Circulatory Problems of the Arteries and Veins

How to Choose a Doctor and Hospital for Your Treatment

Hospitals and doctors are not all alike…

…they vary in quality due to differences in their training, experience and services. These differences in quality become greater and matter more when you need sophisticated medical care for a complex condition.

A surgeon who performs a complex procedure often, for example, has better results with it than a surgeon who does the same procedure only occasionally. The complication rate and death rate of the same procedure may be many times higher at one hospital than another.

Clearly, the doctor and hospital that you choose have a direct impact on how well you do — especially when you need treatment for a condition such as peripheral vascular disease.

Circulatory problems of the arteries and veins outside the heart — peripheral vascular disease — affect more than 5 million Americans. Most people with peripheral vascular disease are over 50 years old, and many of them have underlying health problems such as heart disease, high blood pressure or diabetes.

This guide deals primarily with peripheral artery disease, the more serious of the two types of peripheral vascular disease. Left untreated, peripheral artery disease can cause death, stroke, severe high blood pressure or loss of kidney function, as well as infection, gangrene or loss of a leg or foot.

The full picture, however, is far more hopeful. With proper diagnosis and treatment, the outlook for people with peripheral artery disease can be positive. Many effective treatments are available that allow patients to live normal lives with few restrictions.

But, this means making some difficult and important decisions such as choosing a doctor and hospital for your treatment. Making comparisons like those discussed in this guide is not possible in an emergency. If you make these comparisons early, you will be prepared if and when the need for treatment arises.

How Do You Judge Quality?

Most of us do more research when we buy a car or a television set than when we choose a doctor and hospital. That may be because we don't know what questions to ask or on what to base our evaluation. There are few consumer magazines that rate doctors and hospitals the way Consumer Reports rates air conditioners.

Quality of care can be measured in many different ways, and no universal agreement exists on which should be used. At The Cleveland Clinic Foundation, however, we believe that you can use the following six points, or quality indicators, to compare health care providers:

-Credentials

-Experience

-Range of services

-Participation in research and education

-Patient satisfaction

-Outcome

Choosing a doctor or hospital is often influenced by values. You may want to go to a hospital that is close to home. You may want a hospital with a specific religious affiliation. But when you need specialized medical and surgical care for peripheral vascular disease, you also should consider a doctor's qualifications and a hospital's outcome record. These quality indicators will help you make that kind of evaluation, should you require treatment for peripheral vascular disease.

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A Step-by Step Guide

This brochure deals with peripheral vascular disease and helps you choose a doctor and hospital by:

-explaining peripheral arterial and peripheral venous diseases;

-describing how they are diagnosed;

-explaining the treatments available for peripheral vascular disease, including medical treatment, nonsurgical interventions and surgery for peripheral arterial disease and conservative treatments and medical therapies for peripheral venous disease;

-explaining six points that indicate quality in treating peripheral arterial disease; and

-providing questions and answers from the Cleveland Clinic that you can use to compare doctors and hospitals.

Peripheral Artery Disease

Arteries carry blood from the heart to the rest of the body. Peripheral artery disease includes any changes in the arteries outside the heart that prevent the normal flow of blood or weaken the arterial wall. It is caused by atherosclerosis or "hardening of the arteries," which is the accumulation of plaque (deposits of fat, cholesterol and calcium) on the arteries' interior walls. Plaque frequently narrows the inside of the arteries, which obstructs blood flow.

When atherosclerosis occurs over time in the arteries leading to the heart, it causes a heart attack. In the arteries outside the heart, atherosclerosis causes other types of circulation problems.

If atherosclerosis occurs in the leg arteries, it may cause an ache, pain or cramp during exercise, which is relieved by rest (claudication). As the blockage worsens, the person may have leg or foot pain even when in bed. At worst, circulation problems in the leg may result in skin ulcers, gangrene, or the risk of amputation. Atherosclerosis occurs in the arms only rarely.

