Peripheral Arterial Disease Claudication Mitchell H. Goldman MD The University of Tennessee Graduate School of Medicine
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Peripheral Arterial DiseaseClaudication
Mitchell H. Goldman MDThe University of Tennessee Graduate School of Medicine
Assumptions
• You know anatomy• You know pathophysiology, biochemistry
of atherosclerosis• You are awake
Quiz
The best way to diagnose claudication is;
A. History and Physical Exam
B. Doppler Studies
C. CT scan
D.MRA
E. Contrast Angiography
Peripheral Vascular Disease
• Arterial– Obstruction– Thrombosis– Embolism– Aneurysm– Trauma/bleeding/malformations
• Venous• Lymphatic
Obstruction• The degree of
narrowing at which pressure and flow begin to be affected.
• 75% cross sectional area or 50% reduction in diameter
• Assumes symmetry• High-flow vs. low-flow• Significance must be
correlated clinically.
Normal Artery• Arterial segment
without turn, or narrowing.
• The pressure, or energy, in the blood at P1 is almost identical to that at P2.
• With exception of pulsatility, demonstrates energy loss predicted by
Laminar flow
Poiseuille’s law.
PoiseuillePoiseuille’’ss LawLaw• Describes a
“parabolic profile”• Velocities highest at
the center.• Shear rate(D) = ∆v/∆r• Tube must be long
enough for profile to develop.
• Applies to each branch point and decrease in diameter.
PoiseuillePoiseuille’’ss LawLaw• Energy losses inversely proportional to fourth power of the radius
• Little effect until critical point reached
• Graphs then sharply curved
• Increased flow shifts to left
PoiseuillePoiseuille’’ss LawLaw
Energy losses related to the viscosity of bloodEnergy losses related to the viscosity of bloodViscosityViscosity-- friction existing between contiguous friction existing between contiguous layer of fluidlayer of fluid
rrLQLVPPπ
ηη4221
88 ⋅=⋅=−
Diseased ArteryDiseased ArteryThe blood has to speed The blood has to speed up to get through the up to get through the area of resistance.area of resistance.Pressure in P2 is Pressure in P2 is lower lower than in P1 than in P1 There is less pressure, or There is less pressure, or energy, left in the blood energy, left in the blood once it has got through once it has got through the area of resistance the area of resistance because it had to do because it had to do workwork to get through to get through
Pressure (energy) Loss at aStenosis
Entrance and ExitEntrance and Exit
Doubling the length of a lesion does not affect Doubling the length of a lesion does not affect energy loss significantly.energy loss significantly.Two separate lesions of equal length and Two separate lesions of equal length and diameter will double resistancediameter will double resistanceEntrance and exit effectsEntrance and exit effectsTwo Two stenosesstenoses of unequal diameter in series, of unequal diameter in series, tighter of the two has greatest effect on tighter of the two has greatest effect on resistanceresistance
Turbulence
• Random velocity vectors• Occur at branch points and after areas of
narrowing.• Short-lived• Energy losses not accounted for by
Poiseuille’s law.
Energy Loss
• Inertia• Turbulence• Pulsatility• Poiseuille’s law
defines minimal energy losses.
Pressure distal tostenosis drops
Blood flow goes up but insufficiently to provide enough oxygen
Exercise Induced Ischemia
Ischemia
• Claudication
• Rest Pain
• Ulceration/Tissue Loss/Gangrene
CLAUDICATIONCLAUDICATION
DEFINITION
REPRODUCIBLE PAIN WITH EXERCISE,RELIEVED BY CESSATION
FOUR THINGS
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
• MUSCULOSKELETAL• NEUROLOGIC• NEUROPATHIC• VENOUS• METABOLIC
?
