General Practitioners

• Primary Care
  People aged 55 and older should talk with their primary care physician about their vascular health. Painless, noninvasive tests can determine if there are blockages in a patient’s neck or leg arteries or if there is aneurysm formation in the aorta. If there is an indication of a blockage, patients should seek treatment immediately. Vascular disease can be controlled if diagnosed and treated early. Vascular surgeons treat these diseases with lifestyle changes, medical management, minimally invasive endovascular angioplasty and stent procedures, and open bypass surgery.
• Electrocardiogram
  8." Echocardiography has been enhanced by administration of dobutamine, an inotropic agent that increases oxygen demand and leads to dysfunction of myocardial wall segments that have compromised blood supply. This dysfunction can then be visualized by echocardiography. Shafritz et al (1997) studied the utility of dobutamine echocardiography in evaluating patients for elective aortic surgery. In 110 patients there was no statistically significant difference in overall mortality or cardiac mortality between the two groups. The patients were managed aggressively during surgery with invasive monitoring. In spite of these data, they recommend screening in all patients scheduled for elective aortic surgery unless they have a negative coronary disease history, normal EKG and no active cardiac symptoms

Gynecologists

• Obstetrics
  2. Carotid ultrasound testing - This is a painless, non-invasive view of the arteries which allows the physician to view and measure any disease in the artery. This ultrasound is similar to the type used in obstetrics.

Neurologists

• Neurology
  10 Workup of the lesion involves ruling out other causes of the nonspecific symptoms, and may include cardiology consultation, neurology consultation, Holter monitoring, EEG, CT or MR scan of the brain or cerebral angiography. Addition of a proximal vertebral reconstruction adds little mortality and morbidity to a well-performed carotid endarterectomy.

Endocrinologist

• Diabetes Care

Radiologist

• Ultrasound
  Ultrasound image of a venous valve in the jugular vein. Understanding how these valves work is key in understanding how the venous system works.
• Radiology
  Kristen has been a nurse in this practice since 1997. She was recruited by the physicians after working with her at the Presbyterian St. Luke�s Adult Intensive Care Unit. She continued her work in the ICU and the Interventional Radiology suite for five years after joining the practice. She is well acquainted with patients in these areas, and in the hospital because of these experiences. Also, she has worked in the Surgical Trauma Unit at Denver Health.
• X-Rays
• Computed Tomography
  I would like to express my gratitude to you for your help in treating me for recurrent thoracic outlet syndrome. After spending two years of diagnostic studies at a large university in southern California, I was frustrated with the lack of treatment. I was told by the university vascular surgeons there that I was a complicated case and that surgery was too risky. Recently, I came to Denver to meet with another vascular surgeon. As you know, after meeting with him, I felt that the surgery proposed was too radical. In addition to the magnitude of the surgery advised, there was no literature about the surgery, no follow-up results and no written procedure description to review in order for me to better understand the procedure. After deciding against this major surgery, I called your office. Your staff kindly worked me in quickly to see you before I was scheduled to fly home two days later. I found your manner of obtaining my medical history was interesting and thorough. Also, you performed a lengthy physical exam. After undergoing the 3D CT scan you requested, your office staff again helped me with scheduling surgery in hopes of reducing the painful symptoms I have been experiencing for years. You were willing to help me although other local TOS experts said it was too complicated and risky. Surgery at PSL hospital went without a hitch and the nursing care at the hospital was terrific!
• Interventional Radiology

