easier.

Follow your doctor’s recommendations and adopt a healthy lifestyle.

Some lifestyle recommendations include:

*Ask your doctor about taking low dose aspirin!

Taking a small dose of aspirin thins the blood and helps prevent blood from clotting.

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Cardioversion” tab_id=”Cardioversion”][vc_column_text]

Cardioversion

What is it?

Cardioversion is a procedure used to treat abnormal and rapid heart rhythms known as cardiac arrhythmias. Cardioversion is most commonly used for atrial fibrillation.

Cardioversion delivers an electrical ‘shock’ to the heart to restore the heart to its normal rate and rhythm.

The energy delivered can be given in one of two ways. The electrical energy can be delivered externally with the use of electrodes attached to the chest, or directly to the heart with the use of paddles to the heart during open heart surgery.

An alternative mode of delivery is by the use of a permanent implantable device known as an implantable cardioverter defibrillator (ICD).

 

How does a normal heart beat?

Heart muscle cells are activated by electrical impulses that cause them to contract regularly and in sync. This contraction produces a heartbeat, allowing blood to be pumped out to the entire body.

Electrical impulses originate from specialized cells called the sinoatrial (SA) node, which is the hearts natural pacemaker. The SA node is located in the upper right chamber of the heart, the right atrium.  From the SA node, the impulse spreads across the upper chambers of the heart to reach the atrial ventricular (AV) node located between the atria and lower ventricles. After leaving the AV node, impulses spread across the pumping chambers of the heart, the ventricles. As impulses are spread along the heart, the cardiac muscle cells are stimulated to contract, producing a heartbeat.

 

 

What is an arrhythmia?

During a rapid cardiac arrhythmia, an abnormal electrical mechanism overrides the action of the sinoatrial node. Some arrhythmias start in the atria, while others are produced by the ventricles.

Sometimes, cardiac tissue can form an electrical loop or short-circuit. If the hearts electrical energy goes through this loop, it will cycle over and over again, repeating itself indefinitely causing a re-entrant loop. Each loop through this cycle causes the heart to contract.

Arrhythmias occurring by a re-entrant loop are usually regular, organized, and can be treated with cardioversion. Atrial flutter and ventricular tachycardia are examples of organized arrhythmias. Rapid, disorganized, chaotic arrhythmias include atrial fibrillation.

Cardioversion involves a high energy shock to the heart muscle which activates all of the cardiac muscle and conduction tissue simultaneously. This interrupts and breaks the re-entrant loop ceasing the arrhythmia, triggering the sinoatrial node to fire again and restoring a normal heart rhythm.

 

 

What to do before the procedure?

Prior to a cardioversion, if not already on anticoagulation therapy, your physician will determine your risk of blood clot formation and choose an anticoagulant medicine (i.e. Coumadin) to prevent the risk of stroke or heart attack.

Arrive at least one hour before your procedure to allow for prep time.

Make arrangements to have someone drive you to and from the clinic. You will not be permitted to drive after the procedure.

 

What happens during the procedure?

An external cardioversion is common and is performed in a specially equipped procedure room in our office.

The patient’s heart rate and rhythm, blood pressure, breathing rate, and oxygen levels are monitored.

An I.V. medication is given to sedate the patient to avoid any pain for when the shock is given. Patients will be asleep during the cardioversion and most will not recall the procedure.

Two pads will be applied to the skin. One pad will be placed near the breast bone and the second pad on the back, under the left shoulder blade.

After the patient is sedated, the doctor will deliver the shock given through these pads.

The cardioversion itself only takes a few seconds.

The patient usually wakes up within 5 to 10 minutes.

 

 

What happens after the procedure?

The patient will be monitored for at least one hour after the procedure.

You may also be required to wear a Holter monitor for 24 hours to monitor the electrical activity of the heart after the procedure.

 

What are the benefits?

The benefits of cardioversion include:

 

What are the complications?

Several complications can occur with cardioversion. These include:

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Peripheral Vascular Disease” tab_id=”Peripheral_Vascular_Disease”][vc_column_text]

What is it?

