Download TCD: A Valuable Asset in Stroke Evaluation

ULTRASOUND
SOLUTIONS
January 2013
TCD: A Valuable
Asset in Stroke
Evaluation
Patients matter. Results count.
A Clinical Case for Performing
TCD in Vascular Labs 3
Case Study: Abdominal Aortic
Aneurysm
9
Welcome to our first issue of UltraSound Solutions!
Welcome to our first issue of UltraSound Solutions! This is our quarterly newsletter
designed to provide information on Navix news and events for our employees, clients
and partners.
I’d like to share some exciting developments this past year that resulted from a focus
on national expansion. For the past year, our staff has worked cooperatively with many
of our clients and partners to enable Navix to provide more services to more clients
throughout the United States.
Early in the year, we added a new training site in Philadelphia to allow us to meet the
growing demand for our popular Physician Preceptorship on the Interpretation of NonInvasive Vascular Ultrasound. I am excited to report that the Philadelphia Preceptorship
program has been very successful with all sessions completely booked through March
2013! I’d like to acknowledge the participation of nationally recognized and highly
respected vascular surgeons in the Philadelphia area, Drs. Keith Calligaro and Matthew
Dougherty.
We also invested in the expansion of our on-site educational programs and vascular
ultrasound lab services to Virginia, Florida and Ohio. Our expansion in these regions
included the addition of high quality cardiovascular lab programs as well as providing
physician education to hospitals and physician practices.
In response to our clients’ needs, Navix has developed a comprehensive vascular diagnostic program for vascular access centers
to enhance their ability to more quickly and effectively detect peripheral artery disease (PAD). Our services include pre-screening
patients for PAD, followed by vascular ultrasound imaging services to create a roadmap for interventional procedures as well as
assisting in follow-up patient care. This program has already delivered great results at our client’s site. Specifically, the clinical
information gained has provided guidance for angioplasty and thrombectomy of qualified plaques reducing or eliminating the
need for lower extremity amputation and has ultimately improved the quality of life for many patients.
We are also proud to announce that Navix has been chosen as a Site Management Organization (SMO) for an international clinical
trial evaluating the efficacy of a new anti-platelet therapy in patients with peripheral artery disease (PAD). It is a great credit to our
staff and physicians that so many of our sites were approved to participate in the trial and new sites continue to be added. This
is directly attributable to our advanced protocols and the consistent quality delivered to our patients. Our staff looks forward to
working with our physicians and patients to provide high quality information to this clinical trial.
As part of our expanded objectives this year, we made two executive changes to help strengthen our ability to expand nationally.
George McNellage has joined us to provide leadership in the areas of sales and marketing. With more than 25 years experience
in health care, most recently at Xanitos and Covidien, George provides extensive industry knowledge that we will leverage to
continue building value at our client sites. John Krouskos has joined us as CFO after 19 years with the Harvard Medical Faculty
Group, and has been instrumental in helping us drive quality and productivity at our client sites.
I would like to take this opportunity to recognize Robert Kane, our SVP Clinical Services and Business Development, for his vision
and leadership that have contributed to Navix’s success this year. Robert has led the strategy and delivery of the Preceptorship
program, and his ongoing commitment to excellence has resulted in the most comprehensive physician training in the
interpretation of non-invasive vascular ultrasound. Robert also has provided critical leadership resulting in the selection of Navix
as an SMO.
I am proud of our staff and their constant efforts to ensure we deliver on our promise to provide superior diagnostic services that
result in better patient outcomes. I look forward to sharing more successes in future newsletters.
President and CEO
Navix Diagnostix, Inc.
[email protected]
Did You Know?
Did you know that Navix is responsible for more accredited laboratories than any
other entity in the United States?
Navix works with physician practices, university hospitals and hospital systems throughout the country to ensure that their labs
meet the highest quality standards in patient care. With 81 labs accredited by the Intersocietal Accreditation Commission, 13
by the American Institute of Ultrasound in Medicine, and 1 by the American College of Radiology, Navix is responsible for more
accreditations than any other organization in vascular ultrasound, echocardiography and nuclear testing.
UltraSound Solutions
In This Issue
100 Myles Standish Boulevard
Taunton, MA 02780
Telephone: 508-977-2807
www.navixdiagnostix.com
3 Clinical Applications of Transcranial Doppler
4
Worth the Journey: J.P. Hughes, RVT, RVS, FSVU
5 From the Desk of: Bob Kane
6 Employee Spotlight: Lesa Giambra, RVT
Employee Milestones
7
Physician Preceptorship in Vascular Ultrasound
Navix’s Physician Preceptorship in the Interpretation of Non-Invasive
Vascular Ultrasound prepares cardiologists, vascular surgeons, radiologists
and other clinicians to prepare for the Registered Physician in Vascular
Interpretation (RPVI) exam. Over 100 physicians have completed the
course since 2009. Navix’s Preceptorship course provides the support
that physicians need to obtain their RPVI credential which will be a
requirement in 2014 for the qualifying vascular surgery exam...
