1. Peripheral Vascular Disease
Principles and Practice

2. Risk Factors Hypercholesterolemia Cigarette Smoking Hypertension
Diabetes
Advanced Age
Male gender
Hypertriglyceridemia
Hyperhomocysteinemia
Sedentary Lifestyle
Family History

3. Risk Factor Modification
Lipid Management
Weight Management
Smoking Cessation
Blood Pressure Control
Physical Activity

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Aotoiliac Occlusive Disease Surgical Treatment
Aortobifemoral Bypass
Cross Femoral Bypass – Fem-Fem bypass
Axillofemoral Bypass
Percutaneous Angioplasty

13. Femoral-Popliteal-Tibial Occlusive Disease Surgical 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

14. Carotid Artery Occlusive Disease
Symptoms
TIA
CVA
Amaurosis Fugax
Resolving Neurologic Deficits
NOT Symptoms
Dizziness
Vertigo
Memory Loss
Light Headedness

15. Carotid Artery Occlusive Disease
Imaging Studies
Carotid Duplex Ultrasound
Angiography
CT Scan
MRI/MRA

16. Carotid Artery Occlusive Disease Surgical 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

17. Abdominal Aortic Aneurysm
Natural History
Enlarge and rupture
Embolization
A-V Fistula
GI Fistula

18. 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%

19. 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

20. Abdominal Aortic Aneurysm
Diagnosis
Ultrasound
CT Scan
MRI
Arteriography

21. Abdominal Aortic Aneurysm
Selection of patients for repair
Maximal diameter 5 cms.
Types of repair
Open repair vs. Endovascular