CLAUDICATIONCLAUDICATION
REPRODUCIBLE
PAIN IS REPRODUCED ALMOST EXACTLY THE SAME TIME AND PLACE UNDER THE SAME CONDITIONS
NOT LIKE ORTHOPEDIC PAIN WHICH IS VARIABLE OR NEUROLOGIC PAIN WHICH IS CONSTANT
“EVERY TIME I WALK A BLOCK AND I GET PAIN IN MY LEG”
CLAUDICATIONCLAUDICATION
PAIN
CRAMPY, SHARP, TIGHTENING, SPASMIC, NUMBING IN A MUSCLE DISTRIBUTION BUT USUALLY NOT BURNING (NEURO-PATHY), DERMATOMAL (NEUROLOGIC),OR IN JOINTS
OUCHY!
CLAUDICATIONCLAUDICATION
OUCHY!
EXERCISE
PAIN STARTS, CONTINUES DURING, AND STOPS WITH EXERCISE, IT DOESN’T JUST COME ON.
CLAUDICATIONCLAUDICATION
ALL GONE!
CESSATION
PAIN GOES AWAY WHEN YOU STOP EXERCISING
WITHIN MINITS
DON’T HAVE TO RAISE THE LEG AS IN
VENOUS DISEASE
CLAUDICATION DIFFERENTIALCLAUDICATION DIFFERENTIALDIAGNOSISDIAGNOSIS--REPRISEREPRISE
• VENOUS CLAUDICATION• SPINAL CORD COMPRESSION• OSTEOARTHRITIS• PERIPHERAL NERVE COMPRESSION• CHRONIC COMPARTMENT SYNDROME• POPLITEAL ENTRAPMENT, CYST OR
ANEURYSM• SPASMS OR METABOLIC
ClaudicationClaudication
Harbinger of more severe systemic disease
People who are over 50 and smoke or have diabetes have a 30% chance of having secret PAD
CLAUDICATIONCLAUDICATION
NATURAL HISTORYNATURAL HISTORYAT FIVE YEARSAT FIVE YEARS %%
MORTALITYMORTALITY 3030
OF THE SURVIVORSOF THE SURVIVORS
NONFATAL MI/CVANONFATAL MI/CVA 2020
STABLESTABLE 7373
WORSEWORSE 1616
BYPASSEDBYPASSED 77
AMPUTEEAMPUTEE 44
!!
OVERLAP AMONG PAOD, CAD AND CVDOVERLAP AMONG PAOD, CAD AND CVD
CEREBRALCEREBRAL CARDIACCARDIAC25% 7%
3%4%
12%
30%
19%PAD
PAODPAODCAPRIE, Lancet 1996;348:1349
ABI (Ankle/Brachial Index)
Ankle PressureBrachial Pressure = 1.0-1.2
By Doppler*
HOW AWARE ARE WE ?HOW AWARE ARE WE ?
PARTNERS STUDY (UTMCK)PARTNERS STUDY (UTMCK)ROUTINE ABI DETECTED PAD IN 29% OF 6,979 PTS
44% NOT BEEN PREVIOUSLY DIAGNOSED
6% OF NEW CASES (11%OF ALL) HADCLAUDICATION
49% OF PHYSICIANS AWARE OF EXISTING PAD IN THEIR PTS
33% OF NEW PAD PTS, 71% OF CVD PTS PLACED ON ANTIPLATELET Rx
JAMA 2001 286:1317
MAKE AN ANATOMIC DIAGNOSISMAKE AN ANATOMIC DIAGNOSIS
AORTOAORTO--ILIACILIAC
FEMFEM--POPPOP
PERONEALPERONEAL
PEDALPEDAL
TIBTIB--
••BASED ON BASED ON HISTORY AND HISTORY AND PHISICALPHISICAL
••THINK OF LEVELS THINK OF LEVELS OF DISEASEOF DISEASE
••FOUR STANDARD FOUR STANDARD LEVELSLEVELS
HISTORYHISTORYAREAAREA
HIP, THIGH, BUTTOCKHIP, THIGH, BUTTOCK AORTOILIACAORTOILIAC
CALFCALF AORTOILIAC OR AORTOILIAC OR FEMFEM--POPPOP
FOOTFOOT BUERGERBUERGER’’S S DISEASEDISEASE
HISTORYHISTORYDISTANCEDISTANCE