8 Calendar of Events
9 Case Study: Abdominal Aortic Aneurysm
Physician Preceptorship - Page 7
Become a Contributing Author
Do you have a case study or idea to share? We’d love to hear about it!
Navix’s UltraSound Solutions is an information source for physicians, technologists, executives and administrators working in
advanced diagnostic imaging. We strive to connect industry experts with practitioners. To become one of our contributing
authors, or to share your views on any of the information provided in UltraSound Solutions, email or call Dorie Kilduff, Navix
Director of Marketing, at [email protected] or (508) 977-2807.
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Clinical Applications of Transcranial Doppler
Joseph Patrick Hughes, RVT, RVS, FSVU
Transcranial Doppler (TCD) studies use pulsed Doppler ultrasound to non-invasively evaluate
intracranial arterial hemodynamics. By insonating the Circle of Willis and vertebrobasilar
circulation through the natural cranial windows (orbit, temporal bone and foramen magnum), focal
intracranial lesions, flow disturbances and other findings within the arterial system can be identified
and quantified. These evaluations are performed to document changes in intracranial flow velocity
consistent with vasospasm, focal intracranial arterial stenosis (narrowing) and collateralization.
Additionally, transcranial Doppler can identify intracranial emboli and assess vasomotor reactivity.
Since Rune Aaslid, et al, introduced the clinical application of
transcranial Doppler (TCD) in 1982, many applications of the
technology have been introduced. The American Academy of
Neurology (AAN) published a review of the technology and
its then current clinical uses in 1990. In 2000, the American
Society of Neuroimaging and the Neurosonology Research
Group of the World Federation of Neurology reassessed
the clinical applications of TCD and again reiterated the
usefulness of TCD in several areas. While there are many
clinical indications for performing TCD in the clinical
setting, listed below are the four most common reasons for
performing this evaluation.
neurologic impairment by inducing cerebral ischemia. If
diagnosis and treatment are not initiated near the time of onset,
these neurologic deficits often become permanent, resulting in
severe disability or death. TCD evaluation has become a standard
procedure in the detection, quantification and follow-up of
vasospasm after SAH. Doppler velocities greater than 120 cm/sec
obtained with TCD have shown excellent correlation with spasm
confirmed by angiography.
A baseline TCD should be performed on the day of SAH diagnosis
or following surgical repair of the intracranial aneurysm to
establish baseline velocities, identify the natural acoustic
windows in the temporal bone, and distinguish the intracranial
vessels. Many institutions perform daily TCD monitoring during
the first 10 days after onset of headache. This gives the examiner
the opportunity to show serially the rise in mean velocities in the
affected segment. Additionally, early detection of significant
spasm allows several days before the onset of neurologic
symptoms to institute prophylactic or interventional (i.e.,
angioplasty) therapy. TCD is usually discontinued in grade I
SAH if no vasospasm is encountered within the first
week of monitoring. In higher grade SAH, TCD
monitoring is continued every day.
Extracranial Arterial Stenosis and Assessment
of Collateral Pathways
Hemodynamic changes in the extracranial circulation
occur at approximately 60% stenosis; however, the effects
on brain perfusion vary, particularly due to intracranial
collateralization via the anterior communicating, posterior
communicating and ophthalmic arteries. Reversed ipsilateral
OA flow, a difference of >50% in peak systolic velocities (PSV)
between the carotid siphons, >35% difference in middle
cerebral artery (MCA) PSV and >50% difference between
anterior cerebral artery (ACA) velocities are all indications
of collateral pathways or decreased perfusion. TCD can
affect patient therapy by non-invasively assessing collateral
pathways, allowing the physician to determine the proper
course of treatment.
Sickle Cell Anemia
Children with Sickle Cell Anemia are
at significant risk for stroke. The
abnormal shape of the red blood
cells causes them to become
“stuck” at the smaller bends and
bifurcations in the intracranial
vessels. When enough of
these abnormal cells build up,
patients will have a stroke. By
monitoring with TCD, the
clinician can determine the
appropriate timing for blood
transfusions, which in most
cases will reduce or eliminate the
likelihood of stroke.