Peripheral vascular disease is a disease of the arteries of the circulatory system due to atherosclerosis. Atherosclerosis is a gradual build-up of fat in the arterial walls depriving the limbs of the oxygenated blood flow it needs.

Atherosclerosis is not confined to one artery but may involve other areas as well.

Most commonly peripheral vascular disease is seen in the legs and is noticed by intermittent pain while walking.

Similarly, when atherosclerosis affects the heart it is called coronary artery disease.

 

What causes peripheral vascular disease?

At a young age, fat can start to deposit within the blood vessel walls. Fat builds up over the years that can cause injury to the blood vessel walls. Not only fat, but a number of other substances in blood like inflammatory cells, cellular waste products, proteins, and calcium begin sticking to the inside of vessel wall. All of these substances collectively form what is called Plaque. The formation of plaque is known as atherosclerosis.

Many of the plaque deposits have a soft inner center and hard exterior. If the hard outer surface breaks or tears, the soft inner center will become exposed to our body’s platelets. The platelets will come to the area of breakage and form a clot around the plaque. This causes the artery to narrow even more. A clot may dislodge and permit blood flow again, but the dislodging of a clot can also be dangerous, as it can cause a blockage further downstream.

The reduced blood flow deprives the tissues of oxygen and nutrients. There is more of a demand for oxygen during activities such as walking, climbing stairs, or exercise. During these times, symptoms usually occur.

 

Although atherosclerosis is the most common, other causes of peripheral vascular disease include:

 

What are the risk factors?

 

• Genetic: Inherited tendency within the family

• Age: increasing age, above 50 years

• Sex: Men are slightly more at risk than women

• Family history of peripheral vascular disease, heart disease, or stroke

• Smoking

• Diabetes

• Obesity (BMI > 30)

• High blood pressure

• High cholesterol

• Sedentary lifestyle

• Coronary artery disease

• High levels of homocysteine

 

What are the symptoms?

Many people with peripheral vascular disease have mild or no symptoms.

The first symptom is claudication. This is a pain or cramping in the calf while walking or during exercise. Pain usually subsides at rest, unless the blockage is severe and will also appear at rest.

Other symptoms include:

 

These symptoms are NOT a normal part of aging.

Do not be afraid to speak up and let Dr. Jamnadas or Dr. Kelly know of any symptoms you are having.

 

What are the complications?

If left untreated, peripheral vascular disease can develop:

 

 

How is it diagnosed?

Dr. Jamnadas will know if you have peripheral vascular disease by:

By performing tests including:

 

How is it treated?

It is very important to reduce any risk factors in order to manage the symptoms and progression of peripheral vascular disease.

 

Lifestyle changes

• Quit smoking!!

• Limit alcohol intake if you chose to drink

• Lower blood sugar levels

• Maintain a normal blood pressure and cholesterol

• Eat a well-balanced diet

• Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas.

• Lower your salt intake

• Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food.

• Exercise regularly for 30 minutes at least 3-4 times a week and be more physically active

• Maintain a healthy weight with a BMI below 25

• If you have diabetes, practice proper foot care and prevent injury to the foot. Avoid walking barefoot and wear proper shoes. Maintain toenails and skin care. Be sure to inspect the soles of your feet regularly.

 

Medical treatment

• Cholesterol-lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low-density lipoprotein (LDL- your Lousy cholesterol) and keep your high-density lipoprotein (HDL- your Healthy cholesterol) High
• High blood pressure medications– such as Beta blockers that slow your heart rate and reduce blood pressure which decreases the oxygen demand of the heart

• Antiplatelet medication- such as aspirin or Plavix which prevents platelets clumping together. This thins the blood and reduces the chances of a blood clot narrowing or obstructing the arteries. This is not appropriate for all patients including patients with bleeding disorders or already taking a blood thinner.

• Controlling of blood sugar

• Cilostazol (Pletal) – used for claudication and pain relief by increasing the blood supply to the limbs by dilating blood vessels and preventing clots.

• Pentoxifylline (Trental) – this is an alternative medication which is less effective than Cilostazol but has fewer side effects of headache and diarrhea.

