The Vein Clinic & Interventional Institute

Narrowing of the carotid artery, one of the main arteries supplying blood flow to the brain, by plaque can lead to increased risk of TIAs and stroke and may result in small pieces of plaque breaking off and flowing into and blocking a major blood vessel in the brain. Angioplasty and stenting may be used in combination with thrombectomy to allow passage of the thrombectomy device into the brain in cases where the narrowing of the artery is too severe. The interventional radiologist can treat narrowing of the carotid artery by using a balloon to widen the artery followed by placement of a stent (a tiny mesh tube) to keep the artery open and prevent narrowing from redeveloping. The carotid arteries are the main vessels supplying blood to the brain. Most individuals have one carotid artery on each side of the neck. The carotid arteries can become narrowed (stenosed) by atherosclerosis and fatty or calcified plaque, resulting in diminished blood flow to the brain. The brain has some ability to compensate for some degree of decreased blood flow, but if flow becomes decreased to a point that the blood vessels and brain tissue can no longer compensate for the decreased blood flow caused by the blockage, death of brain tissue can occur leading to a stroke. Stroke is the 2nd leading cause of death and 4th leading cause of disability worldwide. While in developed countries it is the leading cause of disability, 2nd leading cause of dementia, and 3rd leading cause of death 50% of survivors suffer permanent disability Carotid stenosis account for 25-30% of strokes Repair of blockage is typically recommended in patients with 70% blockage or greater and experiencing symptoms such as weakness, dizziness, or visual changes. While somewhat more controversial, most physicians will recommend repair in asymptomatic individuals with greater than 80% blockage While traditional surgical repair of carotid blockage remains the preferred method of repair of carotid blockage in many individuals, carotid artery angioplasty and stenting has assumed a greater role in treatment of the disease, particularly in individuals who have increased risk with surgery or associated anesthesia or may have some unusual anatomy scarring from prior surgery that would increase the risks associated with the traditional surgical approach. In carotid angioplasty, a small needle is placed into the artery at the top of the leg and a tiny angioplasty balloon attached to a plastic catheter is advanced under X-ray guidance to the level of the blockage in the carotid artery. The balloon is inflated for a short period of time. After the dilation, a second small catheter with a self-expanding stent is advanced to the blockage and deployed. Risks associated with carotid stenting are considered similar to those associated with traditional surgery in the normal population and often decreased in those patients considered higher risk for surgery. To further prevent the risk of a small piece of plaque from breaking loose and reaching the brain, a special filter is placed above the blockage in the artery to trap any debris. Post procedure hospital stay is limited, typically one evening. Patients may resume normal daily activities nearly immediately and are typically maintained on mild blood-thinning medications like aspirin or Plavix for a number of months post procedure to further decrease risk of any clot formation following treatment.

