Now that Halloween has passed, I would like to return to our discussion on peripheral vascular disease.

I would like to devote this entry to an exploration of the pathophysiology of lower extremity occlusive disease (LEOD).

LEOD is a progressive disease--specifically, chronic ischemia of the lower limbs due to the atherosclerotic process leading to a deficiency of the local blood supply. The process evolves in several steps. First, early on it may be asymptomatic; catching the disease at this point may be challenging. The next stage may present claudication--cramping in part of the leg with exercise--depending on the patient's age or physical buildup. This also may go ignored for some time. Rest painwill grab your attention at this point, and will be hard to ignore. Ulcerative gangrene is the last step--unfortunately, this is the point where see most of our patients.

There are several medical conditions that affect LEOD; the most common is diabetes. Is there anything a person can do to slow or prevent the disease from occurring? The answer from most physicians would be "yes." Just like coronary artery disease, certain life factors are involved and life style modification--smoking cessation, controlling weight and a balanced diet--can surely alter LEOD, although they're all tough acts to follow for most of us.

The earliest stage you may see a patient is the claudicating stage. Most of these patients are scheduled procedures after seeing their physicians for this complaint. The severity may vary from patient to patient. At times, patients may come in on an emergent situation. Some of these situations may be embolic situations; they cause occlusions that must be handled as an emergency to prevent limb loss. We always referred to these cases as CLIER (cold leg in the ER).

In my next installment, I will present some of the diagnostic procedures that can be used.

Happy Halloween everyone, even though I am not a fan of the celebrations, I hope everyone has a safe and enjoyable time. It is a nice time of the year and I do enjoy fall until it is time to turn the clocks back. Last week I drove to New Hampshire to visit my son for parents' day at his college, and I must say it was a very scenic ride, even though it rained for the trip up. If you ever get the opportunity to visit New England in the fall, you will enjoy it.

It was on this day last year that I ended my 37 year career in vascular radiography. It was a very enjoyable time in my life, well maybe not at 3:00 in the morning. The experiences I had and the people I met along the way will always be with me.

When I read Juneys' blog, describing her entrance into the radiology field, her submissions remind me of my early career. Congrats to her and to all the people just entering the field, learn everything you can, and remember to be nice to the patients.

Some of the times during my career that stick out in my mind are the equipment we had to deal with "back in the day". A few out there have read my entries on some of the early procedures, still makes your hair stand up. Some of you may remember the equipment such as the wires and catheters and stopcocks that we supposedly sterilized and reused over and over. I wonder how that would be thought of today.

I will leave you with one other recollection, since it is time for baseball's World Series games. One day in our special procedures department we had three former major league players at the same time. They all were heroes in my younger days.  How great it was to talk about their experiences "back in the day".

Times are changing. That is a fact we all know too well. In a lot of hospitals cardiac catheterization labs and interventional radiology are being joined in one department with the name cardiovascular interventional services. It helps hospitals consolidate services that utilize very expensive equipment.

I am not getting into all the politics surrounding this issue. I remember working with the nursing staff in the department I was affiliated with and the nurse's one wish was that they were more knowledgeable about the lower extremity artery anatomy. They all knew the cardiac vascular anatomy by working with it over time, but here they were doing complicated procedures on the peripheral system and they were held back by lack of knowledge.

I thought I would devote some time to the vascular anatomy, who knows maybe it will help a lot of people. I will start the lesson at the abdominal aortic bifurcation.

The abdominal aorta divides in the lower lumbar area, somewhere about the level of the umbilicus, each branch going to both lower extremities. The first named part is the iliac arteries. After a short course it divides into the internal iliac, which feeds the organs in the pelvis, and the other branch is the external iliac artery.

Passing through the inguinal ligament the external iliac becomes the common femoral artery. The common femoral artery bifurcates into the superficial femoral artery and the deep femoral artery, also known as the profunda. The profunda supplies the thigh. The superficial femoral artery continues down the medial side of the femur, midway down the femur the SFA goes through the adductor canal and winds behind the knee where it becomes the popliteal artery.

Below the knee the popliteal artery trifurcates into the anterior tibial artery on the lateral side of the lower leg, the posterior tibial artery on the medial side and the peroneal artery between them. The anterior tibial and the posterior tibial artery form the pedal arch.

I hope the description is of some help, I had an illustration but not being totally computer savy I could not get it to show up.

This post is in response to a comment on a previous blog. That particular blog was on peripheral angioplasty and stenting. Jo from Gulphport,MS, wrote in concerning the coding for multiple stenting procedures in the superficial femoral artery (SFA).

