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management of vascular disease weighing natural history against outcomes after interventions

CarotidStenosis. Carotid Endarterectomy100%. AorticAneurysm. Open AAARepair100%. LegIschemia. Lower ExtremityBypass100%. . . . Disease:. Treatment:. Standard Vascular Surgical Practice (circa. 2000). CarotidStenosis. Carotid Endarterectomy60% Carotid Stenting40%. AorticAneurysm. Open AAARepair20% Endograft AAARepair80%.

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management of vascular disease weighing natural history against outcomes after interventions

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    1. Management of Vascular DiseaseWeighing Natural History Against Outcomes after Interventions Scott Berceli, MD PhD Associate Professor of Surgery

    2. Standard Vascular Surgical Practice(circa. 2000)

    3. Standard Vascular Surgical Practice(circa. 2007)

    4. Abdominal Aortic Aneurysms

    5. Incidence Found in 2-5% of individuals > 65 year old Accounts for 1.2% of deaths in > 65 age group 13th leading cause of death in U.S.

    6. Rupture Risk 1960’s to 1990’s

    10. Methods of AAA Repair

    11. Open operative repair

    12. Endovascular repair Material Components Graft: woven polyester Stent: nitinol (nickel-titanium) exoskeleton Thermal shape memory Non-absorbable polyester sutures >2000 hand-sewn suture/stent graft

    15. Carotid Artery Stenosis

    16. Pathophysiology 50% or less due to disease of the carotid bifurcation

    17. Risk Factors TIA’s Hypertension Cigarette smoking Hyperlipidemia Age, male sex, race, heredity Diabetes

    21. History of carotid endarterectomy in the U.S.

    22. NASCET Design 3000 patients randomized to medical or surgical therapy and followed for a minimum of 5 years 50 selected centers (<6% peri op stroke/death rate), sxs within 3 months, <80 yo; specific angio criteria

    23. NASCET 2 year estimate by life table of ipsilateral stroke 26% for medical, 9% for surgical (70-99%) 18 mo mortality risk reduction 58%, stroke risk reduction 71%

    24. NASCET 2 yr Estimate of Ipsilateral Stroke Failure Rate NNT Stenosis Medical Surgical 70-99% 26.1% 12.9% 8 50-69% 22.2% 15.7% 15 <50% 18.7% 14.9% 26

    25. ACAS 39 centers, 17 credentialed surgeons (<3% for asymptomatic) <80 yo 1662 patients with >60% stenosis by angio

    26. ACAS Operative and angio stroke morbidity/mortality 2.3% (1.2% angio) Surgery No Surgery Projected 5 yr 5.1% 11% stroke event rate Stroke risk reduction 55% (only 17% for females)

    27. ACAS Stroke risk reduces from 2%/yr to 1%/yr, or 5% at 5 yrs One stroke prevented for every 20 CEAs done in asymptomatic patients

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