Intracranial Arterial Stenosis
Studies have shown that in patients with MCA stenosis or
occlusion, annual stroke rates of 10% have been reported,
and patients with intracranial ICA stenosis have a reported
8% annual incidence of stroke. Studies have also shown
that patients with intracranial arterial stenosis treated with
anticoagulation therapy have a considerably lower rate of
stroke. TCD has very high sensitivity and specificity in the
detection of intracranial arterial stenosis when compared to
other imaging modalities.
Vasospasm
Joseph P. Hughes, RVT, RVS, FSVU
[email protected]
Vasospasm associated with subarachnoid hemorrhage (SAH)
is the primary cause of delayed ischemic neurologic deficits
and mortality and can produce transient or permanent
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For Joseph P. Hughes, RVT, RVS,
FSVU, it’s been a 20 year professional
journey to advocate for the effective
use of transcranial Doppler (TCD)
exams. Because TCD is one of the most
challenging vascular exams performed by
an ultrasound technologist, they are too
often underutilized by physicians.
Mr. Hughes, Director of Business
Development for Navix, has published
and presented on this topic for several
years, and works to educate physicians
and technologists on TCD. He knows
first-hand how challenging it can be to
complete a comprehensive and effective
TCD exam. In 1988, JP was first
introduced to TCD when the company
that he worked for got their first TCD
unit.
Hughes had his chance to learn how
to perform the exam in 1990. “There
are many
J.P. Hughes:
Worth the Journey
Interview & Insights
improve patient outcomes. A TCD
can provide tremendous value when
determining a course of treatment for
the patient.”
“There is so much valuable clinical
information that you gain from doing a
TCD study that I want everyone to learn
what I know.” Still, many challenges
exist, including:
• Time can be an issue when
challenging
patient
anatomy
is
encountered. If the exam is ordered
as part of a complete cerebrovascular
exam, the technologist may encroach on
the time for the next scheduled patient.
• The completeness of a TCD is
highly technologist dependent.
• Insurers
often
challenge
reimbursement
due
to
perceived limits on its clinical
applications.
Hughes recently conducted
two transcranial Doppler
workshops at the Advances
in Vascular Interpretation
and Diagnostic (AVID)
Symposium
in
New
York City and delivered
presentations to the Society
for
Vascular
Ultrasound
(SVU) and other organizations
on TCD. Hughes is passionate
about educating technologists and
physicians. He has spent more than 20
years focused on enhancing educational
programs for vascular ultrasound
technologists and interpreting physicians.
a p p l i c a t i o n s for TCD – to diagnose
disease, monitor states of disease or
shape the course of a patient’s continued
therapy. If a technologist and physician
understand all the numerous clinical
applications then together they can
Currently Hughes is a lead instructor
for Navix’s Physician Preceptorship
in the Interpretation of Vascular
Ultrasound program that provides
physicians
experience
interpreting
non-invasive vascular examinations –
a more comprehensive program than
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any other in the United States. As part
of the development team for this very
successful program, Hughes says he
“realized there was a gap in what was
being offered to support physicians in
completing their Registered Physician
Vascular
Interpretation
(RPVI)
credential, the physician credential given
by the American Registry for Diagnostic
Medical Sonography (ARDMS). Many
fellowship programs were doing so many
other things that it was nearly impossible
to document the reading experience.
Navix had excellent cases that are used to
train these physicians.”
Navix’s
Vascular
Ultrasound
Preceptorship gives participants the
opportunity to review studies that
have been previously interpreted so
the participant can compare his/her
interpretation to one that has already been
done. “It’s a great program for fellows,
residents and practicing physicians to
interpret up to 500 studies in 4 days.”
Starting as a Registered Vascular
Technologist in 1990 and becoming a
member of the Society for Vascular
Ultrasound, Hughes has developed a
passion for vascular ultrasound. He
has dedicated 23 years to the SVU as
a member volunteering on numerous
committees including his current role
as a Board member and represents
the SVU on the American College of
Cardiology (ACC) Appropriateness
Use Criteria Technical Panel. He is the
recipient of SVU’s 2004 Distinguished
Service Award, 2008 Excellence in Oral
Clinical Presentation, and has been
recognized as a Fellow of the Society of
Vascular Ultrasound in 2005. Hughes has
worked closely with CCI to improve the
RPVI exam, and will continue to work
closely with the SVU, ARDMS, and CCI
throughout the year.
“There are so many great practitioners
in this field that I am truly humbled and
honored to be recognized by the SVU.”
When asked to identify the singular
critical success factor for any vascular
technologist, JP said “Dedication to
patient care. It’s what I live by. Caring
about what you do – that impacts
patients. You need to have passion for
what you do.”