>TWO BLOCKS>TWO BLOCKS ONE LEVELONE LEVEL
< TWO BLOCKS< TWO BLOCKS TWO LEVELSTWO LEVELS
REST PAIN OR TISSUEREST PAIN OR TISSUE
LOSSLOSS THREE LEVELSTHREE LEVELS
PHYSICAL EXAMPHYSICAL EXAM
••PULSESPULSES 0,1,2 PLUS0,1,2 PLUS
ONE LEVEL ABOVEONE LEVEL ABOVE
••BRUITSBRUITS STENOSIS VS STENOSIS VS OCCLUSIONOCCLUSION
••ELEVATION PALLOR/ELEVATION PALLOR/
DEPENDANT RUBORDEPENDANT RUBOR THREE LEVELSTHREE LEVELS
••ONYCHOGRYPHOSISONYCHOGRYPHOSIS CHRONICITYCHRONICITY
ADD PHYSICAL EXAMADD PHYSICAL EXAM
THE PATIENT WITH > TWO BLOCK CALF THE PATIENT WITH > TWO BLOCK CALF CLAUDICATION WHO HAS A FEMORAL CLAUDICATION WHO HAS A FEMORAL PULSE HAS:PULSE HAS:
FEMFEM--POP DISEASEPOP DISEASE AND IF HE HAS AND IF HE HAS A A BRUITBRUIT IN HUNTERSIN HUNTERS’’S CANAL HE S CANAL HE HAS:HAS:
FEMFEM--POP STENOSISPOP STENOSIS
ADD PHYSICAL EXAMADD PHYSICAL EXAM
OR IF HE HAS AN OR IF HE HAS AN ABSENTABSENT OR OR DIMINISHEDDIMINISHED FEMORAL PULSE HE HAS:FEMORAL PULSE HE HAS:
AORTOILIAC DISEASEAORTOILIAC DISEASE
ILIAC OR FEMORAL BRUIT?ILIAC OR FEMORAL BRUIT?NO! AORTOILIAC OCCLUSIONNO! AORTOILIAC OCCLUSION
YES! AORTOILIAC STENOSISYES! AORTOILIAC STENOSIS
ANKLE/BRACHEAL INDEX (ABI)ANKLE/BRACHEAL INDEX (ABI)••OFFICE PROCEEDURE (NURSE CAN DO IT)OFFICE PROCEEDURE (NURSE CAN DO IT)
BLOOD PRESSURE CUFFBLOOD PRESSURE CUFF
HAND HELD DOPPLER (5MHz)HAND HELD DOPPLER (5MHz)
••DIAGNOSE OCCULT PAODDIAGNOSE OCCULT PAOD
••CONFIRM SUSPECTED DISEASECONFIRM SUSPECTED DISEASE>0.7>0.7 > 2 BLOCK CLAUDICATION> 2 BLOCK CLAUDICATION0.50.5--0.7 10.7 1--2 BLOCK CLAUDICATION2 BLOCK CLAUDICATION
<0.4<0.4 REST PAIN, TISSUE LOSSREST PAIN, TISSUE LOSS
SEGMENTAL PRESSURESSEGMENTAL PRESSURESThe RulesThe Rules
•• The thigh pressure The thigh pressure is 1.0is 1.0--1.2x the arm 1.2x the arm and the same on and the same on each sideeach side
•• A difference of A difference of greater than 20 mm greater than 20 mm between segments between segments is significantis significant
•• The toe pressure is The toe pressure is 70% of the ankle70% of the ankle
SEGMENTAL PRESSURESSEGMENTAL PRESSURES
•• ANKLE/BRACHIAL ANKLE/BRACHIAL or TOE/BRACHIAL or TOE/BRACHIAL INDEXINDEX
•• SEGMENTAL SEGMENTAL CUFFSCUFFS
•• FEMORAL FEMORAL WAVEFORMSWAVEFORMS
•• EXERCISEEXERCISE•• PVR
DOPPLER
PRESSURE CUFFS
SUPINE
WARM ROOM
PVR
DIABETIC VESSELS
•• UNCOMPRESSIBLE UNCOMPRESSIBLE VESSELSVESSELS
•• CIRCUMFERENTIAL CIRCUMFERENTIAL CALCIFICATIONCALCIFICATION
•• USE TOE/BRACHIAL USE TOE/BRACHIAL PRESSURE OR PVRPRESSURE OR PVR
