1. Evolving Strategies in the Treatment of Peripheral Vascular Disease Ravish Sachar MD, FACC Wake Heart and Vascular

2. Disclosures Educational Grants: Boston Scientific, Abbott Vascular, ev3 Consultant: Abbott Vascular, ev3 Speakers Bureau: Boston Scientific, Abbott Vascular

3. Atherosclerosis Common Etiology  30-60% of pts with PVD have carotid disease  50-60% of pts with carotid disease have coronary disease  10% of pts with coronary disease have carotid disease

4. Results of Coronary Angiograms in 634 Patients with PAD 8.5%

5. Patient Survival by ABI Newman et al ATVB 1999;19; 538-545.

6. Five year mortality rates PVD versus Cancer *Criqui M. Presentation: Vascular Medicine of the Lower Extremities at the American Diabetes Association’s Scientific Sessions June 1999

7. PVD ….What are the goals? Asymptomatic – treat risk factors Claudication – medical therapy or revascularization to improve symptoms Critical Limb Ischemia – prevent amputation and limb loss

8. Goal…Prevention of Amputation

10. Diagnosis Non-invasive – Bedside Ankle-Brachial Index – Lower extremity Segmental Pressures and PVRs – Arterial Duplex imaging – MRA – CTA Invasive – Angiograpy

15. Magnetic Resonance Angiography

19. Disease Patterns Non-Diabetics Diabetics

20. Aorto Iliac Disease

25. SFA Disease

27. SFA OCCLUSION

28. prepost

31. Subintimal Angioplasty

32. Reentry Catheters Outback Pioneer

34. SFA – PTA/Stenting Post

35. Knee Extension Knee Flexion Problems with SFA Stenting….

36. With Knee Flexion

37. Compression 3. Extension / Contraction 1. Torsion 2. Flexion4. Forces Exerted on Stents in SFA

38. Type I Type II Type III Type IV

39. Directional Atherectomy

41. Atherectomy

42. After Before Directional Atherectomy

43. Orbital Atherectomy

44. Rotational Atherectomy

45. Laser Atherectomy

47. Conclusions Peripheral Vascular Disease is very prevalent in patients with cardiac disease PVD is underdiagnosed and undertreated High Mortality with PVD – usually due to cardiac causes There are many revascularization options available to patients to improve quality of life

48. Thank You!

50. PercutaneousSurgical Patient Preference

51. Treating Critical Limb Ischemia Primary Treatment for severe PVD in the 1800’s

52. Treating Critical Limb Ischemia In some places Primary Treatment for severe PVD in 2008

53. Amputations – current data Less than 20% get an angiogram Only 50% get an ABI Most of these patients do have limb salvage options It is not conservative treatment to amputate!

54. “For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive treatment to even do an angiogram”

55. Amputation (Impact!!) Survivors who ambulate (prosthesis) BKA - 40-50% AKA - 25% Psychological testing :“worse than cancer”

56. Possibilities….