Tools | education | resources for a healthier you!
Vascular Vitality 2013
Aortic Aneurysms: Every Second Counts Page 10
VASCULAR VITALITY
I have Carotid Artery Disease. What are my options? Page 6
Remove Varicose Veins It’s not just for cosmetic reasons… Page 7
What is a STROKE? Page 9
A Publication of Cooper University Health Care, Division of Vascular and Endovascular Surgery
VASCULAR VITALITY Dear Readers, We believe that education is the key to better health, not only in treatment but in prevention and awareness. We have developed this publication as a tool for education, with articles devoted to your vascular health, information about diseases that affect the vascular system, and the latest in treatments. It is our hope that you will read this publication, save it for future reference, and share it with friends and family. Communication with your primary care provider is vital to maintaining the health of your vascular system. Risk factors such as tobacco use, high blood pressure, diabetes, high cholesterol, and a family history of vascular disease can significantly increase your risk. Talk to your doctor about screenings for abdominal aortic aneurysm, carotid artery disease and peripheral vascular disease—these simple, non-invasive screenings can be lifesaving. In good health,
A Publication of Cooper University Health Care, Division of Vascular and Endovascular Surgery
Joseph V. Lombardi, MD, FACS Head, Division of Vascular & Endovascular Surgery Associate Professor of Surgery, Cooper Medical School of Rowan University Program Director, Vascular & Endovascular Surgery Fellowship Director, Cooper Aortic Center
Jeffrey P. Carpenter, MD Chairman and Chief, Department of Surgery Vice President for Perioperative Services, Cooper Health System
James B. Alexander, MD, FACS Vice Chair for Education, Department of Surgery Associate Professor of Surgery, Cooper Medical School of Rowan University Medical Director, Non-invasive Vascular Laboratory at Cooper University Health Care
Jose L. Trani, MD Vascular Surgeon Associate Director, Vascular Surgery Fellowship
Francis J. Caputo, MD Vascular Surgeon
Catherine Cristofalo, MSN, APN Director of Surgical Advanced Practice Nurses; Vascular Surgery Nurse Practitioner
Amy Ward, MSN, APN Vascular Surgery Nurse Practitioner
Cooper Vascular Surgery CooperHealth.org/Vascular 800.8.COOPER – 800.826.6737 Appointments: 856.342.2151 Locations: • Camden • Voorhees • Washington Township • Marlton • Thorofare • Willingboro Contributing writers: Sherlyn Accorsi Wotring Manager, Business Development & QA, Vascular Surgery
Christine Wilkinson, MS, RD, LDN Cardiac Dietitian
Joseph V. Lombardi, MD, FACS Head, Division of Vascular & Endovascular Surgery Associate Professor of Surgery, Cooper Medical School of Rowan University Program Director, Vascular & Endovascular Surgery Fellowship Director, Cooper Aortic Center
Shavani Patel Student at Case Western University
Art Director: Michelle Helfrich MH Design Company, LLC PO Box 8427, Cherry Hill, NJ 08034
CooperHealth.org/Vascular
Tools | education | resources for a healthier you!
Table of Contents Cigarette Smoking and Vascular Disease................................... 2 Arm Pain: Thoracic Outlet Syndrome and its Spectrum of Symptoms..........................................3 Leg Pain: Peripheral Arterial Disease....................................... 4 I was told I have Carotid Artery Disease. What are my options?.............................................................. 6 Varicose Veins.......................................................................... 7 Jason Flood and Joseph V. Lombardi, MD, FACS
What is a Stroke?...................................................................... 9 Aortic Aneurysms: Every Second Counts................................. 10 Recipes.................................................................................. 11 Clinical Trials - Q & As............................................................. 13 Crossword Puzzle................................................................... 16
Cigarette Smoking & Vascular Disease Cigarette smoking is the number-one preventable cause of death in the United States. It is well-known that smoking causes disease of the lung tissue otherwise known as Chronic Obstructive Pulmonary Disease – and is associated with many different types of cancers. Smoking also leads to disease of the arteries, which are the blood vessels that carry oxygenated blood to all of the tissues in the body. When the arteries degenerate or develop significant plaque from smoking (a process called atherosclerosis) it can result in heart attack, stroke, aneurysm, Peripheral Arterial Disease (PAD), limb loss, erectile dysfunction, or even death. Quitting smoking is critical to improving one’s overall health and can halt the degeneration of the arteries, preventing these problems from occurring.
