Peripheral Vascular Disease Ppt Powerpoint Presentation slides Jim Vacek Medical Slideshow A Update in Methods to Evaluate and treat Patients With Peripheral Vascular Disease 2007

Peripheral Vascular Disease

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Show Notes

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Peripheral Vascular DiseaseMay 2005 James L. Vacek, MD Mid America Cardiology

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Peripheral Arterial Disease(PAD) Why, Who and How ?

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Peripheral Arterial Disease

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Peripheral Arterial DiseaseWho? In cardiology training and practice: a strong marker for major cardiovascular events since it is frequently associated with coronary and cerebral atherosclerosis. symptoms of PAD such as intermittent claudication are underdiagnosed and undertreated. Renovascular hypertension has no specific symptoms

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The Most Important Intervention STOP SMOKING !

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Peripheral Arterial Disease Carotid arteries Renal Arteries Abdominal aorta and pelvic arteries Legs Other Arms Mesenteric

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Carotid Arterial Disease Preserving Cognitive Function

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Preserving the Way We Think It only takes 20 years for a liberal to become a conservative without changing a single idea (R A Wilson) A conservative is a man who sits and thinks, mostly sits (W Wilson)

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Causes of Ischemic Stroke: Most common finding in persons over 45 years of age who suffer from a stroke is atherosclerosis. (carotid bifurcation, distal vertebral artery, and basilar artery) Embolus from the heart.(i.e. atrial fibrillation, valve disease, valve replacement, cardiomyopathy, acute MI, and bacterial endocarditis. Hypertensive disease Dissection of the carotid or vertebral artery Prothrombotic state Subarachnoid hemorrhage

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Carotid Anatomy Right Common Carotid arises from the Right Innominate Artery. Left Common Carotid arises from the Aortic Arch. The Vertebral Arteries arise from the Subclavian Arteries.

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Carotid Anatomy

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Indications for Carotid Study 1. CVA2. TIA3. Dizziness4. Vertigo5. Visual Disturbance ( amaurosis fugax-transient monocular blindness)6. Pre-Op Cardiac Evaluation/Vascular Surgery7. Carotid Bruit

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Diagnostic Criteria for Carotid DuplexPlaque Characteristics Intimal thickening Simple (smooth, soft-low level echodensity, homogeneous) Complex (irregular, dense, bright echos, shadowing, mixed, heterogeneous)

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Diagnostic Criteria for Carotid Duplex % Stenosis Velocity 0-49% Peak Systolic Velocity <1.25 m/s 50-79% Peak Systolic >1.25 m/s >70% (IC/CCA Ratio >4) 80-99% Peak Systolic > 2.50 m/s End Diastolic > 1.40 m/s 100% Occluded- No flow detected

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Identifying Features of the Carotid Artery

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Identifying Features A liberal is a man too broadminded to take his own side in a quarrel (R. Frost) A conservative is a man with two perfectly good legs who, however, has never learned to walk forward (F D Roosevelt)

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Spectral Broadening Normally the “window” of the waveform is clear The more the window fills in, the greater the spectral broadening and the likelihood of significant stenosis

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Flow Changes (Normal vs Abnormal Flow) With Stenotic Lesions Normal flow is laminar which is orderly movement of blood cells along lines parallel to the vessel wall (narrow range of velocity and directional vectors) Disturbed flow is movement of blood in less uniform fashion. (larger range of velocity and direction) The degree in which the flow is disorganized is termed spectral broadening. Spectral broadening increases in relation to the severity of the flow disturbance. Moderate flow disturbance-the spectral window is filled in. Severe flow disturbance-the spectral borders are indistinct. A very loud Doppler signal is noted.

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Examples Of Doppler Characteristics

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Normal Carotid Exam

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Normal Carotid (Continued)

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Severe Stenosis >70%

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80-99% Occlusion

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Complete Occlusion

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Carotid Dissection Associated with trauma,inherent weakness of the arterial wall (Marfan’s syndrome), or aortic dissection Blood enters the media of the artery and dissects the layers of the arterial wall. Most commonly, the intimal is dissected from the medial layer. Creates a false lumen. Duplex findings associated with dissection are dramatic due to the fluttering of the flap back and forth with the cardiac cycle. Important for the sonographer to evaluate the extent of the dissection, the presence, direction, and characteristics of the flow in each lumen and the flow characteristics of the internal and external carotid arteries.

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Carotid Dissection

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Technical Limitations Body Habitus-SNS (Short Neck Syndrome) Previous Surgery/Scarring Trauma Tortuous Vessels-can cause falsely elevated systolic velocities.

