Angiogram Information Brochure

At the Center for Vascular Medicine, we believe in the words of Mahatma Gandhi: “A customer is the most important visitor on our premises. They are not dependent on us. We are dependent on them. They are not an interruption in our work. They are the purpose of it. They are not an outsider to our business. They are a part of it. We are not doing them a favor by serving them. They are doing us a favor by giving us an opportunity to do so.” Thank you for choosing the Center for Vascular Medicine. Our staff is committed to the long-term treatment, monitoring and prevention of your Peripheral Arterial Disease (PAD). PAD is a chronic but treatable ailment. We do our utmost to provide immediate interventional care that may provide some relief to symptoms. However, please remember that longterm follow-up is an essential component to your overall vascular health. As a result, I must emphasize that today we are entering into a partnership. For optimal results, we must both keep our promises. The promises we seek from you are lifestyle changes like weight loss, smoking cessation and daily exercise. The promise we offer you is that we will treat you with intellectual integrity and dignity. We pride ourselves on offering the most advanced and patient-focused diagnostic and therapeutic modalities for the treatment of PAD. During the course of your treatments there will be times when you may debate the need to call your doctor or nurse after hours. Follow this simple rule “When in doubt, always call.” Amongst other things, we promise to be always available to our patients.

What is PAD (Peripheral Arterial Disease)? Peripheral arterial disease (PAD) is a disease in which a substance called plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of fat, cholesterol, calcium, fibrous tissue, and other substances in the blood. PAD usually affects the arteries in the legs, but it also can affect the arteries that carry blood from your heart to your head, arms, kidneys, and stomach. When plaque builds up and clogs the arteries, the condition is called atherosclerosis, also known as “hardening of the arteries.” Over time, plaque can harden and narrow the arteries, reducing the amount of blood that can flow through them and limiting the flow of oxygen-rich blood to your organs and other parts of your body. The following factors increase the risk of atherosclerosis, particularly in people with more than one risk factor: •• Gender

Atherosclerosis

•• Race •• Age •• Diabetes •• Smoking •• High blood pressure •• Family history •• Lack of exercise •• Obesity or being overweight •• High levels of blood lipids (cholesterol and/or triglycerides) •• Low levels of high-density lipoproteins (“good” cholesterol) The most common symptoms of PAD are cramping, pain or tiredness in the leg or hip muscles while walking or climbing stairs. Typically, this pain goes away with rest and returns when you walk again.

Additional Facts: •• Many people mistake the symptoms of PAD for something else. •• PAD often goes undiagnosed by healthcare professionals. •• People with peripheral arterial disease have four to five times more risk of heart attack or stroke.

Chronic Critical Limb Ischemia

•• Left untreated, PAD can lead to gangrene (tissue death) and amputation.

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Blocked blood flow to your legs can cause pain and numbness. It also can raise your risk of getting an infection in the affected limbs. Your body may have a hard time fighting the infection. Smoking is the main risk factor for PAD if you smoke or have a history of smoking, your risk of PAD increases up to four times. Although PAD is serious, it’s treatable. PAD treatment may slow or stop disease progress and reduce the risk of complications. Treatments include lifestyle changes such as stopping smoking, getting more exercise and eating a healthier diet. It may also include medicines and surgery or procedures.

Diagnosing PAD Peripheral arterial disease (PAD) is diagnosed based on your medical and family histories, a physical exam, and test results. PAD often is diagnosed after symptoms are reported. A correct diagnosis is important because people who have PAD are at higher risk for coronary heart disease (CHD), heart attack, stroke, and transient ischemic attack (“ministroke”). If you have PAD, your doctor also may want to check for signs of these diseases and conditions. Primary care doctors, such as internists and family doctors, may treat people who have mild PAD. For more advanced PAD, a vascular specialist may be involved. This is a doctor who specializes in treating blood vessel diseases and conditions. A cardiologist also may be involved in treating people who have PAD; cardiologists treat heart problems, such as CHD and heart attack, which often affect people who have PAD.

Physical Exam During the physical exam, your doctor will look for signs of PAD. He or she may check the blood flow in your legs or feet to see whether you have weak or absent pulses. Your doctor also may check the pulses in your leg arteries for an abnormal “whooshing” sound called a bruit (broo-E). He or she can hear this sound with a stethoscope. A bruit may be a warning sign of a narrowed or blocked artery. Your doctor may compare blood pressure between your limbs to see whether the pressure is lower in the affected limb. He or she also may check for poor wound healing or any changes in your hair, skin, or nails that may be signs of PAD.

