Col league. SMMC Vascular Center Opens A PUBLICATION FOR SOUTHERN MAINE PHYSICIANS

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1 A PUBLICATION FOR SOUTHERN MAINE PHYSICIANS Col league SMMC Vascular Center Opens By Frank Lavoie, MD, Executive Vice President and Chief Operating Officer During the last year, Southern Maine Medical Center (SMMC) expanded its partnership with Spectrum Radiology by adding a new service for our patients Vascular Interventional Radiology. By offering this service right here at SMMC, our patients can now access non-surgical approaches to their vascular disease close to home. This means that our patients no longer have to travel out of town and can often avoid an open surgical procedure. Patients can receive care from the same physicians who treat peripheral vascular disease in Portland. And our Interventional Radiologists share space and equipment with SMMC Cardiologists -- our Interventional Lab serving a dual purpose with the Cardiac Catheterization Lab. This allows us to provide care as efficiently as possible. In this issue you will be introduced to the interventional team and learn more about the newest procedures that can be done at SMMC.

2 SMMC Vascular Center Physicians Dr. Paul Kim Director, SMMC Vascular Center, Director, MMC Radiology Residency Research, Assistant Director Vascular & Interventional Radiology. Fellowshiptrained in vascular and interventional radiology, Johns Hopkins Hospital. Principal investigator on several clinical trials involving venous thromboembolic disease and peripheral arterial disease. Reviewer for the Journal of Vascular and Interventional Radiology. Principal areas of interest: peripheral arterial disease, abdominal aortic aneurysm repair, wound healing. Dr. Derek Mittleider Director, Vascular and Interventional Physicians/Vascular and Interventional Radiology. Fellowshiptrained in vascular and interventional radiology, Baptist Cardiac and Vascular Institute. Principal areas of interest: peripheral arterial disease, abdominal aortic aneurysm and wound healing. Dr. Joseph Gerding Director, SMMC Vein Center. Fellowshiptrained in vascular and interventional radiology, Northwestern University School of Medicine. Principal areas of interest: venous insufficiency/varicose veins. SMMC Vascular Center At Southern Maine Medical Center (SMMC), we have established a facility whereby patients in southern Maine can receive state-of-the-art vascular care right in their own backyard. The SMMC Vascular Center is comprised of three components: 1. SMMC Vascular Lab An ACR-accredited facility within the ultrasound division of the Department of Radiology. This facility incorporates the latest in ultrasound technology to perform the following exams: Leg arterial exam: - Segmental pressures and Ankle-Brachial Index - Pulse Volume Recordings - Duplex Analysis Abdominal Aortic Duplex Ultrasound Screening for Aneurysm - Mesenteric and Renal arterial duplex to evaluate for stenosis - Carotid Duplex How to contact us Vascular & Interventional Physicians Spectrum Medical Group 84 Marginal Way, Suite 985, Portland, ME Phone: (207) Fax: (207) Derek Mittleider, MD Paul Kim, MD Joseph Gerding, MD Tom Dykes, MD Daniel Kloda, DO Christopher Baker, MD - DVT evaluation - Venous Insufficiency 2. State-of-the-art Noninvasive Imaging (MRA/ CTA) Allows for accurate anatomic characterization of blood vessels non-invasively 3. Angiography Suite for Minimally Invasive Therapy Since the initial opening in 2011, we have treated over 80 patients successfully with peripheral arterial disease. Due to our volume and outcomes we have been recognized for our achievements and have been selected for a number of firsts in the region. These include trialing new state-of-theart technology for opening up clogged arteries that has not been made available anywhere else in Maine or New England. If you would like your patients seen at the SMMC Vascular Center for consultation of any of the following diseases: 1) Peripheral Arterial Disease 2) Abdominal Aortic Aneurysm 3) Carotid Disease 4) Varicose Veins Please call (207) to schedule an appointment or fax a referral to: (207)