The question was, could there be multiple charges with several stents placed in the SFA. It has been a little while since I had to deal with coding, so I am a bit rusty on the topic. It is my belief that since it is all the same vessel only one charge can apply. If there is a reader out there who is more current on the correct procedure, perhaps they can enlighten us.

The topic brings out some interest in a relatively new field of interventional radiology coding. The specialty is Certified Interventional Radiology Cardiovascular Coder ( CIRCC), and will certainly become one of the top specialty earners. Anyone interested should to some research on how to obtain this classification, I am sure you could be worth your weight in gold to any radiology group.

Interventional radiology coding procedures are certainly very complex. The use of complex coding components allows for thousands of combinations making this a formidable task. Individual coding professionals need to have a strong knowledge of vascular and nonvascular procedures. Each of these have rules that are very challenging.

To be correct documentation needs to accurate. If documentation is not adequate by the physician, it is not considered to be reimbursable by Medicare or other insurance companies. There needs to be a chronological order including timing to different aspects of the procedure to determine what acceptable charges are.

This note is just the very tip of the iceberg, please do some research on how to get certified and as I stated earlier become invaluable to your department.

Naturally there has been several research studies carried out to examine the issue. The main consensus is that most of the findings are insignificant, and these findings should be classified in the patient's record. The main findings are those of pulmonary nodules, which may or may not be cancerous.

Each instance is usually evaluated on a case by case basis. Generalized screenings are expensive and may not be warranted. In the studies performed, fewer than 2% of findings required further evaluation, and of those less than 10% required further intervention.

Patients should become involved with the decisions after an explanation of how common these incidental findings are. It should be up to the patient to choose if any further investigation is performed.

One day a young female, age around sixteen came in to the ER after a minor injury in a scholastic sporting event. The first evaluation was to get vital signs. The nursing staff became alarmed because they could not locate a pulse or get a blood pressure reading.However the young lady appeared just fine.

Since it was so long ago, echocardiography ,ultrasound, and CT were non existent. It seems hard to think how physicians made any diagnosis without them. Eventually the patient was seen by a cardiologist, I do not know or remember how all the steps came about, but talk of this case circuited in the department. I remember the doctor talking about this special case that was very rare only a few of them were diagnosed and most of the similar cases were found on autopsy.

The diagnosis was Coarctation of the Aorta with and aberrant subclavian artery. The question was how to film it. It was decided to place a catheter in the pulmonary artery and inject there as if we were doing a pulmonary angiogram. Manual subtracted films of the area provided the visual proof. The patient was referred to Baylor University for surgery .I did find out later that the young lady did well with the surgery and resumed a normal life.

Reading some of the literature on like cases there are reported cases with differences in where the sub avian artery originates either preductal,ductal or postductal. Unfortunately I do not remember which category that this fell into. Thank science for advances in both techniques and more sophisticated diagnostic equipment.

What I am getting at here, besides depressing everyone, is September is  " Legs for Life" month. We all know about the Legs for Life program, or at least I hope we know. Legs for Life is a program piloted and launched by the Society of Interventional Radiology (SIR), back in the end of the 1990's. The purpose of the program is to educate and make people aware of peripheral arterial disease (PAD).

New this year is a quiz developed to help people assess their risk of  PAD. I sure hope this will create more awareness among the public. The quiz focuses on your cardiac situation and other contributing factors such as diabetes, I fell under both categories, so I will watch out for any signs in my own legs.

During the screening week volunteers will hold one or two day screenings at locations all over the country. Simply they will measure ankle brachial index (ABI) and take it from there. Some places will offer ultrasound exams to look for hidden abdominal aortic aneurysms. It is all good, so I hope there are a lot of places that register as sights and a lot of people take advantage of this great opportunity. To find a location, go to the SIR Doctor Finder and enjoy your walk.

We can all envision the typical signs of a person having a heart attack. A person clutching their chest, breaking out in a sweat and feeling like there is an elephant on their chest. I knew a gentleman who was having an acute MI who held his chest so tight the emergency medical crew broke his humerus trying to pry his hands off of his chest.

Women on the other hand may experience it very different, and most of the women who had an MI, look back and recall some of the symptoms that may have been clues to the impending event. The symptoms most common were fatigue, sleep problems and shortness of breath.

Recently the NIH released the findings on research into women’s early symptoms. The study investigated women’s experience with heart attacks and what some of their symptoms were. Most of the women experienced very little or no pain at all. The purpose of the research was to find out how women were affected and what were the differences from what a male experiences having an MI.

Reviewing the symptoms later on after the event most women admitted to feeling of fatigue, more than regular. Sleep problems and disturbances was also noted. Shortness of breath and anxiety or a feeling of impending doom were noted along with GI complaints of nausea.

It is hoped that not only women but clinicians as well, will understand and pay more attention to these symptoms and not miss an important clue to preventing the biggest cause of death in men and women.