 

Supplements

Food and supplements rich in omega 3 fatty acids help reduce inflammation throughout the body, lower blood pressure, and the risk of heart attack.

 

Procedures to restore blood flow

• Angioplasty and stent placement: this is a procedure considered as non-surgical because it is done by Dr. Jamnadas or Dr. Kelly, who accesses the artery by inserting a long, thin tube (catheter) into the narrowed part of your artery while being visualized under x-ray.  A wire with a deflated balloon is passed through the catheter to the narrow area. The balloon is then inflated, compressing the plaque against the artery wall and widening it, so it no longer restricts blood flow.

Blocked arteries in the renal, iliac, and legs can easily be treated with stenting or arthrectomy.

Unlike stenting done in the coronary arteries, only bare metal stents are used in the peripheries.

Bare metal stents act as a scaffolding to keep an artery open but suffer a 30% re-stenosis rate. This is due to a process called intimal hyperplasia which is attributed to a keloid. A keloid is an overgrowth of the inner lining of the blood vessel that covers over the stent. However, this reparative process lasts no more than 6 months. After 6 months, if an artery has not re-narrowed at the site of the stent, it is unlikely to re-narrow.

If symptoms were to reoccur, it would be due to New blockages at another site within the arteries.

**Patients will need to improve risk factor modifications to prevent New blockage formation.

 

Bypassing artery in the thigh	Bypassing artery in the leg

 

If your disease is very severe and these procedures are not recommended for you, your foot or leg may need to be removed (amputated). This is usually necessary if you have very little to no blood flow leading to death of the tissues which can cause risk of a life-threatening infection.

Amputation is a last resort, but if peripheral vascular disease is not controlled, it is a possible result.

 

How can I prevent this?

 

• Do not smoke!

• Maintain a healthy weight with a BMI <25

• Maintain a normal blood pressure, cholesterol and sugar levels

• Eat nutritious, low fat foods and avoid foods high in cholesterol

• Exercise regularly for 30 minutes at least 3-4 times a week

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Venous Insufficiency” tab_id=”Venous_Insufficiency”][vc_column_text]What is it?

Venous insufficiency is a condition which affects the veins of the legs. In healthy veins, blood is pumped from the legs up to the heart. Blood is pumped upwards due to a series of valves within the veins directing blood flow from the superficial veins to the deep veins leading back to the heart.  Contraction of the calf muscles also aid in pumping the blood flow back up to the heart.

When the valves within the veins are damaged or not working properly, blood flows backwards resulting in a pooling of blood in the legs. Pooling of blood in the legs increases the pressure in the veins leading to venous hypertension. This increase in pressure can cause mild symptoms of leg heaviness and aching or in chronic cases may progress to severe symptoms.

What are the symptoms?

Symptoms of venous insufficiency include:

 

What are the causes?

Several causes may lead to venous insufficiency including:

 

What are the risk factors?

Those at risk of developing venous insufficiency include:

 

What are the complications?

If venous insufficiency is left untreated, complications may arise due to the high pressure within the vein and reduced clearance of metabolites from the legs.

Complications include:

 

How is it diagnosed?

Venous insufficiency is diagnosed based around 3 parameters.

These parameters include: Patient History, Physical Examination, and Testing.

 

A. Patient History:

Symptoms give a strong clue in diagnosing venous insufficiency.

Typical symptoms include:

 

B. Physical Examination:

The appearance of the leg gives an idea of whether venous insufficiency is present.

Skin discoloration, swelling, stasis dermatitis, cellulitis, and dilated veins may be noticed in the legs.

Venous skin ulcers if present are typically located over the inner aspect of the ankle, but can also be present over the leg.

A manual maneuver known as The Trendenlenburg test may help in distinguishing insufficiency due to valvular damage. This is done by elevating the leg to empty the veins and applying pressure to block the junction where reflux is occurring from the deep to superficial veins. While maintaining this blocking, the patient is asked to stand. If the lower portion of the vein remains empty or slowly fills, the occlusion is removed. If this is followed by rapid filling, the junction has been correctly identified. If filling occurs with the occlusion, this may indicate a valvular problem in the deep veins.