From
the
Desk
of
Improving Patient Care Despite $800M in
Medicare Cuts for Diagnostic Imaging
Robert T. Kane
Senior Vice President of
Clinical Services and
Business Development
It was another devastating blow to
diagnostic imaging services when
Congress passed the fiscal cliff package,
which included cuts to Medicare
imaging reimbursements by another
$800 million. When you add these
cuts to the reductions that have been
happening almost yearly, you have to
wonder how long this can continue. A
more critical aspect to consider is, how
will it affect patient care?
According to the US Census Bureau,
Medicare provided health care
insurance to 39.6 million people aged
65 years and older in 2009. The impact
of Medicare cuts will be more significant
as the US population continues to grow
older over the next several decades. In
2050, the number of Americans aged
65 and older is projected to be 88.5
million, more than double its projected
population of 40.2 million in 2010.1
According to the American Heart
Association, coronary heart disease
alone caused ≈1 of every 6 deaths in
the United States in 2009. Considering
that nearly 33% of cardiovascular
disease deaths occur in people before
age 75, the impact of the extensive cuts
to diagnostic imaging could have a
dramatic effect on the aging Medicare
patient.
American College of Radiology’s Board
of Chancellors Chair Paul H. Ellenbogen,
MD, was recently quoted in a statement
regarding the recent cuts to Medicare
imaging reimbursements, “These cuts
will ultimately damage patient access to
medical imaging care and may drive up
long term costs by delaying diagnosis
of illness and disease to later stages
where more expansive, and expensive,
treatments are required. This move by
congress represents a step backward in
patient care.”2
It has to be concerning that the
financial pressures these cuts put on
hospitals and physician practices will
result in larger patient loads forcing
technologists to rush through studies
to meet financial demands. These
measures typically do not result in
optimal patient care.
An effective response to these
reductions is to ensure there is a
team effort in your lab to improve the
quality of administrative and clinical
processes. While you may be tempted
to cut your budget in areas like training,
this could potentially do even more
harm. You might instead increase
training to expand the scope of studies
performed at your lab. For example
transcranial Doppler (TCD) has many
clinical applications that assist in the
identification of many diseases (see TCD
article on page 3 of this publication).
TCDs and other comprehensive
diagnostic exams can lead to more
downstream interventional services that
could offset the reimbursement cuts in
diagnostic imaging.
You may also want to consider new
technologies such as 3D vessel
imaging. Navix has been working with
MediPattern to offer this technology in
our labs. One of the best doctors I have
had the pleasure to work with, Francis J.
Porreca, MD, FACS, RPVI, Weiler Director,
Vascular Surgery, Montefiore Medical
Center and Albert Einstein College of
Medicine, has embraced 3D technology
in the vascular lab. Dr. Porreca views 3D
vessel reconstruction as a new asset for
his Practice that has led to improved
patient care.
TCDs and 3D technologies are just a
couple of examples of how we can
deal with these difficult times. I expect
to learn more from our staff and
technologists on how we can improve
this year. And so, while the Medicare
cuts are certainly disconcerting, we
should maintain a focus on what really
matters – delivering patient care to
each individual we see. With extra time,
training, patience and team work, I am
certain that together we can raise the
bar in diagnostic imaging, despite the
negative reimbursement environment.
Bob Kane, [email protected]
Bob Kane has more than 35 years of experience
in Cardiovascular Medicine in both invasive
and non-invasive surgical and imaging
modalities. Through his participation and
involvement on many local and national health
care committees, Bob has gained a reputation
for his commitment to clinical excellence in the
cardiovascular medical community.
1. Vincent GK, Velkoff AV. THE NEXT FOUR DECADES: The older population in the United States: 2010 to 2050. US Census Bureau. May 2010. http://www.census.gov/
prod/2010pubs/p25-1138.pdf.
2. Fiscal cliff deal means fiscal squeeze for imaging. healthimaging.com. http://www.healthimaging.com/topics/healthcare-economics/fiscal-cliff-deal-means-fiscal-squeezeimaging. Published January 2, 2013.
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Above and Beyond in
Northeast Pennsylvania
Lesa Giambra, RVT
Lesa Giambra works as a vascular
technologist and trainer for Navix.
She has worked for Navix since 2004.
Lesa works a full schedule splitting her
time between two of Navix’s clients in
Scranton, PA – Moses Taylor Hospital
and Mid-Valley Hospital.
Working tirelessly to train other
technologists as well as “fill in”
where needed, Lesa has gained a
reputation as a dependable, flexible
and conscientious team member. Lesa
works days, nights and on call. “Caring
is the single most important attribute
for anyone working in the medical field.
Lesa’s caring nature and excellent skills
make her one of our best technologists.
She is extremely valued by Navix, our
clients and their patients,” said Robert
Kane, Senior Vice President of Clinical
Services and Business Development for
Navix.
