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Peripheral Vascular Disease
Erin Bolken, PA-C
Vascular Surgery
October 15, 2016
Pacific Vascular Specialists9155 SW Barnes Road, #321 Portland,
OR
503-292-0070
pacificvascularspecialists.com
Overview
Goals Insight into the Vascular Surgery specialty
Geared toward the PCP When do you need to refer to a Vascular
Surgeon?
What information will help with a referral and what can the
patient expect?
Venous disease
Arterial disease
What do we do?
Offer comprehensive medical, surgical and endovascular treatment
for: Abdominal and Thoracic Aortic Aneurysms
Peripheral Artery disease
Carotid artery disease
Varicose Veins & Venous Ulcers
Deep Vein Thrombosis
Dialysis and Vascular Access
Aortic Dissection
Other Complex Vascular Diseases
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Peripheral Venous Disease
Anatomy
Varicose Veins
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VV Risk factors
Age
Gender
Obesity
Pregnancy
Family hx
Lifestyle
Prolonged standing
Signs and Symptoms
Edema or swelling Improved with elevation and/or compression
Discomfort Pain, ache, itching
Especially after long periods of standing
Bulging superficial veins Swollen, twisted, dilated, superficial
bleeding
Cosmetic concern
Diagnosis
History
Physical exam
Ultrasound
Checking for reflux (blood flow in the wrong direction)
Antegrade flow
Retrograde flow
Telangectasia (spider veins)
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Treatment
Conservative
Compression*
Various grades
Rx for >20mmHg
Helps with decreasing pressure in the tissues
Elevation
Exercise
Hydration
Treatment Invasive
Sclerotherapy Hypertonic solution used to create inflammatory
response along with compression
Small, spider veins
Stripping of veins Superficial varicosities
Endovenous radiofrequency ablation (GSV)
Laser ablation
Chronic Venous Insufficiency(Venous stasis disease)
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Venous Stasis
High pressure in veins
Incompetent valves retrograde flow and pooling due to
gravity.
Usually noted around the ankles Feet dependent
Venous Stasis risk factors
Age
Obesity
Pregnancy
Family hx
Sedentary Lifestyle
Prolonged standing
Injury or prior surgery of the leg/foot
Post-thrombotic Syndrome (hx of DVT)
VS Signs and Symptoms
Heaviness, aching
Edema/swelling in lower extremities
May also have varicose veins
Skin changes (thin, discolored, flakey, leathery)
Venous stasis ulcerations (non-healing)
May involve cellulitis
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VS Diagnosis
History Investigate origin of the ulcer What are the 4 top
reasons people have staged/non-
healing ulcers??* Pressure, infection, arterial or venous
problem
Physical exam What are the signs and symptoms?
Rule out ischemic ulcer (why?) Pulses, doppler signals (hx of
claudication?)
Important information to know (pt can have both)
Chronic venous ultrasound
VS Treatment
Compression*
Stockings to prevent ulceration
Unna Boot open/active ulcers
Elevation
Exercise
Vein stripping
Venous ablation (GSV)
Venous Thrombosis
Blood clot in the veins
SVT vs. DVT
Pulmonary embolism (lung)
May-Thurner syndrome (iliofemoral v.)
Paget-Schroetter syndrome (subclavian v.)
Thrombophlebitis (inflammation of vein)
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Superficial thrombophlebitis
Superficial Thrombophlebitis
Blood clot in vein just under the skin
Erythema, tenderness, palpable cord
Low risk, patients need reassurance (but watch for progressive
sxs)
Often due to peripheral IV catheter, procedure
Treatment: Warm compresses, NSAIDs, elevation, rest, TIME
Complications of DVT DVT and PE are common, accounting for up to
300,000 deaths per year
Post-operative initiatives
LMWH (Lovenox), SCDs, compression stockings, mobility, etc.
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DVT risk factors Surgery, immobilization, trauma
Hypercoaguable (Coagulopathy) Factor V Leiden, neoplasm, etc
Smoking
Prolonged travel
Pregnancy/hormonal contraception
Intravascular catheters
History of DVT
Dehydration
Virchows Triad
DVT Signs and Symptoms
Up to 40% of people will not have symptoms! Low threshold for
getting an ultrasound if concern is present
Pain
Swelling
Discoloration of affected leg
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Pulmonary Embolus: Signs and Symptoms
Sudden feeling of impending doom
Shortness of Breath (increased respirations)
Decreased SpO2
Elevated Heart Rate
Current or Hx of LE DVT
Hemoptysis
DVT Diagnosis
Physical exam is unreliable Begins with suspicion / recognition
of increased risk
Duplex ultrasound study CT scan (for PE) With or without
contrast?