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Your physical examination also may include the following: •• Ankle-brachial index (ABI): The ABI compares blood pressure in your ankle to blood pressure in your arm. This test shows how well blood is flowing in your limbs. ABI can show whether PAD is affecting your limbs, but it won’t show which blood vessels are narrowed or blocked. •• Peripheral Arterial Duplex Studies: Non-invasive method of visualizing the artery with sound waves and measuring blood flow in an artery to indicate the presence of a blockage. •• CT Angiography or MR Angiography: imaging done by CAT scan or MRI to show specific arteries in detail. •• Aortogram with Run-offs: Angiograms (X-ray tests done by injecting special dye to highlight blood vessels) done to look specifically at the arteries in the legs.

Ankle-brachial Index

•• Treadmill Test: A treadmill test can show the severity of symptoms and the level of exercise that brings them on. You’ll walk on a treadmill for this test. This shows whether you have any problems during normal walking. You may have an ABI test before and after the treadmill test. This will help compare blood flow in your arms and legs before and after exercise. •• Blood Tests: Your doctor may recommend blood tests to check for PAD risk factors. For example, blood tests can help diagnose conditions such as diabetes and high blood cholesterol.

Sources: National Heart Lung and Blood Institute; American Heart Association

What is an Angiogram? An angiogram (also called an arteriogram) is an image taken of blood vessels in an outpatient procedure done in the X-ray room. Typically, angiograms can show the arteries near the heart, lungs, brain, head and neck, legs or arms, and the aorta. Because arteries are not normally visible in X-rays your doctor needs to make use of a special dye and camera; this is called fluoroscopy. The dye is delivered through a catheter that is guided from a blood vessel in the upper thigh or arm. Once the catheter is in the right position, the dye is injected and it goes into the arteries. An X-ray is then taken at the precise time the dye flows through the arteries. The dye is later excreted with the urine.

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Why do we Perform an Angiogram? The test helps you and your doctor decide which treatment may improve your symptoms caused by blockages in the arteries. Treatments may include: •• Changes in lifestyle, including increases in exercise, diet monitoring, diabetes and blood pressure control, quitting smoking and possibly medication •• Angioplasty with stent placement–a procedure using a special catheter with a balloon that can inflate to open blockages in the artery and placing one or more stents (an artificial ‘tube’ inserted to help restore proper blood flow) into the artery •• Laser atherectomy-a procedure using a catheter that emits pulses of ultraviolet light energy that are capable of gently vaporizing plaque and other matter into tiny, microscopic particles that are smaller than a red blood cell. •• Bypass grafting–surgery to re-route blood supply around blocked arteries in the legs

General Risks and Benefits of Endovascular Procedures: •• At the Center for Vascular Medicine we pride ourselves in providing minimally invasive endovascular procedures to our patients. Our physicians and clinical staff are highly trained and efficient in delivering expert care in this field. There are general risks and benefits to all of these procedures.

Benefits of Endovascular Procedures: •• Minimally invasive: Minimally invasive outpatient procedures require no hospital stay with a short recovery period. Most procedures allow patients to return to normal activity within a few days •• Lower level of anesthesia: Patients remain comfortable with minimal anesthesia delivery under constant monitoring. •• High success rate: There is a high success rate of endovascular procedures with relief of symptoms

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Risks of Endovascular Procedures: •• Catheter-related risks: Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection. The chance of any of these events occurring is rare. •• Allergy to x-ray contrast material: Patient may have an allergic reaction to the x-ray contrast material used during endovascular procedures. These episodes range from mild itching to severe reactions that can affect breathing or blood pressure. Patients having procedures are carefully monitored by a physician and a nurse during the procedure, so that any allergic reactions can be detected immediately and reversed. •• X-ray exposure: Endovascular procedures are done under x-ray. Exposure levels usually are well below those where adverse effects on the patient or future children would be a concern. •• Potential adverse effects on the kidneys: Patients who have a known history of impaired function of the kidneys are at higher risk of further damage to the kidney function. Please inform the physician if you have a known history. Blood work will be drawn prior to the procedure to help identify patients at risk and levels will be monitored accordingly. IV fluids will also be given during and after the procedure to dilute the dye and filter the dye through the kidneys. In rare cases additional medication may need to be given or postponing the procedure may be considered.

Preparing for your Procedure? 1. You will need to have current blood work done and may be asked to have a chest X-ray and EKG prior to your procedure if indicated.

2. Shave the bikini area/groin area the day before the procedure.



3. Arrange for a responsible adult to drive you to the facility and home after your procedure.



4. Do not eat or drink after midnight the night before your scheduled procedure.

5. Take all of your medications with sips of water the morning of your procedure except for diabetic medications and other medications that you may be instructed not to take. 6. If you are prescribed any special medications that need to be taken for your procedure, please take all doses prescribed and as ordered.

7. Arrive at the office at your scheduled time.

8. Please give at least 48 hours’ notice for rescheduling when possible. Please contact us as soon as possible for last minute conflicts.