“
Caring is the
single most important
attribute for anyone
working in the medical
field. Lesa’s caring
nature and excellent
skills make her one of
our best technologists.
”
- Robert Kane, SVP of Clinical Services &
Business Development
“Lesa is an integral part of Navix’s
operations team. She is highly
respected by everyone for her strong
work ethics, extensive knowledge and
ability to consistently deliver highquality work,” says Debbie Kratz, Senior
Manager of Clinical Services.
Navix has received praise from clients
and their patients for Lesa’s compassion
New to the Team
and dedication to providing excellent
patient care. Many patients have
shared their appreciation for Lesa’s
natural ability to care and comfort
them while performing comprehensive
diagnostic exams.
“
Employee
Milestones
Allison Gordon, Vascular Sonographer
Alyson Grgurovic,
Ultrasound Technologist
Andrea Bulcao, HR Coordinator
Ashley Pierson, Area Operations Manager
Carl Vicere, Vascular Sonographer
Clarence Brown, Vascular Sonographer
Lesa made me
feel very comfortable
and at ease while
doing a professional
and thorough job.
This young lady is an
asset to her profession
and to your hospital.
”
- Patient, Moses Taylor Hospital
“During my test, Lesa made me feel
very comfortable and at ease while
doing a professional and thorough
job. This young lady is an asset to
her profession and to your hospital,”
wrote a patient at Moses Taylor. In
a conversation with Moses Taylor’s
patient relations officer, another
patient shared her experience saying
that Lesa was “simply amazing, kind
and compassionate” when performing
her testing.
“Lesa does an excellent job for our
clients. Our clients really appreciate the
outstanding work she does every day!”
said Ashley Pierson, Area Operations
Manager.
Lesa earned her Registered Vascular
Technologist (RVT) credential through
the American Registry for Diagnostic
Medical Sonography and is proficient
in all testing modalities for vascular
ultrasound. Lesa resides in the
Scranton area with her two children.
David Hollenback II,
Vascular Sonographer
George McNellage,
Vice President Sales & Marketing
Henry Chua, Vascular Sonographer
John Krouskos, Chief Financial Officer
Lance Smith,
Senior Clinical Service Manager
Leslie Cooper, Ultrasound Technologist
Marianne Conboy,
Ultrasound Technologist
Marta Kostenko, Vascular Sonographer
Roberta Silva,
Contract & Compliance Specialist
Zulma Torres,
Cardiovascular Sonographer
5 Years with Navix
Michael Kane,
Information Technology Manager
Yevgeniya Levin, Vascular Sonographer
15 Years with Navix
Angela Rodriguez-Wong,
Clinical Development & Research Manager
25 Years with Navix
Angela Lawson,
Financial Planning & Analysis Manager
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Physician Preceptorship Makes the Grade
Navix Offers the Most Comprehensive Training for Physicians Seeking RPVI Credential
Since 2009, Navix has been training physicians in the
interpretation of non-invasive vascular ultrasound. Navix’s
Physician Preceptorship in Vascular Ultrasound Interpretation
is an intensive 4-day course designed to train physicians in
Extracranial Cerebrovascular, Extremity Arterial & Extremity
Venous Ultrasound Interpretation. Navix began offering the
Preceptorship program in New York City and later added a
second training site in Philadelphia, PA.
“90% of Navix participants were referred to the program
by physician’s who have taken the Preceptorship which is a
great compliment to Navix and our instructors. In fact, there
is no better compliment to an organization than a new client
gained through a referral,” said George McNellage, VP of Sales
& Marketing for Navix. “I am very pleased with the number of
physicians who actively market our program. Within a month
of releasing our 2013 calendar, sessions in New York and
Philadelphia were completely booked through February, and
Philadelphia was booked through the end of March.”
Navix’s Preceptorship course prepares physicians for successfully
achieving their Registered Physician in Vascular Interpretation
(RPVI) credential through the ARDMS. More than 100 physicians
have completed the program. All of the physicians who have
taken Navix’s Preceptorship course and sat for the exam have
earned their RPVI credential.
“The instructor was excellent. All you need is Navix’s course to
pass the RPVI exam,” stated Dr. Nirav Patel, Westchester Surgical
in Yonkers, NY. “I would recommend this course to anyone!”