Smoking can lead to a stroke in several ways. Most notably, it can cause the main arteries supplying the brain, the carotid arteries, to become filled with plaque. As the degree of plaque increases, there is an increase in likelihood of suffering a stroke. Stroke can lead to paralysis, loss of speech, inability to walk, or even death. Peripheral Arterial Disease (PAD) is the narrowing of arteries that supply blood, rich in oxygen, to the muscles and tissue in the arms and legs. Smoking can cause PAD by reducing adequate blood supply to the limbs, which may lead to leg pain with walking, gangrene and possibly amputation. Smokers are more likely to develop PAD than non-smokers. Smoking can interfere with sexual health, as it can cause damage to the arteries that supply blood to the penis, resulting in Erectile Dysfunction. An erection cannot occur if there is not enough blood flow to the penis. The nicotine in cigarettes can narrow the arteries that supply blood to the penis, causing not enough blood flow to achieve an erection.
There are over 4,000 chemicals in cigarettes, hundreds of which are toxic, and more than 70 cause cancer. Nicotine is the primary chemical in cigarettes that causes addiction. It is a stimulant that causes the heart to beat faster, increases blood pressure, and causes the arteries to narrow or become smaller. Additionally, nicotine causes the release of fat and cholesterol into the bloodstream, which leads to hardening of the arteries. Nicotine dependence is the most common form of chemical dependence in the United States.
Aneurysms occur when walls of the arteries become weak, allowing expansion. This could potentially lead to artery rupture and internal bleeding would result, which could be life-threatening. Smokers are more (Continued on page 15)
“Quitting smoking is critical to improving one’s overall health. The positive effects of smoking cessation start within 48 hours of your last cigarette.” Catherine L. Cristofalo, MSN, APN
Amy E. Ward, MSN, APN Cooper University Health Care
Cooper University Health Care 2
Thoracic Outlet Syndrome (TOS) is a generalized term that describes a set of clinical problems that are caused by constriction of the blood vessels or nerves in the thoracic outlet. The thoracic outlet borders the upper arm, the base of the neck, above and behind the clavicle, and the first rib. It is like a tunnel that nerves and blood vessels travel through to
Thoracic Outlet Syndrome and its spectrum of symptoms reach the arm. Although bony and muscular abnormalities (cervical ribs) can cause symptoms of TOS, most often they are absent. Pre-existing trauma or repetitive motions are often a major contributor.
and may see multiple specialists while undergoing many diagnostic tests. Often, a patient’s response to muscle blocks is used as a diagnostic tool and helps determine surgical response for those with NTOS. Although most patients are best served by NTOS-specific physical therapy, patients with unrelenting and disabling symptoms may require surgical treatment. Surgery for NTOS includes an incision in the neck from which the muscle (anterior scalene), bone (first rib and other bony anomalies), and scar tissue from nerves (brachial plexus neurolysis) are removed.
There are three types of TOS: neurogenic, venous and arterial. Neurogenic TOS (NTOS) is the most frequent type, comprising 90% of patients with TOS. Symptoms include upper extremity pain, tingling and numbness, particularly when patients are asked to perform certain physical exam maneuvers, such as elevating the arm or extending the neck. The symptoms of NTOS can be attributed to compression of the brachial plexus (nerves supplying arm) at the interscalene triangle (base of neck) and/or subcoracoid space (by the shoulder).
Venous TOS (VTOS) is caused by the compression of the major veins of the arm (axillary and subclavian), which can lead to the formation of blood clots (effort thrombosis) and acute swelling of the arm. This condition often affects athletes and active individuals who do frequent upper extremity exercises. VTOS requires
Occasionally, patients have isolated symptoms that may be attributed to compression of the arm nerves by the chest muscle (pectoralis minor syndrome). Due to the difficulty of diagnosis, patients are often misdiagnosed
(Continued on page 15)
“Thoracic Outlet Syndrome remains one of the most controversial, misunderstood and poorly-treated conditions in clinical medicine.” Francis J. Caputo, MD 4 3
Vascular Surgeon Cooper University Health Care
Peripheral Arterial Disease Millions of people in the United States suffer from disease of the arteries in the legs, also known as Peripheral Arterial Disease (PAD). Diabetes and smoking are the primary causes of PAD, and are responsible for the problems seen in most patients.
signs of the most advanced disease. In these situations, a physician who specializes in diseases of the blood vessels can help prevent amputation. Diabetic patients are up to ten times more likely to need an amputation than people who do not have diabetes.
Symptoms
PAD is identified in a simple, non-invasive way by measuring the blood pressure in an arm and comparing it with the blood pressure at each ankle. Many treatment options are available, some of which do not involve surgery.
About half of those with PAD will have no symptoms. The rest will have discomfort, pain or cramping in the legs (claudication), pain at rest, or tissue loss, which are signs that the disease is getting worse. Claudication may occur when walking a certain distance. The pain disappears after resting for a few minutes, but returns after walking again.
treatment There are three non-surgical ways to treat PAD: lifestyle modification, medications and exercise.
