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News & Education

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News & Education

Discover our expert insights.

Percuntaneous Fem-Pop

Percuntaneous Fem-Pop

Claudication Critical Limb Ischemia Leg & Foot Ulcers
75 year old male, prior right leg bypass graft from the common femoral artery to the anterior tibial artery. Bypass graft failed due to poor outflow in the anterior tibial artery. During thrombolysis the patient had a large retroperitoneal bleed. Treatment was stopped and the patient was told there were no other options…
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Renal Vein Stent Adjustment

Renal Vein Stent Adjustment

Pelvic Venous Incompetence Renal Vein
Female initially presenting with pelvic venous congestion secondary to Nutcracker Phenomena. After treatment of the PVC, the patients pelvic complaints improved but they developed worsening symptoms of Nutcracker Syndrome. The NCS was treated with renal vein stenting and the symptoms improved. However, the patient had new right sided pain with deep breathing. The renal vein…
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Left Leg DVT Secondary to IVCS

Left Leg DVT Secondary to IVCS

Iliac Vein Compression Venous Insufficiency Venous Thrombosis
30-year-old female, on oral contraceptives, with severe left leg swelling after a long car ride. Ultrasound showed left iliofemoral deep venous thrombosis (DVT). The patient was started on anticoagulation. 5 days later, the patient still had severe swelling and pain. Pharmacomechanical thrombolysis using TPA and the Angiojet was performed with removal of the bulk of…
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Painful Right Toe

Painful Right Toe

Critical Limb Ischemia Peripheral Arterial Disease
94-year-old female, worsening right toe and foot pain. Seen by primary care and diagnosed as having gout. The clinical findings of critical limb ischemia - dry scaly skin, nail changes, absent pulses and a punched out ulcer on the 2nd toe - were ignored. Popliteal artery occlusion treated with atherectomy.
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Ischemic Ulceration

Ischemic Ulceration

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
92 year old female with left foot rest pain and worsening ulcers of typical of ischemia. CTA demonstrated severe PAD with heavy calcification in the femoral, popliteal, tibial and pedal arteries with a solid wall of calcium at the adductor canal. These types of lesions are often difficult to cross and often result in a…
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Lateral Malleolus Ulcer

Lateral Malleolus Ulcer

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
86 year old female with a several month history of a painful non-healing ulcer over the lateral malleolus. This area is in the peroneal artery angiosome. Occlusions of the peroneal and posterior tibial artery were treated with orbital atherectomy. Ulcer healed within 1 month.​
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Popliteal Aneurysms and Toe Ulcers

Popliteal Aneurysms and Toe Ulcers

Aneurysm Critical Limb Ischemia
The patient was initially seen for ischemic ulceration of right foot toe ulcers and was found to have 2 left popliteal artery aneurysms. The patient declined treatment of the aneurysms at that time. 18 months later the aneurysms occluded and the patient developed ulcerations of several left toes with rest pain. Revascularizion was performed using…
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Gangrene Failed BPG

Gangrene Failed BPG

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
83-year-old male, Type I Diabetes, end stage renal disease, living independently who was told he needed a below knee amputation. The patient had a failed popliteal to dorsalis pedis artery bypass graft. An attempt at endovascular repair also failed. The patient came for a second opinion. A second at endovascular repair was successful. The patient…
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Nonhealing Ulcer

Nonhealing Ulcer

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
82-year-old male, heavy smoker, developed right heel ulcer during rehab after a femur fracture. No pulses in the foot but they could "heard" with doppler. Told to stay off their feet until the ulcer healed. CT angiography shows severe multilevel peripheral artery disease. A simple inflow endovascular procedure restored enough blood flow to achieve healing.
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DPA Wire Fragment Retrieval 

DPA Wire Fragment Retrieval 

Critical Limb Ischemia
82 year old male with non healing ulcer of the great toe. Severe peripheral arterial disease with long segment occlusion of the posterior tibial artery and severe disease of the distal anterior tibial artery. During crossing of the severe stenosis of the ATA the tip of the hydrophilic wire was bent and then fracture while…
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Retrograde ATA Recanalization​