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Time for a Change The radical of one century is the conservative of the next. The radical invents the views. When he has worn them out the conservative adopts them (M Twain) The most radical revolutionary will become a conservative the day after the revolution (H.Ardendt)

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Renovascular Disease

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Renovascular DiseaseWhy Worry? Poorly controlled hypertension Progressive renal dysfunction Reduction of need for multiple meds No specific symptoms Most common secondary cause of HTN Potentially correctable

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Renovascular DiseaseEvaluation Renal artery stenosis Kidney size Abdominal aorta size and characteristics Kidney structure Evidence of renal parenchymal disease

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Renovascular DiseaseEvaluation Renal artery systolic velocity: normal <1.8m/s Systolic velocity ratio relative to aorta: normal <3.5 (measured at level of SMA) If both abnormal: >60% stenosis (significant) If systolic velocity is high but ratio does not meet criteria: ? Mild to moderate stenosis

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Renovascular DiseaseEvaluation Normal kidney size: 9-13 cm in length (? 8-13) Difference of 2 cm significant Resistive index measure of parenchymal function, normal < .80

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Renal Duplex Images

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Renal Duplex Data RRA origin systolic velocity 2.1 m/s Mid aortic velocity .51 m/s RAR 4.1 RRA proximal 2.4 m/s, RAR 4.6 Note also plaque in Ao, aneurysmal change

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Renal Duplex ImagesNote cysts and mass

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Renal Duplex Data

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More Cases

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Thank You! James L. Vacek, MD

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End Renovascular SectionThank you!

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Peripheral Arterial Vascular Disease in the Abdomen and Legs

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Intermittent Claudication Discomfort (aching, cramping, tightness) is exercise-induced. May involve one or both legs. The onset is predictable and occurs at a constant walking distance. Relieved by standing still. The discomfort usually occurs in the muscle group just distal to the stenosis/occlusion.

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Peripheral Vascular Disease The diagnosis is made clinically Non-invasive testing (ABI’s with exercise and/or duplex ultrasound) can confirm and quantify Angiography is usually not needed for diagnosis and should be reserved for patients undergoing planned treatment either with endovascular or surgical therapy. It is also of value to diagnose uncommon types of vascular disease. Angiography will likely be replaced by CT/MRA for most cases in the near future.

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Peripheral Vascular Disease Symptom - Intermittent Claudication Diagnosis - Clinical Ankle Brachial Index (ABI) to Confirm Supine Resting ABI Post-Exercise ABI* Normal > 1.0 No change/increase Mild 0.8 - 0.9 Moderate 0.5 - 0.8 Usually worsens Severe < 0.5 *2mph, 10% grade, 5 min.

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Peripheral Vascular Disease Reduced ABI’s are associated with increased risk of: Stroke MI Cardiovascular death Intermittent claudication is associated with: 5 year mortality of 30% 5 year risk of amputation 2-5%

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Peripheral Vascular Disease Diabetes & PVD Diabetic PVD accounts for 60% of amputations Diabetes imparts a 12x increase in risk of amputation Smoking & PVD Smoking results in a 10x increase in risk of amputation 2x increase in mortality

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Peripheral Vascular DiseaseTreatment Conservative Smoking Cessation Cholesterol Rx Glucose Management for DM Foot Care and Protection Aspirin (or Clopidogrel) Walking Program 100% - 400% increase in walking distances @ 3 months Pletal Phosphodiesterase inhibitor Randomized trial data shows increased walking distance Contraindicated in CHF

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Peripheral Vascular DiseaseNonMedical Treatment Endovascular Surgical

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Aorta scanned longitudinally, velocities taken proximal, mid and distal. Transverse imaging done to identify any dilatation. Common, internal and external iliac identified and systolic velocities documented. Scan through common femoral, profunda, superficial femoral, popliteal and tibial arteries measuring systolic velocities. Phase of signal; triphasic, biphasic or monophasic Peripheral Vascular DiseaseTechnique

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Peripheral Vascular DiseaseAbdominal Aorta Normal diameter < 3.0 cm Distal diameter usually < 2.5 cm Abdominal aorta tapers from proximal to distal with no focal increase in size Normal velocity is 0.4 – 1.0 m/sec Iliac artery diameter < 1.5 cm

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Peripheral Vascular DiseaseTechnique More severe stenosis results in loss of flow reversal component and becomes monophasic. Limitations: Aorto/iliac imaging may be limited due to overlying bowel gas and patient size. Stenosis Classifications: Normal=Systolic velocity <1.5m/s 30-49%=Systolic velocity 1.5-2.0 50-75%=Systolic velocity 2.0-4.0 >75%=Systolic velocity >4.0 with ratio >4.1

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Peripheral Vascular DiseaseSample Cases

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Thank You! James L. Vacek, MD

	jlvacek@mac.md 1 Years ago. Category: Cardiology

Tags:	Cardiology

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