Pain in the foot, both at rest and with exercise, or tissue loss, including ulcers that don’t heal or black toes, are 4
Finally, ACE inhibitors have been shown to improve walking distance by up to 20% in PAD patients with claudication. In addition, ACE inhibitors have been shown to protect kidney function in diabetic patients.
Lifestyle modification Quitting smoking, managing blood sugar, and eating a diet low in cholesterol are examples of lifestyle modification. Quitting smoking can help by slowing the progression of arterial disease and maximizing the length of time a surgical intervention or treatment is effective. For example, interventions such as stent placement (a small mesh tube inserted into narrow or weak arteries) or bypass surgery performed on active smokers only last half as long as they do in non-smokers.
exercise Although lifestyle changes and medications may slow the progression of PAD, exercise has the greatest potential to help someone with the disease. Patients should exercise for 20 to 30 minutes 4 to 5 times per week for the greatest effect. Within 6 to 12 months, patients with PAD who exercise can walk two to ten times farther than their starting distance. Either a treadmill or the same walking route should be used in order to see improvements in walking distance.
medications Important medications for patients with PAD include aspirin and Plavix (clopidogrel), statins (medications that lower cholesterol), and ACE inhibitors (a type of blood pressure medication).
Patients who improve their walking distance through exercise alone have results that are similar to patients who have had an intervention, and patients who exercise generally are happier with the results than patients who rely only on an intervention for improvement.
Aspirin and Plavix prevent blood platelets from clotting. These medications are important in preventing a heart attack, the most common cause of death in people with PAD. Studies have shown that Plavix and aspirin (81mg) taken together reduce heart attacks by 20% over aspirin alone. An inexpensive generic form of Plavix, called clopidogrel, is now available.
Peripheral Arterial Disease is a relatively common disease in older Americans, and it may affect freedom and independence by restricting one’s ability to walk. An understanding of the disease process, as well as the options for treating the disease, should enable people to make healthy decisions about their lifestyle and help them avoid surgery.
Statins (for example, Simvastatin, Lovastatin, Crestor and Zocor) are medications used to treat high cholesterol. Statins can also reduce inflammation and stabilize blockages in arteries. Even people with normal cholesterol levels and PAD will likely benefit from taking a statin.
“Treating Peripheral Arterial Disease is as important to your health as taking care of your heart.� Jose L. Trani, MD 5
Vascular Surgeon Cooper University Health Care
I was told I have Carotid Artery Disease... What are my options? Have you been told you have diseased or clogged carotid arteries (carotid stenosis)? Are you nervous about what this may mean in terms of your risk of stroke? Here are some answers to commonly-asked questions regarding Carotid Artery Disease. What are the carotid arteries? Carotid arteries are the two main blood vessels that supply most of your brain with blood.
What are the risks associated with carotid artery blockage? The biggest concern is the risk of stroke. Stroke is the leading cause of serious, long-term disability in the United States. Each year, about 795,000 people suffer a stroke. About 600,000 of these are first attacks, and 185,000 are recurrent attacks. Approximately 30% of strokes are related to carotid disease.
What is a carotid bruit and does it definitely mean that the carotid is blocked? A carotid bruit is a physical exam finding in which the physician hears a swooshing sound in the neck. When blood passes through a narrowing channel, it will give a very distinctive sound when your doctor listens with a stethoscope. Approximately 30% of patients with a carotid bruit will have a significant carotid blockage. However, carotid bruits are often associated with the presence of other atherosclerotic heart disease as well as other cardiovascular problems.
What is the treatment of carotid disease? The greater the degree a carotid artery is blocked, the greater the risk of stroke. While surgery/stenting is offered for patients with severe blockage, most patients with carotid disease do well with aggressive medical management in order to prevent progression of the blockage. This medical management includes lowering your cholesterol, stopping smoking, decreasing your blood pressure, eating healthier, taking an aspirin, and controlling your blood sugar if you are diabetic.
How is a carotid bruit assessed by my physician? Most of the time, a simple carotid ultrasound will determine the presence and degree of carotid blockage. There are usually all types of ultrasound labs that are more skilled than others; therefore, make sure the lab you visit is “ICAVL Accredited” for an accurate assessment. If more information is needed after your ultrasound, a CT scan or MRI with contrast is performed.
What if a stroke already happened and they have found carotid disease? In this setting, it is even more important to have your carotid disease checked. If a patient already had a stroke or a mini-stroke (TIA) from carotid disease, this is called Symptomatic Carotid Disease. Patients with symptomatic disease are at very high risk of having a major stroke. While optimal medical management (Continued on Page 15)
“One of the most important factors in preventing strokes in patients with Carotid Artery Disease is being treated aggressively medically and, when indicated, having prompt surgical intervention.” Jeffrey P. Carpenter, MD Chairman and Chief, Department of Surgery Vice President for Perioperative Services, Cooper University Health Care 7 6
and increases pressure on the vein walls. The veins then weaken, bulge and twist, leaving a roadmap of bumpy lines on the legs. Varicose veins – and their less conspicuous variety, spider veins – can be painful and contribute to leg fatigue and restlessness. They may also cause a feeling of heaviness or throbbing in your legs. Varicose veins generally will worsen with time. If varicose veins are not treated, they may cause inflammation, ulcers and other skin sores, itching, redness, thickening, and hardening of the skin. More severe problems include bleeding, superficial blood clots and deep vein thrombosis, which is a blood clot in a deeper vein.