Several weeks ago an article I wrote appeared in Advance web. It was an article that discussed radiation and safety in the cardiovascular interventional suite. Two weeks ago a story was published concerning the amount of radiation the general public was receiving from overused diagnostic studies. Maybe someone is paying attention to my articles; somehow I do not think that is the case. I am laughing to myself.

In the study performed, the main target was the amount of radiation received during myocardial perfusion studies and computed tomography of the chest, abdomen and pelvis of non elderly patients. The study was conducted with data acquired over a two year period, and is available for general viewing.

There are, of course, many ways to take the results of the study. The bottom line should be and I am sure it is the bottom line going through all clinicians thoughts when they meet with patients, is that the risks and benefits are fully taken into account. The benefits of the information acquired from the diagnostic study are what is paramount.

The correct study will provide the most information needed to treat the patients symptoms. Presumably more research studies are needed to prove that theory.

As I promised last time, it is time to dwell more on digital filming. I am here, my favorite Sunday DooWop music  coming through the earphones and I am ready to go. Shaboom, shaboom.

Rather than dealing with individual programmed exposures on cut film, images are acquired fluoroscopically and stored in sequence on a computer disc. Here we come across the first drawback, there always needs to be some type of backup, just in case of the old computer glitch. This would raise the ire of a vascular surgeon or radiologist. We had one such situation occur in the past, a repair person came in and  tried to rectify a problem that was occurring. Unfortunately, he performed his corrective action before we had a chance to transfer the images on backup, and all the information was lost. The vascular surgeon was not a very happy person.

Once the information is acquired a number of processes can be performed with the images. Digital subtraction can be carried out electronically, as the acquisition begins an initial film with no contrast occurs and anatomy you do not want to see can be subtracted out. It is always helpful to review the unsubtracted image at the same time. As we all know the biggest drawback to subtraction is motion, this can be corrected by doing pixel shifting.
Pixel stands for picture element, by moving the pixels the anatomy can be realigned..

Originally DSA was performed with an intravenous injection however large injections of contrast was needed. With arterial injections the amount of contrast can be markedly diminished. Spatial resolution has markedly improved over the last several years, but it is not as good as film. Equipment improvements have made the difference between digital and cut film almost negligible except in very rare cases.

Road mapping is another welcome improvement with digital filming. Flouro is performed over a saved film with contrast. This allows movement of guidewires and catheters through tortuous areas.

In all aspects digital filming has made our life much easier, studies can be performed more quickly. Contrast load is another savings, this is good for the patient, obviously. All aspects considered the age of the computer is welcome in the angio suite.

The computer age is here, it's value in health care, especially Radiology, is well documented. I would like to make a comparison  between filming equipment now and those ancient monstrosities that some of us had to deal with years ago.

I remember early in my career attending a Radiology Society meeting, the speaker for the evening was a gentleman I admired very much. If I were to have a mentor for my career, John Cullinan would be that person. Mr Cullinan authored several books on Radiographic Technic, it was kind of the bible to me. The point to this is on the way out of the meeting Mr. Cullinan mentioned that by the end of the century, we would not be using film any longer, and technologists would be needing college degrees. I will state that when he said this it was the mid sixties and here we are, how prophetic is that

Getting back to filming, I am sure there are some out there who remember all the fun and disasters working with film changers. I think the hospital I worked at had the last surviving Schoenander in captivity. Do you remember getting the two AM angio call-in and having to fill the magazines. Those were the good times. The Franklin roll changer was a lot easier, but it had its share of disasters, like when you forgot to tape the film onto the receiving spool. I am not even going into the Sanchez-Perez unit, the memories are still evil.

Fast forward to today, rather than exposing cut films at regular intervals, fluoroscopically acquired images are stored on a computer disc. This allows a hole host of little computer tricks to be done after acquisition. Digital subtraction is done electronically, no more fooling in the darkroom and making masks, then aligning the two pictures accurately. The best thing to come out of the digital era is road mapping. This allows you to flouro on top of a previous run allowing the operator to see all the curves and kinks in the artery and guiding the wire and catheter with less effort.

In future blogs we will discuss more of  computers in medicine. It is amazing to see the advancements come into play. It is like the old IBM ads that stated  " what if .... "

Several years ago, it feels like a lifetime ago, the heart of any radiology department revolved around radiographic film and of course the film processor. When the processor operated correctly and the films dropped out as they were supposed to the department ran like clockwork. When a roller would break or a gear broke off films jammed leaving most of us helpless. At those moments the most important person in the world was the gentleman from the company who serviced these devices and who knew where every squeak came from.

