Wide Range of VASCULAR DISEASES

APRIL 2012
SurgeryNews
SPOTLIGHT ON
VASCULAR
AND ENDOVASCULAR SURGERY
Comprehensive, Complete Care for
Wide Range of VASCULAR DISEASES
THOMAS R. BERNIK, MD
Chief, Vascular and Endovascular Surgery, Department of Surgery
The Division of Vascular and Endovascular
Surgery has immense expertise in the
treatment of all arterial and venous pathology.
What sets the Division apart from competitors
is its sophisticated diagnostic capabilities,
its broad range of modalities and the intensive
follow-up of all patients. The Division prides
itself on comprehensive vascular care, with
an emphasis on personalized communication
to referring physicians.
Atherosclerosis has roots in the Latin word for gruel. Like sticky
porridge, plaque builds up in arteries causing stenosis of the
lumen (shown upper right). This process leads to three main
conditions: peripheral vascular disease (PVD), carotid artery
disease and aortic aneurysms. Vascular surgeons routinely treat
all of these entities. Rounding out the Division’s expertise is
its full offering of venous treatments (for more specifics on
how the Division diagnoses and treats these conditions, see
inside spread).
A full vascular service is virtually impossible without the
benefit of a comprehensive vascular lab. The Division has four
ICAVL-accredited vascular labs, including a brand-new site
across the street from the Petrie Division (see back page for
more on the vascular labs).
Most important in a successful surgical division is the level
of the surgeons’ expertise. Few others can match the depth
of experience Beth Israel’s surgeons offer. In total, the
Division has performed thousands of standard, traditional open
and endovascular interventions. It has been offering sophisticated and complex endovascular minimally invasive procedures
for more than a decade. The Division of Vascular and Endovascular Surgery has the broadest perspective to guide the optimal
treatment choice and the commitment to follow patients
throughout their treatment and during close postoperative,
lifelong care.
All physicians, including internists, primary care specialists,
endocrinologists, podiatrists and cardiologists, are encouraged
to refer patients with symptoms of vascular disease to
the Division. Asymptomatic patients who have cardiac disease,
a history of stroke, a family history of aneurysms, or who have
risk factors for PVD, should also be evaluated and screened.
To refer a patient for various vascular evaluations, please see
page 4 for a list of our vascular surgeons and their respective
phone numbers.
www.BISurgery.org
Beth Israel’s Vascular and Endovascular Expertise in
FOUR MAIN DISEASE CATEGORIES
THOMAS R. BERNIK, MD
Chief, Vascular and Endovascular Surgery
ROBERT J. GROSSI, MD
Attending, Vascular and Endovascular Surgery
JENNIFER SVAHN, MD
Attending, Vascular and Endovascular Surgery
PAUL M. YANG, MD
Attending, Vascular and Endovascular Surgery
The Division of Vascular and Endovascular
Surgery offers it all, from traditional,
open surgeries to advanced minimally
invasive approaches. Vascular conditions fall
Less invasive than endarterectomy, atherectomy enables future
interventions at the treated site, if necessary.
into four main disease categories: Peripheral
vascular disease, aneurysms (including
abdominal aortic, thoracic aortic and peripheral aneurysms), carotid artery disease, and venous
conditions; the latter which includes the treatment of deep vein thrombosis. Here, a closer look
at how each pathologic entity presents, the criteria for referral to the Division, as well as the
diagnostic and treatment modalities available within each category.
Peripheral Vascular Disease
Peripheral vascular disease (PVD) presents with a broad range
of possible symptoms from mild calf pain during walking, to
ischemic rest pain, to frank gangrene. A hallmark of PVD is
claudication within a fixed distance, for instance, when a
patient reports consistently that he cannot walk more than a
half block before experiencing leg cramps or heaviness.
Properly diagnosed, PVD is also an important marker for
atherosclerosis elsewhere in the body.
A thorough workup in the vascular lab helps to
assess the amount of circulatory compromise. If the
peripheral circulation is not seriously compromised, a conservative approach is warranted. Such an approach includes an
exercise program, smoking cessation, nutritional support, and
antihypertensive and anticholesterol medications, with the goal
of stabilizing or improving walking distance gradually over time.
If the patient has more significant disease, the
Division can best advise a course of action. Based upon
arterial duplex, PVR or diagnostic/therapeutic angiography with
intention to treat, a minimally invasive, open or a combined
hybrid procedure can be used to achieve relief of symptoms
and salvage limbs.