What factors increase the risk of Varicose Veins?
Varicose Veins Are your VEINS a PAIN? Treatment for Varicose Veins can give your legs new life! Varicose veins, most commonly found in the legs and ankles, can appear as blue, twisted and enlarged beneath the skin. While unsightly, they usually aren’t serious. However, varicose veins can sometimes be painful and may be a sign of blockage in other veins located deeper under the skin.
What causes Varicose Veins? Varicose veins develop when the one-way valves within the veins, which keep blood flowing to the heart, stop working. Blood then pools within the veins 7
Increasing age. Varicose veins are more common as people age and the veins lose elasticity. Varicose veins affect about half of the population age 50 and older. Gender. Women are four times more likely to develop varicose veins, but men get them too. Pregnancy. Blood volume increases during pregnancy which may cause veins to enlarge, while the additional weight of a growing uterus puts pressure on the abdomen and veins in the legs. Multiple pregnancies bring an increased risk of developing more varicose veins. Hormonal changes. Hormonal changes that occur with pregnancy and menopause, as well as medications containing estrogen or progesterone, can contribute to the formation of varicose veins. Obesity. As with pregnancy, additional weight puts extra pressure on the veins, weakening and enlarging them. Medical history/heredity. People born with weak or defective veins are more likely to develop varicose veins, as are people who have family members who have vein problems. Work. People who stand for long periods of time may be more prone to developing varicose veins because of the increased pressure on the legs. Sedentary lifestyle. Sitting and a general lack of movement forces the veins to work harder to move blood through the body. Sitting with your legs bent or crossed inhibits circulation and may worsen varicose veins. (Continued on Page 8)
the abnormal vein. No surgical incisions are necessary. The procedure is performed under local anesthesia.
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When should I consult a doctor?
Sclerotherapy is a common, non-surgical procedure in which a solution is injected directly into the vein. The solution causes the vein walls to swell and seal • You want to improve the appearance of the veins shut, stopping the blood flow. Anesthesia is typically • Discomfort interferes with your daily activities not needed. Over time, the • The veins are swollen, vein will fade. Multiple tender or warm to the touch injections may be needed to • There are unusual sores or treat the vein, depending on • Maintain a low-sodium/high-fiber diet its size and location. Recova rash on the leg or ankle ery may take up to five days. • Exercise regularly • The skin on the leg or ankle Do not hesitate to see a doctor if:
QUICK TIPS
becomes thick or discolored
• There is suspicious bleeding from the leg
How are Varicose Veins diagnosed?
Phelebectomy is used when larger veins become swollen and inflamed. In this minimally-invasive procedure, physicians remove individual vein clusters from the leg through a series of small incisions. Phelebectomy is performed under local anesthesia using micro instruments and magnification. No stitches are necessary. Patients are typically back on their feet immediately and can resume normal activities within a week.
• Avoid sitting with your legs crossed at the knees • Avoid standing or sitting for long periods, or wearing tight garments that inhibit circulation
The vascular professionals at Cooper Vein Center will look closely at your legs and feet for signs of swelling, discoloration, sores and tenderness. A painless and non-invasive ultrasound can assess the vein structure and can show blood flow, as well as blood clots, in your veins.
Compression socks and stockings can support the veins to prevent swelling and stop the blood from flowing backward. They can help heal sores, relieve pain and prevent varicose veins from returning.
What are my treatment options? After diagnosis, vascular surgeons from the Cooper Vein Center will discuss the best course of treatment for your individual needs. In some cases, a combination of procedures will provide the best results.
How can I prevent or diminish Varicose Veins?
If the physician determines that your varicose veins should be removed, several minimally-invasive options are available and can conveniently be performed in Cooper’s outpatient offices. Most patients are back on their feet in as little as a day or two, and can resume normal activities within a week.
Watch your weight and your diet. Maintain a low sodium/high-fiber diet. You can increase your daily fiber by eating whole grains, fresh fruits and vegetables. A daily multivitamin can help you get the recommended allowance of vitamins and minerals. And drink plenty of water, up to 6-8 glasses daily.
Endovenous Laser Therapy (EVLT) is performed most frequently and uses laser energy, guided by ultrasound, to collapse and seal off the damaged vein. The procedure is performed under local anesthesia and requires no surgical incisions.