Peripheral arterial disease (PAD) is a common disorder related to narrowing and blockage of blood vessels that lead to the extremities and is many times more common in the lower extremities. Blockages result in inadequate blood flow to the legs to keep up with demand for nutrients and oxygen during activity and, if severe enough, even at rest in bed at night. Decreased blood flow to the legs can lead to fatigue or weakness in the leg. One of the most common symptoms of advancing disease is cramping pain in the thigh or calf that develops while walking (claudication) and may resolve in a few minutes if standing still, only to recur when walking is resumed. Pain that occurs in the feet at night and resolves with hanging the feet over the side of the bed (rest pain) may be a sign of a particularly severe blockage that prevents adequate blood flow to the limb, even while resting. Such a severe degree of blockage can lead to skin breakdown (ulceration) and even death of the tissue in the area (gangrene). Some men may present to their doctor with impotence as the first sign of their arterial disease. Peripheral vascular disease is typically caused by the buildup of fatty and calcified deposits (plaque) in the wall of the blood vessels supplying the leg and may be associated with blockages to the arteries that supply the brain and heart as well as the legs. PAD is strongly associated with smoking, diabetes and high blood pressure. Family history may play a role as well. PAD is more common in older individuals and is estimated to affect approximately 10% of Americans. Some patients who present with symptoms such as claudication may be able to make simple lifestyle modifications, such as smoking cessation, establishment of a regular and reasonable walking/exercise program, as well as treatment of underlying medical issues such as high blood pressure or diabetes. Diagnosis of PAD may be established by your physician by medical history and physical exam, often combined with assessment of blood flow with ultrasound examination or CT scan. For patients with more advanced blockage of PAD that does not respond to medical treatment, several options may be available. Surgical bypass is a well-established procedure to surgically position and implant a small fabric tube across the area of blockage to redirect blood flow around the blockage and restore adequate flow to the leg. However, not all patients will be candidates for surgical repair due to health issues that may increase risks and complications. Recovery times required following surgery, as well as additional risk factors may make a minimally invasive approach to resolving the blockage much more attractive. Angioplasty with stenting involves placement of a small plastic catheter into the blocked artery through a small needle hole in the skin of the arm or leg. The balloon catheter is advanced to the blockage under X-ray guidance and inflated for a period of time and then deflated. The small metal mesh stent can then be advanced through or with the same catheter and deployed to maintain the vessel and prevent reformation of the blockage. Percutaneous atherectomy may be used in combination with angioplasty and stenting, particularly in small blood vessels further down the leg or when plaque buildup is excessive and may not allow initial passage or inflation of a balloon catheter. During atherectomy a small catheter with a fine cutting edge is advanced to the blockage and activated, trimming and removing obstructing plaque while simultaneously applying suction to the catheter to remove plaque.

A stroke occurs when blood flow to a portion of the brain is interrupted or there is bleeding into the brain and the tissue in that area of the brain begins to die, resulting in sudden symptoms and neurologic impairment. Often referred to as a “brain attack” a stroke is the neurologic equivalent of a heart attack. Every year, more than 800,000 people experience a stroke, with almost 90% of strokes being “ischemic” and related to interruption in blood flow either due to blockage of the carotid artery in the neck or due to a clot escaping the heart or other vessels and lodging in an artery in the brain. A stroke is a medical emergency and the fifth leading cause of death in the United States. Prompt treatment is critical in an attempt to save brain tissue and minimize long-term damage. Early symptoms may include: Weakness of the facial muscles or limbs Numbness or tingling Trouble speaking Severe headache Some patients may initially show signs of a “mini-stroke” or transient cerebral ischemic attack (TIA), with symptoms that may resolve in a few days or within a day. TIA may be a strong predictor of impending stroke and should not be ignored; rather it should immediately be brought to the attention of your medical provider. When stroke occurs, minutes matter. Restoration of adequate flow to the brain tissue provides the best opportunity to prevent death and limit long-term disability. Endovascular Thrombectomy Thrombotic clot removed with Solitaire thrombectomy device Through a tiny incision in the skin of the leg, an interventional radiologist can precisely navigate special catheters under X-ray guidance to the level of the blocked artery. A stent-like device can be utilized to remove the clot and to restore blood flow to the part of the brain that is not receiving blood due to blockage by the clot. The faster this blood flow is restored, the better the chances for good recovery from the stroke.

Uterine fibroid, a type of tumor in the uterus that is very typically benign, arises from the muscle tissue layer that surrounds the uterus. Fibroids may affect of 70-80% of all women in the United States before they are 50 years old and can present with a variety of symptoms that include: Uterine pressure or pain Heavy menstrual bleeding or cramps Pain during or following intercourse Leg pain Constipation Urge to urinate frequently Some women will have one large dominant fibroid, while others may have multiple smaller fibroids that together lead to symptoms. If symptoms are suggestive of fibroid problems, ultrasound and MRI will often be ordered to confirm the diagnosis and define tumors that require treatment. Not all patients with fibroids will be candidates for UFE, but for those who are appropriate candidates, the procedure may provide a desirable alternative to traditional surgical hysterectomy. Fibroids require significant blood flow from the blood vessels that supply the uterus to grow, and by limiting blood flow with Uterine Artery Embolization (UAE), the fibroids may greatly reduce in size with marked improvement in symptoms in over 90% of women. During UAE. the interventional radiologist may guide a small plastic catheter into the specific blood vessels that supply the uterus and fibroid, utilizing X-ray guidance. Once in position, tiny particles are injected under X-ray control to block the vessels feeding the fibroid and starve it of flow and associated nutrients, resulting in shrinkage of the benign tumor. When embolization is felt to be adequate, the catheter is removed and a small bandage placed. Most patients are kept overnight to allow for treatment of immediate cramping and discomfort that may occur after the procedure. Some discomfort may continue for a few days up to a week, including possible low-grade fever as the benign fibroid tumors die and shrink. Risk of infection is very small but is observed, and you may also be treated with antibiotics following the procedure as a precaution.