“Data suggests that vascular fellows are not being adequately
trained in the vascular lab. Since the vascular lab is a significant
source of revenue for the practicing vascular surgeon, and
since it plays a very significant role in caring for our patients,
we suggest that the vascular lab become a specific area
of focus for fellowship training,” said Dr. Anil Hingorani,
Maimonides Medical Center in Brooklyn, NY.1
Navix’s Vascular Ultrasound Preceptorship is one of the only
programs that covers the entire scope of vascular ultrasound
studies in four days. According to a survey of 376 vascular
fellows conducted by the Eastern Vascular Society from 20042010, only 36% of vascular fellows reported actually performing
a duplex exam, and only 47% indicated that they would feel
comfortable managing a vascular laboratory.1
Navix has been working with many fellowship
programs across the country to support the educational
requirements for managing vascular diagnostic
labs. Navix has worked with many institutions with
cardiovascular disease and vascular surgery programs to
complement their curriculum with hands-on experience
in a vascular lab.
The Preceptorship course provides interpretation experience
for 500 exams including carotid duplex ultrasound, transcranial
Doppler, peripheral arterial physiologic testing, peripheral
arterial duplex ultrasound, venous duplex ultrasound and
visceral vascular duplex ultrasound. Physicians attending
Navix’s program get hands-on scanning experience so they are
better able to coach their technologists on the best methods
for obtaining comprehensive ultrasound studies.
“I really appreciated the clarity and thorough
nature of the instructor. The didactic portion
was excellent, and I would definitely
recommend the course,” said Dr. Ramesh
Gowda, Associate Director, Fellowship
Program, Beth Israel Medical Center Petrie Division in Manhattan, NY.
The Preceptorship program can
be an extension of a fellowship
program providing the critical
experience
and
instruction
fellows need to gain their RPVI
credential. The cost of tuition
for Navix’s Preceptorship is
discounted for fellows to make
it more affordable. Fellows
benefit from a rigorous
program that provides
them with the necessary
interpretation experience
and instruction on
clinical protocols and
lab management.
“The Vascular Surgery Board of the American Board of Surgery
recognizes the importance of noninvasive vascular testing as a
cornerstone of practice and patient care; the complete vascular
specialist must be fully competent in interpreting a wide variety
of such studies,” said Joseph Mills, MD, Chair of the VSB-ABS and
Chief of Vascular and Endovascular Surgery at the University of
Arizona.2
Having worked with many hospitals and physician practices,
Navix recognized that in addition to teaching physicians how to
interpret vascular ultrasound, there is also a need for physicians
to learn how to effectively manage a vascular diagnostic lab.
Participants learn how to standardize on advanced clinical
protocols that result in more efficient and effective diagnosis
of vascular disease.
1. Lesney MS. Survey Cites Need to Improve Training in Vascular Labs: Results indicate lack of confidence. Vascular
Specialist. Nov 2011;7(6):1. http://www.vascularspecialistonline.com/fileadmin/content_images/svs/issue_
pdfs/2011_Issues/Vascular_Specialist_Nov-Dec-2011.pdf.
2. Registered Physician in Vascular Interpretation (RPVI) Credential Required for the Vascular Surgery Qualifying
Examination Starting in 2014. www.ardms.org. http://www.ardms.org/files/downloads/Press%20Releases/RPVIR
equiredVascularSurgeryQualifyingExamination-January2011.pdf.
-7-
Calendar of Events
January 14 – 17, 2013 FULL
Vascular Ultrasound Preceptorship
Bronx, NY
March 18 – 21, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
May 13 – 16, 2013
Vascular Ultrasound Preceptorship
Philadelphia, PA
January 28 – 31, 2013 FULL
Vascular Ultrasound Preceptorship
Philadelphia, PA
March 25 – 28, 2013 FULL
Vascular Ultrasound Preceptorship
Philadelphia, PA
May 20 – 23, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
February 11 – 14, 2013 FULL
Vascular Ultrasound Preceptorship
Bronx, NY
April 1 – 4, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
May 28 – 31, 2013
Vascular Ultrasound Preceptorship
Philadelphia, PA
February 25 – 28, 2013 FULL
Vascular Ultrasound Preceptorship
Philadelphia, PA
April 8 – 11, 2013 FULL
Vascular Ultrasound Preceptorship
Philadelphia, PA
June 3 – 6, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
March 1, 2013
Cooper University Hospital
Vascular Screening
Willingboro, NJ
April 15 – 18, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
June 10 – 13, 2013
Vascular Ultrasound Preceptorship
Philadelphia, PA
April 22 – 25, 2013
Vascular Ultrasound Preceptorship
Philadelphia, PA
June 17 – 20, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
May 6 – 9, 2013
Vascular Ultrasound Preceptorship
Bronx, NY
June 24 – 27, 2013
Vascular Ultrasound Preceptorship
Philadelphia, PA
March 4 – 7, 2013 FULL
Vascular Ultrasound Preceptorship
Bronx, NY
March 11 – 14, 2013 FULL
Vascular Ultrasound Preceptorship
Philadelphia, PA
Physician Preceptorship (Cont.)
clients appreciate the flexibility to schedule the training in a
way that allows them to maintain optimal care of their patients.”