2
With all modalities available, a vascular surgeon can
best treat all aspects of PVD. Open modalities include
endarterectomy to remove occluding plaque from the inside
of the diseased vessel or a bypass to circumvent long segments
of severe disease. Minimally invasive approaches may
include angioplasty, stent placement and/or atherectomy
(the latter, illustrated above), typically with only an overnight
stay in the hospital.
Aortic Aneurysms
The Division of Vascular and Endovascular Surgery treats both
abdominal aortic aneurysms and thoracic aortic aneurysms.
Although abdominal aneurysms are more common than
thoracic they are just as deadly if overlooked. Because most
aortic aneurysms are asymptomatic, they commonly present as
incidental findings on CT or duplex scans performed for other
reasons. Patients with a significant smoking history and hypertension or family history of aneurysms should be referred for
initial and insurance-covered aortic duplex screeing. Patients
with connective tissue disorder, such as Marfan syndrome, are
also especially at risk for thoracic aortic aneurysms.
J Gregory ‘11
LC
RC
LSC
Aneurysm
RSC
Stent
(inside aorta)
Aorta
A complex surgical procedure recently done at Beth Israel
included various grafts and a stent in the aorta.
An expanding aneurysm may cause symptoms of back or
flank/groin pain. These are symptoms of impending rupture,
which, without prompt treatment, can be fatal. Unfortunately,
rupture is often the first symptom, which carries a very high
mortality rate.
The endovascular aortic aneurysm repair usually
involves the placement of an endovascular stent
through the femoral arteries into the aneurysmal portion of
the aorta. This technique has been reported to have a lower
mortality and morbidity rate compared to open surgery.
However, certain procedures to treat aortic aneurysms can
be more complex than others. Recently, for example, several
thoracic aortic aneurysms involving the aortic arch
were repaired at Beth Israel in a team effort that
involved the Division’s endovascular surgeon and a
cardiac surgeon and combined open-heart surgery, stenting
and bypass (see illustration above).
Carotid Artery Disease
Carotid artery stenosis is most commonly caused by
atherosclerosis. In the majority of patients, carotid artery
disease is diagnosed before a patient presents with symptoms. Physical exam findings usually document a bruit, which
may be indicative of underlying carotid artery disease. Upon
detection of a bruit, further noninvasive studies are warranted. These can include ultrasound of the carotid arteries
(carotid duplex or Doppler study), magnetic resonance
angiography, or computerized tomographic angiography.
Minimally invasive stenting is an option for blockages in the
carotid artery.
Screening for carotid artery disease is best done in an
accredited vascular lab.
Risk factors for carotid artery disease include hypertension,
diabetes, heart disease, hyperlipidemia, heavy smoking and/or
alcohol use, renal disease, history of transient ischemic attack
(TIAs or mini strokes), and family history of stroke.
Asymptomatic carotid artery disease is followed closely
with regular non-invasive duplex scanning every three to six
months. Guidelines state that patients can safely be followed
without intervention if they remain asymptomatic with a
stenosis less than 80 percent. In addition to regular office visits,
lifestyle modifications are instituted. These changes may
include dietary modification, strict lipid and hypertension
control, as well as the possible addition of antiplatelet agents
to further lower the risk of stroke.
When surgical intervention is indicated, vascular
surgeons can determine the best course of action.
Traditional carotid endarterectomy (CEA) is an effective and
safe open surgical procedure that removes the build-up of
plaque in the carotid artery and prevents strokes. Recent studies
further indicate that carotid endarterectomy is safe and carries
a low morbidity and mortality. Therefore, CEA should be the
primary treatment for patients of low surgical risk. For high-risk
patients where CEA is contraindicated, the Division also
offers expertise in minimally invasive options such as carotid
angioplasty and stenting (see illustration above). Outcomes
of carotid artery stenting are largely dependent on the level
of physician experience and volume. Beth Israel vascular
surgeons have been doing these interventions for more than
3
Beth Israel’s vascular and
endovascular surgeons
THOMAS R. BERNIK, MD, Division
Chief, was fellowship trained in
endovascular surgery/interventional
radiology (Strong Memorial) and vascular surgery (North Shore University).
He did his residency at St. Vincent’s
Hospital, New York Medical College.