An embolus is a blood clot or piece of plaque that floats through the bloodstream to a new location and blocks the flow of blood. Embolization gradually or suddenly stops the flow of blood to a limb, the kidneys, intestines or brain. The sudden onset of embolization in a limb may cause pain, numbness or paralysis. Left untreated, an embolus in a limb can cause permanent damage, and amputation may be necessary.

Atherosclerosis or embolization in the carotid (neck) arteries that lead to the brain can cause a stroke. Blockages that occur in the kidney arteries may result in uncontrollable high blood pressure or kidney failure.

Atherosclerosis may also cause an aneurysm, a bulging out of the arterial wall. Aneurysms can occur in any artery, but are often found in the abdominal aorta, the main artery in the abdomen that carries blood to the legs and major organs. Aneurysms occur most often in people over 60 and are more common in men than in women. Untreated, an abdominal aneurysm can rupture and cause massive internal bleeding, which is often fatal.

How is peripheral artery disease diagnosed?

Peripheral artery disease is diagnosed by a physician performing a history and physical examination combined with special tests that measure blood flow and allow visualization of the arteries.

Typical tests include:

-Doppler ultrasound, which uses a microphone placed on the skin over the pulse areas to determine if a blockage is present;

-Segmental pressure readings that measure changes or drops in blood pressure along the leg;

-Duplex ultrasound, which combines a microphone with an image of the vessel to measure velocity of the blood flow; and

-Computerized axial tomography (CAT or CT), a computer-directed scan that takes cross-sectional X-ray views of the head and body to reveal the size and location of aneurysms.

These noninvasive tests have greatly reduced the need for invasive tests such as angiography (a series of X-rays of the blood vessels taken after injection of a dye). Angiograms are usually necessary only in patients who will be undergoing an operation or other intervention.

How is peripheral artery disease treated?

Determining the most appropriate treatment for an individual patient with peripheral artery disease often requires a multidisciplinary team involving physicians from several specialties. Vascular medicine specialists, interventional radiologists and vascular surgeons collaborate to develop a treatment plan for the peripheral vascular problem and may choose to consult with other specialists to coordinate treatment of underlying problems such as diabetes or heart disease.

Depending on the severity of the disease, the patient's general health and related medical problems, treatment may involve medical, nonsurgical or surgical intervention, or a combination of these.

Patients with mild forms of disease may be treated effectively with exercise, medication and risk reduction. The most commonly used drugs include cholesterol-lowering agents, aspirin, and other drugs that improve blood flow and prevent clot formation. Risk reduction education includes smoking cessation and dietary modifications.

Patients with more severe disease, particularly those with blockages in the arteries of the leg who have pain on walking, may undergo a percutaneous (through the skin) nonsurgical intervention. The options include:

Thrombolytic therapy: the use of drugs administered directly into a clot or embolus by a small, thin tube (catheter) to break it up and restore blood flow. Thrombolysis is most commonly used in conjunction with other nonsurgical interventions.

Balloon angioplasty: the use of a catheter equipped with a small balloon to open blocked arteries and restore blood flow.

Stenting: the insertion of small, stainless steel tubes into an artery to maintain its interior diameter.

Atherectomy: the use of a device that shaves plaque from artery walls to restore the vessel's interior diameter and improve blood flow.

Patients with the most severe peripheral artery disease usually require surgery to open the blocked or weakened arteries. Many different types of surgical intervention are performed for peripheral artery disease. Several of the most important ones are described below:

Carotid endarterectomy is the surgical opening of the carotid artery and removal of plaque that is blocking blood flow to the brain.

Arterial reconstruction and revascularization involve surgically rebuilding or bypassing arteries, usually in the leg, using grafts from healthy vessels.

Aortic aneurysm resection is the repair of an abdominal aortic aneurysm to prevent its rupture. An artificial graft is used to replace the weakened section of arterial wall.

Peripheral Venous Disease

Peripheral venous system disorders may affect people in any age group. These problems may be acute or chronic. Although they can cause discomfort, they are generally not life-threatening and do not involve the risk of amputation.