CALCIUM
SEGMENTAL PRESSURESSEGMENTAL PRESSURES
••CONFIRMS ANATOMIC DIAGNOSIS BY CONFIRMS ANATOMIC DIAGNOSIS BY PHYSIOLOGIC MEANSPHYSIOLOGIC MEANS
••PRETTY GOOD WAY TO FOLLOW OR PRETTY GOOD WAY TO FOLLOW OR SHOW THE PATIENTS HARD DATASHOW THE PATIENTS HARD DATA
••BB--MODE ULTRASOUND OF QUESTIONABLE MODE ULTRASOUND OF QUESTIONABLE VALUE AND ADDS EXPENSEVALUE AND ADDS EXPENSE
••IN THE NONINVASIVE VASCULAR LABIN THE NONINVASIVE VASCULAR LAB
TREATMENTTREATMENT
CLAUDICATION RISK FACTORSCLAUDICATION RISK FACTORSFACTOR_________RELATIVE RISK (ODDS RATIO)FACTOR_________RELATIVE RISK (ODDS RATIO)
MALE GENDER 2.5
AGE (PER 10 yrs) 2.1
DIABETES 2.0
SMOKING 2.7
HYPERTENSION 1.1
HYPERCHOLESTEROLEMIA 0.9
HOMOCYSTEINEMIA 7.0
ETOH -2.0COEXISTANCE OF MORE THAN ONE - MORE THAN ADDITIVE
JVS 2000; 31:S17
!!!!!!
MEDICAL THERAPYMEDICAL THERAPY
•• CONTROL RISK FACTORSCONTROL RISK FACTORS-- PROLONG LIFE PROLONG LIFE (LIPIDS, DIABETES, HTN)(LIPIDS, DIABETES, HTN)
•• SMOKING CESSATIONSMOKING CESSATION•• ANTIPLATLET THERAPYANTIPLATLET THERAPY--REDUCE CARDIAC REDUCE CARDIAC
AND VASCULAR RISKAND VASCULAR RISK•• DIET AND WEIGHT LOSSDIET AND WEIGHT LOSS•• EXERCISE THERAPYEXERCISE THERAPY•• PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY
CONTROL RISK FACTORSCONTROL RISK FACTORS
•• LIPIDS LIPIDS ““TRY DIET FIRSTTRY DIET FIRST””–– LDL CHOL<100 mg/dl , better < 70 mg/dl for high risk PAD LDL CHOL<100 mg/dl , better < 70 mg/dl for high risk PAD
ptspts–– Niacin side effectsNiacin side effects–– FibratesFibrates for low HDL and high TG for low HDL and high TG –– StatinsStatins ((simvastatinsimvastatin))--check liver enzymes, check liver enzymes, rhabdomyolysisrhabdomyolysis
•• HTNHTN–– Controlled according to joint committee IV guidelines 140/90Controlled according to joint committee IV guidelines 140/90–– Beta blocker (Beta blocker (atenololatenolol) and ACE inhibitor) and ACE inhibitor
•• HOMOCYSTEINEMIAHOMOCYSTEINEMIA–– For level >5mmole/L, folic acid, B12, B6For level >5mmole/L, folic acid, B12, B6
CONTROL RISK FACTORSCONTROL RISK FACTORS
DIABETESDIABETES–– FBS RANGE 80FBS RANGE 80--120 mg/dl120 mg/dl–– POSTPRANDIAL <180 mg/dlPOSTPRANDIAL <180 mg/dl–– HEMOGLOBIN A1C <7.0%HEMOGLOBIN A1C <7.0%–– FOOT CAREFOOT CARE
•• OrthoticsOrthotics•• InspectionInspection
ANTIPLATELET THERAPYANTIPLATELET THERAPY
••ASA, 75ASA, 75--350 mg/d, REDUCES CARDIAC AND 350 mg/d, REDUCES CARDIAC AND VASCULAR DEATH, NONFATAL MI VASCULAR DEATH, NONFATAL MI AND PERIPHERAL ARTERY SURGERYAND PERIPHERAL ARTERY SURGERY
