What Is Peripheral Vascular Disease?What Is Peripheral Vascular Disease?What Is Peripheral Vascular Disease?What Is Peripheral Vascular Disease?

Daniel B. Walsh, M.D.Professor of Surgery, Section of Vascular Surgery

Vice-Chair, Department of Sugery

Dartmouth-Hitchcock Medical Center

Perhipheral vascular disease is Perhipheral vascular disease is considered to be any abnormality considered to be any abnormality of the arteries and veins outside of of the arteries and veins outside of

the skull and the heart.the skull and the heart.

Perhipheral vascular disease is Perhipheral vascular disease is considered to be any abnormality considered to be any abnormality of the arteries and veins outside of of the arteries and veins outside of

the skull and the heart.the skull and the heart.

Differences Between Differences Between

Arteries & VeinsArteries & Veins

Differences Between Differences Between

Arteries & VeinsArteries & Veins

ComponentsComponentsComponentsComponents Problems with veinsProblems with veins

Varicose veinsVaricose veins

Blood clots and sequelaeBlood clots and sequelae

Arterial AneurysmsArterial Aneurysms

Aorta and branchesAorta and branches

Arteries blocked by atherosclerosisArteries blocked by atherosclerosis

Carotid, Legs. Kidneys, GI tractCarotid, Legs. Kidneys, GI tract

Risk Factors for AtherosclerosisRisk Factors for AtherosclerosisRisk Factors for AtherosclerosisRisk Factors for Atherosclerosis

AgeAge

DiabetesDiabetes

ObesityObesity

GeneticsGenetics

DyslipidemiaDyslipidemia

HypertensionHypertension

HyperhomocysteinemiaHyperhomocysteinemia

Atheroscleroris

Atherosclerotic Disease and Complications(coronary, cerebrovascular, peripheral arterial events

SmokingSmoking

Natural History of PAD in US PopulationNatural History of PAD in US PopulationNatural History of PAD in US PopulationNatural History of PAD in US Population

Adapted from Weitz JI. Circulation 1996;94:3026-49.

Population Aged >55y

AsymptomaticABI <0.9

10%

Intermittentclaudication

5%

Critical leg ischemia1%

PADoutcomes (5-year outcomes)

Cardiovascularmorbidity/mortality

Stableclaudication

73%

Worseningclaudication

16%

Leg bypasssurgery

7%

Majoramputation

4%

Nonfatal events(MI/stroke)

20%

Mortality30%

Intervention for Tissue Loss/Intervention for Tissue Loss/Rest Pain, Severe ClaudicationRest Pain, Severe Claudication

Intervention for Tissue Loss/Intervention for Tissue Loss/Rest Pain, Severe ClaudicationRest Pain, Severe Claudication

• Medications

• Risk factor assessment & reduction

• Exercise program

• PTA/Stents

• Operation

Aneurysms can occur in these arteries:Aneurysms can occur in these arteries:Aneurysms can occur in these arteries:Aneurysms can occur in these arteries:

• Carotid

• Subclavian

• Thoracic

• INFRARENAL

• Renal

• Hypogastric

• Iliac

• Femoral

• Popliteal

What is an Aortic Aneurysm?What is an Aortic Aneurysm?

Abdominal Aortic Aneurysm (AAA)

Thoracic Aortic Aneurysm(front view)

““Endovascular” Aortic Aneurysm RepairEndovascular” Aortic Aneurysm Repair““Endovascular” Aortic Aneurysm RepairEndovascular” Aortic Aneurysm Repair

Pre-repair Post-repair

Freedom from Re-InterventionFreedom from Re-Intervention

DHMC vs EUROSTAR*DHMC vs EUROSTAR*

Freedom from Re-InterventionFreedom from Re-Intervention

DHMC vs EUROSTAR*DHMC vs EUROSTAR*

* Eurostar Data Registry, Jan.2001

Fre

ed

om

fro

m R

e-I

nte

rven

tion

0

.2

.4

.6

.8

1

0 10 20 30 40 50 60 70

Time (months)

DHMC, entire series

EUROSTAR*

First Successful CEAFirst Successful CEA First Successful CEAFirst Successful CEA

F. EastcottF. EastcottMay 19, 1954May 19, 1954

C. RobC. Rob

Carotid AtherosclerosisCarotid Atherosclerosis

Proven Benefit of CEAProven Benefit of CEAProven Benefit of CEAProven Benefit of CEA

0

5

10

15

20

25

30

NASCET ECST ACAS ACST

Medical

Surgical

Percent 30 Day Stroke, Death + Late Ipsilateral Stroke

2 Year 3 Year 5 Year 5 YearSymptomatic Asymptomatic

4 Randomized Trials

> 12,000 patients

Relative risk reduction:

Symptomatic:50-69%50-69% - -

25%25%70-99%70-99% - -

61%61%

Asymptomatic:Asymptomatic:60-99%60-99% - -

48%48%

Selective carotid Selective carotid injectioninjection

Selective carotid Selective carotid injectioninjection

Acculink 6-8x40mm

SummarySummarySummarySummary

3D CTA can be used to screen 3D CTA can be used to screen “high risk” CAS patients better “high risk” CAS patients better served with modified CAS, CEA, served with modified CAS, CEA, or medical managementor medical management

Comparison of Carotid Endarterectomy and StentComparison of Carotid Endarterectomy and StentDartmouth Experience (2000-Present)Dartmouth Experience (2000-Present)

Comparison of Carotid Endarterectomy and StentComparison of Carotid Endarterectomy and StentDartmouth Experience (2000-Present)Dartmouth Experience (2000-Present)

NumberNumber 366 366 173173

StrokeStroke 0.5% 0.5% 2.9%2.9%

Myocardial Infarct 4%Myocardial Infarct 4% 1.2%1.2%

DeathDeath 0.8% 0.8% 0.8%0.8%

Endarterectomy StentEndarterectomy Stent

ConclusionsConclusionsConclusionsConclusions CEA remains the “gold standard” RXCEA remains the “gold standard” RX CAS risk increases with age and requires EPDCAS risk increases with age and requires EPD Carotid stent treatment of extracranial carotid occlusive Carotid stent treatment of extracranial carotid occlusive

disease is safe in disease is safe in selectedselected patients. patients. ? Asymptomatic medical high risk? Asymptomatic medical high risk

3D CTA can assist in selecting patients for CAS3D CTA can assist in selecting patients for CAS Need to be prepared to handle technical difficultiesNeed to be prepared to handle technical difficulties

Know when to stopKnow when to stop Long-term durability of the procedure needs to be determinedLong-term durability of the procedure needs to be determined