Peripheral Vascular Intervention (PVI) with Dr. Daniel Bertges, University of Vermont

1. Peripheral Vascular Intervention (PVI) Dr. Daniel Bertges, University of Vermont

2. Agenda: • De-identified case review • IRR variable variation discussion • General Q & A for PVI

3. Limitations of the IRR project: • Independent audit: Please do not ask for any help from anyone (i.e. other data abstractors/physicians/etc). • No dates included • Instructed if they could not find a data element, it was ok to leave it blank and submit without validation

4. Q1: Urgency • Elective = planned/scheduled procedure; • Urgent = required operation within 72 hours, but > 12 hours of admission; • Emergent = required operation within 12 hours of admission to prevent limb loss

5. Select A1: Urgency • Elective • Urgent • Emergent • Unknown (leave blank)

6. A1: Urgency • Elective • Urgent • Emergent • Unknown (leave blank)

7. Q2: Leg Symptoms, Left • Asymptomatic: documented peripheral arterial disease without symptoms of claudication or ischemic pain • Mild Claudication: ischemic limb muscle pain that does not limit walking or limits walking only after > 2 blocks (>600 feet or 2 football fields); • Moderate Claudication: ischemic limb muscle pain that limits walking 1-2 blocks (300-600 feet, or 1-2 football fields); • Severe Claudication: ischemic limb muscle pain that limits walking < 1 block (<300 feet or 1 football field); • Ischemic Rest Pain: pain in the distal foot at rest felt to be due to limited arterial perfusion

8. Q2: Leg Symptoms, Left (cont’d) • Ulcer or necrosis (gangrene) = de novo tissue loss due to peripheral arterial disease, not due to non-healing prior amputation. • Non-healing amputation = ulcer, necrosis or lack of primary healing at site of prior amputation causing current tissue loss. • Ulcer + non-healing amp = combination of de novo ulcer (or necrosis/gangrene) separate from a non-healing amputation site. • Acute Ischemia: Acute limb ischemia is defined as a sudden decrease in limb perfusion that causes a potential threat to limb viability (manifested by ischemic rest pain, ischemic ulcers, and/or gangrene) in patients who present within two weeks of the acute event.

9. Select A2: Leg Symptoms, Left • Asymptomatic • Mild Claudication • Moderate Claudication • Severe Claudication • Ischemic Rest Pain • Ulcer/necrosis • Non-healing Amputation • Both Ulcer + Non-healing Amp • Acute Ischemia • Unknown (leave blank)

10. A2: Leg Symptoms, Left • Asymptomatic • Mild Claudication • Moderate Claudication • Severe Claudication • Ischemic Rest Pain • Ulcer/necrosis • Non-healing Amputation • Both Ulcer + Non-healing Amp • Acute Ischemia • Unknown (leave blank)

11. Q3: TASC Grade • TASC - Trans-Atlantic Society Consensus • Please go to the resource tab for the diagram for TASC. Note that if femoral and popliteal arteries are treated separately, or common and external iliac, record the TASC classification based on the TASC definition for the combined segments for each of the 2 lesions treated separately. • Protect adjacent artery is recorded when a balloon or stent was placed in an artery with no significant lesion in order to prevent compression by treatment in an adjacent branch, which is commonly done in the proximal common iliac arteries with "kissing" stents. • In this case, sometimes only one side is stenosed but both sides are treated, so use "Protect adjacent artery" to indicate the non-diseased side that was also treated.

12. Q3: TASC Grade

13. Select A3: TASC Grade • A • B • C • D • Protect Adjacent Artery • Unknown (leave blank)

14. A3: TASC Grade • A • B • C • D • Protect Adjacent Artery • Unknown (leave blank)

15. Q4: CIN Prophylaxis • CIN: Contrast Induced Nephropathy • None= none given before or during the procedure to prevent CIN; • Bicarb = IV Bicarb - Sodium Bicarbonate IV; • Saline = Saline IV hydration or other hydration fluid such as lactated ringers; • Both= both Bicarb and Saline

16. Select A4: CIN Prophylaxis • None • Bicarb • Saline • Both Bicarb and Saline • Unknown (leave blank)

17. A4: CIN Prophylaxis • None • Bicarb • Saline • Both Bicarb and Saline • Unknown (leave blank)

18. Q5: Number of Arteries Treated • Enter up to 4 arteries. • When the treatment includes the common and external iliac enter as one (com + ext iliac). • When the treatment includes the SFA and popliteal enter as one (SFA + pop). • For procedures with greater than 4 arteries treated enter those most clinically important in the judgment of the interventionalist.

19. Select A5: Number of Arteries Treated (which one/s) • 1 • 2 • 3 • 4 • Unknown (leave blank)

20. A5: Number of Arteries Treated • 1 • 2 • 3 • 4 • Unknown (leave blank)

21. Q6: Calcification • None=no calcification visible on fluoroscopic, CT or IVUS imaging; • Focal=calcification on one side of artery < half length of lesion; • Mild= calcification on one side of artery > half length of lesion; • Moderate = calcification on both sides of artery < half length of lesion; • Severe = calcification on both sides of artery > half length of lesion; • Not Evaluated=Calcification not evaluated.

22. Select A6: Calcification • None • Focal • Mild • Moderate • Severe • Not evaluated • Unknown (leave blank)

23. A6: Calcification • None • Focal • Mild • Moderate • Severe • Not evaluated • Unknown (leave blank)

24. Q7: Thrombosis: Post op • No = no thrombosis complication occurred; • Medical = thrombosis complication occurred but required no invasive management, i.e. only medical management which could range from outpatient observation to admission to hospital, administration of medications such as heparin, or any non-invasive escalation of care from what was planned, including longer admission; • Interventional = treatment with additional angioplasty, stenting, thrombolysis, suction catheter, etc.; • Surgical = any open surgical procedure including open thrombectomy, bypass, etc.

25. Select A7: Thrombosis: Post op • No • Medical • Interventional • Surgical • Unknown (leave blank)

26. A7: Thrombosis: Post op • No • Medical • Interventional • Surgical • Unknown (leave blank)

27. Q8: Renal Complication • Renal=New increase in creatinine of >= 0.5mg/dl (44.2 umol/L), new dialysis (peritoneal, hemodialysis or hemo-filtration), observed during the procedure or before discharge after the procedure. • Note that complications occurring after discharge are entered on a follow-up form. • Does not apply to patients on dialysis prior to procedure.

28. Select A8: Renal Complication • No • Yes • Unknown (leave blank)

29. A8: Renal Complication • No • Yes • Unknown (leave blank)

30. Q9: Occlusion Length Popliteal • If more than one segment of occlusion, add total of all segments within treated artery. • Occlusion length should be measured with a marker catheter or overlying ruler. Must be between 0 and 90 (round to the nearest integer). • Enter zero if no occlusion.

31. Select A9: Occlusion Length Popliteal • 0 • 8 • 20 • Other • Unknown (leave blank)

32. A9: Occlusion Length Popliteal • 0 • 8 • 20 • Other • Unknown (leave blank)

33. Q10: Treated Length Popliteal • If more than one discrete lesion is treated, add the lengths of each treated segment to derive total treated length. • Lesion length should be measured with a marker catheter or overlying ruler. • Must be between 0 and 90 (round to the nearest integer).

34. Select A10: Treated Length Popliteal • 0 • 10 • 20 • 25 • 30 • Other • Unknown (leave blank)

35. A10: Treated Length • 0 • 10 • 20 • 25 • 30 • Other • Unknown (leave blank)

36. Questions