What Should I Expect with My Angiogram? To prepare you for the angiogram, you will be given medicine through an IV to keep you comfortable but awake. Local anesthetic is usually given in the groin area where a needle will be inserted. The catheter is threaded through this needle. You will feel pain when the needle breaks the skin, but the passage of the catheter through the blood vessel is painless. You will feel a warm sensation when the injected dye spreads through the arteries.

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During the procedure you will be asked to stay still and not move so that the images that are taken will be clear. Afterwards, the catheter is removed and the area where the catheter was removed is pressed firmly for about 30 minutes to stop the bleeding. The angiogram procedure usually takes about an hour and 2-3 hours for recovery. Expect your total time in the office to be 4-6 hours.

PATIENT INSTRUCTIONS: ANGIOGRAM PROCEDURE Preparing for Your Angiogram Procedure 1. Arrange for a responsible adult to drive you to your appointment and home after the procedure. 2. Do not eat or drink after midnight the night before your scheduled procedure. 3. Take all of your medications with sips of water the morning of your procedure except for diabetic medications. 4. You will need to have current blood work and may be asked to have a chest X-ray and EKG prior to your procedure. 5. If you are prescribed any special medications that need to be taken for your procedure, please take all doses prescribed and as ordered. 6. Arrive at the office at your scheduled time.

What will happen during your recovery? 1. The catheter will be removed from your groin area and direct pressure will be applied over the area for 30 minutes. 2. You will need to lay flat and keep your leg straight for two hours following the removal of the catheter. 3. Total recovery time is typically 2-3 hours.

Discharge after Your Angiogram

You must have a responsible adult available to drive you home

After your angiogram there are several points we would like you to keep in mind. Most patients will be able to resume a fairly normal level of activity within a day or two of the procedure. We do ask that you adhere to the activity restrictions described, as well as note some of the other care instructions. We value your health, well-being and comfort. If you do have any questions or issues related to your angiogram, please feel free to contact our office.

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Activity Restrictions Following your discharge, we ask that you please refrain from any heavy lifting (i.e. no more than 10 pounds), straining, pushing or impact exercises (i.e. running, jogging, cycling) for the first 3 days. You may walk, climb steps and possibly drive, so long as you do not have excessive bruising, swelling or pain at the puncture site. NOTE: You should not drive or operate any type of machinery the day of discharge.

Dressing Removal You will be discharged with a dressing over the puncture site. This may be removed the next morning. Please inspect the puncture site daily for the first few days and notify us for any significant changes; especially bleeding and swelling with increased pain. Bruising around the area may be present. If you do notice bleeding, swelling, or increase in bruising apply constant direct pressure over the area and seek medical attention immediately.

Showering & Bathing You may shower within 24 hours of your procedure. We ask that you refrain from soaking in a bathtub, hot-tub or pool until the puncture site is healed. Failure to do this may lead to infection.

Eating & Drinking You may resume your normal diet following your procedure. We encourage you to drink lots of water and noncaffeinated beverages for the first 2 days after your procedure.

Medication Outside of certain blood thinning agents, most medications can be continued immediately following your procedure. Medications such as Coumadin (Warfarin) and injectible Heparin/Lovenox are potent blood thinners that can cause delayed bleeding from the puncture site. We usually ask that these blood thinners be held for 1-2 days following the procedure, and we will specify when to begin use of these medications. If you take aspirin, Plavix or Aggrenox, you may continue use of these medications, so long as there are no signs of delayed bleeding or swelling at the puncture site. Please call our office immediately if you notice any of the following signs or symptoms: •• Increased swelling or bleeding at the puncture site. •• Increased bruising down the leg or by the abdomen. •• Painful, cold leg or foot with or without discoloration. •• Increasing low back, abdominal, or leg pain. •• Redness, swelling and/or drainage from the puncture site with fever. •• Swollen, painful calf with or without fever. If you are unable to reach our office and have noticed any of the above conditions, please report to the nearest emergency room for prompt medical attention.

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Appointment Date: Appointment Time:

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Patient Notes

Center for Vascular Medicine

Center for Vascular Medicine Clinic Locations Greenbelt, MD 7300 Hanover Drive Suite 104 Greenbelt, MD 20770

Prince Frederick, MD 205 Steeple Chase Drive Suite 302 Prince Frederick, MD 20678

Annapolis, MD 108 Forbes Street 2nd Floor Annapolis, MD 21401

Glen Burnie, MD 1600 Crain Highway South Suite 409 Glen Burnie, MD 21061

Silver Spring, MD 831 University Boulevard Suite 34 Silver Spring, MD 20903

888-206-1110

www.CVMUS.com Center for Vascular Medicine