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 DiseaseSurgical Treatment

• Aortobifemoral Bypass

• Cross Femoral Bypass – Fem-Fem bypass

• Axillofemoral Bypass

• Percutaneous Angioplasty

Femoral-Popliteal-Tibial Occlusive DiseaseSurgical 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 DiseaseSurgical 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