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