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8/17/2019 Peripheral Vascular Disease McGinnis
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Peripheral Vascular Disease
Principles and Practice
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Risk Factor odi"ication
• !ipid anagement
• #eight anagement
• Smoking Cessation• $lood Pressure Control
• Physical Activity
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Pathology o" Atherogenesis
• %Response to &n'ury( )heory
Alteration in endothelial cell layer *hich may
be to+ic, mechanical, hypo+ic, or in"ectious
• -arly pla.ue "ormation can be seen in second
and third decades o" li"e as lipid streaking
• Arterial enlargement
• Anatomic distribution Constant at areas o" bi"urcation
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Classi"ication o" !imb &schemia
• Functional
• /ormal blood "lo* at rest, but cannot beincreased in response to e+ercise 0 Claudication
• )hree main clinical "eatures Pain is al*ays e+perienced in "unctional muscle
unit
&t is reproducibly precipitated by a consistentamount o" e+ercise
Symptoms are promptly relieved by stoppingthe e+ercise
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Classi"ication o" !imb &schemia
• Chronic critical limb ischemia
Recurring ischemic pain at rest that
persists "or more than 1 *eeks andre.uires regular analgesics *ith an ankle
systolic pressure o" 23 mm Hg or less
4lceration or gangrene o" the "oot or toes
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Classi"ication o" !imb &schemia
• &t is &P5R)A/) to di""erentiate these types o"
patients because
• Patients *ith claudication can be treated initially*ithout surgery 0 -+ercise program, Risk
reduction
• Patients *ith rest pain, gangrene, or ulceration
are candidates "or revasculari6ation
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Chronic 5cclusive !o*er -+tremity
Disease
• Patients *ith claudication
• Have lo* risk o" limb loss 0 Annual risk o"
mortality and limb loss 0 27 and 87• ore than hal" o" patients *ill improve or
symptoms remain stable
• 13 0 937 undergo surgery "or progressiono" symptoms
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Chronic 5cclusive !o*er -+tremity
Disease
• Patients *ith critical ischemia 0 rest pain,
gangrene, or tissue breakdo*n are at high
risk "or limb loss
• Patients should undergo angiographic
evaluation "or potential revasculari6ation
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Aortoiliac 5cclusive Disease
• 5"ten present *ith complaints o" buttock, hip, or
thigh claudication
• &n men, impotence may be present in 93:237 o"
patients• 5nly a small percent ;837< o" patients have
disease con"ined to 'ust the distal aorta and
common iliac segments
• =3 7 o" patients *ill have more di""use disease
involving e+ternal iliac and>or "emoral vessels
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Aortoiliac 5cclusive Disease
• /oninvasive Vascular Studies
• Help to improve diagnostic accuracy
• Physiologic .uanti"ication o" severity o"disease
• ay serve as baseline "or "ollo*:up
• Angiography "or patients *ith limb
threatening ischemia
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Aotoiliac 5cclusive Disease
Surgical )reatment
• Aortobi"emoral $ypass
• Cross Femoral $ypass 0 Fem:Fem
bypass
• A+illo"emoral $ypass
• Percutaneous Angioplasty
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Femoral:Popliteal:)ibial 5cclusive Disease
Surgical )reatment
• Femoral 0 Popliteal $ypass
Above ?nee or $elo* ?nee $ypass
• Femoral 0 )ibial $ypass Anterior, Posterior tibial or Peroneal
• Femoral 0 Dorsalis Pedis $ypass
• $ypass Conduits and )echni.ue /onautogenous vs@ Vein gra"ts
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Carotid Artery 5cclusive Disease
• Symptoms
)&A
CVA
Amaurosis Fuga+ Resolving /eurologic De"icits• /5) Symptoms
Di66iness
Vertigo emory !oss
!ight Headedness
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Carotid Artery 5cclusive Disease
• &maging Studies
Carotid Duple+ 4ltrasound
Angiography C) Scan
R&>RA
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Carotid Artery 5cclusive Disease
Surgical &ndications
• Symptomatic
Carotid Stenosis 237 in patients *ithipsilateral )&A, Amaurosis, or R/D
Patients *ith lesser degrees o" stenosis can beconsidered "or operation i" they have "ailedmedical therapy, large ulcerations orcontralateral occlusion
• Asymptomatic &ndications less clear but generally reserved "or
patients *ith B3:==7 Stenosis
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Abdominal Aortic Aneurysm
• /atural History
-nlarge and rupture
-mboli6ation A:V Fistula
& Fistula
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Abdominal Aortic Aneurysm
• Follo*ing rupture o" AAA
5nly 237 o" patients arrive at the
hospital alive
17 die be"ore operation
17 die in the post operative period
5verall mortality o" E3:=27
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Abdominal Aortic Aneurysm
• ost important risk "actor "or rupture is
ma+imal transverse diameter
AAA 2 cm 0 8:97 per year
AAA 2:E cm 0 B:887 per year
AAA E cm 0 13 7 per year
• Symptomatic AAA are at increased risk o"rupture as *ell
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Abdominal Aortic Aneurysm
• Diagnosis
4ltrasound
C) Scan R&
Arteriography
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Abdominal Aortic Aneurysm
• Selection o" patients "or repair
a+imal diameter 2 cms@
• )ypes o" repair 5pen repair vs@ -ndovascular
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