“We developed this program because we recognized a need for
better training in reading vascular ultrasound and managing
labs” said Robert Kane, SVP of Clinical Services and Business
Development for Navix. “It has been difficult for us to keep up
with demand for this program. We will continue to identify
more opportunities for expansion because it’s important that
physicians and fellows who need this training can get into our
course.”
In 2014, physicians seeking to take the vascular surgery
qualifying exam will be required to hold their RPVI credential.
“The decision to require the RPVI credential highlights the
importance of expertise in vascular sonography interpretation
as an essential component of vascular surgery,” said Dr. R.
Eugene Zierler, Vascular Surgeon and Member of the ARDMS
Board of Directors.2
“We unanimously voted to require RPVI credentialing as a
prerequisite for vascular surgery certification. Our trainees, and
the patients they serve, will be assured that our certified vascular
surgeons possess a high-level of knowledge and competence
in noninvasive testing and have been independently
assessed and credentialed by the ARDMS, a highly-respected
multidisciplinary organization involved in developing high
standards of care in the noninvasive arena,” said Dr. Mills.2
An on-site training option for Navix’s Preceptorship program
was also added in response to the growing interest from
integrated delivery networks, hospitals and large physician
practices. Navix instructors strive for excellence in bringing
top-quality, practical information to Navix clients across the
nation. Our on-site programs are based on training provided
in our public courses, evolving based on client comments.
Navix training programs consistently achieve extremely high
ratings. Our instructors have excellent educational credentials,
are involved in patient care, and have well-honed presentation
skills.
Each month Navix offers two Preceptorship sessions in New York
City and Philadelphia. Navix will also work with organizations to
provide customized instruction that meets the needs of their
physicians and staff that can be taught on-site or at a location
of their choosing.
“On-site training offers our clients the opportunity to customize
the training to better meet their needs,” says Nancy DiGiacomo,
Director of Compliance and Clinical Operations for Navix. “ Our
Dorie Kilduff, [email protected]
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Case
Study
Abdominal Aortic Aneurysm
Angela Rodriguez-Wong, MD, RVT, RPVI
Lois Eliassi, BS, RVT
Figure 1 Distal abdominal aortic aneurysm
with mural thrombus.
An aneurysm is defined as a focally dilated
segment of an artery that is 1.5 times its
normal diameter and involves all three
arterial walls (intima, media and adventitia).
Aneurysms can be found in the common
femoral and popliteal arteries in the lower
extremities, the splenic, mesenteric, and
renal arteries in the abdomen, and also in
the intracranial vessels. However, the most
common is an abdominal aortic aneurysm
(AAA) involving the aorta and iliac arteries.
Abdominal aortic aneurysms are generally
asymptomatic
and
are
discovered
accidentally either by physician palpation
or by a radiologic examination such as a
chest or abdominal X-ray. The risk factors
that increase the probability of developing
a AAA are primarily smoking and family history. An abdominal
aortic aneurysm can rupture and, according to the Centers for
Disease Control and Prevention, ruptured AAA was the 10th
leading cause of death in males between the ages of 65-74 in
the United States in 2000.
The preferred method of screening for AAA is diagnostic
ultrasound. According to the Journal of Vascular Surgery,
diagnostic ultrasound performed by a registered vascular
technologist has a sensitivity of 100 percent and a specificity
of 96 percent for the detection of an infrarenal AAA. The
abdominal aorta is considered aneurysmal
when it measures >3.0 cm.
Because of its accuracy, diagnostic
ultrasound not only has become an integral
part in diagnosing AAA but is also an integral
part in the evaluation of disease progression,
the preoperative AAA evaluation, and
the follow-up of AAA surgical repair. It is
important to note that a rupture of an AAA
is a surgical emergency and is difficult to
evaluate with ultrasound due to the inability
to easily demonstrate abdominal free fluid.
If a rupture is suspected, it is recommended
that other imaging modalities such as CT
be employed to better demonstrate the
ruptured aneurysm and any intra-abdominal
free fluid.
Figure 2 Bifurcation of the aorta.
1. Anderson RN. Deaths: Leading causes for 2000. Natl Vital Stat Rep. 2002;50:1–85.
2. Kent KC, Zwolak RM, Jaff MR, et al. Screening for abdominal aortic aneurysm. J Vasc Surg. 2004;39:267–9.
3. Upchurch G Jr, Schaub T. Abdominal aortic aneurysm. American Family Physician. 2006;73(7), 1198-1204. http://www.aafp.org/afp/2006/0401/p1198.html
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Figure 3 Sagittal image of the right common
iliac artery demonstrating the measurement of
the aneurysm and the true lumen.
