Your body’s heart and blood vessels form a system which works together to keep you healthy and strong. So do the many programs, services and people of Florida Heart and Vascular Multi-Specialty Group.
Our physicians have special expertise in the procedures which follow. Some of these procedures are used for cardiac and peripheral vascular testing. Others are used to treat conditions using minimally-invasive interventional treatments. Others use traditional surgery to achieve the best possible outcomes.
Working as a team across cardiovascular disciplines, we are able to provide the best-possible individualized plan of care for the diagnosis and treatment of each patient.
In 1977 the first balloon angioplasty of the heart artery was performed in Zurich, Switzerland by Dr. Andreas Gruentzig. Percutaneous transluminal angioplasty (PTA), is a minimally-invasive procedure performed under local anesthesia, to improve blood flow which has been reduced due to a blockage in the artery. A balloon catheter is temporarily inserted, usually into the groin or wrist, and advanced over a wire under X-ray to the site of blockage. The balloon is then inflated to compress the plaque comprised of fat, calcium, cholesterol deposits and fibrous tissue. This results in remodeling of the artery (Angioplasty) and a larger arterial opening to allow enhanced blood flow.
At times, the artery may develop re-closure or dissection (tear) which then is promptly treated with a stent acting as a vascular scaffold.
Coronary percutaneous transluminal angioplasty (PTA) or coronary angioplasty, is a minimally-invasive procedure done under local anesthesia, to improve blood flow to the heart muscle which has been reduced due to a blockage in the artery. A balloon catheter is temporarily inserted into the groin or wrist and advanced using fluoroscopy to the site of the blockage. The balloon is then inflated to compress fat and cholesterol deposits within the blockage, improving blood flow.
Dr. Lew was one of 12 PAMI-No SOS investigators in North America who performed successful cardiac angioplasty and stents in patients presenting with an acute heart attack to a hospital without open heart facilities. The positive result of this landmark study is one of the reasons why an acute cardiac angioplasty is permitted in other hospitals without surgical facilities in the United States.
Stenting (Medicated and Non-Medicated)
In 1986, Puel and Sigwart deployed the first coronary stent to act as a scaffold but it was not until 1994 when the Johnson and Johnson Palmaz-Schatz stent was approved by the United States FDA for deployment in humans.
Subsequent studies have shown that stenting as compared to balloon angioplasty alone is associated with 50% reduction of arterial (vessel) reclosure or blockage.
Stenting is a procedure in which your cardiologist inserts a slender, metal-mesh tube, called a stent, which expands inside your artery to increase blood flow in areas blocked by plaque. Stents are most commonly placed in the heart, lower extremity, and carotid arteries but can be placed in almost any artery in the body when necessary. In atherosclerosis or hardening of the arteries, plaque builds up in the walls of your arteries as you age. Cholesterol, calcium, and fibrous tissue make up the plaque. As more plaque accumulates, your arteries can narrow and stiffen. Eventually, enough plaque may build up to reduce blood flow through your arteries, or cause blood clots or pieces of plaque to break free and to block the arteries in the heart, brain, kidneys, legs, etc. When this occurs, a heart attack, stroke or other potentially life-threatening event may occur. The stent is a tiny, coiled wire or mesh that is permanently placed at the angioplasty site acting as a scaffold to maintain the new opening. For coronary patients, this is often done after a recent heart attack, for stable or unstable angina. It can also be used during an acute heart attack to quickly open blockages and reduce damage to the heart muscle.
Dr. Lew was the first physician in Lake county to successfully perform the carotid stenting procedure with distal embolic protection (DEP).
Peripheral Angioplasty is also a minimally-invasive procedure which is performed using a catheter which is temporarily inserted to open narrowed arteries of the legs, arms, aorta, and its branches. Blockages to the arteries of the legs can cause pain and cramps when walking, a condition known as claudication. Stents may be inserted to maintain healthy blood flow which if left untreated may result in gangrene and infection, which may lead to amputation.
Like the coronary arteries (the blood vessels of the heart), the carotid arteries (the blood vessels to the brain), can be blocked by fat and cholesterol deposits, called plaque. Over time, the build-up narrows the artery, decreases blood flow to the brain and can lead to a stroke, also known as a brain attack.
Carotid stenting is an exciting procedure that may eliminate the need in many individuals for traditional surgery to treat carotid artery blockage. Dr. Lew has been a pioneer and has been the local principal investigator for multiple carotid stenting trials, including the prestigious National Institute of Health sponsored CREST trial.