Retrograde ATA Recanalization​

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
79-year-old female with non healing ulcers. Occlusion of all three arteries in the calf. Antegrade attempt at opening the anterior tibial artery failed. Retrograde crossing from the distal anterior tibial artery was successful. Treated with orbital atherectomy and angiograplasty. Ulcers healed in under 4 weeks. Entire procedure done in 75 minutes. Patients entire stay was…
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Two Failed Fem-Pop BPGs

Two Failed Fem-Pop BPGs

Critical Limb Ischemia Peripheral Arterial Disease
71-year-old female with a non healing ulcer on the left foot. Previously had a femoral to popliteal artery vein bypass graft which had occluded and was not salvageable. In addition, the patient had end stage renal disease but was not on dialysis. The long superficial femoral artery occlusion was crossed in the subintimal space. Reentry…
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2nd Toe Ulcer

2nd Toe Ulcer

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
67 year old male, type1 diabetic, with painful ulceration at the tip of the second toe. Patient did not toe amputation. Although toe amputation sounds simple it leads to biomechanical changes in the foot which can cause progressive deterioration and further more significant amputations. Angiography showed the severe stenosis in the plantar arch. The plantar…
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Failed Bypass Graft

Failed Bypass Graft

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
64 year old male, type 1 diabetes, with a prior femoral to politeal bypass graft and a subsequent poplileal to tibial bypass graft. The later graft failed and the patient was told there were no other options to restore blood flow. Endovascular reconstruction of the popliteal artery and tibioperoneal trunk restored blood flow and wound...
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Neuro-Ischemic Ulcer

Neuro-Ischemic Ulcer

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
61 year old male, diabetic, developed a lateral right foot ulcer after a pedicure. The posterior tibial artery pulse was palpable. No dorsalis pedis artery pulse. Monofilament testing showed decreased sensation typical of diabetic neuropathy. Angiography showed distal PTA stenosis and severe stenosis in the proximal lateral plantar artery - the blood supply to the…
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Blue Toe from Ulcerated Popliteal Artery Plaque

Blue Toe from Ulcerated Popliteal Artery Plaque

Atheroembolism Critical Limb Ischemia Peripheral Arterial Disease
59 year old male, smoker, sudden onset of pain and discoloration of the right 3rd toe. Comprehensive workup for an embolic source demonstrated a focal plaque in the popliteal artery. Catheter angiography showed the ulcerated plaque. Directional atherectomy using a SilverHawk atherectomy device was performed. Patients symptoms resolved and at last follow up 2 years…
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Neuro-Ischemic Ulceration

Neuro-Ischemic Ulceration

Critical Limb Ischemia
51 year old male with Type 1 Diabetes and a lateral foot ulcer for 4 months. Patient received standard wound care with slow progression of the ulcer and was offered a below knee amputation. Skin perfusion testing showed normal perfusion. CT angiography demonstrated severe stenosis at the origin of the anterior and posterior tibial arteries…
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Pedal Loop Reconstruction

Pedal Loop Reconstruction

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
46 year old male, type 1 diabetes, with ulcers on several toes. Patient had palpable pulses at the ankle. Angiography shows occlusion of the distal dorsalis pedis artery and of the distal lateral plantar artery. The deep plantar artery and plantar arch were reconstructed and the wounds healed
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Rest Pain in Elderly Female

Rest Pain in Elderly Female

Critical Limb Ischemia Peripheral Arterial Disease
104 year old female, treated 3 years earlier for critical limb ischemia of the right foot. Now presents with a 2 month history of worsening left foot rest pain.
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Misdiagnosed Painful Toe

Misdiagnosed Painful Toe

Critical Limb Ischemia Leg & Foot Ulcers Peripheral Arterial Disease
Patient told the pain was due to an ingrown toe nail and sent home on narcotics. The patient went to podiatry and was correctly diagnosed as having critical limb ischemia.​
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Internal Iliac Artery Aneurysm

Internal Iliac Artery Aneurysm

Aneurysm Peripheral Arterial Disease
Internal iliac artery aneurysms are rare. In most instances, they do not cause symptoms unless they rupture. Mortality after rupture is about 50%. Aneurysm under 25-30mm in size can be watched with serial imaging - typically CT. Aneurysms > 25-30mm should be treated to avoid rupture. Endovascular repair is preferred to open surgery as it...
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Groin Pseudoaneurysm