Exercise regularly. Regular exercise boosts your circulation and helps keep your muscles and bones strong. Incorporating more exercise and activities into your day will improve your overall health. Avoid sitting or standing for long periods. Avoid sitting with your legs crossed at the knees or wearing tight
Radiofrequency Ablation (RFA) uses a tiny catheter to deliver heat to the vein wall, which shrinks and seals
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Stroke.
The word puts a chill down your spine, but if your doctor finds a plaque in the artery to your brain, then what? of a stroke develop (sudden weakness of an arm, leg, or one side of the face, difficulty speaking, or loss of vision in one eye), doctors may request a CT or an MRI scan to look for plaques as well as to assess damage to the brain.
A stroke is an injury to the brain. There are many causes. One of the most common, preventable causes is a plaque in the artery carrying blood to the brain, called the carotid artery. If the plaque is large enough, it can narrow the artery and disrupt the flow so that small clots can form and travel up to the brain, causing a stroke.
Blood thinners are sometimes helpful in reducing the risk of these clots, but unblocking the narrowed artery is the most definitive treatment. For over 50 years, surgeons have been operating through a small incision in the neck to remove the plaque and repair the carotid artery – a procedure called a carotid endarterectomy. More recently, surgeons have developed techniques to open the artery using balloons and stents. Both procedures are usually successful, but both have a small risk of causing a stroke as well. Which procedure is safest depends on the individual characteristics of each patient, so it’s important to undergo an evaluation by doctors who are familiar with both techniques.
Plaques are caused by atherosclerosis, sometimes referred to as “hardening of the arteries”. High blood pressure, diabetes, high cholesterol, smoking, and being overweight can all contribute to the formation of a plaque in the carotid artery that can lead to stroke. Therefore, it’s important to work closely with your doctor to control these conditions. The most common location for such a plaque is in the middle of the neck where the carotid artery divides into two major branches. Sometimes the turbulent blood flow can be detected just by listening with a stethoscope. Alternatively, an ultrasound scan will show the artery and measure the blood flow, thereby determining if a large plaque is present. Of course, if symptoms
Strokes are not always preventable, but if we find a plaque that’s threatening, it deserves to be thoroughly evaluated.
“If the old adage about an ounce of prevention being worth a pound of the cure ever rang true, it was never so true as it is of stroke.” James B. Alexander, MD, FACS Vice Chair for Education, Department of Surgery Associate Professor of Surgery, Cooper Medical School of Rowan University Medical Director, Non-Invasive Vascular Laboratory at Cooper University Health Care 9
Aortic Aneurysms:
Every Second Counts An aneurysm is a weakened area of a blood vessel that expands or bulges. Typically, aneurysms occur in the aorta, an important artery through which blood flows from the heart to the rest of the body. Severe internal bleeding can result when an aneurysm expands and bursts. If a ruptured aneurysm is not treated immediately, a patient may not survive. Most aneurysms, however, are diagnosed before they rupture, allowing ample time for treatment. Most aneurysms are caused by arteriosclerosis, or hardening of the arteries, which weakens the aortic wall. Some aneurysms may be caused by genetic factors, while others are caused by trauma. Aortic aneurysms are most common in men over 60, but women with certain risk factors also have an increased chance of developing an aneurysm. High blood pressure, high cholesterol, diabetes and cigarette smoking all increase the risk of developing a life-threatening aneurysm. People with family members who had an aortic aneurysm have an increased risk, therefore; proper screening is very important.
There are three main types of aortic aneurysms: Abdominal Aortic Aneurysms (AAA) occur in the abdominal aorta, which supplies blood to the lower part of the body. Symptoms may include abdominal and back pain, and a physical exam may reveal an abnormal prominent pulse in the abdomen. Sometimes an abdominal aortic aneurysm may be discovered on ultrasound or CT scan. Often, however, an abdominal aortic aneurysm produces no symptoms, making it particularly deadly. Thoracic Aortic Aneurysms (TAA) occur in the chest area. These bulging, weakened areas in the aortic wall can rupture and cause severe, life-threatening bleeding. They may not produce symptoms until the aorta bursts, causing chest or back pain. Thoracic Aortic Dissection (TAD) is a tear that causes a ballooning of the aortic wall which can rupture. Symptoms of a thoracic aortic dissection include constant chest or upper back pain, which may feel like a “tearing” pain. The pain can migrate from one area to another. If diagnosed early, aneurysms can be repaired by a vascular surgeon. Remember, unusual back and abdominal pain can be symptoms of an aortic aneurysm rupture. Do not hesitate to go to the nearest emergency room if you experience one of these symptoms.
