PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEONS POINT OF VIEWDANIEL S. RUSH, M.D.NEW HORIZONS IN CARDIOVASCULAR HEALTHJANUARY 27, 2012

INTRODUCTIONLOWER EXTREMITY PERIPHERAL ARTERIAL DISEASE (PAD)Affects 10 million people in the U.S.About 4.3 % of everyone > 40 years oldAbout 14.5% of people > 70 years old2 X increased incidence with each decade of life100,000 patients undergo some form of revascularization each year

CLINICAL CONSIDERATIONS IN PADUnderlying etiology of symptomsAnatomy of arterial occlusionDegree of limb ischemiaCo-morbid medical conditionsFunctional statusAmbulation potentialSuitability for arterial intervention or reconstructionAppropriate decision making

CLASSIFICATION OF LOWER EXTREMITY PADIntermittent ClaudicationCritical Limb Ischemia (CLI)Ischemia pain at restIschemia ulcerationGangreneInfection

INTERMITTENT CLAUDICAITONMost common symptom of PADExtertional leg painLife-style limiting to disablingGenerally one anatomic segment of arterial occlusionModerate limb ischemia 33% have treatable CAD3% - 5% per year risk of cardiac death

DIFFERENTIAL DIAGNOSIS OF LEG PAINSpinal stenosisNerve root compressionPeripheral neuropathyDegenerative joint diseaseBakers cystVenous claudicationChronic compartment syndromeCardiac disease

CRITICAL LIMB ISCHEMIAA systemic diseaseConstant ischemic painFailure to heal wounds, ischemic ulcerations, and gangreneUsually requires two or more segments of arterial occlusionSevere limb ischemia25% risk of amputation in one year25% risk of cardiac death within one year

RISK FACTORS FOR PADAgeSexRace and Family historySedentary life-styleSmokingHyperlipidemiaHypertensionDiabetes mellitusHypercaogulabilityHyperhomocysteinemiaRenal insufficiency

VASCULAR ASSESMENT IN PATIENTS WITH PADHistory and physical examinationDoppler examinationVascular laboratory studiesCT ateriographyMR ateriographyInvasive contrast ateriography

VASCULAR LOBORATORY ASSESMENT OF PADPresence and direction of arterial blood flowCharacter or quality of blood flow (Doppler waveforms)Precise arterial systolic blood pressure measurementAnkle / Brachial Index (ABI) relative severity of arterial insufficiencyQualitative anatomy of PAD (segmental arterial pressures)Serial or comparative arterial assessmentsArterial Duplex (B-mode ultrasound and Doppler flow velocities)

CLINICAL USES OF VASCULAR LABORATORY ASSESSMENTEvaluation of leg pain (PAD or something else?)Severity of limb ischemiaAnatomic pattern of arterial occlusionObjective limb function (exercise) Post-operative follow-upWound healing or amputation level

INTERPRETATION OF ANKLE / BRACHIAL INDICIES (ABIS)Normal ABI 0.9 1.2Mild limb ischemia ABI 0.7 0.9Minimal symptomsModerate limb ischemia ABI 0.4 0.7ClaudicationSevere limb ischemia ABI < 0.4Rest pain, Tissue lossNon-compressible ABI > 1.2

MEDICAL MANAGEMENT OF PADEstablish a diagnosis of PADSmoking cessation (disease progression)Risk factor modification:Hypertension (stroke risk reduction ACE inhibitors)Hyperlipidemia (disease progression, inflammatory response statins)Diabetes mellitus (wound healing and infection glycemic control)Coronary artery disease (MI risk reduction Beta blockers)Supervise exercise and conditioning (improve exercise tolerance and strength)Treated associated causes of leg pain (neuropathy and arthritis)

CHARACTERISTICS OF INTERMETTEMNT CLAUDICATIONExercise induced pain symptomsAbsent femoral and/or pedal pulsesABIs 0.4 - 0.7 range indicating moderate limb ischemiaOne level of arterial occlusionAorto-iliac (LeRiche Syndrome) hip or calf pain, vasogenic impotenceSFA occlusion calf painMedical treatment preferredOften successfully treated with endovascular techniquesSurgery reserved for sever symptoms in good risk patients

CHARACTERISTICS OF CRITICAL LIMB ISCHEMIAIschemia pain at rest or tissue lossAbsent femoral and/or pedal pulsesDistal rubor, ulceration, gangrene, and/or infection (risk of amputation)ABIS < 0.4 indication severe limb ischemiaTwo levels of arterial occlusion (unless diabetic)Medical treatment alone is usually ineffectiveSometimes improved with endovascular techniquesSurgical bypass is usually required

SURGICAL AND INTERVENTIONAL TREATMENT OPTIONSArterial reconstructionsEndarterectomyPatch angioplastyBypass (autologous vein graft, prosthetic graft)Endovascular techniquesThrombectomyAtherectomyBalloon angioplastyStent placementEndograft (covered stent)

TREATMENT OF AORTO-ILIAC OCCLUSIVE DISEASEAorto-Femoral Bypass (AFB) 3-5% M&M 90% 5 year patencyAortic endarterectomy 3-5% M&M 80% 5 year patencyExtra-anatomic Bypass 1-2% M&M 60% 5 year patencyIliac balloon angioplasty < 1% M&M Claudication Stenosis 65% 5 year patency Occlusion 54% 5 year patencyCritical ischemia Stenosis 53% 5 year patency Occlusion 45% 5 year patencyIliac stent

TREATMENT OF INFRA-INGUAL OCCLUSIVE DISEASEAk Fem-pop bypass 1-2% M&MGSV graft 69% 5 year patencyPTFE graft 60% 5 year patencyBK Fem-pop bypass 1-2% M&MGSV graft 77% 5 year patencyPTFE 40% 5 year patency

SFA-pop balloon angioplasty< 1% M&MClaudication Stenosis 53% 5 year patency Occlusion 36% 5 year patencyCritical ischemia Stenosis 31% 5 year patency Occlusion 16% 5 year patency

MORBIDITY AFTER LOWER EXTREMITY BYPASSHealing and recovery time15-20 weeksWound complications15-25%Lymphedema10-20%Graft stenosis20%Graft thrombosis10-20%Graft infection1-3%Major amputation5-10%

PROBABILITY OF BYPASS FAILURE BY CO-MORBIDITYImpaired ambulation58%6.4 Odds ratioDistal PAD46%3.9 Odds ratioESRD35%2.5 Odds ratioGangrene34%2.4 Odds ratioHyperlipidemia11%0.6 Odds ratio

FACTORS INFLUENCING SURGICAL TREATMENT RESULTS OF PADAgeAtherogenic risk factorsCo-morbiditiesClinical indication for treatmentSeverity of ischemiaSegmental anatomy of arterial occlusive diseaseChoice of treatment (open or endovascular)Technical difficultyChoice of materialsPrimary or secondary procedure

CONCLUSIONThe diagnosis and treatment of PAD is not just a vascular surgical problem.Risk factor modification (Vascular Medicine) will become an increasingly important adjunct to all surgical and endovascular therapies.Primary care providers will have a greater role in the treatment of PAD.Traditional measures of procedural treatment success such as morbidity and vessel patency are no longer a sufficient means of evaluating success.New endovascular technologies have greatly broadened the number of treatment options available and will continue to evolve in the near future.