Evolving Strategies in the Treatment of Peripheral Vascular Disease Ravish Sachar MD, FACC Wake Heart and Vascular

Disclosures Educational Grants: Boston Scientific, Abbott Vascular, ev3 Consultant: Abbott Vascular, ev3 Speakers Bureau: Boston Scientific, Abbott Vascular

Atherosclerosis Common Etiology  30-60% of pts with PVD have carotid disease  50-60% of pts with carotid disease have coronary disease  10% of pts with coronary disease have carotid disease

Results of Coronary Angiograms in 634 Patients with PAD 8.5%

Patient Survival by ABI Newman et al ATVB 1999;19;

Five year mortality rates PVD versus Cancer *Criqui M. Presentation: Vascular Medicine of the Lower Extremities at the American Diabetes Association’s Scientific Sessions June 1999

PVD ….What are the goals? Asymptomatic – treat risk factors Claudication – medical therapy or revascularization to improve symptoms Critical Limb Ischemia – prevent amputation and limb loss

Goal…Prevention of Amputation

Diagnosis Non-invasive – Bedside Ankle-Brachial Index – Lower extremity Segmental Pressures and PVRs – Arterial Duplex imaging – MRA – CTA Invasive – Angiograpy

Magnetic Resonance Angiography

Disease Patterns Non-Diabetics Diabetics

Aorto Iliac Disease

SFA Disease

SFA OCCLUSION

prepost

Subintimal Angioplasty

Reentry Catheters Outback Pioneer

SFA – PTA/Stenting Post

Knee Extension Knee Flexion Problems with SFA Stenting….

With Knee Flexion

Compression 3. Extension / Contraction 1. Torsion 2. Flexion4. Forces Exerted on Stents in SFA

Type I Type II Type III Type IV

Directional Atherectomy

Atherectomy

After Before Directional Atherectomy

Orbital Atherectomy

Rotational Atherectomy

Laser Atherectomy

Conclusions Peripheral Vascular Disease is very prevalent in patients with cardiac disease PVD is underdiagnosed and undertreated High Mortality with PVD – usually due to cardiac causes There are many revascularization options available to patients to improve quality of life

Thank You!

PercutaneousSurgical Patient Preference

Treating Critical Limb Ischemia Primary Treatment for severe PVD in the 1800’s

Treating Critical Limb Ischemia In some places Primary Treatment for severe PVD in 2008

Amputations – current data Less than 20% get an angiogram Only 50% get an ABI Most of these patients do have limb salvage options It is not conservative treatment to amputate!

“For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive treatment to even do an angiogram”

Amputation (Impact!!) Survivors who ambulate (prosthesis) BKA % AKA - 25% Psychological testing :“worse than cancer”

Possibilities….