••TICLOPIDINE REDUCES MI AND STROKETICLOPIDINE REDUCES MI AND STROKE
••CLOPIDOGREL REDUCES STROKE, MI OR CLOPIDOGREL REDUCES STROKE, MI OR VASCULAR DEATHVASCULAR DEATH
••COST BENEFIT NOT AVAILABLE, COST BENEFIT NOT AVAILABLE, CONSIDER SIDE EFFECTSCONSIDER SIDE EFFECTS
PHARMACOTHERAPYPHARMACOTHERAPY••PENTOXIFYLLINEPENTOXIFYLLINE
RBC DEFORMITY, DECREASE RBC DEFORMITY, DECREASE FIBRINOGEN, FIBRINOGEN, PLATLET AGGREGATIONPLATLET AGGREGATIONVARIED IMPROVEMENT/SIDE EFFECTSVARIED IMPROVEMENT/SIDE EFFECTS
••PROSTAGLANDINSPROSTAGLANDINSPGEPGE--1, PGI1, PGI--1(UTMCK DEPT. SURGERY TRIAL)1(UTMCK DEPT. SURGERY TRIAL)SIDE EFFECTSSIDE EFFECTS
••CARNITINECARNITINE--SMALL TRIALSSMALL TRIALS
••VASODILATORSVASODILATORS--NOT A STITCH OF INDICATIONNOT A STITCH OF INDICATION
••CILOSTAZOLCILOSTAZOLPHOSPHODIESTERASE III INHIBITOR, PHOSPHODIESTERASE III INHIBITOR, VASODILATOR, ANTIPLATLET ACTIVITYVASODILATOR, ANTIPLATLET ACTIVITYIMPROVEMENT/SIDE EFFECTSIMPROVEMENT/SIDE EFFECTS
MEDICAL THERAPYMEDICAL THERAPY
0
20
40
60
0 4 8 12 16 20 24
WEEKS
MEA
N %
CHA
NGE PLACEBO
PENTOXIFYLINE
CILOSTAZOL
Am. J. Cardiology 2001 87;19D
Tobacco Dependence
• Reduction does not reduce all causes mortality (Am. J Epidem 2002;156:194)
• Behavior therapy-20% quit rate in a program
• Nicotine replacement therapy (gum, patch etc) 40-60% quit rate when combined with behavior modification but 25-30% at 1 yr
Tobacco Dependence
• Buproprion SR-(Zyban) antidepressant, dopaminergic and adrenergic effects, 7-12 wks, twice as good as placebo, side effects
• Varenicline-(Chantrix) a4B2 nicotinic acetylcholine receptor partial agonist, 12 wks, reduces side effects of withdrawal
Risk Factor Reduction
Reduces risks of death and other cardiovascular complications
EXERCISE THERAPYEXERCISE THERAPY
EXERCISEEXERCISE NN CHANGE ACD (%)CHANGE ACD (%)
SUPERVISED/ASASUPERVISED/ASA 1010 +105+105
ASAASA 1010 ----------
SUPERVISED/PTSFN 15SUPERVISED/PTSFN 15 +371+371
TMTM 1010 +74+74
HOMEHOME 4141 +61+61
SUPERVISEDSUPERVISED 5959 +99+99--195195
HOME/PGI 123HOME/PGI 123 +69+69--142 142 Ann Vasc Surg; 1999 13:109
INDICATIONS FOR INVASIVEINDICATIONS FOR INVASIVEINTERVENTIONINTERVENTION
•• LIFESTYLE OR OCCUPATIONAL LIFESTYLE OR OCCUPATIONAL INTERFERENCEINTERFERENCE
•• FAILURE OF MEDICAL THERAPYFAILURE OF MEDICAL THERAPY•• PROGRESSIONPROGRESSION•• UNTOWARD EVENTUNTOWARD EVENT•• ASSOCIATED DISEASEASSOCIATED DISEASE•• SURGICAL RISKS REASONABLESURGICAL RISKS REASONABLE
