Cardiovascular Services

The Heart and Beyond:Diseases of theCirculatory System

Mobeen A. Sheikh, M.D.

Cerebrovascular disease• Ischemic stroke• Transient Ischaemic Attack (TIA)

Peripheral arterial disease (PAD)Intermittent claudication

• Pain on walkingSevere limb ischaemia

• Rest pain• Gangrene, necrosis

Cardiovascular disease• Heart Attack• Angina (stable/unstable)

Atherosclerosis affectsall arterial beds

CardiovascularServices

Where does PAD fit?

• Atherosclerosis is commonlyfound in more than onearterial bed

• PAD is often overlooked asone of the manifestations ofatheroscelerosis

PAD

MIStroke

Data from CAPRIE study (n=19,185). Figure adapted from Coccheri S. Eur Heart J 2002; 4 (Suppl B): B46-B49

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PAD Prevalence

• 10-12 million in U.S.

• 30% symptomatic

• < 40% treatedHirsch AT, JAMA 2001;286:1317-24.

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Ankle Brachial Index (ABI)

Systolic ankle pressure (mm Hg)

Systolic brachial pressure (mm Hg)

•Simple diagnostic tool

•Use Doppler ultrasound probeand sphygmomanometer

•Office based

•Non invasive

•Patient lying flat

CardiovascularServices

Ankle Brachial PressureIndex

High. May be due to arterial wallstiffening, especially in patients withdiabetes

>1.3

Consider referral to vascular specialist ifpatient has classic PAD symptoms

0.9

Confirms PAD diagnosis. Initiatemanagement and consider referral ifquality of life issues

<0.9

Indicates severe disease. Consider referralto vascular specialist

≤0.5

CardiovascularServices

Projected Increasein the Prevalence of PAD

0

2

4

6

8

10

12

14U

.S.I

ndi

vidu

als

(Mill

ion

s)

40-59 60-69 70+ Total

20002020

Prevalence rate: 3% 8% 19%

Chart from the 1999 Advisory Board Company. Source: Criqui NW et al., N Engl J Med (1992); Newman AB et al.,Arteriosclerosis, Thrombosis, and Vascular Biology (1999); U.S. Census Bureau(http://www.census.gov/population/projections/nation/nas)

818

2332

39

86

0

20

40

60

80

100

ProstateCancer*

Hodgkin'sDisease

BreastCancer*

PAD ColorectalCancer*

LungCancer*

Pat

ient

s(%

)

*American Cancer Society. Cancer Facts and Figures, 2000.†Criqui MH et al. N Engl J Med. 1992;326:381-6.

Relative 5-Year Mortality Rates

*

†

Cause of Death in PAD Patients

50

25

15

10

0 10 20 30 40 50 60

CAD

nonvascular

CVA

abdominalvascular

* percentage of deathsattributed to a given cause

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Increased risk vs general population (%)

Original event Heart Attack Stroke

Heart Attack

Stroke

Peripheral arterial disease

5–7 x greater risk1

(includes death)3–4 x greater risk2

(includes TIA)

2–3 x greater risk2

(includes angina andsudden death*)

9 x greater risk3

4 x greater risk4

(includes only fatal MIand other CHD death†)

2–3 x greater risk3

(includes TIA)

Risk of a Second Vascular EventRisk of a Second Vascular Event

CardiovascularServices

“Global Vascular Care”

Ischemia inIschemia inButtock, hip,Buttock, hip,Thigh and calfThigh and calf

Thigh,Thigh,calfcalf

Calf, ankle,Calf, ankle,footfoot

Obstruction inObstruction inAorta orAorta oriliac arteryiliac artery

Femoral arteryFemoral arteryor branchesor branches

PoplitealPoplitealarteryartery

Common Sites of Claudication

Why Endovascular Therapy?

• Minimally Invasive

• Increased safety

• Patient comfort

• Patient preference

• Less Expensive

• Glamorous

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SFASFAInterventionIntervention

SFA Intervention - Nature of the Problem

Contraction

Torsion

Flexion

Compression

CardiovascularServices

Nitinol self-expanding stent

CardiovascularServices

CardiovascularServices

• Unique helical patternenables multi-dimensional flexibility– Bending up to 180°

or twisting withoutkinking

– High radial strength– Low shear stresses

Choosing the Right Stent

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VIABAHN™ Endoprosthesis

• ePTFE lining with anexternal nitinol support

• No foreshortening• Easy deployment• 5 – 13 mm diameters• 2.5 – 15 cm lengths• 75 cm and 110 cm

working lengths• 8 Fr to 12 Fr sheaths

required

CardiovascularServices

Alternative Strategies:Debulking First

CardiovascularServices

FoxHollow SilverHawk

• Excises large volumesof plaque from de novoand restenotic lesions

• Single-operator,monorail catheter thatcan treat multifocaland multivesseldisease

SilverHawk System

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Magnified Cutter View

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Plaque Excised: 293 mg

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Renal Artery Stenosis

10 clues to the diagnosis ofRenovascular Disease

• Onset of HTN before 30 or after 55 yrs• Exacerbation of previously well controlled hypertension• Malignant hypertension• Resistant hypertension• Epigastric bruit (sound heard through stethoscope• Unexplained elevation of blood tests for kidney function• Elevation of blood tests for kidney function while

receiving ACE inhibitors• Shrunken kidney or size discrepancy• Atherosclerosis elsewhere• “Flash”pulmonary edema or recurrent CHF

Update on Carotid StentingUpdate on Carotid Stenting

CardiovascularServices

CardiovascularServices

Mednova, Neuroshield

Filter wire, EPI

Angioguard, Cordis

Different types of protection devices

7.5mmRX ACCUNETTM

12 mm