Blockages of arteries to the kidneys can lead to high blood pressure and renal insufficiency. The procedure for performing renal angioplasty and stenting is similar to other peripheral angioplasties and can help to lower blood pressure caused by these blockages.
The goal of an atherectomy is to remove the buildup of plaque in your arteries. Florida Heart & Vascular, Multi-Specialty Group utilizes a variety of atherectomy devices such as: Foxhollow Excisional Catheter, Diamondback, Rotoblator, and Excimer Laser Catheter. These catheters work in different fashion: cut and remove the plaque with a sharp rotating blade, vaporization of the plaque, or pulverizing the plaque into micro-particles with high speed rotating burrs (like a drill bit). Under local anesthesia, the catheter is inserted into the artery through a small puncture in the artery, usually in the groin or wrist.
An AV fistula is one of three methods for gaining vascular access for treating kidney disease through hemodialysis. Hemodialysis pulls blood from the patient, circulates and cleanses it, then returns the blood to the patient. This is normally performed three times a week and the purpose of an AV fistula is to provide reliable sites where the bloodstream can be easily accessed each time.
Complications that can occur include infection and bleeding. The surgeon should be contacted as soon as possible for any fever over 100°, or if there is drainage from the incision or active bleeding. A potential complication of arteriovenous fistulas is non-maturation. In other words, the vein never enlarges or becomes thickwalled enough to be used for dialysis. In some cases, causes for non-maturation can be identified and corrected, allowing maturation to occur. After a fistula has been in place for a period of time, it may become abnormally large, or develop an aneurysm. There are procedures that can be performed to correct aneurysmal fistulas. AV fistulas can develop narrow areas (stenoses) which may decrease the efficiency of dialysis or put the access at risk for developing a clot. Stenoses can be treated with an operation, or with a minimally invasive/endovascular approach. After an access has developed a clot, it may or may not be able to be salvaged.
Diagnostic cardiac catheterization, also called heart catheterization, is the most sophisticated procedure available to determine how well your heart and its arteries are functioning. Your doctor threads a catheter into your heart. When the catheter is in place, your doctor will perform certain tests that will include an injection of a special dye. What your doctor sees will help him to decide what additional treatment might improve your heart’s function. By combining the results of the cardiac catheterization with other test results, your doctor can determine the most effective treatment plan.
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Cardiac rehabilitation (cardiac rehab) is a professionally supervised program to help people recover from heart attacks, heart surgery and percutaneous coronary intervention (PCI) procedures such as stenting and angioplasty. Our cardiac rehab programs provide education and counseling services to help heart patients increase physical fitness, reduce cardiac symptoms, improve health and reduce the risk of future heart problems, including heart attack.
View our Cardiac Rehab video.
Computerized Tomography Scanning (CT or CAT Scanning) is invaluable in diagnosing and evaluating blood flow in organs such as the liver and kidney, monitoring changes in tumor size, searching the lungs for pulmonary emboli (blood clots), identifying narrowed brain arteries that put patients at risk of having a stroke, and pinpointing other problems.
To produce a CT image, computer-driven machinery passes X-rays through the body, producing digitized signals that are detected and reconstructed. Each X-ray measurement lasts just a fraction of a second and represents a “slice” of an organ or tissue. The greater the number of detectors, the better the speed and resolution of the picture. A computer then uses these slices to reconstruct highly detailed, three- dimensional images of the heart, other organs, and blood vessels throughout the body.
Cardiac and Vascular CT/CT Angiography
Carotid CT gathers images of the arteries of the neck leading to the brain to determine how well blood is flowing.
What to Expect from Your CT Scan – Click Here
CT angiography provides additional images of blood flow in the arteries. A contrast dye is injected into a blood vessel, and a CT scan gathers the images which can be viewed in 3D and manipulated to provide views from many angles.
The Coumadin level-PT/INR is checked every four weeks once it is regulated. The INR is the primary number used and the range should be 2-3 or 2.5-3.5. On occasion the doctor may require slightly different parameters. The test can be done by drawing blood or by a finger stick, similar to testing for blood sugar. Some medications and foods can affect the results and your doctor or Coumadin nurse should be notified of any changes. Coumadin dosages are adjusted to maintain therapeutic levels.
An Echocardiogram is an ultrasound images that help your doctor to identify abnormalities in the heart muscle and the valves. It shows their shape, size, and movements. There are no risks and it is a painless test that takes approximately 30-45 minutes. This procedure is similar to fetal ultrasounds. There is no preparation for an echocardiogram.
