Approach to CLI – Consider Arterial & Venous Insufficiency Khusrow Niazi, MD, FACC, FSCAI Director, Peripheral Vascular Intervention Emory University Atlanta, USA

Khusrow Niazi, MD, FACC, FSCAI Disclosure: Research Grants: Medtronic Bard Peripheral Spectranetics   Speaker/Consultant: Examples of relationships are: Advisory Board/Board Member, Consultant, Honoraria, Research Support, Speaker’s Bureau, Stockholder Please list full company name

Peripheral Vascular Disease – elephant in your waiting room

PVD

? Dermatologic disease Arterial insufficiency Venous insufficiency Malignant lesion I D K 5. I don’t know

“….cognitive impairment…..”

RN – 67yoM Impression: 1. Nonhealing wound on his left leg above the medial malleolus for past couple of weeks. 2. Right below-knee amputation after 2 attempts at percutaneous revascularization on the right leg for a wound on his right foot, a yr back in North Carolina. 3. Diabetes mellitus for past 15 years. 4. Hypertension. 5. Past history of pericarditis. 6. Systolic murmur suggesting aortic stenosis.

Recommendations: 1.The patient had an ABI performed a week before by vascular surgery on his left lower extremity, 0.79 and 0.68. Proceed with an MRA to define the extent of arterial disease in his left lower extremity. 2. Venous Doppler ultrasound. 3. Echocardiogram to assess his cardiac murmur.

Revascularization of left trifurcation

4 weeks after presentation

Venous Doppler Severe reflux in the left GSV >3sec GSV 6.3mm

4 weeks after presentation Ablation of left GSV

8 weeks

8 weeks ABI 1.1 and 0.96

11 weeks

? STOP

Amputations in the U.S. Approximately 185,000 amputations occur in the U.S. each year1 [all cause amputations] 82% of all amputations in the U.S. are due to vascular disease2 97% are lower extremity amputations2 The risk of major amputation is increased significantly when total occlusion is present in the Popliteal and Infrapopliteal arteries3 1. www.amputee-coalition .org/fact_sheets/limbloss_us.html 2. Hakimi, Kevin. “Pre-Operative Rehabilitation Evaluation of the Dysvascular Patient Prior to Amputation.” Phys Med Rhabil Clin N Am 20, 2009: 677-688. 3. Faglia et al. “Angiographic Evaluation of Peripheral Arterial Occlusive Disease and its Role as a Prognotstic Determinant for Major Amputation in Diabetic Subjects with Foot Ulcers” Diabetes Care. 1998; vol 21, no 4: 625-630.

After arterial recannalization After venous ablation

Annual Incidence and Prevalence of Venous Insufficiency Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1

When do I suspect CVI

Clinical Suspicion of CVI Heredity Age Female sex Obesity Pregnancy Prolonged standing Greater height Obesity Pregnancy Prolonged standing Greater height

Clinical Suspicion of CVI Leg Pain or Aching or Heaviness Leg Cramps or Tingling Leg Swelling or feeling of swelling Itching Restless Legs Varicose veins Blood Clots Bleeding Ulcers

? How do you diagnose?

Transverse view of GSV

Take home message…..

Location of Ulcer J Vasc Surg 2007;45:S5-S67

History Leg pain/ulcer Physical exam Arterial insufficiency Venous insufficiency Other causes ABI Venous Doppler