“The technology for treating aneurysms has changed so dramatically, the real challenge is now knowing if you have one.” Joseph V. Lombardi, MD, FACS Head, Division of Vascular & Endovascular Surgery Associate Professor of Surgery, Cooper Medical School of Rowan University Program Director, Vascular & Endovascular Surgery Fellowship Director, Cooper Aortic Center 10
Grilled Salmon & Spinach Salad Serves 4 Ingredients
Directions
Vinaigrette: 1/4 cup fresh orange juice 2 tbsp olive oil 2 tbsp balsamic blend seasoned rice vinegar 1/2 tsp honey mustard 2 tsp black pepper 1 garlic clove, minced Nutrition Information: Calories: 474 Fat: 25.7g Saturated fat: 4.7g Monounsaturated fat: 11.6g Polyunsaturated fat: 7.7g Protein: 36.2g
Salad: 2 tbsp fresh lemon juice 4 (6-ounce) salmon fillets 1/2 tsp black pepper Cooking Spray 1 (6 oz) package spinach 4 oranges, peeled and cut into 6 slices Carbohydrate: 27.5g Fiber: 8.4g Cholesterol: 100mg Iron: 2.5mg Sodium: 286mg Calcium: 129mg
1. Preheat the grill to medium-high heat. 2. To prepare vinaigrette, combine first 6 ingredients in a large bowl; stir well with a whisk. 3. To prepare salad, drizzle lemon juice over fillets; sprinkle with 2 teaspoons pepper. Place fillets, skin sides up, on a grill rack coated with cooking spray; grill 5 minutes on each side or until fish flakes easily when tested with a fork or until desired degree of doneness. Remove skin from fillets; discard. 4. Add spinach to vinaigrette in bowl; toss well. Place 2 cups spinach mixture on each of 4 serving plates; arrange 1 fillet and 6 orange slices on top of greens. Salmon is full of omega 3s which are heart healthy. Spinach is low in calories, but still manages to be chock-full of vitamins and minerals, like iron, and Vitamin A. And the salad is flexible, change the spinach to romaine, the oranges to peaches, tailor it to what you like. Source: Arlene Ghent, New Haven, Connecticut, Cooking Light JULY 2009
Sweet Potato & Cabbage Slaw Serves 6 Directions Ingredients 2 tablespoons canola oil 1 tablespoon lime juice
1. Whisk canola oil, lime juice, sesame oil and salt in a large bowl. 2. Add sweet potato, cabbage, scallions and serrano (or jalapeno, if using); toss to combine.
1 1/2 teaspoons toasted sesame oil
3. Serve immediately.
1/2 teaspoon salt
This versatile side dish is low calorie, inexpensive, and easy to whip up. Double the recipe and take it along to your favorite BBQ, or sautĂŠ it in a pan as an accompaniment to your favorite fish. Providing lots of fiber and Vitamin K, this recipe is a winner. From: American Heart Association Nutrition Information: Sodium: 212 mg Calories Per Serving: 81 Carbohydrates: 7 g Total Fat: 6 g Fiber: 1 g Saturated Fat: 1 g Protein: 1 g Monounsaturated Fat: 3 g Potassium: 104 mg
3 cups coarsely grated peeled sweet potato (about 1 large) 3 cups thinly shredded napaor savoy cabbage 4 scallions, trimmed and thinly sliced 1 teaspoon finely-minced serrano or jalapeno pepper with seeds (optional)
11
Strawberry Rhubarb Cobbler Serves 12
Ingredients Filling: 1 quart strawberries, halved or quartered 3 cups sliced rhubarb 1/2 cup sugar 1/4 cup water 1 tbsp cornstarch 2 tbsp orange juice Top Crust: 1 cup whole grain pastry flour 1 tsp baking powder 1/2 tsp baking soda 1/2 cup sugar 1/8 tsp salt 4 tsp sugar 2 tbsp cold butter, cut in small pieces 1 tbsp fat-free plain yogurt 2 tbsp fat-free milk 1/4 tsp ground cinnamon Nutrition Information: Calories: 111.4 Fat: 2.3g Saturated Fat: 1.2g Sodium: 121.6mg
Carbohydrates: 22.1g Total Sugars: 12.8g Dietary Fiber: 2.4g Protein: 1.8 g
Directions 1. Preheat the oven to 400°F. Coat a 3-quart baking dish with cooking spray. 2. To make the filling: Place half of the strawberries in a large saucepan. Add the rhubarb, sugar, and water. Cover and cook over medium heat, stirring occasionally, for 10 minutes. 3. Place the cornstarch in a cup. Add the liqueur or orange juice and stir until smooth. Add to the saucepan and cook, stirring constantly for 1 minute or until thickened. Stir in the remaining strawberries. Pour the mixture into the prepared baking dish. 4. To make the top crust: In a medium bowl, mix the flour, baking powder, baking soda, salt, and 2 teaspoons of the sugar. Cut in the butter and yogurt until the mixture resembles coarse crumbs. Add the milk 1 tablespoon at a time and stir until the dough just holds together. 5. Turn out onto a lightly-floured surface and shape the dough 1” smaller than the size of the baking dish. Carefully lay the dough over the center of the strawberry mixture. 6. In a cup, mix the cinnamon and the remaining 2 teaspoons sugar. Sprinkle over the dough. 7. Bake for 20 to 25 minutes or until bubbling and golden brown. Cool on a rack for at least 10 minutes before serving. This wonderful dessert uses strawberries and rhubarb, which is grown and picked in the spring, which means they are at the peak of freshness and nutrition. Try using cherries, or apricots which are also in season. Using fruit is a great way to sweeten your dessert naturally. From: PREVENTION’S DECADENT DESSERTS FOR DIABETICS
Christine Wilkinson, MS, RD, LDN Cardiac Dietitian, Cooper University Health Care. 12
Clinical Trials
Q&As Clinical Trials
Jason Flood, a 20-year-old pilot, participated in a clinical trial to save his life.