D-dimer (sensitive but not specific) Breakdown products of
thrombosis More useful when suspect PE (and patient has not had
recent surgery/trauma)
Venography
DVT/PE Treatment and Prevention Treatment must begin
immediately
Anticoagulation* heparin (IV)
LMWH (enoxaparin, dalteparin) subQ injection
warfarin (Vit. K antagonists)
Factor Xa inhibitors (rivaroxaban, apixaban)
Direct thrombin inhibitor (dabigatran)
IVC Filter Useful if not a candidate for anticoagulation
Most are placed for temporary treatment, should be removed after
6-8 wks.
Endovascular lysis of the clot Evidence shows minimal benefit
unless symptoms are severe (and acute)
Prevention: Compression stockings, LMWH prophylaxis, SCDs,
ambulation
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Peripheral Arterial Disease
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Anatomy
Peripheral Arterial Disease
Insufficient blood flow to a limb or organ system
Atherosclerosis (plaque formation) Carotid stenosis Mesenteric
ischemia (Celiac, SMA, IMA) Aortic, iliac, femoral, popliteal, and
tibial artery disease Other: renal a. stenosis, anything else
requiring blood flow
Arterial Embolism causing occlusion Patent foramen ovale Atrial
fibrillation Hypercoagulable pathology
Who is at risk for atherosclerosis?
Smokers!
Hypertension
Hyperlipidemia
Family History
Diabetes
Poor exercise
Poor Diet
Age
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Symptoms of LE PAD
Claudication Vascular vs. neurogenic
Whats the difference?
What is their baseline activity?
Hair loss Non-healing ulcers Arterial vs. venous
Numbness Does the pt have peripheral neuropathy due to
diabetes?
Rest pain Classic sign hangs foot off edge of bed at night
Gangrene (tissue death)
Diagnosis of LE PAD History Presence of above symptoms
Ankle-brachial index (ABI) Easy to do, good information (need a
doppler)
Systolic ankle mmHg/systolic brachial mmHg
>1 considered normal, abnormal if less than 1.
Peripheral arterial exam* Provides waveforms of the LE blood
flow
At rest or with treadmill exercise
Doppler ultrasound (arteries)* CTA (contrast needed) Angiography
(contrast needed)
* = Performed in a vascular lab
Ankle-brachial index (ABI)
ABI = Ankle SBP/Brachial SBP>1 = normal
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Peripheral arterial exam (PAE)
CT Angiogram
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Angiogram
PAD Treatment
Conservative measures (non-invasive) Exercise (try to improve
endurance) Risk factor control
Smoking cessation, HLD, HTN, diet, etc.
Daily Aspirin Pletal (cilostazol)
Helpful for some, but if no benefit noted, then discontinue
Lipid lowering medications (statin*)
Surgical interventions Endovascular - Angioplasty/stent
Direct/open repair - Endarterectomy or arterial bypass Amputation
(no revascularization options)
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Arterial bypass surgery
Most common in the lower extremities
When to proceed with surgery? Limited function/mobility
Affecting quality of life, debilitating symptoms Treat the
patient, not the numberssurgery comes with risk too.
Non-healing ulcers or gangrene Rest pain in the foot (limb
threatening)
Conduit: Pts greater saphenous vein (arm veins if big enough)
PTFE graft (synthetic) Cryovein (preserved and frozen cadaver
vein)
Carotid Occlusive Disease Plaque build-up at the bifurcation of
the common carotid artery
Increased risk of stroke as the stenosis becomes more severe
Stenosis based on internal carotid artery (ICA) measurements
Intervention recommended when stenosis is: Greater than 80%
(asymptomatic)
Greater than 50% with active TIA/stroke sxs
Interventions Carotid endarterectomy (CEA) vs. carotid stent
Recommend CEA if patient is a good surgical candidate Carotid
stent has a ~1% higher perioperative risk of stroke, selected
patients
Only to reduce the risk of further stroke
Does not improve symptoms that have already occurred!
Carotid Endarterectomy
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Carotid Endarterectomy
Carotid Plaque
Carotid Endarterectomy
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Carotid Stenting
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Aneurysms
AAA
Congenital
Found by US screening, PE, incidental
Repair: Endograft placement vs. open repair
Risks:
Rupture (risk when >5-5.5cm)
AAA Endograft
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Post-op AAA endograft
Dialysis access
Arteriovenous Fistula (vein)
Arteriovenous graft (synthetic)
Questions?