Acute venous disorders

Thrombophlebitis, commonly referred to as phlebitis, is the formation of a blood clot in an arm or leg vein. It can occur in a superficial vein near the skin surface or in a deep vein. Pain and inflammation are the most common symptoms.

When the clot is in a deep vein, it is called deep vein thrombosis or thrombophlebitis (DVT). It typically occurs suddenly, and may be related to prolonged periods of inactivity, injury to the vein, surgery or pregnancy. DVT is often characterized by swelling of the arm or leg and some enlargement of the veins in the arm or leg.

One of the dangers of DVT is that a blood clot from an arm or leg may break loose and travel through the central venous system and into the lungs. This is called a pulmonary embolism, and it is a potentially life-threatening problem.

Chronic venous disorders

Chronic venous insufficiency is a serious, long-term venous disorder caused by defective valves in the veins. When the valves do not close correctly, blood pools in the leg. This creates high venous pressure in the lower leg (venous stasis) and can cause swelling, skin discoloration, pain, skin ulcers and disfigurement of the leg.

Varicose veins and spider veins are much less serious than chronic venous insufficiency, although they may also be caused by defective valves in the leg veins. Obesity, hormonal factors in women, pregnancy or occupations that require long periods of standing can aggravate varicose veins.

How are peripheral venous diseases diagnosed?

Vascular medicine specialists diagnose these conditions by listening to a patient's history, performing a physical examination, and using a variety of noninvasive and invasive techniques.

Noninvasive tests include Doppler ultrasound in which a small ultrasound microphone is placed on the skin over the vein to determine the presence of clots or blockages and the condition of the valves. Duplex scans may be used in which a Doppler test is combined with an image of the vessel to detect blood clots or assess the valves.

A venogram is the most frequently used invasive test. It involves the injection of a dye into the vein, followed by X-rays to evaluate blood flow and clot formation.

How are peripheral venous diseases treated?

Bed rest, elevation of the leg and use of support stockings are all conservative measures that can be effective elements of treatment for any venous disease. For patients who require more aggressive intervention, other effective medical treatments are available. Surgery is seldom necessary. In fact, most patients are treated without hospitalization.

Most patients with deep vein thrombosis are successfully treated using anticoagulant drugs (blood thinners), agents that prevent further clot formation. Thrombolytic agents (clot dissolvers) may also be used to treat some patients, which requires that the patient be hospitalized.

Stasis ulcers (open sores on the lower legs) are usually treated by applying topical medications and one of several types of dressings (bandages) to the area affected, in addition to the use of support stockings.

The pain of varicose veins is often relieved through conservative treatments combined with an exercise program of walking and swimming. When varicose veins or spider veins are unsightly or very painful, sclerotherapy offers a nonsurgical solution. In this office procedure, a chemical solution is injected into the veins, causing them to collapse and reducing their visibility.

Where Do You Begin?

Measuring quality in ways that are useful to consumers is a new idea in health care. Because of that, it may not be possible to get complete information for each of these quality indicators. But the willingness of providers to give you as much information as possible is a good sign. It shows that they are dedicated to maintaining and improving their quality, responsive to patients, and confident of their capabilities.

If you are diagnosed with peripheral artery disease, ask your doctor about seeing a physician who specializes in vascular medicine. If you are told you may need surgery, ask for a referral to a vascular surgeon who has experience with the full range of surgeries used to treat peripheral artery problems.

Get the names of several doctors and hospitals that offer the newest, most effective treatments and have the most experience in treating peripheral artery disease. Look for a hospital that offers a team approach to diagnosis and treatment. Ask the questions we suggest. Make sure the answers are not just data from medical journals, but actually reflect that doctor's and hospital's experience. Make comparisons. Then make your decision. Be an informed consumer.

How to Use Quality Indicators

How can you use these indicators to judge if one doctor or hospital is better for you than another? By combining information from more than one quality indicator, according to a report, "The Quality of Medical Care: Information for Consumers," produced by the U.S. Congress, Office of Technology Assessment.