He is board certified in surgery and
vascular surgery. 212.844.5555.
J Gregory ‘11
Mechanical thrombectomy and thrombolysis using angiojet morselates and suctions the deep vein thrombosis.
nine years and have completed hundreds of cases with a very
low complication rate.
Venous Conditions
Deep vein thrombosis (DVT) is a blood clot that forms in a
deep vein, typically in the lower leg or thigh, but can involve the
entire vena cava. DVT usually presents with a painful swollen
leg. If the DVT embolizes, there is a risk of life-threatening pulmonary embolism. While small DVTs can be managed conservatively with anticoagulation and compression stockings, large
DVTs are best treated with aggressive debulking, since a large
percentage of patients will develop post-phlebitic syndrome
and chronic disabling edema/wounds.
The Division’s vascular surgeons have been involved in
the development and implementation of invasive management
of deep venous thrombosis for many years. Mechanical
thrombectomy and thrombolysis using angiojet allows
the surgeon to deliver tissue plasminogen activator (tPA) directly
into clot, while morselating the clot with high-catheter turbulent
flow. The clot is, in turn, suctioned back into the device (see
illustration above). Patients with a suspected DVT should be
referred witin the first week for possible thrombectomy.
The Division of Vascular and Endovascular Surgery also
continues to offer its expert treatment of cosmetic vein disorders and varicose veins using the latest minimally invasive
endovenous laser techniques, including ablation procedures.
The Division encompassess one of the busiest vein practices in
New York City.
ROBERT J. GROSSI, MD, Vice Chairman
of Surgery and Attending Surgeon,
specializes in vascular surgery and
was fellowship trained in vascular
surgery at Temple University Hospital.
Dr. Grossi did his general surgery residency at St. Vincent’s Hospital. He is
board certified in surgery and vascular
surgery. 212.844.5559.
GARY A. GWERTZMAN, MD, FACS,
Director of Vascular and Endovascular
Surgery at Beth Israel Brooklyn, trained
in general surgery at Montefiore
Medical Center and received vascular
training at UMDNJ-New Jersey
Medical School. He is board certified
in surgery and vascular surgery.
718.677.0109.
STEPHEN P. HAVESON, MD,
Attending Surgeon, specializes in
vascular surgery and wound care.
Dr. Haveson was fellowship trained
in peripheral vascular surgery at
New York University. He did his surgical
residency at Bronx Municipal Hospital.
He is board certified in surgery.
212.844.1330.
JENNIFER SVAHN, MD, FACS,
Attending Surgeon, is an NYU-trained,
board-certified vascular surgeon who
specializes in treating all aspects of
venous disease. She performs 550
endovenous laser ablation procedures
yearly. Her practice is sought out by
patients throughout New York City
and the Northeast. 212.420.5648.
PAUL M. YANG, MD, Attending
Surgeon, specializes in vascular surgery.
He was fellowship trained in vascular
surgery at Long Island Jewish Medical
Center. He did his residency at Albert
Einstein-Montefiore Medical Center.
He is board certified in surgery and
vascular surgery. 212.844.8008 and
212.420.2295.
4
The Department of
Surgery at Beth Israel
Medical Center
Beth Israel Medical Center is
more than 100 years old with
a long history of devotion
to quality, service, academic
excellence and first-rate
clinical achievement, all of
which the Department of
Surgery proudly shares with
the institution.
Our mission—to provide quality
surgical care to all patients in
collaboration with referring
physicians—informs our current
role as a major provider of
tertiary surgical care for the
New York metropolitan area.
Key Administration
Martin S. Karpeh, Jr., MD
Chairman
Department of Surgery
212.420.4041
Jessica Kovac, Administrator
Department of Surgery
212.420.4457
Expertise with
Complex Cases in:
FYI...
Hemodialysis Access at Beth Israel
Beth Israel’s vascular and endovascular surgeons routinely provide hemodialysis access.
The gold standard of renal access is an arteriovenous fistula, whereby an artery is
connected to the vein in the forearm. This connection causes more blood to flow into
the vein. The vein grows larger, allowing easier repeated renal access for hemodialysis
treatment. Properly matured fistulas tend to last many years—longer than any other
kind of vascular access.
If a patient is not an appropriate candidate for an arteriovenous fistula, the
Division’s surgeons can create vascular access by connecting an artery to a vein using
a graft implanted under the skin. The graft functions as an artificial vein that can be
used repeatedly for needle insertions and blood access during hemodialysis.