DIAGNOSTIC TESTSDIAGNOSTIC TESTS
•• ANGIOGRAPHYANGIOGRAPHY•• 33--D CAT SCAND CAT SCAN•• MAGNETIC RESONANCE MAGNETIC RESONANCE
ANGIOGRAPHYANGIOGRAPHY•• CARDIAC STRESS TESTCARDIAC STRESS TEST
CTA
MRAAngio
Invasive Treatment
• Surgery– Traditional– Durability– Higher mortality, LOS
• Angioplasty, stent– Percutaneous– Lower LOS, mortality– Durability
PRIMARY ILIAC PTA AND STENTPRIMARY ILIAC PTA AND STENTPATENCYPATENCY--METAANALYSISMETAANALYSIS
0
20
40
60
80
100
120
0 1 2 3 4 5YEARS
PRIM
ARY
PATE
NCY
(%)
Stenosis-Stent
Stenosis-PTA
Occlusion-Stent
Occlusion-PTA
Radiology 2001 221:137
Time (months)
6050403020100
Prim
ary
Sten
t Pat
ency
1.0
.8
.6
.4
.2
0.0
PRIMARY STENT AND PTA PATENCYPRIMARY STENT AND PTA PATENCYUT DATAUT DATA
CIA
EIA
P < 0.001
Timeran et al JVS
PRIMARY STENT PATENCYPRIMARY STENT PATENCY
Time (months)
6050403020100
Prim
ary
Sten
t Pat
ency
1.0
.8
.6
.4
.2
0.0
Men
Women
P = 0.02
Timeran et al JVS
PRIMARY STENT PATENCY IN WOMENPRIMARY STENT PATENCY IN WOMEN
Time (months)
6050403020100
Prim
ary
Sten
t Pat
ency
1.0
.8
.6
.4
.2
0.0
CIA
EIA
P < 0.001
Timeran et al JVS
Time (months)6050403020100
Prim
ary
Pate
ncy
1.0
.8
.6
.4
.2
0.0
Non-HRT users
HRT users
P = 0.003
PRIMARY STENT PATENCYAHA Category 1 and 2 Lesions
Timeran et al JVS
PRIMARY STENT PATENCYUnivariate Analysis - Kaplan-Meier
P valueVariable
Hormone replacement therapy 0.020EIA stenting 0.001Renal insufficiency (creatinine ≥ 1.6) 0.199Hyperlipemia 0.061Diabetes (IDDM or NIDDM) 0.881Smoking history 0.134Indication (claudication vs. critical ischemia) 0.582Type of stent (Palmaz vs. Wallstent) 0.663Runoff score < 5 0.161Disease severity (AHA categories) 0.182
Timeran et al JVS
METAANALYSIS OF WEIGHTEDMETAANALYSIS OF WEIGHTEDPRIMARY PATENCY(%)PRIMARY PATENCY(%)
PTA AND STENTS PTA AND STENTS AFB FPBAFB FPB
YRS TS 1 3 5 YRS TS 1 3 5 5 105 10 55
ILIAC PTAILIAC PTA
STENOSISSTENOSIS 95 78 66 6195 78 66 61
OCCLUSIONOCCLUSION 83 68 60 83 68 60 --
ILIAC STENTILIAC STENT 8686 7979
STENOSISSTENOSIS 99 9O 74 7299 9O 74 72
OCCLUSIONOCCLUSION 82 75 64 82 75 64 --
FEMFEM--POPPOP
STENOSISSTENOSIS 90 61 51 48 90 61 51 48 AK 80AK 80
OCCLUSIONOCCLUSION 88 67 88 67 -- -- BK 65BK 65
TASC Consensus Data JVS 2000 31TASC Consensus Data JVS 2000 31
FEMFEM--POP PRIMARY GRAFT PATENCYPOP PRIMARY GRAFT PATENCY
Time (months)
80706050403020100
Pate
ncy
Rat
e (%
)
100
80
60
40
20
0
Non-HRT users
HRT users
P = 0.004