3 Society of Interventional Radiology , All rights reserved. Varicose Veins By Joseph Gerding, MD, SMMC Vein Center Director Nearly one-quarter of all adults have chronic venous disease (CVD), making it one of the most common conditions affecting our health. Although the exact cause of CVD remains unclear, several contributing factors have been identified, including a history of deep venous thrombosis, age, family history, obesity, hormonal changes, immobilization, and prolonged standing. Chronic venous disease is a progressive disease that is not curable. Early signs of CVD include spider veins and varicose veins. These can be asymptomatic, but many people experience aching, burning, itching, and throbbing of the veins, and heaviness, tiredness, and cramping of the legs. Other complications of varicose veins include bleeding and superficial thrombophlebitis. As CVD progresses, leg swelling may occur, which can lead to cellulitis. Skin changes can develop at this stage, including hyperpigmentation, eczema, atrophie blanche, and lipodermatosclerosis. Once venous disease has reached an advanced stage, ulcers can develop, which can have a significant impact on quality of life. There are two general treatment options for CVD: conservative measures, such as compression stockings, and corrective measures, such as surgery and endovascular treatments. Compression stockings can be effective in relieving the symptoms of venous disease, stopping its progression, and decreasing the likelihood of deep venous thrombosis. In patients with venous ulcers, they can improve swelling and promote healing. The drawback to compression therapy is that stockings must be worn daily. Traditional ligation and stripping of incompetent veins was once considered the most effective treatment available for varicose veins. Endovenous thermal ablation is an alternative to surgical stripping that entails sealing the incompetent saphenous vein closed with heat delivered through a catheter inserted through a tiny puncture in the skin using either laser or radio frequency energy. This procedure is performed in an office with local anesthesia. Patients are able to walk immediately after the procedure, and most individuals are able to return to work the next day. Vascular & Interventional Physicians of Spectrum Medical Group now offers all of these endovascular treatments at the SMMC Vascular Center. During the initial consultation, a thorough physical exam and comprehensive venous ultrasound will be performed to confirm the diagnosis of CVD and determine its severity, the cause, and the best treatment strategy. Early diagnosis of CVD allows effective treatment in most cases, and can help avoid more serious problems like venous ulcers later on. If you would like any additional information, or if you wish to schedule a consultation, please contact Vascular & Interventional Physicians at (207)

4 A Patient s Story Raymond Dussault, Biddeford Raymond Dussault, 80, of Biddeford, suffered from severe foot pain called rest pain. This was secondary to severe ischemia resulting from 100% blockages in several arteries from his pelvis (iliac artery) through his thigh (femoral artery). He was diagnosed with Peripheral Arterial Disease (PAD). Through a small needle hole in the artery, Dr. Kim was able to cross these blockages and open them with balloon angioplasty and stenting, restoring normal blood flow to the foot. Mr. Dussault enjoyed immediate relief. I like working with Dr. Kim. He s a very good doctor and I definitely love getting my care locally. Before this procedure, my leg kept me up all night, he notes. I had cramps, and restless leg syndrome kept me jumping. I couldn t sleep more than two hours and I was tired all the time. Now I sleep all night. My circulation is better. Dr. (Charles) Parent in Kennebunk recommended Dr. Kim because I had very poor circulation in my leg. Dr. Parent said, If you don t do something with your leg you might lose it. I like working with Dr. Kim. He s a very good doctor. And I definitely love getting my care locally.

5 Society of Interventional Radiology , All rights reserved. Spotlight on Abdominal Aortic Aneurysms AAA The Silent Killer By Paul Kim, MD, SMMC Vascular Center Director and Vascular & Interventional Radiology Assistant Director Abdominal aortic aneurysms (AAA) are the seventeenth leading cause of death accounting for more than 15,000 deaths per year. AAA is often undiagnosed and known as the silent killer until rupture occurs. AAA rupture results in mortality of 80-90%. Patients at highest risk are males over the age of 60 who have a prior smoking history or risk factors for atherosclerosis. Screening/Diagnosis: Abdominal aortic aneurysm duplex screening exams are available at the SMMC Vascular Lab and recommended for anyone over the age of 50 with a history of smoking, hypertension or a family history of aneurysms. SMMC Vascular Lab AAA Surveillance Program: Imaging is performed every 6 12 months to detect the growth rate and overall size of the aneurysm. Treatment: AAA > 4.5 cm in males and 5.5 cm in females or fast growth rate. Open surgical repair Minimally invasive endovascular repair (EVAR) EVAR: Insertion of a fabric-covered stent to seal off the AAA through a small incision in the groin. Benefits of EVAR over traditional surgical repair include lower morbidity, overnight hospital stay and faster return to full activity. Several large randomized studies have demonstrated equal efficacy of EVAR to surgery for prevention of aneurysm rupture. Patient Story: Morris Hale, a 73 year-old man from Biddeford, had a growing AAA and was treated by Drs. Kim and Mittleider with EVAR. He went home the next day. I am thankful Dr. Denning-Bolle had me see Dr. Kim. I had my aneurysm treated and went home the next day and felt like mowing my lawn! We have extensive experience in the treatment of AAA using minimally invasive techniques and are excited to bring this offering to the SMMC patient population. Please refer any patient with a AAA (aorta > 3 cm) to the SMMC Vascular Center. Patients are followed closely through the AAA surveillance program until the size or growth rate threshold is met, at which point consultation is arranged for discussion of treatment options.

