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. INTRODUCTION LOWER 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 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 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.