Transesophageal Echocardiography (TEE)
A transesophageal echocardiogram is an ultrasound of the heart used to identify abnormalities in the heart muscle and valves. This test is done by passing a tiny probe down your throat into your esophagus. This test provides more detailed views/angles of the heart than a traditional echocardiogram, because it does not have as much tissue/muscle or ribs to see through. This test does require you to fast prior. Patients are given mild sedation to ensure greater comfort during the exam.
Your heartbeat is controlled by a smooth, constant flow of electricity through the heart. A short-circuit anywhere along this electrical pathway can disrupt the normal flow of signals, causing an arrhythmia (an irregular heartbeat). Electrophysiology evaluates electrical impulses in your heart. The tests are performed in a manner which is very similar to a cardiac catheterization.
Treatment options for arrhythmias may include watchful waiting, medications or may include interventions such as:
A pacemaker is a small device placed under the skin of the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. Pacemakers are used to treat heart rhythms that are too slow, fast, or irregular, and may relieve some of the symptoms related to arrhythmias, such as fatigue and fainting. A pacemaker can help a person who has an abnormal heart rhythm resume a more active lifestyle.
Implantable cardioverter defibrillators or implantable cardiac devices (ICD), are small electronic devices that monitor heart rhythm and deliver a shock to correct a potentially fatal heart rhythm if it should occur. The generator is surgically implanted beneath the skin and muscle beneath the collarbone. Wire electrodes attach the pulse generator to the heart. Some of the wires are inserted through veins into the inside of the heart and can sense the heartbeat. Other wires may be attached directly to the heart.
Cardiac ablation is a procedure used either to destroy short-circuits in the heart’s electrical system and restore normal rhythm, or to block damaged electrical pathways from sending faulty signals to the rest of the heart. Once the precise location is confirmed, a catheterization-like procedure is performed so your doctor can deliver small amounts of energy to these areas. The energy may be either hot (radiofrequency energy), which cauterizes the tissue, or extremely cold, which freezes or “cryoablates” it. This makes a helpful scar on the heart muscle. In some cases, when ablation is done in certain parts of the heart, you may still need a pacemaker afterwards.
Enhanced External Counterpulsation (EECP) is an outpatient treatment that can relieve or eliminate angina symptoms without surgery. Angina symptoms occur when your heart is not receiving enough blood or oxygen. During EECP, your legs are compressed to increase blood flow to your heart. There are two parts to the cardiac cycle, diastole and systole. Each wave of compression is electronically timed to your heartbeat so that the increased blood flow reaches your heart when it is resting (diastole). When the heart begins to pump again, pressure is released instantly. This lowers the resistance in the blood vessels in your legs so that blood may be pumped more easily from the heart, which decreases the amount of work for your heart.
Aneurysms of the aorta occur in weakened areas of the large blood vessel which allows for significant bulges. As the aneurysm enlarges, it weakens more, and eventually will rupture, causing a massive hemorrhage. Approximately 25 percent of aortic aneurysms occur in the chest, and the rest involve the abdominal aorta. Endovascular repair involves placing a graft (synthetic tube) inside the aorta, which is held in place with a stent. The procedure is minimally invasive and the delivery is done through the femoral vessels (groin). The endograft then becomes the new aorta.
Event recording is often necessary when we cannot catch rhythm disturbances on a holter monitor or electrocardiogram. This type of monitoring allows the patient to transmit rhythm disturbances from outside our office with a small transmitter device. An event monitor is a portable heart monitor worn for up to 30 days. It requires only two wires and can be taken off to take showers/baths. You will be given extra electrodes, as well as instructions on how and where to apply them. The monitor continuously shows your heart rhythm and when you feel anything abnormal (ie. dizziness, chest pains, palpitations). To record your current rhythm, you will press a button and the monitor will record it. Then, you will phone the monitoring company and transmit the record over the phone. The receiving company will speak with you regarding your symptoms and give you appropriate instructions. The company will then fax your doctor a copy of your rhythm. There is no preparation for this test.
The holter monitor is a portable heart monitor worn for a continuous 24-48 hours. Seven electrodes are placed and taped to your chest. You must record in a diary your activities and any symptoms you have and the time they occurred. After the monitor is removed, a computer card will be scanned and a report will be given to your doctor to interpret. There is no preparation for the test but you cannot shower, take a tub bath or swim while wearing the monitor.