Surgeons

• General Surgery
  Dr Brantigan completed his medical education at the Johns Hopkins University and at the University of Colorado. He is board certified in General Surgery, Vascular Surgery, Thoracic Surgery and Surgical Critical Care with active certificates in each field. The diverse education and experience reflected in these certifications allow a creative and sometimes eclectic approach to clinical problem solving. Each clinical problem is looked at as an exercise in physiology tempered by the interests and desires of the patient.
• Wound Care
  There is a huge expense associated with diabetic foot problems. Feet account for 16% of hospital admissions for diabetes. Feet account for 23% diabetic hospital days. Foot ulcers occur in 15% of diabetics. Almost half of diabetics are neuropathic at 20 years. Traditional wound care is not very effective in healing the ulcers that become chronic. Many of these result in amputation. Over half of the major amputations occur in diabetics, and at least a third of these amputees loose the opposite leg within the next 3 years. The direct medical costs are high enough to mandate definitive action. The social costs, in terms of time off work, disability and dependency, although not the subject of this analysis, are even greater. In spite of these statistics only 12% of physicians routinely examine the feet.
• Gangrene
  This is the completion arteriogram of a diabetic patient referred from Florida in early 2001 for gangrene of his foot. The bypass connected to the lateral tarsal artery in the foot, and maintains his foot to the present.
• Vascular Surgery
  Essam El-Kady, chief of Vascular Surgery at the El Maadi Armed Forces Hospital in Cairo, Egypt operating with Dr. Brantigan. Click to enlarge.
• Reconstructive Surgery
  All vascular surgeons are engaged in a quest to find ways to decrease the morbidity and mortality of vascular reconstructive surgery. Although PVD patients are beset by a wide variety of other diseases including diabetes, renal failure, wounds, infections and the like, their leading source of mortality is coronary artery disease. Many strategies have been proposed for dealing with the associated CAD ranging from submitting all to coronary arteriography, to screening all patients with one test or another, to selectively screening patients based on various criteria, to not screening at all. All of the proposed screening tests succeed in identifying patients who will do well with reconstructive surgery. None are very specific in picking the ones who will not do well. There is question concerning the effectiveness of the various interventional strategies once critical CAD is found. Not only do PVD patients have higher comorbidity than routine CAD patients, but PVD is an independent marker for increased morbidity and mortality for coronary interventions, both on a short and long term basis. In addition, the group of vascular patients with the highest expected cardiac mortality and morbidity are the limb salvage patients. Their vascular operations are not elective and can not be delayed. They have been historically operated on with a mortality rate less than the mortality of CABG providing that they receive good critical care during the perioperative period. If coronary screening has a role in PVD, it is in the elective patient, the patient whose vascular disease is not critical. These are the patients who will have the best short term and long term results from coronary revascularization. The best strategy for managing combined CAD and PVD appears to be based on clinical judgement. Patients whose clinical presentation includes indications for a coronary intervention should be tested and treated for this. Those whose clinical presentation is one of PVD should simply undergo the peripheral reconstruction, using careful monitoring and management that assumes that there is associated coronary disease.

Dermatologists

• Calluses
  There are no easy answers to the medical management of diabetic foot problems. Simply providing a "shoe benefit" is ineffective. An effective program couples risk assessment with targeted interventions. Such interventions may include education, extra depth shoes, inserts, custom shoes, trimming nails and calluses, casting and a host of others. High risk patients may need to see a specialist on a monthly basis for routine care. The few available studies of the cost effectiveness of this approach are summarized, and are compelling. In Denver this service is best provided by the podiatrists.
• Lesions
  Vertebral artery surgery is much less common than carotid surgery, and is usually the province of the Certified Vascular Surgeons. Vertebral territory symptoms are quite nonspecific and may even alternate from side to side with different attacks. Vertebrobasilar symptoms are usually a manifestation of global brain ischemia, as a complex collection of lesions in the extracranial cerebral circulation and the Circle of Willis are found. Clouding of consciousness, confusion, unconsciousness and drop attacks are characteristic of this condition and have been recognized since the first description of the syndrome in 1955.
• Skin Care
  Pathway #5: Autosympathectomy, Poor Care, Dry Skin, Fissuring, Infection, Amputation. Good skin care with over the counter emollients should prevent all of these amputations. Don't forget superglue to close early cracks.

Physical Therapists

• Physical Therapy
  Once the diagnosis of thoracic outlet syndrome is made, two courses are available for treatment: physical therapy and/or surgery. In some cases an gentle stretching program can relieve nerve compression symptoms. This is done by giving patients a regime to follow using alternative therapies easing the neurologic symptoms above. Specialized therapists in the feild of TOS will work with our patients prior to surgery and follow their progress postoperatively. All of these treatments will be arranged prior to your visit.
• Shoulder Pain

Podiatrists

• Calluses
• Diabetic Foot Care
• Foot Infections
  Most of the effective strategies for managing the cost of the complications of diabetes are intuitive. Much can be said about the importance of glycemic control in the prevention of complications. Treatment of micro proteinuria is equally important. Routine foot care self-provided by the patient and routine patient examination of his or her own feet is important as well. It should also be intuitive that complex problems managed early are associated with less morbidity and less cost. Futile care for a patient with a major foot infection should be avoided. A determination should be made early on as to whether a wound is healable, whether the patient is a candidate for limb salvage surgery, or if the patient is a candidate for amputation. Amputations when done should done early after infection is controlled, and should be guided by the vascular laboratory to insure that the initial amputation will heal. Consideration should be given to two stage amputations when infection is uncontrolled. Patients who do not use an extremity are candidates for early amputation rather than limb salvage. Both money and suffering are saved by this strategy.