Groin Pseudoaneurysm

Aneurysm Peripheral Arterial Disease
Advantages of an endovascular approach versus an open surgical procedure are clear - safer, faster recovery, no general anesthesia, almost no risk of infection, and no large groin incision.
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Post Thrombotic IVCS in a Triathlete

Post Thrombotic IVCS in a Triathlete

Iliac Vein Compression Venous Insufficiency Venous Thrombosis
36-year-old female with a left lower extremity iliofemoral deep venous thrombosis (DVT) and pulmonary embolism (PE) 9 years prior. Increasing problems with left leg venous claudication with exercise. Symptoms limiting the patient's ability to be active. MR venography showed occlusion of the left iliac venous system typical of May Thurner syndrome or iliac vein compression syndrome…
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Thrombosed Popliteal Artery Aneurysm

Thrombosed Popliteal Artery Aneurysm

Claudication Critical Limb Ischemia Peripheral Arterial Disease
A 75-year-old male with severe PAD. Prior endovascular AAA repair. Prior right leg bypass graft times 2. Both failed. Prior right leg percutaneous bypass graft 9 months ago for CLI. Worsening left leg claudication and rest pain. The patient has a thrombosed bilobed popliteal artery aneurysms. Recanalization failed using conventional techniques even with antegrade and retrograde…
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Ulceration due to External Iliac Vein Compression

Ulceration due to External Iliac Vein Compression

Iliac Vein Compression Leg & Foot Ulcers Venous Insufficiency
A 65-year-old male presented with a right lower extremity venous ulcer. During workup, the patient was found to have extensive incompetence of the superficial and deep venous systems. This prompted evaluation for venous outflow obstruction. CT Venography showed compression of the proximal right external iliac vein at the right common iliac artery bifurcation between the external…
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Recurrent Leg DVT

Recurrent Leg DVT

Iliac Vein Compression Venous Thrombosis
72-year-old male patient with 3 left lower extremity DVTs. The patient was developing severe post-thrombotic syndrome (PTS). The patient was positive for Lupus anticoagulant was being treated with oral anticoagulation. Apart from a lower extremity venous ultrasound, no investigation of the pelvic venous system was done. Imaging of the venous outflow in the abdomen and pelvis…
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Painful Varicoceles in a High School Athlete

Painful Varicoceles in a High School Athlete

Varicoceles
17-year-old male with 2 years of worsening bilateral testicular pain. The pain progressively got worse as the day progressed and with any strenuous activity. In particular, the pain was interfering with high school sports. The patient wanted the procedure with the fastest recovery and best outcomes. Data from patients I have treated show that in…
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CFA Occlusion, Claudication and Rest Pain

CFA Occlusion, Claudication and Rest Pain

Claudication
62-year-old female, a heavy smoker, noticed a relatively sudden worsening of chronic right calf claudication. Ultrasound and CT angiography demonstrated occlusion of the common femoral artery. The patient is overweight with a body mass index of 35. The patient was self-employed and did not want to, nor could afford the time off work to undergo…
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Venous, Arterial, or Mixed Ankle Ulceration

Venous, Arterial, or Mixed Ankle Ulceration

Venous Insufficiency
86-year-old male with left ankle ulceration. Recurrent ulceration at the left ankle over the last 6 years. The current ulcer had been present for over 5 months. Local wound care only. No investigation into the cause of the ulcer. Patient had symptoms of rest pain. Venous ultrasound showed superficial venous incompetence. Arterial testing showed severe…
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AortoIliac Occlusive Disease

AortoIliac Occlusive Disease

Claudication Critical Limb Ischemia Peripheral Arterial Disease
62-year-old male, heavy smoker, with a long history of leg pain with walking. Lumar spine fusion was done with no improvement in symptoms. Exercise ABI's demonstrated severe peripheral arterial disease. CT angiography showed occlusion of the infrarenal abdominal aorta, bilateral common iliac arteries, left external iliac artery, and severe right external iliac artery disease. Recanalization…
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Chronic Pelvic and Low Back Pain