There are almost 2 million people with limb loss in the US alone, and almost 200,000 amputations occur on an annual basis. African- Americans are up to 4 times more likely to have an amputation. Up to 55% of diabetic patients who have a lower limb amputation, will also require amputation of the 2nd limb within 2-3 years. Peripheral arterial disease (PAD) and diabetes mellitus are both highly morbid conditions. The expected mortality rate following an amputation is 20-40% within 1 year.
At Florida Heart & Vascular Limb Salvage Institute (LSI), we have developed a multi-disciplinary team approach comprised of world-class Interventional cardiovascular specialists and vascular surgeons. We have also developed a close working relationship with the local wound care centers, podiatrists, and infectious disease specialists to deliver the best care and outcomes to our PAD patients. Our goal and mission is to deliver the most comprehensive and compassionate care to our patients and to help delay or to avoid amputation at all cost.
We utilize the most up-to-date surgical and endovascular techniques (stents, angioplasty, atherectomy, bypass, endarterectomy) and equipment to achieve maximum revascularization to optimize blood flow to the affected limb.
For questions regarding PAD, and when faced with the prospect of an amputation, feel free to contact us for an expert opinion from our world class Interventional cardiologists and vascular surgeons.
A non-invasive electrical test for detecting abnormalities of the nerves is often ordered to evaluate nerves in patients with diabetes. The nerves are stimulated with surface electrodes. A computer is used to record the response. You will feel a light tingling as the nerve is being stimulated. You should feel no pain once the test is finished.
People who have a permanent pacemaker require periodic clinical check-ups, including certain tests such as ECGs, which record the electrical activity of the heart. In addition, the status of the pacemaker will be regularly checked to evaluate the battery and electronic functioning and the effectiveness of any programmed settings.
All contemporary devices are programmable with information and settings that can be altered and stored. Information is obtained by transmitting data from the pulse generator to a programmer, usually done during a follow-up office visit. However, with newer pulse generators it may be possible to obtain information about the pacemaker’s performance by downloading data from the patient’s device to the internet and then to the caregiver’s office. Pacemaker activity can also be checked routinely via the telephone, using a telephone-transmitting device.
Some researchers believe the number one cause of cardiovascular disease is sleep apnea, which is also linked to conditions such as diabetes and hypertension. While it’s normal to drop into bed exhausted after a busy day, it’s not to wake up that way. If you do, your doctor may recommend a sleep study.
Sleep studies generally take place in a sleep lab during normal sleeping hours. The goal is to record brain and body activity that occur during sleep so that sleep disorders can be diagnosed and treated.
A trained sleep technician will be with you in the sleep lab during the testing period.
What to Expect from Your Sleep Study – Click Here
Stress tests are screening tools to help detect heart disease. EKG monitoring is performed while you walk on a treadmill. The speed and incline of the treadmill increase every three minutes until you reach a maximum heart rate, become fatigued, develop symptoms, or have specific EKG changes.
A nuclear stress test helps measure blood flow to your heart. It is similar to a cardiac stress test, however, in a nuclear stress test, you are injected with a small amount of radioactive substance. A special device detects this radioactive material and creates images of the heart muscle. If part of your heart muscle does not receive an adequate blood supply, it will show up as a light spot on the images. A nuclear stress test can provide more information than an exercise stress test or electrocardiogram. A nuclear stress test usually consists of taking pictures of your heart in two phases while resting and after stress.
If you are unable to manage exercise, you may be given a drug, by injection, intended to have a similar effect on the heart to that of exercise.
What to Expect from Your Nuclear Stress Test – Click Here
Cardiac PET Imaging (Positron Emission Tomography), is the most advanced and accurate form of non-invasive cardiac imaging to date, and the latest technology for the evaluation of patients with known or suspected coronary artery disease. It is beginning to replace traditional nuclear stress tests to evaluate the health of your heart.
Cardiac PET imaging may be used for those with known heart disease, as well as for those who have symptoms and/or risk factors for heart disease. The whole process typically takes less than an hour compared to 4-6 hours with a traditional nuclear stress test, so it also reduces radiation exposure. Results from this test can help us determine the best individual treatment for you, or help us manage your treatment more effectively.