Timeran et al JVS
FEMFEM--POP MULTIVARIATE ANALYSISPOP MULTIVARIATE ANALYSIS(COX REGRESSION)(COX REGRESSION)
Coefficient Relative 95% CI P valueRisk
Primary patencyPrimary patencyHRT 0.914 2.5 1.3-4.8 0.006
0.916 1.3-5.0 0.009Estrogen alone 2.5HRT + PTFE 1.191 3.3 1.4-7.5 0.005
Assisted primary patencyAssisted primary patency
1.044 2.8HRT 1.4-5.6 0.003Renal insufficiency 0.784 2.2 1.1-4.3 0.025
Timeran et al JVS
Effects of Estrogen, Progesterone, and Combination Exposure on Interleukin-1βInduced Expression of VCAM-1, ICAM-1,
PECAM, and E-Selectin by Human Female Iliac Artery Endothelial Cells
K.T. Piercy, MD, R.L. Donnell, DVM, PhD, ACVP, S. Kirkpatrick, BS,
S.D. Pappas, BS, S.L Stevens, MD, FACS, M.B. Freeman, MD, FACS,
M.H. Goldman, MD, FACSDepartment of SurgeryUniversity of Tennessee Medical Center,
Knoxville
Luminal Flow
RollingE-selectinP-selectinL-selectin
LooseAdhesion
FirmAdhesionICAM-1ICAM-2VCAM-1
MigrationPECAM-1ICAM-1VCAM-1
Hormonal Effects onAdhesion MoleculeExpression
0
25
50
75
100
125
Mea
n FI
Control Est Prog Est/Prog
VCAM-1
*
!!!!
0
250
500
750
1000
Mea
n FI
Control Est Prog Est/Prog
ICAM-1
*
HORMONE REPLACEMENTHORMONE REPLACEMENTTHERAPYTHERAPY
••MAY AFFECT CARDIAC RISK IN MAY AFFECT CARDIAC RISK IN PATIENTS WITH PREEXISTING PATIENTS WITH PREEXISTING DISEASEDISEASE
••AFFECTS PATENCY OF VASCULAR AFFECTS PATENCY OF VASCULAR INTERVENTIONSINTERVENTIONS
••MAY BE RESULT OF INDUCED MAY BE RESULT OF INDUCED HYPERCOACUABLE STATE HYPERCOACUABLE STATE ORORINTIMAL HYPERPLASIAINTIMAL HYPERPLASIA
VASCULAR SURGERYVASCULAR SURGERYA NEW PARADIGM A NEW PARADIGM ““ONE STOPONE STOP SHOPPINGSHOPPING””
A PHYSICIAN FIRSTA PHYSICIAN FIRST--WITH THE PRIMARY MDWITH THE PRIMARY MD
RISK MANAGEMENTRISK MANAGEMENT
DIAGNOSTIC METHODSDIAGNOSTIC METHODS
MEDICAL THERAPYMEDICAL THERAPY
INTERVENTIONAL SKILLS INTERVENTIONAL SKILLS ““NOT ROCKET SCIENCENOT ROCKET SCIENCE””
SURGERYSURGERY
FOLLOW UPFOLLOW UP--WITH PRIMARY MDWITH PRIMARY MD
QUALITY ASSESSMENTQUALITY ASSESSMENT--OBJECTIVE LOOK BACKOBJECTIVE LOOK BACK
REVIEWREVIEW--CLAUDICATIONCLAUDICATION
•• DIAGNOSIS BY HISTORY AND DIAGNOSIS BY HISTORY AND PHYSICALPHYSICAL
•• CONFIRM BY ANKLE/BRACHIAL INDEXCONFIRM BY ANKLE/BRACHIAL INDEX•• TREAT RISK FACTORSTREAT RISK FACTORS•• MEDICAL THERAPYMEDICAL THERAPY•• REFER FOR INVASIVE REFER FOR INVASIVE
INTERVENTIONINTERVENTION•• LONG TERM FOLLOW UP
I know!I know!
LONG TERM FOLLOW UP
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