According to the report, patients about to have surgery can be confident if the hospital performs a high number of surgeries, has a low mortality (death) rate, and if the surgeon has extensive training and experience in the procedure.

On the other hand, the report states "...if a hospital has a high mortality rate and a low volume of procedures, the patient might wish to question the surgeon about that hospital and about alternatives, even if other hospitals require longer travel."

1. Credentials

Do the doctor and hospital measure up?

Credentials have been set by nationally recognized medical professional organizations to verify that doctors and hospitals meet certain standards in health care delivery.

Doctors:

Board certification, or the international equivalent, is a sign that doctors are highly trained in their fields. Doctors who specialize, such as vascular surgeons and vascular medicine specialists, should be board certified in the specialty in which they are practicing. Each specialty has a national board that is responsible for setting standards doctors must meet in order to be certified. Doctors who are board certified in their specialties have completed the amount of training that the specialty board requires, have practiced for a specified number of years in that specialty and have passed a difficult examination in their specialty areas. Some excellent doctors are not board certified. Board certification, however, is generally a good indicator of competence and experience.

Hospitals:

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nationwide authority that surveys hospitals. The JCAHO decides whether a hospital gets, keeps or loses accreditation based on its meeting certain criteria for staffing, equipment and facility safety requirements. Although accreditation is voluntary, most hospitals go through the process. If the hospital that you are considering is not accredited, it is important to know why.

Hospitals that do measure up are often in the public spotlight for their medical advances and the quality of their care. Information about a hospital's reputation is widely available through the mass media, magazines such as U.S. News & World Report, the government and consumer groups.

Vascular Laboratories

The Intersocietal Commission on the Accreditation of Vascular Laboratories (ICAVL) sets the standards for noninvasive vascular testing facilities. To be accredited by the ICAVL, a laboratory must perform at least 100 tests annually in at least three of the four specialty areas of vascular testing.

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For information about a hospital's status, call the Joint Commission on Accreditation of Health-care Organizations at 708/916-5800.

Are the vascular medicine specialists board certified?*

All Cleveland Clinic vascular medicine specialists are board certified in internal medicine and have subspecialty certification in fields directly related to vascular medicine (cardiology, nephrology, hematology), or have long-standing specialty interest in vascular problems.

This multiple specialization is essential to the comprehensive care required for people who have peripheral vascular disease because they often have associated underlying conditions such as heart disease, diabetes or high blood pressure.

Are the vascular surgeons board certified?*

All Cleveland Clinic vascular surgeons are board certified in general surgery with specialty certification in vascular surgery.

Is the hospital accredited by JCAHO?

Yes. The Cleveland Clinic is accredited by the JCAHO.

Is the vascular laboratory accredited?

The Cleveland Clinic's Noninvasive Vascular Laboratory is accredited by the ICAVL in all four specialty areas of vascular testing.

Through noninvasive tests performed in the laboratory, vascular specialists obtain painless outpatient diagnosis for a range of vascular disorders without requiring dye injection or exposure to radiation. Based on the results of the noninvasive tests, the physician determines which patients need further evaluation such as an angiogram.

Has the hospital been positively and consistently recognized for medical excellence and leadership?

Yes. The Cleveland Clinic is often named among the top medical centers in the country. Some of the publications that have recognized the Clinic for excellence are listed in the box at the left.

*Board certification or its international equivalent became a requirement at the Cleveland Clinic in 1989 for doctors being appointed to the medical full staff.

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One of America's Best

The Cleveland Clinic is often named among the top medical centers in the country.

For each of the last five years since 1990, U.S. News & World Report has designated the Cleveland Clinic as one of only ten hospitals in America considered "The Best of the Best" in its annual ranking of hospitals.

n U.S. News & World Report has named the Cleveland Clinic one of "America's Ten Best Hospitals" for the past five years (1990-1994).

n American Health, April 1993, named the Clinic among the top medical centers in the country.

n "The Best in Medicine: Where to Get the Finest Health Care For You and Your Family" (Crown, 1990) singled out the Cleveland Clinic for excellence.