6 Peripheral Arterial Disease (PAD) By Paul Kim, MD, SMMC Vascular Center Director and Vascular & Interventional Radiology Assistant Director Peripheral arterial disease (PAD) is one of the most prevalent diseases in the adult population over the age of 50. Symptoms may include claudication (pain with walking), rest pain or non-healing ulcers. Too often PAD goes undiagnosed due to patients often thinking their symptoms are just part of getting older. Undiagnosed, patients with claudication may then exercise less resulting in sequelae including: weight gain, poor diabetes control and all the concomitant risks of a sedentary lifestyle. Patients with rest pain and foot ulcers are classified as having Critical Limb Ischemia due to their high incidence of limb loss within a few years of diagnosis if left untreated. In 2001, the PARTNERS study demonstrated both the high prevalence (30%) but often overlooked (49% of patients with PAD had physicians who were not aware their patients had PAD) of peripheral arterial disease. PAD has been shown to be a stronger predictor for adverse cardiovascular events and demise than either prior stroke or heart attack. For every 0.1 decrease in the ankle-brachial index (ABI), there is a 10% increase in the risk of heart attack or stroke. Screening/Diagnosis In 2011, the American Heart Association produced guidelines on whom to screen for PAD: 1) Anyone over the age of 65. 2) Anyone with exertional leg symptoms (heaviness, tightness, aching). 3) Anyone with non-healing wounds. 4) Anyone over the age of 50 with a personal history of diabetes or smoking. In these patients, physiologic testing is recommended for diagnosis: pulse volume recordings, segmental pressures and duplex analysis. These tests can be performed at the SMMC Vascular Lab Department of Radiology to allow for the accurate diagnosis and localization of blocked arteries. Optimizing Medical Therapy Because PAD is a systemic marker for atherosclerotic disease, patients should be enrolled in secondary prevention with the following goals: Smoking cessation LDL < 100 mg/dl Triglycerides <150 mg/dl Diabetes control (HgbA1c<7%) Blood pressure < 130/85 mm Hg Specific forms of medical therapy have convincing evidence of utility in patients with PAD: Statins have been shown to reduce mortality and the five year risk of new or worsening claudication. ACE inhibitors in patients with PAD had a 22% decrease in stroke and heart attacks. Antiplatelet therapy with aspirin reduced the risk of cardiovascular events in patients with PAD. Clopidogrel had a 24% risk reduction of cardiovascular events over aspirin. Our Approach All patients are seen in consultation prior to treatment. A detailed history and physical are obtained by one of our physicians who have specific training and expertise in vascular disease. A thorough discussion is had between the patient and the physician to ensure that all questions have been answered. We examine all patients medical histories to ensure that their medical treatment has been optimized and smoking cessation efforts are utilized. In appropriate patients, minimally invasive treatment options are utilized including: angioplasty/ stenting, atherectomy (removal of plaque), thrombectomy (removal of clot). In certain patients, medical therapy such as cilostazol is offered in patients with mild claudication or who may not tolerate endovascular therapy. Surgical consultation is arranged for all patients who need evaluation. Most patients are treated as outpatients and are able to resume full activity in 2 days. We follow all patients longitudinally in our outpatient clinic Monday through Friday and one of our physicians is always available 24 hours a day, 7 days a week, 365 days a year to both patients and other referring physicians. Legs for Life Campaign This September we will be holding our annual Legs for Life Campaign cosponsored by the Society of Interventional Radiology, American Diabetes Association, Society for Vascular Nursing and the American Heart Association. This program will raise awareness and offer screening to southern Maine for: Peripheral Arterial Disease Abdominal Aortic Aneurysm Venous Insufficiency/Varicose Veins