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PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEON’S POINT OF VIEW

PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEON’S POINT OF VIEW. DANIEL S. RUSH, M.D. NEW HORIZONS IN CARDIOVASCULAR HEALTH JANUARY 27, 2012. INTRODUCTION LOWER EXTREMITY PERIPHERAL ARTERIAL DISEASE (PAD ). Affects 10 million people in the U.S. About 4.3 % of everyone > 40 years old

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PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEON’S POINT OF VIEW

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  1. PERIPHERAL VASCULAR DISEASE: A VASCULAR SURGEON’S POINT OF VIEW DANIEL S. RUSH, M.D. NEW HORIZONS IN CARDIOVASCULAR HEALTH JANUARY 27, 2012

  2. INTRODUCTIONLOWER EXTREMITY PERIPHERAL ARTERIAL DISEASE (PAD) Affects 10 million people in the U.S. About 4.3 % of everyone > 40 years old About 14.5% of people > 70 years old 2 X increased incidence with each decade of life 100,000 patients undergo some form of revascularization each year

  3. CLINICAL CONSIDERATIONS IN PAD Underlying etiology of symptoms Anatomy of arterial occlusion Degree of limb ischemia Co-morbid medical conditions Functional status Ambulation potential Suitability for arterial intervention or reconstruction Appropriate decision making

  4. CLASSIFICATION OF LOWER EXTREMITY PAD Intermittent Claudication Critical Limb Ischemia (CLI) Ischemia pain at rest Ischemia ulceration Gangrene Infection

  5. INTERMITTENT CLAUDICAITON Most common symptom of PAD Extertional leg pain Life-style limiting to disabling Generally one anatomic segment of arterial occlusion Moderate limb ischemia 33% have treatable CAD <1% per year risk of amputation >3% - 5% per year risk of cardiac death

  6. DIFFERENTIAL DIAGNOSIS OF LEG PAIN Spinal stenosis Nerve root compression Peripheral neuropathy Degenerative joint disease Baker’s cyst Venous claudication Chronic compartment syndrome Cardiac disease

  7. CRITICAL LIMB ISCHEMIA A systemic disease Constant ischemic pain Failure to heal wounds, ischemic ulcerations, and gangrene Usually requires two or more segments of arterial occlusion Severe limb ischemia 25% risk of amputation in one year 25% risk of cardiac death within one year

  8. RISK FACTORS FOR PAD Age Sex Race and Family history Sedentary life-style Smoking Hyperlipidemia Hypertension Diabetes mellitus Hypercaogulability Hyperhomocysteinemia Renal insufficiency

  9. VASCULAR ASSESMENT IN PATIENTS WITH PAD History and physical examination Doppler examination Vascular laboratory studies CT ateriography MR ateriography Invasive contrast ateriography

  10. VASCULAR LOBORATORY ASSESMENT OF PAD Presence and direction of arterial blood flow Character or quality of blood flow (Doppler waveforms) Precise arterial systolic blood pressure measurement Ankle / Brachial Index (ABI) – relative severity of arterial insufficiency Qualitative anatomy of PAD (segmental arterial pressures) Serial or comparative arterial assessments Arterial Duplex (B-mode ultrasound and Doppler flow velocities)

  11. CLINICAL USES OF VASCULAR LABORATORY ASSESSMENT Evaluation of leg pain (PAD or something else?) Severity of limb ischemia Anatomic pattern of arterial occlusion Objective limb function (exercise) Post-operative follow-up Wound healing or amputation level

  12. INTERPRETATION OF ANKLE / BRACHIAL INDICIES (ABI’S) Normal ABI 0.9 – 1.2 Mild limb ischemia ABI 0.7 – 0.9 Minimal symptoms Moderate limb ischemia ABI 0.4 – 0.7 Claudication Severe limb ischemia ABI < 0.4 Rest pain, Tissue loss Non-compressible ABI > 1.2

  13. MEDICAL MANAGEMENT OF PAD Establish a diagnosis of PAD Smoking cessation (disease progression) Risk factor modification: Hypertension (stroke risk reduction – ACE inhibitors) Hyperlipidemia (disease progression, inflammatory response – “statins”) Diabetes mellitus (wound healing and infection – glycemic control) Coronary artery disease (MI risk reduction – Beta blockers) Supervise exercise and conditioning (improve exercise tolerance and strength) Treated associated causes of leg pain (neuropathy and arthritis)