You may have heard about the importance of clinical trials in cancer treatment, but did you know that there are many clinical trials under way in the field of vascular health? What are Clinical Trials? Before a new drug or medical device is put on the market, it must meet U.S. Food and Drug Administration (FDA) guidelines and go through a series of clinical trials. A clinical trial is a study involving human volunteers that is designed to answer specific health questions. The drugs and devices tested in clinical trials may or may not yet be FDA approved. A clinical trial can compare a new drug or device to the standard of care or follow the outcomes of patients who have received a surgical implant device, such as a stent. Clinical trials allow physicians and hospitals to provide the best and most recent methods of treatment to patients.
When Jason flew a plane at 300 ft. that crashed suddenly to the ground, he was not expected to live. Found at the crash site near the Jersey Shore – the plane was demolished – dozens of Jason’s bones were shattered as he was crumpled in the cockpit, and he was bleeding extensively. Rushed to a local hospital in critical condition, Jason was eventually air-lifted to Cooper University Hospital.
How are Clinical Trials conducted? Most drug and device clinical trials are divided into five phases. The first phase, Phase 0, involves pre-human testing. All phases following the first phase (Phase 1, Phase 2, Phase 3, and Phase 4) involve voluntary human testing on a larger scale. By the time the drug or device reaches Phase 4, hundreds to thousands of participants are part of the clinical trial.
Physicians first focused on the injury to his aorta, the largest artery in the body, which delivers blood from the heart to the rest of his body. If the aorta was not repaired immediately, Jason would die. Jason’s injury, known as “aortic transection,” resulted from traumatic force to his chest at the time of impact, resulting in ripping the aorta in half. (Continued on Page 14)
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At the beginning of a clinical trial, all participants must give their consent, known as informed consent. With informed consent, the participant is told the requirements of the study, treatment procedure, and the potential risks and benefits of treatment. Who can participate in Clinical Trials? Anyone can participate in clinical trials as long as that person meets the requirements set by the researchers or inclusion criteria. Each trial has a different set of requirements that must be met, including age, medical conditions, or medications.
Jason Flood and Joseph V. Lombardi, MD, FACS
(Continued from Page 13) Complications from Jason’s other injuries made conventional invasive surgery to repair his aorta through the ribs and chest too risky.
Why should you participate in a Clinical Trial?
His physician, Joseph V. Lombardi, Chief of Vascular and Endovascular Surgery, recommended Jason enroll in a clinical trial, named RESCUE, that involved a minimally-invasive procedure in which a stent graft was inserted into the aorta. The procedure would repair Jason’s aorta in a minimally-invasive way through a small groin incision, thereby allowing the other teams of physicians to address his other injuries quickly and effectively.
Clinical trials can benefit the medical community as well as the trial participants. Clinical trials can help medical researchers discover better treatments or a cure to certain medical conditions. Participants receive the opportunity to play an active role in the progress of medicine, as well as the potential to help others in the future. In Jason’s case, enrolling in a clinical trial saved his life. Clinicaltrials.gov provides a brief description of the clinical trials taking place in the United States. If you are interested in participating, ask your vascular surgeon if you qualify for any current clinical trials.
It has been a year later since Jason underwent his procedure. He is fully recovered following a successful repair of his aorta, as well as other surgeries involving his lower spine, legs and feet. Many of his physicians believed that Jason would never walk again. But not only is Jason walking, he is flying again in aerobatic competitions where he recently placed 2nd in a regional air show.
“Being at a center that offers clinical trials allows patients to participate in studies that may allow the use of advanced devices that are pending FDA approval.” Jonelle O’Shea, RN, MSN 14 16
Clinical Research Nurse Cooper University Health Care
TOS article (Continued from Page 3) immediate diagnosis and treatment. The first stage of treatment may include efforts to dissolve the clot. The second stage is geared toward removing the anatomical compression (first rib resection; removal of anterior scalene) of the vein and possible vascular reconstruction.