2. Experience

Does practice make perfect?

In the case of complex medical and surgical care for peripheral artery disease, the more experience the doctors and hospital have, the better the results usually will be.

A physician experienced in treating peripheral artery disease has an in-depth understanding of the disease and its natural progression. Years of experience give the physician the professional judgement to know when surgery is necessary and when conservative management may be just as effective.

When vascular surgery is needed, outcome depends on the surgeon's judgement, developed by training and experience, as well as technical skill. An experienced vascular surgeon who performs many procedures generally has a higher level of expertise than a surgeon who performs these procedures only occasionally. The experienced surgeon who has handled many cases is prepared for the most difficult situations and knows how to avoid the potential pitfalls of a particular procedure. Research studies show that the risk of complications is significantly lower when the vascular surgeon performs the procedure many times a year compared with a surgeon who performs fewer procedures.

How many people with peripheral artery disease are treated at the hospital each year?

Cleveland Clinic specialists annually treat more than 8,000 patients with peripheral artery disease, for a total of nearly 17,000 outpatient visits.

How many surgical procedures for peripheral artery disease are performed at the hospital each year?

Cleveland Clinic vascular surgeons annually perform more than 1,400 operations for peripheral vascular disease, making the department among the most experienced in the United States.

How many patients undergo percutaneous interventions for peripheral artery disease at the hospital each year?

The interventional team at the Cleveland Clinic annually performs more than 600 percutaneous interventions for peripheral artery disease.

These procedures are performed in the Cleveland Clinic's Peripheral Vascular Interventional Laboratory, one of only a handful of such facilities in the United States. These innovative treatments are an alternative to surgery for 25 to 30 percent of patients with peripheral vascular disease.

3. Range of Services

What services are available?

Hospitals with a broad range of services can treat more complex medical conditions and better handle complications that may occur.

Range of specialty departments

Peripheral vascular disease does not exist in isolation. Related conditions such as diabetes, kidney disease or heart disease also require treatment. The presence of these other problems increases the risk of complications during treatment of the peripheral artery problem. Therefore, immediate access to a full range of specialty departments within a facility is critical.

Range of diagnostic and treatment options

The diagnosis and treatment of peripheral vascular disease involve health care professionals from several disciplines working as a team. Diagnosis may require several different noninvasive and invasive tests, and treatment may require a combined medical and surgical approach.

Is help available from a full range of specialty departments?

The Cleveland Clinic's 600 physicians — all on staff full-time — provide care in 100 specialties and subspecialties. All of these specialties are present in one facility, so multidisciplinary consultation, diagnosis and treatment are readily available.

Does the hospital offer a variety of options for diagnosing and treating peripheral artery disease?

The Clinic offers a full range of options which include:

-Laboratory tests

-Risk-factor modification education

-The latest cholesterol-lowering agents and drugs to improve blood flow, including experimental ones not widely available

-Doppler ultrasound

-Duplex scan

-Segmental pressure testing

-Computerized axial tomography (CAT or CT scan)

-Angiography

-Thrombolysis, including use of investigational drugs

-Balloon angioplasty

-Stenting

-Atherectomy

-State-of-the-art surgical intervention by some of the most experienced vascular surgeons in the country

-Comprehensive follow-up care

4. Participation in Research and Education

What type of hospital is it?

Selecting a hospital that combines patient care with research and education offers many advantages.

Physicians who engage in clinical research compare and study the results of different treatments in thousands of patients. They apply what they learn from these large clinical trials to future treatment decisions. In this way, all the patients at a hospital which engages in clinical trials benefit from research, even if they have not personally participated.

Clinical trials are also an important aspect of medical education. Physicians who are responsible for teaching residents and medical students must stay up-to-date on the newest treatments and technology so that they can effectively instruct their students. At a teaching hospital, clinical trials allow physicians to examine the effectiveness of the latest investigative treatment strategies. And patients who choose to participate in clinical trials can receive promising new therapies before they are available in the general community.

