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
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
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
CLASSIFICATION OF LOWER
EXTREMITY PAD
Intermittent Claudication
Critical Limb Ischemia (CLI)
Ischemia pain at rest
Ischemia ulceration
Gangrene
Infection
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
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
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
RISK FACTORS FOR PAD
Age
Sex
Race and Family history
Sedentary life-style
Smoking
Hyperlipidemia
Hypertension
Diabetes mellitus
Hypercaogulability
Hyperhomocysteinemia
Renal insufficiency
VASCULAR ASSESMENT IN
PATIENTS WITH PAD
History and physical examination
Doppler examination
Vascular laboratory studies
CT ateriography
MR ateriography
Invasive contrast ateriography
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)
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
INTERPRETATION OF ANKLE /
BRACHIAL INDICIES (ABI’S)
Normal
Mild limb ischemia
Moderate limb ischemia
Severe limb ischemia
Non-compressible
ABI 0.9 – 1.2
ABI 0.7 – 0.9
ABI 0.4 – 0.7
ABI
< 0.4
ABI
> 1.2
Minimal symptoms
Claudication
Rest pain, Tissue loss
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)
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
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
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)
TREATMENT OF AORTO-ILIAC
OCCLUSIVE DISEASE
Aorto-Femoral Bypass (AFB)
3-5% M&M
Aortic endarterectomy
3-5% M&M
Extra-anatomic Bypass
1-2% M&M
Iliac balloon angioplasty
< 1% M&M
Claudication
Stenosis
Occlusion
Critical ischemia Stenosis
Occlusion
Iliac stent
<1% M&M
Claudication
Stenosis
Occlusion
Critical ischemia Stenosis
Occlusion
90% 5 year patency
80% 5 year patency
60% 5 year patency
65% 5 year patency
54% 5 year patency
53% 5 year patency
45% 5 year patency
77% 5 year patency
61% 5 year patency
57% 5 year patency
51% 5 year patency
TREATMENT OF INFRA-INGUAL
OCCLUSIVE DISEASE
Ak Fem-pop bypass
GSV graft
PTFE graft
BK Fem-pop bypass
GSV graft
PTFE
1-2% M&M
69% 5 year patency
60% 5 year patency
1-2% M&M
SFA-pop balloon angioplasty
< 1% M&M
Claudication
Stenosis
Occlusion
Critical ischemia Stenosis
Occlusion
77% 5 year patency
40% 5 year patency
53% 5 year patency
36% 5 year patency
31% 5 year patency
16% 5 year patency
MORBIDITY AFTER LOWER
EXTREMITY BYPASS
Healing and recovery time
Wound complications
Lymphedema
Graft stenosis
Graft thrombosis
Graft infection
Major amputation
15-20 weeks
15-25%
10-20%
20%
10-20%
1-3%
5-10%
PROBABILITY OF BYPASS
FAILURE BY CO-MORBIDITY
Impaired ambulation
Distal PAD
ESRD
Gangrene
Hyperlipidemia
58%
46%
35%
34%
11%
6.4 Odds ratio
3.9 Odds ratio
2.5 Odds ratio
2.4 Odds ratio
0.6 Odds ratio
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
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.