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Diagnosis and Treatment
Diagnostic Testing at UVa
Noninvasive Tests
At UVa, we perform a number of noninvasive tests to determine the presence and/or extent of vascular disease.
- Ankle-Brachial Index - A blood pressure reading is taken with a blood pressure cuff at the ankles. This reading is then compared to blood pressure taken in the arm. The comparison of the two numbers determines if the patient has indications of peripheral vascular disease and if more tests are needed.
- Pulse Volume Recordings (PVR) - A blood pressure cuff is placed at thigh, calf, ankle and toe levels. Cuffs are inflated, and waveforms give the physician information about blood flow in the legs.
- Carotid Ultrasound - Using high-frequency sound waves to image vessels, this procedure is similar to obtaining ultrasound images of a fetus. It employs an ultrasound wand that is placed on the skin of the neck to produce an image. Blockages of the carotid arteries may increase the likelihood of stroke.
- Abdominal Ultrasound - Similar to carotid ultrasound, it employs an ultrasound wand that is placed on the skin of the abdomen to produce an image. Aortic aneurysms are detected in this manner.
- Vascular Ultrasound - This simple, noninvasive test is very important to evaluate the abdominal aorta and its branches. It is also frequently used to evaluate the arteries of the arms and legs. Ultrasound is also the first choice for evaluation of venous diseases.
- Computed Tomography Angiography - A CAT scan is a common radiologic test, which can be tuned to study the blood vessels. This test is very important for assessing aneurysms of the aorta and other vessels.
- Magnetic Resonance Angiography - Magnetic resonance imaging, commonly known as MRI, makes images of the body using a very strong magnet. The images can be focused to provide images of the arteries.
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Invasive Tests
Depending on the results of the noninvasive tests that have been performed, our physicians may order angiograms for further evaluation of the disease.
- Angiography - The most accurate test of the blood vessels is an angiogram. In this test, a small needle is put through the skin and into an artery at the top of the leg. A small plastic tube is then slid into the arterial system. X-ray contrast is then injected into the arterial system so that X-ray images of the vessels can be taken. During angiography, additional images can be obtained, using intravascular ultrasound (IVUS). A small ultrasound device is advanced into the arterial or venous system. The IVUS is useful for measuring blood vessels and for obtaining images of atherosclerotic plaque and other abnormalities.
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Treatment Options
The goal of treatment for vascular disease (disease of the blood, or circulatory, system) is to slow the disease's progression. Individual treatment options depend on a number of factors that will be explained by the physician. One size does not fit all in managing the disease. Oftentimes a combination of risk reduction, medicines, less invasive treatment options and surgery provides the patient with the best chance for a good outcome. Therefore, it is important to have a team of medical specialists who are knowledgeable in all aspects of vascular disease so that patients can be offered the full menu of treatment options to get the best care for each case.
- Risk Factor Modification/ Management - For patients with mild or early stages of vascular disease, lifestyle modification and medical management of risk factors can slow down the progression of disease to the point that the individual may never need surgery or endovascular intervention.
- Balloon Angioplasty - A special device called a balloon catheter is carefully moved through a blood vessel to the point of a blockage and inflated to stretch open the blocked area. Then the balloon is deflated and removed from the blood vessel. The opened area allows for more flow of blood through the blood vessel. This procedure can be used to treat blockages of the following arteries:
· Carotid (feeding blood to the brain)
· Subclavian (feeding blood to the arms and hands)
· Aorta, iliac, femoral, popliteal and calf arteries (feeding blood to the pelvis and legs)
· Renal (feeding blood to the kidneys)
· Mesenteric (feeding blood to the abdomen and intestines).
- Stents - Stents are metal devices that are placed inside a blood vessel to help keep a blocked area open. Stents are similar to a scaffold that helps to keep a tunnel from collapsing. Stents are currently being used to treat all the same blood vessels that can be treated with balloon angioplasty and are often used when balloon angioplasty alone is unable to completely open up the blocked blood vessel.
- Covered stents - Special stents covered with a cloth-like material can be used to treat blood vessels that are:
· Weakened and ballooning-out (aneurysms)
· At risk for popping open (rupturing like a balloon or tire)
· Injured and is leaking blood (bleeding)
Many of these covered stents can be placed into the blood vessels by making a very small incision in the groin area, which eliminates the need for a bigger operation.
- Subintimal recanalization - This is another procedure being used at UVa to improve blood flow in legs that have a lot of blocked vessels. In many instances, balloon angioplasty, stent use or bypass surgery alone is not possible. This procedure creates a new path in the wall of the blocked artery without the use of open surgery or bypass grafts. It is most often used in patients who have been told they have no option other than amputation or in whom surgery might not work. The new path that is created by subintimal recanalization allows the blood flow to go around the blocked areas and improve blood flow to the areas below the blockage.
- Mechanical thrombectomy device - This device uses high speed jets of water to help break up and remove fresh blood clots that are completely blocking the blood vessel. Removing the fresh blood clot restores blood flow. The device is similar to breaking up and removing fresh mud from a blocked pipe so that water can flow down the pipe.
- Thrombolysis - In this procedure, drugs are used to break-up fresh blood clots that are blocking a blood vessel or bypass graft. Using these drugs is similar to using liquid drain cleaner to unplug blocked water pipes. Thrombolysis and the mechanical thrombectomy devices are often used together to remove fresh blood clot from a blocked blood vessel.
Surgical Options
Surgeons in the Division of Thoracic and Cardiovascular Surgery at UVa provide a number of options for surgical treatment of vascular disease. These procedures do not cure vascular disease but treat symptoms and with proper medical management can slow down the progression of the disease.
- Vascular bypass - This procedure uses synthetic material or a portion of a person's own vein to route blood around a blockage in an artery. This is the most common surgical technique used in treating peripheral artery disease (Anita, link to webpage). The bypass material is sewn into the blood vessel above the blockage and then sewn below the blockage. This creates a new pathway for the blood to travel through. Bypass can be used to treat blockages in the legs, kidney arteries and aorta. This procedure uses a traditional surgical incision (not laparoscopy), and recovery time is longer than for any of the endovascular interventions.
- Endarterectomy - This is a procedure in which the blood vessel is opened and plaque is removed or scraped out of the artery to restore blood flow through the vessel. The artery then is closed with a patch that makes the vessel wider. This works best for narrow areas or complete blockages of an artery. This procedure is used to treat blockages in the carotid arteries, which feed blood to the brain, and is sometimes used for other blood vessels in the upper leg.
- Aneurysmectomy - This involves placing graft material in an aneurysm so that blood flows through the graft. The aneurysm collapses against the wall of the graft, and is no longer at risk for rupture. This is used for treatment of any type of aneurysm.
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