Chronic Pelvic and Low Back Pain

Iliac Vein Compression Pelvic Venous Insufficiency
A 51-year-old female with chronic pelvic complaints undiagnosed for many years. She was referred after her doctor saw a presentation I gave about pelvic venous disease in females. Workup of her pelvic pain using trans-vaginal and trans-abdominal ultrasound demonstrated an incompetent left internal iliac vein. CT venography was obtained, confirming severe compression of the left…
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30 Years of Pelvic Pain

30 Years of Pelvic Pain

Iliac Vein Compression Pelvic Venous Insufficiency Renal Vein
62-year-old female correctly diagnosed over 15 years ago with pelvic congestion syndrome (PCS). The patient was offered a hysterectomy which is not the first line of treatment for this condition. She declined. The patient was identified by her chiropractor as have PCS and was referred for treatment. In this patient, the primary cause of PCS…
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Debilitating Leg Pain

Claudication Peripheral Arterial Disease
A 59-year-old male with short distance exercise-induced left leg pain. The pain was severe and was interfering with the patients actively living. He was seen and treated for neurogenic claudication for several months without any improvement. The patient had palpable pulses in the left foot, which was mistaken as indicating he had good blood flow…
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Non-Healing Ulcer After Skin Biopsy

Non-Healing Ulcer After Skin Biopsy

Leg & Foot Ulcers Venous Insufficiency
A 55-year-old female with ulceration after a skin lesion was removed from the posterior calf. Lesion turned out to be a basal carcinoma. Seven weeks after the surgery, the patient had a large area of ulceration with copious drainage of fluid. The patient returned to the physician that did the procedure was told to continue…
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Right Flank Pain With Exertion

Right Flank Pain With Exertion

Claudication Peripheral Arterial Disease
A 50-year-old female has right flank pain that occurs when walking. Extensive workup for nonvascular causes was done, and severe stenosis in the abdominal aorta was found. During further workup, the patient had typical symptoms of leg claudication. However, it was their flank pain that was causing the most concern. Flank pain due to claudication…
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Endovascular Treatment of EIA and CFA Occlusions

Endovascular Treatment of EIA and CFA Occlusions

Claudication Peripheral Arterial Disease
56-year-old male, a lifelong smoker, presents with severe bilateral lower extremity claudication. At the initial visit, medical management and risk factors were addressed. Trial of management with Pletal failed at 1 month due to side effects. The patient's employment was at risk due to limitations in walking. CT angiography showed left external iliac, common femoral…
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Post Aorto-Bifemoral Graft Placement

Post Aorto-Bifemoral Graft Placement

Claudication Peripheral Arterial Disease
60 year old female, smoker, underwent aorto-bifemoral bypass graft placement for severe iliac artery occlusive disease and short distance claudication. Patient had symptomatic improvement but quickly deteriorated on the right with worse symptoms than prior to surgery. Exercise ABI's showed severe PAD with claudication at 125 yards. Patient was at risk of losing employment…
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Dyspareunia and Dysuria

Dyspareunia and Dysuria

Pelvic Venous Incompetence Venous Insufficiency
A 36-year-old female with typical symptoms of pelvic venous insufficiency. Primary complaints of pelvic heaviness, painful intercourse, and urinary frequency. Transvaginal ultrasound demonstrated left ovarian vein incompetence with extensive pelvic varicosities. Large varicose veins were found around the base of the bladder consistent with the patient's symptoms of urinary frequency. Treatment with foam sclerotherapy and…
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Prostate Cancer with Left Leg Swelling

Prostate Cancer with Left Leg Swelling

Iliac Vein Compression
65-year-old male, T3a prostate cancer. Prior robotic lymph node dissection for staging. Post-operative lymphocele developed along the left external iliac vein. Percutaneous drainage decompressed the fluid collection and improved the leg swelling. Collection re-occurred, and the leg swelling worsened with severe pain. Venography and intravascular ultrasound (IVUS) showed severe narrowing of the external iliac vein…
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50 Yard Claudication