Venous Ablation Venous ablation is a minimally-invasive treatment concept that is used to Laser Ablation Treatmentclose and treat problematic superficial veins that are often the largest and most troublesome in a patient with symptoms of venous insufficiency. Entry to the vein is typically performed under direct ultrasound guidance. After a small amount of anesthetic is instilled, a small needle is directed into the problematic vein, allowing placement of the treatment device. A variety of options are available for ablative closure of the problematic veins. The Vein Clinic offers the largest variety of ablative options available in Upper Michigan and is the only clinic to offer both thermal and non-thermal treatment options. Our physicians will work with you to select the best ablative option for your venous issues. Endovenous Ablation (ELVS) Radio Frequency Ablation (RFA) Varithena Endovenous laser ablation treatment (EVLT) with 1320nm CoolTouch or 1470nm VenaCure laser technology involves the placement of a very small laser fiber into the problematic vein under ultrasound guidance. Anesthetic numbing medication is then placed along the vein, and the fiber is gently pulled back through the vein with typically no sense of discomfort during the ablation procedure. The laser heat energy causes the vein to collapse and close. Typically the patient can return to normal daily activities in 24-48 hours. Phlebectomy Procedure Details Often performed in combination with endovenous ablation, or occasionally with sclerotherapy, microphlebectomy is used for the removal of typical, twisting, or bulging branch veins which lie just below the skin’s surface. Tiny microincisions are made along the course of the vein to be removed. A special instrument is then used to hook the segment of vein, which is then gently removed through the tiny incision. These microincisions are so small that there is usually no need for a suture to close the tiny hole. Small sterile adhesive strips are placed over the microincisions. Sclerotherapy Procedure Details Pre Procedure Post Procedure Sclerotherapy-animateSclerotherapy is typically performed for the treatment of smaller veins such as spider veins or can also be used in combination with additional treatment options such as ablation or microphlebectomy when larger veins exist in combination with spider-type varicose veins. Sclerotherapy is a safe procedure requiring no anesthesia, often done right in our office. A very small and typically painless needle is directed into the spider vein or its feeding vein. The doctor or the nurse uses the needle to inject a small amount of sclerosing solution into the vein. This solution irritates the vein wall and results in a permanent closure of that vein. Once the vein has been closed, it will typically shrink and dissolve in the body and disappear in approximately one to three months. Image below is our nurse performing sclerotherapy procedure for spider veins. She is using a vein light to enhance her view of the spider veins while injecting the scleroscene solution.