Smoking article (Continued from page 2) likely to develop aneurysms than non-smokers and continued smoking can cause aneurysms to grow and expand. Buerger’s Disease (thromboangiitis obliterans) is a vascular disease that affects smokers. This condition can strike young patients (ages 20-40) and can unfortunately result in limb loss due to poor circulation. It would otherwise be uncommon for a person of this age group to experience problems with blood flow that results in an amputation.
Arterial TOS (ATOS), the rarest form of TOS, is caused by compression of the major arteries of the arm (axillary and subclavian). This can lead to acute ischemia of the arm, resulting in tissue loss (ulcers and gangrene) and nerve damage. Additionally, ATOS may lead to the formation of an aneurysm (bulge in the blood vessel), causing small blood clots (thrombus) to break up and spread (embolize) to distal hand arteries.
It can be very difficult to quit smoking. As research suggests, nicotine may be as addictive as substances such as heroin, cocaine, or alcohol. Quitting smoking may take a patient several attempts before achieving success. Personal stress, weight gain, and uncomfortable symptoms of withdrawal (anxiety, irritability, increased appetite) can cause a person to fail at their attempt at smoking cessation. The benefits of quitting smoking are numerous, including reducing the risk for cancers, heart disease, stroke, PAD, lung disease, and infertility. The positive effects of smoking cessation start within 48 hours of your last cigarette. Blood pressure will decrease, heart rate lowers, carbon monoxide levels in the blood return to normal, oxygen levels in the blood increase, the chance of having a heart attack decreases, and one’s sense of taste and smell improves. Within the first year of quitting smoking, circulation and lung function improves and shortness of breath and coughing will decrease.
TOS is a rare medical problem. Although the vascular forms are more straightforward to diagnoses, they require prompt medical attention and treatment to prevent further complications. NTOS remains very difficult to diagnose and often requires a team approach to formalize the diagnosis and design a treatment plan. Varicose Veins article (Continued from Page 8) garments that inhibit circulation. If you sit or stand for a long time at your job, be sure to get up, stretch or move around several times during the day. Prop up legs if necessary. Always speak with your physician before making any lifestyle changes.
Resources are available to help smokers achieve success when abstaining from cigarettes. There are over-the-counter nicotine replacement medications (nicotine patch, gum, lozenge), prescription nicotine replacement medications (nicotine inhaler and nasal spray), prescription non-nicotine medications (buproprion SR, Chantix), counseling, support groups, and alternative therapies (hypnosis, acupuncture). 1-800-QUIT-NOW is a free telephone support service that is available to help smokers who are interested in quitting. Combining medications and counseling is recommended for the greatest success. Cooper Cancer Institute offers a Smoking Cessation 6-week group along with individual counseling. For more information, call 856.673.4254.
Carotid Artery Disease article (Continued from Page 6) is important for every circumstance, there is a lower threshold for surgery for the “symptomatic patient”. What should I do if I am found to have carotid disease? The most important thing to do is to see a vascular surgeon who specializes in both surgical carotid endarterectomy as well as minimally-invasive stenting. This will allow the best possible treatment to be selected for your particular disease. 15
Test your VaScular Vascular Vitality knowledge!
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DOWN 1. Weakened area of a blood vessel that expands or bulges (pg. 10) 2. Contains 4,000 chemicals, of which 70 of them cause cancer (pg. 2) 4. Most likely to develop varicose veins (pg. 7) 5. A common, non-invasive treatment for varicose veins (pg. 8) 6. Artery in which blood flows from the heart to the rest of the body (pg. 9) 7. Hardening of the arteries (pg. 9) 8. Risk factor for PAD (pg. 4) 9. Rarest form of Thoracic Outlet Syndrome (pg. 15) 13. Laser-guided energy to treat varicose veins (pg. 8)
Across 2. Pain or cramping in the legs (pg. 4) 3. The 2 main blood vessels that supply most of your brain with blood (pg. 6) 2 words 7. Most aneurysms are caused by (pg. 10) 10. Largest risk associated with carotid artery blockage (pg. 6) 11. A study involving human volunteers (pg. 13) 2 words 12. These are mostly found in the legs & can appear blue, twisted and enlarged (pg. 7) A T H E R O S C C L E V A R O S I S
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A N E C L A U D I C A T I O N U R I Y G C A R O T I D A R T E R I E S M R E S A W R T E R I O S C L E R O S I S T M L R M E O A E T E S K R R A N I T O N E T G R H T R O K E I E I N I C A L T R I A L L A P Y
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Vascular Vitality VASCULAR VITALITY A Publication of Cooper University Health Care, Division of Vascular and Endovascular Surgery 1.800.8.COOPER CooperHealth.org