A Update in Methods to Evaluate and treat Patients With Peripheral Vascular Disease 2007

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Slide 1 :

A Update in Methods to Evaluate and treat Patients With Peripheral Vascular Disease 2007 Jeremiah H. Holleman,Jr.MD Sanger Clinic

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Etiology.-(1) As an involution process arterio-sclerosis is an accompaniment of old age, and is the expression of the natural wear and tear to which the tubes are subjected. Longevity is a vascular question, and has been well expressed in the axiom that " a man is only as old as his arteries."To a majority of men death comes primarily or secondarily through this portal. The onset of what may be called physiological arterio-sclerosis depends, in the first place, -upon the quality of arterial tissue (vital rubber) which the individual has inherited, and secondly upon the amount of wear and tear to which he has subjected it. That the former plays the most important role is shown in the cases in which arterio-sclerosis sets in early in life in individuals in whom none of the recognized etiological factors can be found. Thus, for instance, a man of twenty-eight or twenty-nine may have arteries of sixty, and a man of forty may present vessels as much degenerated as they should be at eighty. Entire families sometimes show this tendency to early arteriosclerosis, a tendency which cannot be explained in any other way than that in the make-up of the machine bad material was used for the tubing. William Osler The Principles and Practice of Medicine, 1892

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Arterial Occlusive Disease Carotid Artery Disease Aortic Aneurysm Disease

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PAOD Incidence and Prevalence Int. claud. 5.2% over age 70 Asymptomatic disease 15% over age 70 3.4-fold increase in cardiac mortality w/PAOD

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Projected Increase in the Prevalence of PAD Age group US individuals, (millions) Chart from The 1999 Advisory Board Company Source: Criqui NW, et al., N Engl J Med (1992); Newman AB, et al., Arteriosclersis, Thrombosis, and Vascular Biology (1999); U.S. Census Bureau (http://www.census.gov/population/projections/nation/nas. Prevalence rate 3% 8% 19%

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

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Risk Factors Age:1.5-2 fold increase each 10 years Diabetes Mellitus: 4-5 fold increase Smoking 16 fold increase 10 mg/dl increase increase in cholesterol 10% increase in PAOD Hypertension 2-3 fold increase in PAOD

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Clinical syndromes of PAOD Asymptomatic- no symptoms Intermittent claudication- muscular pain associated with exertion Ischemic Rest Pain –possible limb loss Ulceration and Gangrene-likely limb loss

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Intermittent Claudication Exercise-induced lower extremity pain that is caused by ischemia and relieved by rest relief with cessation of ambulation very consistent usually one level of disease Therapy based on the need to relieve symptoms Approximately 3.4 million people in the US Primary symptom of lower-extremity occlusive disease

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Claudeo, Latin: to limp, to be lame

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Rest Pain Usually occurs at night when the person lies supine Dull aching sensation in the toes or forefoot Pain is relieved when legs are lowered to floor Indicative of severe arterial insufficiency and usually involves multiple arterial segments Absent distal pulses Rubor with dependancy, Pallor with elevation Risk for possible limb loss

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PAOD Diagnostic Tests Non-invasive tests ABI (Ankle/Brachial Index) Exercise Test Duplex Ultrasonography MRA (Magnetic Resonance Arteriography) CT angiography Invasive tests Peripheral Angiogram

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PAOD Diagnostic Test ABI (Ankle-Brachial Index)

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PAOD Diagnostic Test Duplex Scanning

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The Good and the Bad of Vascular U/S The Good…. Non-invasive Relatively inexpensive First extension of clinical judgement The Bad Not always practical Lacking in precision

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CT angiography Intravenous injection of IV conrast Acquisition of thin slice axial images on high speed scanner Post processing into multiple formats and projections Almost replaced intra-arterial angiography

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CTA….. The Good Relatively non-invasive Quick. Often under 10 minutes Usually superb images The Bad Iodinated contrast-possible renal failure Calcified vessels may be difficult to interpret

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MR angiography Images are acquired in multiple planes Complex multi-planer reconstructions possible No iodinated contrast No pacemaker, ICD, other metal, some stents Motion is a problem Frequently overstates stenosis

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Contrast angiography Injection of iodinated contrast Best detail Painful Risk of complications Usually as part of a percutanous intervention Occasionally to clarify an inconclusive CTA

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PAOD Goals of Therapy Primary goal1: Reduce or eliminate ischemic symptoms Prevent progression of disease Secondary goal1: Prevent cardiovascular complications

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PAOD Medical Treatment Risk Factor Modification Exercise Therapy Drug Therapy Trental (pentoxifylline) Pletal (cilostazol) Antiplatelet agents ASA Statins

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Surgery Favorable anatomy good inflow good outflow good conduit Favorable physiology Minimal cardiac disease minimal pulmonary disease

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What is New in Bypass Surgery Hybrid procedures Bypass combined with an intraoperative stent or angioplasty procedure Propaten Gore-tex graft Heparin bonded graft Two year patencies similar to vein

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Percutaneous Intervention Less Severe Disease Favorable anatomy-stenoses or short segment occlusions Life style altering symptoms More Severe Disease Poor general health Limb threatening disease Anatomy unfavorable for bypass

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Angioplasty and Stent

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Laser Atherectomy

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Laser Atherectomy

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Silverhawk

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Silverhawk Atherectomy

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Carotid Artery Disease 400,000 Strokes annually in US Second leading cause of death wordwide estimated that one third are related to carotid artery disease Carotid related strokes related to degree of stenosis 60% of patients with stenosis >75% stroke within 5 years 13% of patients with stenosis < 75% stroke within 5 years 46% of patients with stenosis progressing from < 80% to > 80% had stroke within 12 months

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Treatment of Carotid Stenosis Medical management ASA Statins Plavix? Risk factors

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Treatment of Carotid Stenosis Carotid endarterectomy effective and durable .5-2% perioperative stroke risk 3-5% risk of complications in good risk patients

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Treatment of Carotid Stenosis Carotid Stenting 1-2% stroke risk ??? risk of complications in high risk patients FDA approved CMS reimbursed >80% high risk symptomatic Post approval trials high risk > 50% symptomatic >80% asymptomatic

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Aortic aneurysm affects 4-8% of elderly males increased in males > 65 y/o history of smoking family history Screening of elderly male smokers reduces aneurysm related mortality by 46% Not clearly indicated in women USPHTF Ann Int Med Feb 2005

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Diagnosis of aneurysm Physical examination < 50% Ultrasound reliable well suited to serial exams specific anatomy not well demonstrated relatively inexpensive CTA very reliable and reproducible contrast radiation cost specific technique

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Threshold for repair 5.5 cm in men; 5.0 cm. in women 6 cm AAA 15% /yr rupture rate Open repair Endovascular repair

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Open repair 50 year track record 97% intervention free follow-up Higher morbidity Probably higher mortality in high risk patients 6 week to 6 month recovery

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Stent graft repair Two small groin incisions ? 60% of patients have favorable anatomy Need indefinite follow-up 10-15% re-intervention rate Strong patient preference Percutaneous?

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Key points Early detection Periodic surveillance of known small AAA U/S screening of high risk patients ? onetime U/S screening of everyone at ~65

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Thoracic Stent Grafting

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