Blood thinners, also called anticoagulants, remain the mainstay of treatment for deep vein thrombosis. Anticoagulants do not actually dissolve or break up clots, but rather they prevent clots from forming or getting larger once they occur. Heparin and warfarin (Coumadin) are two of the most common blood thinning medications but may require frequent testing or may not be appropriate for some clinical situations. Some newer medications such as apixaban (Eliquis) or rivaroxaban (Xarelto) can be given orally or less frequently and do not require frequent blood testing. Some patients may require anticoagulant therapy for only a few months, while others may require life-long treatment if risk of new or worsening clot formation is considered too high to tolerate. Venous Thrombolysis Procedure Details Venous Thrombolysis utilizes the well-proven and time-tested clot-busting agents, already proven useful in the treatment of clots, stroke, heart attack, and arterial thrombosis. The most common drug currently utilized is tissue plasminogen activator (t-PA). With this technique, a small catheter is placed into the vein behind the knee under ultrasound guidance, through a very tiny nick in the skin. The catheter is then actually directed into the clot under X-ray guidance and the clot-busting drug is slowly infused through the catheter. Depending on the age of the clot, the infusion and clot dissolution may be completed in a couple of hours or may take as long as a day or two. If there is an underlying blockage in the vein that may have caused the clot to form or would act as a stimulus for new clot to form, this may be able to be treated with angioplasty right at the time of the thrombolysis procedure. Venous Stenting Procedure Details Stenting may be used in combination with thrombolysis to fix and improve narrowing within a vein after a clot is dissolved. It may also be used by itself if a narrowing is found that has contributed to the development of deep vein thrombosis or perhaps chronic leg swelling and pain. The most common example of this situation is May-Thurner Syndrome, where the main vein that drains the left leg (common iliac vein) is compressed and narrowed by an adjacent artery, limiting venous blood flow. May-Thurner is known to be present in many patients with deep vein insufficiency and has been shown to increase the likelihood of developing deep vein thrombosis. Inferior Vena Cava Filter Placement Procedure Details In some individuals, thrombolysis or stenting may not be possible. Likewise, some standard blood-thinning medications may have previously failed or be contraindicated due to risk of bleeding complications. In these patients, a vena cava filter may present the best option for treatment. The vena cava is the large vein in the abdomen that collects the venous blood from the legs and returns it to the heart. The filter is a small, umbrella-shaped device that is easily and painlessly deployed under X-ray guidance through a small needle hole in the vein in the neck or top of the leg. Almost all modern filters can now be easily removed once a blood clot has been treated and/or the risk of clot development has passed.

Graduated compression stockings have a long and well-proven role in the treatment and prevention of both venous insufficiency and deep vein thrombosis. The unique construction of these specialized stockings allows the greatest degree of compression to be delivered at the level of the foot withlesser degrees of pressure applied as the stocking moves further up the leg. This progressive, or graduated, compression: Helps improve blood flow and keeps blood and fluid from pooling in the lower portion of the legs May help prevent blood clots from forming Helps relieve and heal skin changes and symptoms associated with venous insufficiency and varicose veins, such as itching and venous ulceration Specially-fitted compression stockings are typically tighter at the foot with a gradually looser fit higher on the leg. There are varying types and compression gradients, and our specialists at the Vein Clinic will work with you to provide the best solution for your problem. The stockings should be snug but comfortable and ultimately work best when worn daily and while awake and on your feet. Stockings are not typically worn at night or while bathing. How to put on the compresion hoseTips for stocking use: Put stockings on early in the day when swelling is at a minimum. Sitting in a chair with a back allows you something to lean against. Put your toes in the stocking and gently roll and slide it back over the heel. Then use your fingers or palms to slowly roll and slide the stocking further up the leg. Do not grab or pull at the top of the stocking as this may cause it to tear or rip. If you have trouble, rubber gloves may help grip the fabric. Assist devices such as a slip sock or stocking butler are also available. Our nurses or your certified fitting expert can provide further help. If you experience numbness, or the toes turn dark or painful while wearing compression hosiery, call your doctor immediately.

A spinal cord stimulator is a small device implanted under the skin’s surface, connected to a small set of wires and electrodes that extend to the spinal canal. The device uses a low-level electrical stimulation of the spinal nerves to block pain impulses from passing through the spinal cord to the brain, thereby impeding the pain sensation. By blocking these pain signals, the overall sense of pain may be markedly reduced and quality of life may be significantly improved. Prior to implantation of the device, a test stimulation procedure is performed with one or two small wire leads placed into the spinal canal through a small needle and attached to a belt pack. If successful, with improvement in both pain level and functional abilities, consideration and discussion will then be given to movement to permanent implantation. After both the trial and implantation procedures, we will be in frequent contact and may make changes to the programming of the stimulator device to optimize the level of pain relief.

