Peripheral Vascular Disease
Principles and Practice
Risk Factors
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Hypercholesterolemia
Cigarette Smoking
Hypertension
Diabetes
Advanced Age
Male gender
Hypertriglyceridemia
Hyperhomocysteinemia
Sedentary Lifestyle
Family History
Risk Factor Modification
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Lipid Management
Weight Management
Smoking Cessation
Blood Pressure Control
Physical Activity
Pathology of Atherogenesis
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“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
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Anatomic distribution
Constant at areas of bifurcation
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
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
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
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
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
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
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
Aotoiliac Occlusive Disease
Surgical Treatment
• Aortobifemoral Bypass
• Cross Femoral Bypass – Fem-Fem
bypass
• Axillofemoral Bypass
• Percutaneous Angioplasty
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
Carotid Artery Occlusive Disease
• Symptoms
TIA
CVA
Amaurosis Fugax
Resolving Neurologic Deficits
• NOT Symptoms
Dizziness
Vertigo
Memory Loss
Light Headedness
Carotid Artery Occlusive Disease
• Imaging Studies
Carotid Duplex Ultrasound
Angiography
CT Scan
MRI/MRA
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
Abdominal Aortic Aneurysm
• Natural History
Enlarge and rupture
Embolization
A-V Fistula
GI Fistula
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%
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
Abdominal Aortic Aneurysm
• Diagnosis
Ultrasound
CT Scan
MRI
Arteriography
Abdominal Aortic Aneurysm
• Selection of patients for repair
Maximal diameter 5 cms.
• Types of repair
Open repair vs. Endovascular