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PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEON’S POINT OF VIEW. DANIEL S. RUSH, M.D. NEW HORIZONS IN CARDIOVASCULAR HEALTH JANUARY 27, 2012. INTRODUCTION LOWER EXTREMITY PERIPHERAL ARTERIAL DISEASE (PAD ). Affects 10 million people in the U.S. About 4.3 % of everyone > 40 years old - PowerPoint PPT Presentation
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PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEON’S POINT OF VIEW
DANIEL S. RUSH, M.D.
NEW HORIZONS IN CARDIOVASCULAR HEALTH
JANUARY 27, 2012
INTRODUCTIONLOWER EXTREMITY PERIPHERAL
ARTERIAL DISEASE (PAD)
Affects 10 million people in the U.S.
About 4.3 % of everyone > 40 years old
About 14.5% of people > 70 years old
2 X increased incidence with each decade of life
100,000 patients undergo some form of revascularization each year
CLINICAL CONSIDERATIONS IN PAD
Underlying etiology of symptoms
Anatomy of arterial occlusion
Degree of limb ischemia
Co-morbid medical conditions
Functional status
Ambulation potential
Suitability for arterial intervention or reconstruction
Appropriate decision making
CLASSIFICATION OF LOWER EXTREMITY PAD
Intermittent Claudication
Critical Limb Ischemia (CLI)
Ischemia pain at rest
Ischemia ulceration
Gangrene
Infection
INTERMITTENT CLAUDICAITON
Most common symptom of PAD
Extertional leg pain
Life-style limiting to disabling
Generally one anatomic segment of arterial occlusion
Moderate limb ischemia
33% have treatable CAD
<1% per year risk of amputation
>3% - 5% per year risk of cardiac death
DIFFERENTIAL DIAGNOSIS OF LEG PAIN
Spinal stenosis
Nerve root compression
Peripheral neuropathy
Degenerative joint disease
Baker’s cyst
Venous claudication
Chronic compartment syndrome
Cardiac disease
CRITICAL LIMB ISCHEMIA
A systemic disease
Constant ischemic pain
Failure to heal wounds, ischemic ulcerations, and gangrene
Usually requires two or more segments of arterial occlusion
Severe limb ischemia
25% risk of amputation in one year
25% risk of cardiac death within one year
RISK FACTORS FOR PAD
Age
Sex
Race and Family history
Sedentary life-style
Smoking
Hyperlipidemia
Hypertension
Diabetes mellitus
Hypercaogulability
Hyperhomocysteinemia
Renal insufficiency
VASCULAR ASSESMENT IN PATIENTS WITH PAD
History and physical examination
Doppler examination
Vascular laboratory studies
CT ateriography
MR ateriography
Invasive contrast ateriography
VASCULAR LOBORATORY ASSESMENT OF PAD
Presence and direction of arterial blood flow
Character or quality of blood flow (Doppler waveforms)
Precise arterial systolic blood pressure measurement
Ankle / Brachial Index (ABI) – relative severity of arterial insufficiency
Qualitative anatomy of PAD (segmental arterial pressures)
Serial or comparative arterial assessments
Arterial Duplex (B-mode ultrasound and Doppler flow velocities)
CLINICAL USES OF VASCULAR LABORATORY ASSESSMENT
Evaluation of leg pain (PAD or something else?)
Severity of limb ischemia
Anatomic pattern of arterial occlusion
Objective limb function (exercise)
Post-operative follow-up
Wound healing or amputation level
INTERPRETATION OF ANKLE / BRACHIAL INDICIES (ABI’S)
Normal ABI 0.9 – 1.2
Mild limb ischemia ABI 0.7 – 0.9 Minimal symptoms
Moderate limb ischemia ABI 0.4 – 0.7 Claudication
Severe limb ischemia ABI < 0.4 Rest pain, Tissue loss
Non-compressible ABI > 1.2
MEDICAL MANAGEMENT OF PAD
Establish a diagnosis of PAD
Smoking 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 CLAUDICATION
Exercise induced pain symptoms
Absent femoral and/or pedal pulses
ABI’s 0.4 - 0.7 range indicating moderate limb ischemia
One level of arterial occlusion
Aorto-iliac (LeRiche Syndrome) – hip or calf pain, vasogenic impotence
SFA occlusion – calf pain
Medical treatment preferred
Often successfully treated with endovascular techniques
Surgery reserved for sever symptoms in good risk patients
CHARACTERISTICS OF CRITICAL LIMB ISCHEMIA
Ischemia pain at rest or tissue loss
Absent femoral and/or pedal pulses
Distal rubor, ulceration, gangrene, and/or infection (risk of amputation)
ABI’S < 0.4 indication severe limb ischemia
Two levels of arterial occlusion (unless diabetic)
Medical treatment alone is usually ineffective
Sometimes improved with endovascular techniques
Surgical bypass is usually required
SURGICAL AND INTERVENTIONAL TREATMENT OPTIONS
Arterial reconstructions
Endarterectomy
Patch angioplasty
Bypass (autologous vein graft, prosthetic graft)
Endovascular techniques
Thrombectomy
Atherectomy
Balloon angioplasty
Stent placement
Endograft (covered stent)
TREATMENT OF AORTO-ILIAC OCCLUSIVE DISEASE
Aorto-Femoral Bypass (AFB) 3-5% M&M 90% 5 year patency
Aortic endarterectomy 3-5% M&M 80% 5 year patency
Extra-anatomic Bypass 1-2% M&M 60% 5 year patency
Iliac balloon angioplasty < 1% M&M
Claudication Stenosis 65% 5 year patency
Occlusion 54% 5 year patency
Critical ischemia Stenosis 53% 5 year patency
Occlusion 45% 5 year patency
Iliac stent <1% M&M
Claudication Stenosis 77% 5 year patency
Occlusion 61% 5 year patency
Critical ischemia Stenosis 57% 5 year patency
Occlusion 51% 5 year patency
TREATMENT OF INFRA-INGUAL OCCLUSIVE DISEASE
Ak Fem-pop bypass 1-2% M&M
GSV graft 69% 5 year patency
PTFE graft 60% 5 year patency
BK Fem-pop bypass 1-2% M&M
GSV graft 77% 5 year patency
PTFE 40% 5 year patency
SFA-pop balloon angioplasty < 1% M&M
Claudication Stenosis 53% 5 year patency
Occlusion 36% 5 year patency
Critical ischemia Stenosis 31% 5 year patency
Occlusion 16% 5 year patency
MORBIDITY AFTER LOWER EXTREMITY BYPASS
Healing and recovery time 15-20 weeks
Wound complications 15-25%
Lymphedema 10-20%
Graft stenosis 20%
Graft thrombosis 10-20%
Graft infection 1-3%
Major amputation 5-10%
PROBABILITY OF BYPASS FAILURE BY CO-MORBIDITY
Impaired ambulation 58% 6.4 Odds ratio
Distal PAD 46% 3.9 Odds ratio
ESRD 35% 2.5 Odds ratio
Gangrene 34% 2.4 Odds ratio
Hyperlipidemia 11% 0.6 Odds ratio
FACTORS INFLUENCING SURGICAL TREATMENT RESULTS OF PAD
Age
Atherogenic risk factors
Co-morbidities
Clinical indication for treatment
Severity of ischemia
Segmental anatomy of arterial occlusive disease
Choice of treatment (open or endovascular)
Technical difficulty
Choice of materials
Primary or secondary procedure
CONCLUSION
The 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.