Choosing a teaching hospital for your care may offer other advantages as well. Private, not-for-profit teaching hospitals had lower mortality rates than other types of hospitals, according to a study in the December 1989 issue of the New England Journal of Medicine.

Is the hospital associated with a teaching program?

Yes. Incorporated in 1935, The Cleveland Clinic Educational Foundation sponsors one of the nation's largest physician postgraduate training programs, and is affiliated with the medical school at The Ohio State University.

Does the hospital have a fully accredited residency training program in vascular surgery?

Yes.

Does the hospital have fully accredited residency training programs in subspecialties related to vascular medicine?

Yes. The Cleveland Clinic offers residency training programs in internal medicine, cardiology, nephrology and hypertension, and hematology. Since it has the largest vascular medicine department in the country, the Cleveland Clinic is the largest training center for vascular medicine physicians.

Does the hospital conduct clinical trials related to peripheral vascular disease?

Cleveland Clinic scientists and physicians engage in many clinical trials related to peripheral artery disease:

-Developing a stent graft for treatment of aortic aneurysms

-Testing a new drug, clopidogrel, as a vasodilator in peripheral artery disease

-Evaluating the effectiveness of flousinoquan, a new drug, as a vasodilator in patients with Raynaud's disease, a rare form of peripheral vascular disease

-Testing the use of stenting in arteries in the lower leg and kidney

-Testing the use of the Rotablator, an experimental atherectomy device

-Evaluating the effectiveness of the thrombolytic agents urokinase and tissue plasminogen activator as clot dissolvers

-Vascular medicine specialists collaborate with scientists in the Cleveland Clinic Research Institute who are conducting basic laboratory research into atherosclerosis.

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Research into Quality of Life Outcomes

The Cleveland Clinic is beginning to measure and determine the health status and quality of life patients experience following their treatment here. Returning to work, being able to perform the usual activities of daily living and being free from pain are some of these important indicators of successful care.

We asked approximately 250 patients with a variety of medical conditions to tell us their health status before, during and after treatment.

More than 80% responded.

All of the patients who responded (100%) thought their ability to function and quality of life generally improved following their care here.

Approximately 70% experienced substantial improvement in physical function, pain relief and energy.

5. Patient Satisfaction

Is everybody happy?

How satisfied are hospitalized patients with their experience at this facility?

92% of patients who are hospitalized at the Cleveland Clinic for a vascular condition said they were either very satisfied or satisfied with their hospital care.

91% said they definitely or probably would return.

How satisfied are outpatients with their experience at this facility?

98% of patients with a vascular condition who come to the Cleveland Clinic for outpatient services said they were either very satisfied or satisfied with their experience.

100% said they definitely or probably would return.

Is there a program to help patients and their families with the difficulties that may arise during a hospital stay?

Cleveland Clinic patients may call an ombudsman — another name for a patient-relations representative — if they have concerns about their care.

Patients in the Cleveland Clinic Hospital may dial a 24-hour Helpline from their hospital rooms if they have any problems, questions, suggestions or concerns related to service.

6. Outcome Indicators

What are the risks?

Many outcome indicators can be used to measure the success of treatment and the risks associated with it. The indicators used depend on the treatment or procedure. For procedures used to treat life-threatening conditions, the mortality (death) and morbidity (complication) rates associated with a procedure are important measures of quality.

On the following page, we provide the mortality rates for patients who underwent surgery for peripheral artery disease at the Cleveland Clinic during a recent four and one-half year period.

Peripheral artery disease is the more serious of the two types of circulatory disease. The treatments available to treat it have potential complications as well as specific outcome measures to be factored into your choice of a doctor and hospital. For these reasons, the questions and answers on the facing page relate to peripheral artery disease.

What is the hospital's mortality rate for carotid endarterectomy to restore blood flow to the brain?

From January 1989 through August 1994, the mortality rate for 1,504 patients who underwent this type of surgery electively at the Cleveland Clinic was 0.5%.

The stroke rate was 2.1%

What is the hospital's mortality rate for lower extremity revascularization of the leg arteries?

