- ECHO COLOR DOPPLER - TVP PROTOCOL
- ECHO COLOR DOPPLER ACTIVITIES
- DIAGNOSIS AND MANAGEMENT OF CAROTIDEAL PATHOLOGY
- EVAR'S FOLLOW-UP
- PREVENTION: A.A.A... ABDOMINAL AORTIC ANEURYSM WANTED
Three ambulatories of vascular diagnostic were active from Monday to Friday 8 am-4 pm where arterial and venous Eco-color Doppler was performed. There were both outpatients and inpatient’s with scheduled daily appointments. There were also patients sent by the Emergency Department. We also offered guidelines for the Emergency Department and General Physicians of the territory to inform them of the diagnosis, management, treatment and follow-up of venous thromboembolic disease .
Close collaboration with vascular surgeons, daily contact with “vascular disease” and cooperation in the operating room had allowed angiologists to develop expertise in carotid disease and that convinced Dr. Ronsivalle, in 1999, to examine all carotid endarterectomy patients by doing an Eco-color Doppler study, a choice that gained significant time and showed, once more, that vascular surgeon and angiologist’s collaboration could lead to a significant advantage for the patient.
“A careful echo-color doppler study, performed with equipment by experienced operators, can replace angiography in the study of patients to be subject to carotid surgery ” -G.I.U.V. PALERMO (ITALY) 1999-
It is well known that endovascular treatment of abdominal aorta aneurysms is a good and “advantageous” procedure for the patient because it reduces intervention time, blood loss and hospitalization.
It is equally clear that patients will have to undergo a careful and life long follow-up and that the gold standard method is angio CT scan.
Over the years we have been able to develop a different type of follow up, thanks to noninvasive vascular diagnostic expertise, along with the new knowledge of the endovascular procedure including the materials used, in collaboration with Vascular Surgeons .The follow up is still troublesome, but certainly less “harmful” for the patient.
Since 2000 our follow up protocol included an aorto iliac echocolordoppler at discharge, at three, six and twelve months with subsequent half-yearly checks; an X-ray of the abdomen at discharge and at one year, and an angio CT scan at 6 months. Further echo-color Doppler study with echocontrast or angio CT scan or angiography were performed in situations in which the ultrasound images were not of univocal interpretation. From 1999 to 2013 we performed roughly 9000 echocolordoppler examinations in EVAR follow up and thanks to our experienceunivoca interpretazione.
“We believe that the ECD carried out by experienced and dedicated operators and with the latest technology is a reliable method in long-term EVAR patients’s follow up. In this sense the ECD, even with echocontrast medium and in association with classic radiologic methods, can be a viable solution both in health care and economic organization system “. -FLORENCE 2010-
From 2007 to 2013 Angiology ambulatories opened their doors to a huge prevention project, planned by Dr. Ronsivalle and named A.A.A… Abdominal Aortic Aneurysm wanted whose objective was the prevention of death from ruptured aneurysm of the abdominal aorta through the identification of asymptomatic aneurysms. Patient groups, booked by the organizing secretary of the project, came 5 days a week from 2 pm to 4 pm and underwent an abdominal vessel Eco-color Doppler. In spite of the difficulty due to the management of so many people (16.685 persons were examined), it turned out to be an exciting and engaging experience not only professional but also human. The abrupt suspension of the project after the closure of Vascular Surgery Unit has been devastating, not only for the patients but also for the operators who had believed in the project.
- AOCP AND D.H. AMBULATORY
The peripheral arterial occlusive disease (PAD) due to atherosclerotic disease is common in patients with cardiovascular risk factors. It affects 12% of the adult population and 20% of those are over 70 years old. It is associated with high cardiovascular morbidity and mortality and cerebrovascular disease, with a risk of death six times higher than that of the population without PAD. Arteriopathics patients have always been a problem for the vascular surgeon even after a successful intervention. Due to the characteristics of the pathology these patients could never be considered cured, and frequent check ups are needed in order to prevent any serious complications. The angiology ambulatory has always managed the arteriopathic patient in different clinical stages of the disease, not only to prepare them for surgical or endovascular revascularization and follow them up, but also to manage asymptomatic or non patients with the following aims:
- improve prognosis through careful cardiovascular risk factors;
- improve prognosis in case of disease’ s progression with local complications (minor or major amputations);
- improve life quality taking into account their needs and expectations.
It had always been evident that it was not possible to get it just by running a simple lower limbs Eco-color Doppler , but it was necessary to create a dedicated ambulatory, where arteriopathic patients could find qualified answers to their problems.
Ambulatory for Peripheral Arteriopathy and Diabetic Foot Arteriopathy Study started up in 2006 and over the years has become the ‘”Excellence” of our Angiology and a reference for many patients suffering from a debilitating disease such as the PAD. Patients who ended up in our ambulatory, through the integration of Angiology and Vascular Surgery found a 360° answer to their problem; they were in fact subjected to:
- clinical and instrumental diagnosis and staging;
- case discussion with Vascular Surgeons and therapeutic definition (surgical, endovascular, medical treatment, rehabilitation);
- Day Hospital advanced medication and vasoactive intravenous drip;
- ambulatory follow-up.
In order to simplify the access to our ambulatory and to create a network between different specialists who managed arteriopathic patients (Internists, Diabetologists, Nephrologists, Cardiologists) we had activated a SHARED PROTOCOL FOR STUDY AND TREATMENT OF PERIPHERAL ARTERIOPATY AND DIABETIC FOOT AND NEPHROPATIC ARTERIOPATHY , which allowed to ensure the arteriopathic patient all the treatment he needs.
Once considered a rare disease in mostly post-traumatic genesis, with the increased number of percutaneous interventions via artery cannulation, the incidence rate of iatrogenic pseudoaneurysm has become more frequently seen, usually in common femoral artery. It occurs in 0.2% of diagnostic and 8% of interventional procedures but could increase up to 16%. It is caused by many different aspects such as the characteristics of the artery wall (as atherosclerotic plaques and loss of elasticity), lengthy procedures and investigations, the use of large bore catheters, anticoagulant or antifibrinolytic therapy, insufficient compression of the vessel at the end of the procedure. The use of fibrin glue in EL type II prevention after EVAR was a fundamental technique of our Vascular Surgery and because it was so successful it was obvious for us to extend the use of fibrin glue in echo-guided iatrogenic pseudo aneurysms treatment. It is a frequent pathology in our hospital due to our having an Interventional Cardiology Unit (reference for the territory of our Health Units and others) which performs coronary or peripheral angiography and angioplasty in the Cathlab. A color Doppler ultrasound analysis evaluated the presence of a pseudoaneurysm and excluded other complications, such as arteriovenous fistula. After discussing the clinical case, the patient underwent the procedure under the guidance of both the Vascular Surgeon and Angiologist working together using direct ultrasound scan the tip of the needle was placed within the pseudoaneurysm and the two components of fibrin glue were simultaneously injected into the sac. After the procedure was completed, the patient returned to the ward of origin. Echo-color-doppler ultrasound evaluations were performed at 24 hours and at 30 days.