Case Study: A 77 year-old male with a past
medical history of diabetes, hypertension,
arthritis, aortic valve disease and heavy
smoking was referred to Eastern Vascular
Diagnostic Center with a 4.2 centimeter
aneurysm. The patient denied any family
history of aneurysm and is allergic to
intravenous contrast. A physical exam found
the patient alert with a blood pressure of
100/60 mmHg, a pulse of 58 and respiration
of 16. Auscultation found a bruit in the left
carotid artery, clear lungs, and a regular heart
rhythm with an aortic systolic murmur. The
patient had a well healed sub-costal incision
on his abdomen. The physician was unable
to palpate the aneurysms. The patient had
an aortic valve replacement in 2007 and also a cholecystectomy.
On May 12, 2012, a magnetic resonance imaging (MRI) scan
without contrast was performed on the patient’s abdomen. The
MRI found an AAA measuring greater than 3 cm with extensive
plaque near the bifurcation. The aneurysm extended into the
right common iliac artery (CIA) measuring 4.2 cm and into the
left CIA measuring 3.1 cm. The MRI exam did not include the
pelvis, so the extent of the iliac aneurysms was not clear. On July
31, 2012, the ultrasound was performed, demonstrating normal
ankle brachial index (right-1.2, left-1.1) and a AAA measuring 3.9
cm which extended into the right and left CIA. The maximum
diameter of the right CIA measures 4.1 cm with mural thrombus
creating a residual lumen of 2.0 cm. The maximum diameter
of the left CIA measures 4.3 cm, there is also mural thrombus
noted but without significant appreciable diameter reduction
within the vessel. A computed tomography (CT) scan of the
abdomen and pelvis without contrast was performed on July
18th confirming the infrarenal AAA with
extension into the iliac arteries bilaterally.
The U.S. Preventive Services Task Force has released a statement
summarizing recommendations for screening for AAA. It states
that screening benefits patients who have a relatively high
risk for dying from an aneurysm; major risk factors are age 65
years or older, male sex, and smoking at least 100 cigarettes
in a lifetime. The guideline recommends one-time screening
with ultrasound for AAA in men 65 to 75 years of age who have
ever smoked. No recommendation was made for or against
screening in men 65 to 75 years of age who have never smoked,
and it recommended against screening women. Men with a
strong family history of AAA should be counseled about the
risks and benefits of screening as they approach 65 years of age.
Surgery is recommended when an AAA
reaches 5.0-5.5 cm in a male and 4.5-5.0
cm in females. Surgery, depending on the
aneurysm, can be an open repair or an
endovascular repair. In this patient, despite
the size of the AAA being 4.1 cm, the
disease also involved the bilateral common
iliacs prompting the need for surgical
intervention. The patient was cleared by
cardiology and on July 31st had an AAA
and bilateral Iliac aneurysm resection with
a re-implantation of the inferior mesenteric
artery and an Aorta to right Hypogastric
bypass to maintain pelvic perfusion.
Figure 4 Coronal view of the left common
iliac artery.
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Angela Rodriguez-Wong, MD, RVT, RPVI
[email protected]
Lois Eliassi, BS, RVT
[email protected]
PRSRT STD
US POSTAGE
PAID
100 Myles Standish Blvd.
Taunton MA 02780
HOLLISTON, MA
PERMIT NO. 72
PHYSICIAN PRECEPTORSHIP IN
VASCULAR ULTRASOUND INTERPRETATION
Navix’s Vascular Ultrasound Program is an intensive 4-day program to train physicians in
Extracranial Cerebrovascular, Extremity Arterial & Extremity Venous Ultrasound interpretation.
This course prepares physicians for the Registered Physician Vascular Interpretation
exam as well as provides other medical practitioners the opportunity to expand or
enhance their knowledge in vascular ultrasound interpretation.
Here are three reasons why you should choose our program:
1. Small group didactic lectures
2. Interpretation of 500 studies including:
• Carotid duplex ultrasound
• Transcranial Doppler
• Peripheral arterial physiologic testing
• Peripheral arterial duplex ultrasound
• Venous duplex ultrasound
• Visceral vascular duplex ultrasound
3. 100% pass rate for participants who have taken the RPVI exam
Navix now offers on-site programs for
physicians at a location of your choice.
Call 508-977-2807 to reserve your session!
Patients matter. Results count.
100 Myles Standish Boulevard
Taunton, MA 02780
Telephone: 508-977-2807
www.navixdiagnostix.com