The Division of Vascular and Endovascular Surgery monitors these patients closely
at three-month intervals with the goal to intervene via minor catheter intervention
before the access fails. Interventions, if necessary, may include angioplasty, stenting
and/or maturation procedures.
Beth Israel Experts on
TM
> Colorectal Surgery
Beth Israel’s surgeons discuss many topics on camera on the hospital’s
YouTube channel, www.YouTube.com/BethIsraelNYC.
Each of the nearly 80 clips efficiently offers information
and practical advice on a wide variety of health and medical topics.
> Endocrine Surgery
Visit the site and let your patients know about this invaluable
> General Surgery
and informative resource.
> Bariatric Surgery
> Breast Cancer Surgery
> Cardiac Surgery
> Head and Neck Surgery
> Hernia Surgery
> Pediatric Surgery
> Plastic and Reconstructive
Surgery
> Surgical Critical Care
and Acute-Care Surgery
> Surgical Oncology
> Thoracic Surgery
> Vascular and Endovascular
Surgery
> Wound Care
For more information,
call 212.420.4044 or
visit our website at
www.BISurgery.org
Extended Hours at PACC
Beth Israel Medical Center works
hard to improve patient access to
services. In the last year, an ongoing
initiative to expand evening and
weekend hours at Philips Ambulatory
Care Center (10 Union Square East,
Manhattan) has tripled extendedhour visits and doubled the number
of physicians offering such hours.
Remembering a Dear Friend and Colleague
William I. Wolff, MD, died on August 20, 2011,
at the age of 94. Working with Hiromi Shinya, MD,
at Beth Israel in the 1960s, Dr. Wolff introduced
colonoscopy and colonoscopic polypectomy to
the United States. An important innovation of the
duo’s work was the development of a device
that could remove a polyp immediately during a
colonoscopy. Their original study established the
procedure as the gold standard of clinical care.
Dr. Wolff was Director of Beth Israel’s
Department of Surgery from 1970 to 1977.
A beloved surgeon, colleague and teacher,
Dr. Wolff attended many surgical grand rounds
and teaching conferences up until the last years
of his life.
5
NONPROFIT
ORGANIZATION
US POSTAGE
PAID
PERMIT NO. 8048
NEW YORK, NY
Beth Israel Medical Center
First Avenue at 16th Street
New York, NY 10003
APRIL 2012
SurgeryNews
SPOTLIGHT ON
VASCULAR
In this
issue...
AND ENDOVASCULAR SURGERY
PVD, Aortic Aneurysms,
Carotid Artery Disease,
Venous Conditions
VASCULAR LABS at Beth Israel
The Division of Vascular and Endovascular
Surgery at Beth Israel Medical Center offers
state-of-the-art diagnostic capabilities in
its fully accredited, non-invasive vascular
laboratories. Through these vascular laboratories, the Division is able to diagnose a
full range of vascular disorders. Diagnostic
testing determines the severity of the problems and guides the treatment plan.
The vascular labs at Beth Israel offer
the latest diagnostic technology such as:
> Peripheral arterial duplex exams
> Pulse-volume recordings
> Treadmill exercise testing for claudication
> Carotid artery visceral and renal artery duplex
> Venous duplex—lower, upper, extremity,
abdomen
> Abdominal and peripheral aneurysm
screening
6
Webcast:
> Transcranial Dopler
> Dialysis access scans
The vascular laboratory services are
located in three sites throughout Beth Israel:
> Petrie Division (317 East 17th Street,
Fierman Hall, 12th floor, Manhattan). This
brand-new vascular laboratory site is now
open five days a week.
> Philips Ambulatory Care Center
(PACC, 10 Union Square East, Suite 2N,
Manhattan).
> Beth Israel Brooklyn (3201 Kings
Highway, Room 123, Brooklyn).
To refer a patient or for more information
about the Vascular Labs, please call
212.844.5555.
www.BISurgery.org
VATS For
Lung Cancer
Visit
www.or-live.com/vats
for a unique opportunity
to view Video-Assisted
Thoracic Surgery (VATS),
performed by
Angelo T. Reyes, MD, Chief,
Division of Thoracic Surgery.
The webcast introduces
the patient and the
rest of the care team,
as well as offers links
to make a referral
or an appointment.