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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. -2- 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 -3- 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 -4- 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. -5- 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 -6- 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] -8- 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 -9- 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. - 10 - 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