What to Expect from Your PET Scan – Click Here
Critical aortic valve stenosis (narrowing) is a serious medical condition which may result in up to a 50% mortality rate in 1 year with medical therapy alone (non-surgical), as shown in the landmark PARTNER study. Conventional open surgical aortic valve replacement (SAVR) is highly effective but compromised by high surgical mortality and morbidity rates especially in elderly patients with multiple medical issues. To circumvent this clinical dilemma, TAVR, a safer alternative to SAVR, was developed and was first implanted in a male patient by Dr. A. Carpentier in Rouen, France in 2002. In 2011, United States FDA gave approval to the first Edwards TAVR system and since then, the device has undergone several modifications to make it smaller and safer for its delivery and deployment in the patient.
TAVR, as opposed to SAVR, does not involve opening the chest, but instead the procedure may be performed through a small groin incision and puncture of the femoral artery.
On rare occasion, other locations may be utilized for entry including the axilla, sternum, or chest when the groin artery is unsuitable. Due to the minimally invasive nature of TAVR, the recovery time is significantly reduced and most patients may be discharged from the hospital in 3 to 4 days without a debilitating scar. TAVR is currently reserved only for patients who are deemed inoperable or high risk for SAVR. With further refinement of the TAVR procedure, it is anticipated that this procedure will have an expanded use and be offered to both high and intermediate risk patients in the very near future.
This life-saving procedure is made available to our eligible patients by Dr. Lew and staff in conjunction with our surgical colleagues at Leesburg Regional Medical Center.
Dr. Lew now has more than 4 years of experience performing TAVR with excellent proven outcomes.
Ultrasound is the general term for a non-invasive painless test that uses high-frequency sound waves to image blood vessels including arteries and veins.
This test uses ultrasound images to help your doctor identify abnormalities in the carotid artery that leads to the brain. It shows its shape, size, and movements. There are no risks and this painless test takes approximately 30 – 45 minutes.
This test uses sound waves to look at the kidneys, liver, bladder, and ureters. This test looks for changes that include size, stones, masses, cysts, or other obstructions.
Peripheral Arterial Ultrasound.
Peripheral arterial ultrasounds look for plaque build-up in the arteries of the arms and legs that affect your circulation. Lower extremity arterial ultrasound may be performed in patients with peripheral arterial disease (PAD), particularly for planning an endovascular procedure or surgery. It is also used after the procedure to monitor stents and grafts for signs of the blockage returning (“restenosis”). If a hematoma develops after a catheterization procedure, arterial ultrasound is also used to check the integrity of the arteries and veins in the groin. The ankle-brachial index test compares blood pressure in the arms and legs.
Peripheral Venous Ultrasound
Peripheral venous ultrasounds are also painless test that looks at the flow of blood through the veins in the arms and legs. Lower extremity venous ultrasound is typically performed if a clot in the vein (deep venous thrombosis or DVT) is suspected. The veins in the legs are compressed and the blood flow is assessed to make sure the vein is not clogged. This test is also used to look for chronic venous insufficiency, or leaky valves in the veins which may cause swelling or edema.
Vascular surgery specializes in the surgical and interventional treatment of diseases of the vessels. This includes open surgical and percutaneous techniques. It does not include heart surgery. We combine over 30 years of experience with Dr. Sustarsic and the recent completion of training in the latest skills with Dr. Miller. We combine our skills and efforts in teamwork for our patients’ benefit. We take pride in the outcomes that our patients achieve.
Chronic Venous Disease
Chronic venous disease (CVD) is a common illness affecting 40 million Americans. Twenty percent of women and 15% of men suffer from the disease, which has 4 times the prevalence of peripheral arterial disease. Symptoms range from asymptomatic small spider veins to severe bulging venous varicosities causing edema, pain, cramping, restless legs, difficulty walking, bleeding, and venous stasis ulcers. If conservative therapy, such as support stockings and lower extremity elevation, do not relieve symptoms, multiple management approaches are available.
Smaller symptomatic varicosities and asymptomatic spider veins can be treated with the injection of sclerosants, agents which irritate the vein and collapse it naturally. The body will absorb the remnant vein within weeks.
Varilase and RF ablation are two techniques used to treat some of the larger varicosities which become symptomatic, and are usually associated with the larger lower extremity veins.
In endovenous laser therapy (Varilase) or RF ablation, a thin laser or RF fiber is put into the diseased vein, usually through a small puncture above the visible veins. Then, laser or radiofrequency energy is transmitted through the fiber, which causes the vein to close as the fiber is gradually removed. The procedure is well tolerated and the patient is ambulatory immediately. Endovenous laser and RF therapy eliminate the risk of nerve damage, bleeding, and scarring. This form of therapy can be performed within an hour, usually less.