From January 1989 through August 1994, the mortality rate for 814 patients who underwent this type of surgery at the Cleveland Clinic was 4.0%.

The amputation rate was 2.2%.

What is the hospital's mortality rate for aortic aneurysm resection to prevent rupture of the aortic aneurysm?

From January 1989 through August 1994, the mortality rate for 754 patients who had this type of surgery electively at the Cleveland Clinic was 1.7%.

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Nonsurgical Interventions

Cleveland Clinic vascular specialists (physicians, surgeons and interventional radiologists) are among the most experienced in the country in treating peripheral vascular disease by applying many of the same technologies that are used in treating heart disease to open blocked peripheral arteries. These nonsurgical interventions usually require only an overnight hospital stay and allow patients to return to their normal activities much sooner. They include the following:

-Balloon angioplasty in arm and leg arteries

-Atherectomy of arm and leg arteries

-Stenting in the abdominal aorta and kidney arteries

-The use of thrombolytics — drugs originally developed to dissolve clots in heart attacks — alone or in combination with these therapies

Clinic specialists are also helping to develop a technique for repairing abdominal aortic aneurysms that will offer an alternative to surgery and significantly reduce hospital stays.

Pioneering Work in Peripheral Vascular Disease

Physicians in the Clinic's departments of Vascular Medicine and Vascular Surgery use a unique team approach — one that combines nonsurgical and surgical philosophies to deliver the most effective treatment to each patient.

These departments have a vast experience in highly complicated repeat operations for vascular conditions and care for one of the nation's largest populations of patients under age 50 with circulatory problems. This group of patients requires a high level of expertise, combined with highly sophisticated diagnostic techniques, for proper diagnosis and treatment.

Cleveland Clinic vascular specialists have made important contributions to the field of peripheral vascular disease. Some of them are listed below:

-The Cleveland Clinic Department of Vascular Medicine was the second department in the country established to specialize in peripheral vascular disease. It is the largest clinically active vascular medicine department in the world.

-Members of the Cleveland Clinic Department of Vascular Medicine are the editors of the definitive medical textbook in the field of vascular disease.

-Vascular medicine specialists pioneered the use of thrombolytic agents to open blocked arteries and bypass grafts.

-The Cleveland Clinic's vascular departments pioneered the presurgical cardiac evaluation of patients with peripheral vascular disease, significantly reducing surgical mortality and morbidity.

-Cleveland Clinic vascular surgeons are recognized worldwide for their work in carotid endarterectomy and aortic reconstruction for aneurysms.

-Cleveland Clinic surgeons pioneered blood conservation and re-use techniques during vascular surgery.

-Cleveland Clinic vascular surgeons have made significant contributions to the management of bypass graft infections and arterial reconstruction and revascularization.

-Cleveland Clinic vascular specialists frequently hold offices in important national medical groups that study peripheral vascular disease and its treatment.

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For An Appointment

If you would like to make an appointment with a Cleveland Clinic peripheral vascular specialist, please call one of the numbers below:

216/444-2142

(in Cleveland)

800/223-2273, ext. 42142

(toll-free outside Cleveland)

About Second Opinions

Many physicians choose to refer their patients with complex problems to the Cleveland Clinic, but this does not mean you must have a physician referral to make an appointment with a Cleveland Clinic specialist. The departments of Vascular Medicine and Vascular Surgery are always willing to provide a second opinion on circulatory problems at the request of either a patient, a family member, or referring physician.

Cleveland Clinic Florida

Cleveland Clinic Florida's vascular surgeons and peripheral vascular disease specialists trained at The Cleveland Clinic Foundation have established a corresponding program of outstanding care for patients at the Fort Lauderdale campus. For more information or to make an appointment at Cleveland Clinic Florida, call 800/359-5101.

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For More Information

If you would like to receive any of the other guides in our series "How to Choose a Doctor and Hospital for Your Treatment," please call one of the numbers below:

216/444-8919

(in Cleveland)

800/545-7718

(toll-free outside Cleveland)