  14. CHARACTERISTICS OF INTERMETTEMNT CLAUDICATION Exercise induced pain symptoms Absent femoral and/or pedal pulses ABI’s 0.4 - 0.7 range indicating moderate limb ischemia One level of arterial occlusion Aorto-iliac (LeRiche Syndrome) – hip or calf pain, vasogenic impotence SFA occlusion – calf pain Medical treatment preferred Often successfully treated with endovascular techniques Surgery reserved for sever symptoms in good risk patients

  15. CHARACTERISTICS OF CRITICAL LIMB ISCHEMIA Ischemia pain at rest or tissue loss Absent femoral and/or pedal pulses Distal rubor, ulceration, gangrene, and/or infection (risk of amputation) ABI’S < 0.4 indication severe limb ischemia Two levels of arterial occlusion (unless diabetic) Medical treatment alone is usually ineffective Sometimes improved with endovascular techniques Surgical bypass is usually required

  16. SURGICAL AND INTERVENTIONAL TREATMENT OPTIONS Arterial reconstructions Endarterectomy Patch angioplasty Bypass (autologous vein graft, prosthetic graft) Endovascular techniques Thrombectomy Atherectomy Balloon angioplasty Stent placement Endograft (covered stent)

  17. TREATMENT OF AORTO-ILIAC OCCLUSIVE DISEASE Aorto-Femoral Bypass (AFB) 3-5% M&M 90% 5 year patency Aortic endarterectomy 3-5% M&M 80% 5 year patency Extra-anatomic Bypass 1-2% M&M 60% 5 year patency Iliac balloon angioplasty < 1% M&M Claudication Stenosis 65% 5 year patency Occlusion 54% 5 year patency Critical ischemia Stenosis 53% 5 year patency Occlusion 45% 5 year patency Iliac stent <1% M&M Claudication Stenosis 77% 5 year patency Occlusion 61% 5 year patency Critical ischemia Stenosis 57% 5 year patency Occlusion 51% 5 year patency

  18. TREATMENT OF INFRA-INGUAL OCCLUSIVE DISEASE Ak Fem-pop bypass 1-2% M&M GSV graft 69% 5 year patency PTFE graft 60% 5 year patency BK Fem-pop bypass 1-2% M&M GSV graft 77% 5 year patency PTFE 40% 5 year patency SFA-pop balloon angioplasty < 1% M&M Claudication Stenosis 53% 5 year patency Occlusion 36% 5 year patency Critical ischemia Stenosis 31% 5 year patency Occlusion 16% 5 year patency

  19. MORBIDITY AFTER LOWER EXTREMITY BYPASS Healing and recovery time 15-20 weeks Wound complications 15-25% Lymphedema 10-20% Graft stenosis 20% Graft thrombosis 10-20% Graft infection 1-3% Major amputation 5-10%

  20. PROBABILITY OF BYPASS FAILURE BY CO-MORBIDITY Impaired ambulation 58% 6.4 Odds ratio Distal PAD 46% 3.9 Odds ratio ESRD 35% 2.5 Odds ratio Gangrene 34% 2.4 Odds ratio Hyperlipidemia 11% 0.6 Odds ratio

  21. FACTORS INFLUENCING SURGICAL TREATMENT RESULTS OF PAD Age Atherogenic risk factors Co-morbidities Clinical indication for treatment Severity of ischemia Segmental anatomy of arterial occlusive disease Choice of treatment (open or endovascular) Technical difficulty Choice of materials Primary or secondary procedure

  22. CONCLUSION The diagnosis and treatment of PAD is not just a vascular surgical problem. Risk factor modification (Vascular Medicine) will become an increasingly important adjunct to all surgical and endovascular therapies. Primary care providers will have a greater role in the treatment of PAD. Traditional measures of procedural treatment success such as morbidity and vessel patency are no longer a sufficient means of evaluating success. New endovascular technologies have greatly broadened the number of treatment options available and will continue to evolve in the near future.

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