Peripheral Vascular Disease Principles and Practice

Risk Factors Hypercholesterolemia Cigarette Smoking Hypertension Diabetes Advanced Age Male gender Hypertriglyceridemia Hyperhomocysteinemia Sedentary Lifestyle Family History

Risk Factor Modification Lipid Management Weight Management Smoking Cessation Blood Pressure Control Physical Activity

Pathology of Atherogenesis “Response to Injury” Theory Alteration in endothelial cell layer which may be toxic, mechanical, hypoxic, or infectious Early plaque formation can be seen in second and third decades of life as lipid streaking Arterial enlargement Anatomic distribution Constant at areas of bifurcation

Classification of Limb Ischemia Functional Normal blood flow at rest, but cannot be increased in response to exercise – Claudication Three main clinical features Pain is always experienced in functional muscle unit It is reproducibly precipitated by a consistent amount of exercise Symptoms are promptly relieved by stopping the exercise

Classification of Limb Ischemia Chronic critical limb ischemia Recurring ischemic pain at rest that persists for more than 2 weeks and requires regular analgesics with an ankle systolic pressure of 50 mm Hg or less Ulceration or gangrene of the foot or toes

Classification of Limb Ischemia It is IMPORTANT to differentiate these types of patients because Patients with claudication can be treated initially without surgery – Exercise program, Risk reduction Patients with rest pain, gangrene, or ulceration are candidates for revascularization

Chronic Occlusive Lower Extremity Disease Patients with claudication Have low risk of limb loss – Annual risk of mortality and limb loss – 5% and 1% More than half of patients will improve or symptoms remain stable 20 – 30% undergo surgery for progression of symptoms

Chronic Occlusive Lower Extremity Disease Patients with critical ischemia – rest pain, gangrene, or tissue breakdown are at high risk for limb loss Patients should undergo angiographic evaluation for potential revascularization

Aortoiliac Occlusive Disease Often present with complaints of buttock, hip, or thigh claudication In men, impotence may be present in 30-50% of patients Only a small percent (10%) of patients have disease confined to just the distal aorta and common iliac segments 90 % of patients will have more diffuse disease involving external iliac and/or femoral vessels

Aortoiliac Occlusive Disease Noninvasive Vascular Studies Help to improve diagnostic accuracy Physiologic quantification of severity of disease May serve as baseline for follow-up Angiography for patients with limb threatening ischemia

Aotoiliac Occlusive Disease Surgical Treatment Aortobifemoral Bypass Cross Femoral Bypass – Fem-Fem bypass Axillofemoral Bypass Percutaneous Angioplasty

Femoral-Popliteal-Tibial Occlusive Disease Surgical Treatment Femoral – Popliteal Bypass Above Knee or Below Knee Bypass Femoral – Tibial Bypass Anterior, Posterior tibial or Peroneal Femoral – Dorsalis Pedis Bypass Bypass Conduits and Technique Nonautogenous vs. Vein grafts

Carotid Artery Occlusive Disease Symptoms TIA CVA Amaurosis Fugax Resolving Neurologic Deficits NOT Symptoms Dizziness Vertigo Memory Loss Light Headedness

Carotid Artery Occlusive Disease Imaging Studies Carotid Duplex Ultrasound Angiography CT Scan MRI/MRA

Carotid Artery Occlusive Disease Surgical Indications Symptomatic Carotid Stenosis > 50% in patients with ipsilateral TIA, Amaurosis, or RND Patients with lesser degrees of stenosis can be considered for operation if they have failed medical therapy, large ulcerations or contralateral occlusion Asymptomatic Indications less clear but generally reserved for patients with 60-99% Stenosis

Abdominal Aortic Aneurysm Natural History Enlarge and rupture Embolization A-V Fistula GI Fistula

Abdominal Aortic Aneurysm Following rupture of AAA Only 50% of patients arrive at the hospital alive 24% die before operation 42% die in the post operative period Overall mortality of 70-95%

Abdominal Aortic Aneurysm Most important risk factor for rupture is maximal transverse diameter AAA < 5 cm – 1-3% per year AAA 5-7 cm – 6-11% per year AAA > 7 cm – 20 % per year Symptomatic AAA are at increased risk of rupture as well

Abdominal Aortic Aneurysm Diagnosis Ultrasound CT Scan MRI Arteriography

Abdominal Aortic Aneurysm Selection of patients for repair Maximal diameter 5 cms. Types of repair Open repair vs. Endovascular