50 Yard Claudication

Claudication Peripheral Arterial Disease
64-year-old female with a 2-year history of worsening left calf claudication. Pain has become severe enough the patient is having a hard time working and staying employed. CT angiography showed a heavily calcified common femoral artery plaque causing near occlusion of the artery. Retrograde superficial femoral access with directional atherectomy was attempted but limited due…
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Orbital Atherectomy

Orbital Atherectomy

Claudication Peripheral Arterial Disease
87-year-old male, living independently in a long-term facility. He could not walk from his room to the dining hall without stopping twice for severe left leg pain. Would 15 minutes to walk one block. Treated with atherectomy and angioplasty. He was able to walk out from the procedure to his car with no leg pain…
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Chronic Iliofemoral DVT in a Young Male

Chronic Iliofemoral DVT in a Young Male

Iliac Vein Compression Venous Insufficiency Venous Thrombosis
22 year old with severe post thrombotic syndrome 6 months after left leg deep venous thrombosis (DVT). Initial attempt at catheter directed thrombolysis without iliac vein stenting resulted in re-thrombosis. The patient had severe restriction in activity due to venous claudication and he wanted to see if anything could be done. He underwent stenting and…
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Post Thrombotic Ulcer

Post Thrombotic Ulcer

Venous Insufficiency Venous Thrombosis
A 38-year-old female with deep venous thrombosis 14 years ago while on birth control pills. Second DVT shortly after discontinuing anticoagulation. Hematologic workup showed the patient to have Protein S deficiency. The patient suffered from severe post-thrombotic syndrome, eventually resulting in venous ulceration 8 years ago. The patient suffered from a chronic ulcer that eventually…
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Recurrent Varicocele After Incomplete Embolization

Recurrent Varicocele After Incomplete Embolization

Varicoceles
22 year old with a 10 year history of left groin and testicular pain. Prior embolization about 4 years ago with a temporary improvement of symptoms. Only the proximal left testicular vein was embolized. The patient had asymptomatic compression of the left renal vein (Nutcracker Phenomena) leading to the develop of renal vein collaterals to…
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Claudication for 4 Months

Claudication
63-year-old male with a sudden onset of left leg claudication. Symptoms started after a day of gardening. CT Angiography demonstrated a thrombosed right popliteal artery aneurysm. The aneurysm was treated with stent grafting and resolution of symptoms.
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Pelvic Venous Congestion: Symptoms

Pelvic Venous Incompetence
Pelvic congestion syndrome (PCS) is a condition that causes significant pain and discomfort for women.
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Venous Claudication

Iliac Vein Compression Venous Insufficiency Venous Thrombosis
Venous claudication occurs when venous drainage from the left is impaired, Diagnosis and treatment are often delayed.
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Venous Valves on Ultrasound

Venous Insufficiency
Valves are one of the key components of normal venous function. There are valves throughout the veins in the body.
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Clinical Evaluation of the Foot for Peripheral Arterial Disease

Critical Limb Ischemia Peripheral Arterial Disease
Peripheral arterial disease (PAD) and its more severe variant critical limb ischemia (CLI) can be notoriously difficult to diagnose.
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Reperfusion Syndrome and Critical Limb Ischemia

Reperfusion Syndrome and Critical Limb Ischemia

Critical Limb Ischemia Peripheral Arterial Disease
Reperfusion syndrome and inury can occur after revascularization in patients with critical limb ischemia but the entity is poorly understood.
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Varicocele Embolization Outcomes – Skill Matters

Varicocele Embolization Outcomes – Skill Matters

Varicoceles
Varicoceles are a collection of dilated veins around the testicle. They are common and occur in about 1 of 10 men, usually 20-40 years of age.
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Vascular Evaluation in Patients with Lower Extremity Ulceration

Vascular Evaluation in Patients with Lower Extremity Ulceration

Critical Limb Ischemia Leg & Foot Ulcers Venous Insufficiency
Lower extremity wounds are complex and challenging for patients, families, and healthcare providers. Most lower extremity ulcers are secondary to either or both arterial and venous problems. A comprehensive history and physical assessment followed by appropriate imaging are essential to identify, diagnose and develop care plans. Dedicated vascular specialists should be involved in the care…
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