 

C. Tests

Laboratory investigations:

Blood analysis: Elevated platelets levels increase the susceptibility to clot formation.

Diagnostic Studies:

• Venous Reflux Study: this is a non-invasive test carried out in our clinic used to detect the presence of venous insufficiency
• Venous Doppler: is a non-invasive test done in our clinic showing the direction of blood flow and detects thrombus (clot) formation
• Magnetic Resonance Venography (MRV): is an imaging study used to provide a detailed picture of the deep and superficial veins of the legs using radio waves within a strong magnetic field
• Direct Contrast Venography: is an invasive test used to detect venous and nonvascular causes of leg pain and edema
• Intravenous Ultrasound (IVUS): A catheter is placed into the veins in the pelvis and an ultrasound image is taken from inside the vein. This gives an accurate assessment of whether there are any obstructions to blood flow.

 

How is it treated?
The goal in treatment is to reduce symptoms and correct the underlying problem.

 

Conservative treatment:

• Weight loss: Losing weight can boost the blood flow in your legs.
• Leg Elevation: Legs are elevated just above the level of your heart for about 30 minutes and should be done three to four times a day. Elevation improves the drainage of blood and metabolites from the lower extremities. This helps relieve symptoms in patients with mild venous insufficiencies.
• Exercise: Foot and leg exercises help to improve symptoms. Movement helps prevent stasis of blood and also helps the calf muscles pump blood up towards the heart.

 

Compression stockings can be used in all patients with venous insufficiency and is available in our clinic.  Compression stockings apply a greater amount of pressure toward the ankle while pressure tapers as it goes up the leg. Compression stockings prevent pooling of blood and help to improve blood flow from the lower extremities.

Compression bandages are used for patients with severe symptoms including severe leg swelling or ulcers. Ulcers must have a dressing on before the application of a compression bandage. Application should be done by trained personnel. The bandage must stay dry and covered while bathing. If the bandage becomes wet, the bandage should be removed due to development of potential infection. The bandage may be changed once to twice a week.

Procedures:

The goal of these procedures is to improve the venous circulation by correcting insufficiencies by removing the reflux pathways.

 

How can I prevent this?

• Lose weight

• Avoid prolonged standing or sitting

• Be more physically active by walking or running to promote the calf pumping function

• Elevate your legs to improve circulation

• Correct the underlying problem to prevent progression

• Change your sitting or standing position regularly

• Protect your legs from injury

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Venous Ablation” tab_id=”Venous_Ablation”][vc_column_text]

What is it?

Venous ablation is a minimally invasive technique using intense thermal energy to irreversibly destroy an incompetent or diseased vein.

A catheter with heat is inserted into the targeted vein and closes off the vein. The vein is closed off, but not removed.

Who needs it?

Venous ablation is indicated in patients with symptoms of venous disease with reflux.

A venous Doppler ultrasound is used to confirm the presence of venous obstruction, reflux, valvular incompetence, or clot formation.

 

 

Who does not qualify as a candidate?

Patients who do not qualify for venous ablation include patients with:

 
Why do I need it?

The goal of venous ablation is to treat and reduce the symptoms and signs of venous disease.

Venous ablation is also useful in preventing the risk of complications from venous disease (blood clot formation).

 

How to prepare for the procedure:

 

Before the procedure:

This procedure is done here in our clinic. Arrive at the clinic at the time of your appointment.

You may eat and drink before and after the procedure. This procedure is not effecting by eating.

This procedure does not require any alteration in medications, so take your morning medications as prescribed.

Arrange for someone to drive you home after the procedure. You may not be permitted to drive immediately after the procedure.

The procedure lasts about 1-2 hours.

 

During the procedure:

The procedure will be carried out in our clinic in our procedure room.

During the procedure you will lay on a table positioned on your back.

Under ultrasound guidance, the exact location of the vein will be determined.

A guide wire is inserted through a small opening in the skin into the targeted vein.

Once the guide wire is in, an introducer sheath is passed over the guide wire. The guide wire can then be removed. Under ultrasound guidance, the catheter is passed through the sheath and is advanced up the vein until it reaches 2cms below a junction called the saphenofemoral junction.