Epidural steroid injection has been known historically as the first-line, minimally invasive treatment for your pain of the neck or back. This technique is utilized in a large percentage of patients with unrelenting pain and has been successfully used since 1953. The physician uses an X-ray device called a fluoroscope to guide a needle down to the vertebrae that is causing the pain. The needle is carefully advanced under X-ray guidance into the epidural space, which is the area surrounding the spinal cord. After the physician injects a contrast solution to confirm the needle’s position, a steroid-anesthetic mix will then be injected into the epidural space. This mixture will help soothe the painful area and will aid in reducing inflammation.

As facet changes may be subtle and confounding, CT and MR imaging may not always be reliable. Careful patient history and physical exam may be crucial in the diagnosis of facet-related pain. The facet is served by a small nerve fiber called the medial branch, which is key to facet pain. In most cases, an initial test injection of anesthetic, called a block procedure, is used to evaluate the relevance of the facet to the patient’s pain. Often, two block procedures are required by insurance companies and have been shown to statistically improve the chance for successful rhizotomy if both block procedures show a substantial amount of relief. If there is good reduction of pain with block injection, a more permanent treatment may be used to deaden the nerve (neurolysis or rhizotomy) in an attempt to affect long-term relief.

A minimally-invasive technique that can be performed in a matter of minutes, typically without need for any sedation, utilizing CT or X-ray guidance. Selective nerve blocks are similar to epidural steroid injections in many ways. Instead of targeting a large area of the spinal column and its nerve tissue, injecting a diluted solution, selective nerve blocks use a concentrated mixture of both anti-inflammatory steroid and/or anesthetic agent. The concentrated solution only makes slight contact directly with one or two specific nerve fibers or bundles, and the patient may obtain significant pain relief in a matter of a few minutes. A block without steroid is often used for diagnostic purposes at the request of an ordering neurosurgeon to identify or confirm a specific problematic nerve that is causing pain or weakness, before offering surgical or non-surgical intervention to treat the problem.

When sacroiliac pain is suspected, injection of the joint space may serve as a dual purpose. A small amount of local anesthetic mixed with steroid solution, typically performed under CT guidance, allows early onset of pain relief along with the more extended anti-inflammatory pain relief of the steroid. The rapid onset anesthetic also helps to confirm or deny the injected joint as the source of the patient’s pain and may help direct additional treatment, such as physical therapy.

Sympathetic ganglia are clusters of specialized nerve cells that are present in the neck and chest, as well as the abdomen and pelvis and play a role in the transmission and perception of pain impulses as they travel to the spinal cord and brain. It is well-known, but not completely understood, that these clusters of nerve cells play a role in the develop of chronic pain syndromes, such as Chronic Regional Pain Syndrome (CRPS) and coccydynia, often occurring after what may be mild trauma, and possibly related to abnormal function and firing of the nerve fibers. Sympathetic ganglion block may also be useful in the treatment of pain related to cancer or inflammatory disease, such as pancreatitis. During a block, a small needle is guided to the group of fibers, utilizing X-ray, CT scan, or ultrasound guidance. A mixture of anesthetic and, often, some steroid is injected along the nerves, and the needle removed. It is suspected that the mixture resets and calms the firing of the nerve fibers and decreases the level of perceived pain. The steroid may also reduce some associated inflammation. The most commonly utilized sympathetic blocks are the stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and impar ganglion block. Sympathetic blocks may be used in combination with other treatment options, such as medications and in pain situations that occur after trauma or injury. Often, they are combined with intense physical therapy to improve strength and flexibility and potentially retrain the nerve fibers.

Vertebroplasty is one of our procedures that is used to help pain related to collapse of a vertebral body in the spine, possibly due to osteoporosis, trauma, or cancer. Under X-ray guidance, bone cement is placed into the weakened vertebral body through a small needle to improve strength of the porous and weakened bone, preventing further collapse, diminishing pain, and allowing improved function. The procedure has a high rate of success in appropriately selected patients, and multiple fractured vertebral bodies may be treated in a single treatment session.