Thumbing through the pages of the local newspaper this week I came across the obituary of one such person. His name was Terry Rossman and he toiled over Kodak M6 processors at several hospitals in southeast PA. Some of you readers may remember this wizard of the processors. He was employed by Picker X-Ray and by North Central X-Ray Companies. I always enjoyed talking with Terry, he also taught me a lot about processors.

We all knew about him and his work life, but it was informative learning all about his other life. The life that did not involve Radiology. Terry was involved with a whole grocery list of out of work accomplishments, we should all be so accomplished in life, J.J. Brown, summarized it by writing, " Keep your priorities straight no one ever said on his deathbed; Gee if only I'd spent more time at the office".

Some of Terry's other accomplishments were, at his church, Terry was a Sunday School superintendent, and a member of the church council. He was a member of the local Jaycees served on the King Frost Parade committee. Terry received the Jaycees Lifetime Achievement Award. Terry also was a member of the Lions club and served a term as president.

Terry is survived by a life partner, one son, two daughters and a number of grandchildren and great grandchildren.

It was my honor to have known Terry and I am sure his life touched many.

A stent is a little metal scaffold, that resembles the spring in your fountain pen, it is placed in the narrow areas of an artery. While most think of the arteries to the heart when speaking of stents, but actually they can be placed in other arteries of the body as well.

Stents were developed in the middle part of the twentieth century following the work of Dr. A. Grunzig, in the early days it was called the Grunzig Procedure. The purpose was to reopen blocked arteries without resorting to bypass surgery. Initially arteries were treated with angioplasty alone, but technical advances led to the development of the stent. There are limitations associated with stent placement and it is known as stent restenosis.

Stent restenosis occurs when the stent again becomes blocked. This may occur usually 6 to nine monts after the original placement. The question is why does this occur?  Once the stent is placed in the artery, new healthy tissue develops inside the stent. In the beginning this is beneficial, it is the endothelium from the artery wall and it makes a smooth flow for the blood through the stent. Over time scar tissue develops and causes the artery to narrow again.

How can this be prevented?  Accurate placement is very crucial, some institutions utilize untra arterial ultrasound to pinpoint accurate placement. A newer development is the use of drug eluting stents. These are the same stents coated with a drug, an example is paclotaxil, to reduce the incidence of restenosis. Further treatment includes taking blood thinners for one year after placement and aspirin therapy for the rest of your life.

After stent placement the patient can also help by developing a heart healthy lifestyle which includes limiting animal fat intake and smoking cessation, all the things in life we all like to do without. Taking the medications and frequent follow up visits with the cardiologist are also highly recommended.

Until this technology came along, cardiac catheterization was the gold standard for diagnosing arterial plaques and stenosis. We all know catheterization is an invasive procedure that is not without it's share of risks. Patients undergoing this testing were required to be a patient in the hospital, or spend the day at the hospital. In the case with CT imaging, the exam lasts a few minutes, generally all you need is an IV which is removed after the scan, and to borrow a advertising phrase," you're in, you're out, you're on your way".

Due to the quickness of the filming sequence, the patient receives approximately 50% less radiation , than other diagnostic procedures.. In a typical exam a patient receives about 8 to 12 mSv radiation compared to 12-25 mSv for a nuclear medicine stress test.

Cardiac CT Angiography is highly accurate and is recommended in patients with a positive stress test but unlikely to have significant disease. In the emergency room it saves diagnostic time and allows for quicker determination. It also is highly useful in patients with negative stress tests, but have a high risk for cardiac disease. If a patient has a high Coronary Calcium Score, CT Angiography can be used to determine if there is arterial narrowing and how severe it is.

Cardiac CT is covered by Medicare and many private health care plans.

Here is a story that highlights generational differences.Last night I stopped at a local convenience store for my staple, a diet caffeine-free cola, I never thought I would be drinking a diet anything but so much for that.

As I placed the bottle on the counter, a 20-something guy walked in and placed one of those small shot bottles of Red Bull on the counter next to my soda. The clerk thought his soda was for me, but I told her I couldn't do that anymore. I think I have related the story of my early morning ordeal with atrial fib in one of my prior writings, so I won't bore you with that one again.

When the guy returned to the counter I began kidding him about his choice. He stated he had to go work the night shift so he needed the boost; he said he wasn't too concerned about heart attack risk just yet, even as he asked for a pack of cigarettes. I said I had been there and done that, and maybe would he  like to see the scar? I don't think I did get my message across, but I don't think I listened to all the warnings at that age, either. All we had were commercials expounding how cool and manly we looked with a cigarette. Good luck to the next generation. Do you think they will get it?

Speaking of atrial fibrillation, there is a new drug treatment for it on the market. Dronedarone was approved by the FDA on July 2. I'll have more on that as information becomes available.