Under sterile precautions, a local anesthetic along with sodium bicarbonate will be injected into the tissue along the length of the vein to ensure that you do not feel any heat from the catheter. This compresses the vein from two sides and also separates the vein from other structures including nerves.

After the catheter is in place, the tip of this will send out a radiofrequency which is converted into heat that reaches 120oC. When the catheter is slowly withdrawn, the heat causes the vein to collapse and close off. Once the vein is closed off, blood is re-routed into other healthy veins.

 

 

After the procedure:

While you are on the table, an ultrasound will be done over the ablated vessel to confirm that the vessel is collapsed as well as an absence of blood flow in that vein.

Following the procedure, a bandage will be placed over the insertion site. A compression bandage will be wrapped around the entire length of the leg and should be worn for 2-3 days.

A compression bandage is important because it helps prevent bruising and tenderness as well as reduces the risk of blood clot formation and dislodgment. A compression stocking is required to be worn for up to 4 weeks.

You are encouraged to walk for at least 30 minutes a day after the procedure to prevent deep vein thrombosis.

Avoid heavy or strenuous exercise for a few days.

Avoid prolonged sitting or standing.

Wear compression stockings for up to 2 weeks.

An ultrasound follow up is required 3 days after the procedure to rule out any deep vein thrombosis (clot formation).

After 4 weeks of the procedure, an ultrasound follow up is required to ensure the complete closure of the vein and no reflux.

 

What are the possible risks and complications?

Venous ablation is generally a safe procedure, but with any surgical procedure it carries a risk.

If they occur are usually minor and temporary.

Complications include:

 

 

What are the benefits?

The benefits of venous ablation include:

[/vc_column_text][/vc_tta_section][vc_tta_section title=”Venous Stenting” tab_id=”Syncope”][vc_column_text]What is it?

Syncope is defined as a brief loss of consciousness with an inability to maintain postural tone that is followed by a rapid and complete recovery.

Syncope is common and about one-third of the population experiences a syncopal episode in their life. Syncope may be an alarming sign in some people who have a serious underlying medical condition. In a younger age group, more than 75% of cases are not associated with an underlying medical problem.

 

What are the symptoms?

Syncope is often preceded by symptoms of ‘faintness’ including:

 

What are the causes?

A number of causes can lead to syncope. To remain conscious, oxygen-rich blood must supply the brain without delay. A delay of blood to the brain for even 3-5 seconds can result in syncope.

Consciousness is regained after falling or lying down because blood returns to the brain once gravity is removed. A number of medical conditions can cause syncope.

The most common causes include:

 
A. Vasovagal Syncope

This is the most common type of syncope. This is triggered by a number of conditions including physical or emotional stress, fear (i.e. sight of blood), dehydration, bleeding, pain, anemia, fever, or fasting.

These conditions or ‘triggers’ stimulate a nerve to slow the heart rate and dilate the blood vessels, which causes blood to pool in the legs, resulting in low blood pressure (hypotension). This leads to a decrease or delay in blood flow to the brain resulting in syncope.

Symptoms include nausea, sweating, stomach pain, hyperventilation, weakness, and confusion.

 

B. Cardiac Syncope:

Cardiac syncope can be due to arrhythmia or obstruction to cardiac outflow.

• Alteration of the heart rate and rhythm can produce cardiac syncope. The heart rate and rhythm are controlled by the natural pacemaker of the heart known as the Sinoatrial Node.

This regulates the electrical activity of the heart which follows through a conduction pathway.

Syncope can occur due to problems at several places in this pathway.

When this is altered the condition is termed as arrhythmia.

Arrhythmias are produced by:

Other obstructive causes include mitral stenosis, pulmonary stenosis, pulmonary embolus, left atrial myxoma, and pericardial tamponade.

 How is it diagnosed?

Dr. Jamnadas or Dr. Kelly will better understand your syncope based around 3 parameters.

These parameters include: Patient History, Physical Examination, and Testing.

 

A. Patient History:

 

Obtaining patient history is the most important diagnostic tool in syncope. 85% of the diagnosis comes from the history given from the patient.

 

 

B. Physical Examination:

 

• During a physical examination, your vitals will be taken. Vitals include taking your pulse, blood pressure, and temperature. Blood pressure may be taken more than once, in the laying and sitting position.

        

  Laboratory investigations:

• Blood Analysis- this includes a CBC to reveal signs of anemia, serum glucose levels, electrolytes and renal function tests. Cardiac enzymes may be checked in patients whom cardiac origin is high.

      

   Diagnostic Studies:

• Electrocardiogram (EKG) – this is a common and easy test to perform which records the electrical activity of the heart. This detects any irregular heart rhythms and may show evidence of a preexisting heart attack.
• 24-Hour Holter monitor– records the electrical events of the heart during your normal daily activities. This helps in detecting signs of arrhythmias. It is important to accurately record your activities and symptoms so Dr. Jamnadas or Dr. Kelly can compare them to the Holter monitor findings.
• Event monitor- If symptoms of arrhythmia are infrequent and do not occur within 24 hours, an event recorder may be ordered for you for up to 30 days.
• Echocardiogram (ECHO) – shows images of the heart determining the size and shape of the heart, and shows whether the heart walls and pumping activity are normal or performing weakly.
• Tilt Table Test– In this test you will be asked to lay flat on a table. The table will be tilted in various angles while your heart rate and blood pressure are monitored. This test is useful in revealing abnormal cardiovascular reflexes that produce syncope.
• Stress test- helps access the blood flow to the heart at rest and during stress. Will detect if any areas are receiving less blood flow.

 

        Other Studies:

• Chest x-ray– to assess the size and shape of the heart in congestive cardiac failure, infections within the lung causing pneumonia, or any fluid or mass can be seen in the lungs.

 

How is it treated?

Syncope is treated depending on the underlying cause. The goal of treatment is to prevent recurrences and the progression of serious problems.

Vasovagal syncope:

Vasovagal syncope can be treated by educating the patient of the precautions to be taken as well as avoiding potential triggers to minimize the potential risk of harm.

For example:

• If you have carotid sinus syncope, you will be instructed to not wear tight collars, to use a razor instead of electric razor, and drink plenty of fluids.

 

Cardiac Syncope:

Cardiac syncope is treated with antiarrhythmic drugs or pacemaker/ ICD placement. A pacemaker is a small device that is implanted under the skin of the chest. This connects wires to the heart which transmits impulses to regulate the heart rate and rhythm.

 

Patients with life-threatening ventricular arrhythmias may need an implantable cardioverter defibrillator (ICD). This does the same as the pacemaker, but also administers an electric shock to correct the electrical problem that can prevent a person from dying.

Cardiac outflow obstruction can be treated with Beta Blockers to decrease the workload of the heart. Cardiovascular intervention procedures may be required or valvular correction surgeries.

 

Orthostatic Syncope:

Orthostatic syncope treatment also involves patient education. Certain techniques are designed to decrease the pooling of blood in the legs that allows blood pressure to drop once you stand. These techniques include the contraction of the leg muscles before and during standing. You will also be instructed to and rise slowly, in stages to stand.

Additional therapy may be given such as increasing salt in your diet, foot exercises, compression stockings for the legs, and consumption of plenty of fluids can be useful in the treatment of syncope.

It is important to Stay Hydrated.

Antihypertensive medications, especially diuretics are notorious for causing orthostatic syncope and many need adjustment.

Medications used:

 

What is the prognosis?

Vasovagal syncope and orthostatic syncope have an excellent prognosis and do not increase the risk of death.

Patients with cardiac syncope may be restricted from their daily activities.

Without treatment, the prognosis for people with cardiac conditions is usually poor and has a mortality of 25%.

 

How can I prevent this?

Patient education is very important!

Education may have a vital impact on prevention and recurrence of syncope.

 

Safety Issues:

Patients who present with syncope are instructed not to drive until cleared by the doctor to do so.

This is recommended mostly for patients with no warning signs of syncope.

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