What Is Peripheral Vascular Disease?

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What Is Peripheral Vascular Disease? Outline

What Is Peripheral Vascular Disease? Daniel B. Walsh, M.D. Professor of Surgery, Section of Vascular Surgery Vice-Chair, Department of Sugery Dartmouth-Hitchcock Medical Center

Perhi erhipheral vascular disease i ease is considered to be any a be any abnormality of the arte f the arteries and v es an ei d veins outsi ns outside of the skull and the heart. he heart.

Differences Between Arteries & Veins

Components q Problems with veins q Varicose veins q Blood clots and sequelae q Arterial Aneurysms q Aorta and branches q Arteries blocked by atherosclerosis q Carotid, Legs. Kidneys, GI tract

Risk Factors for Atherosclerosis Dyslipidemia Hyperhomocysteinemia Diabetes Hypertension Smoking Obesity Age Genetics Atheroscleroris Atherosclerotic Disease and Complications (coronary, cerebrovascular, peripheral arterial events

Natural History of PAD in US Population Population Aged >55y Asymptomatic Intermittent Critical leg ischemia ABI <0.9 claudication 1% 10% 5% PAD Cardiovascular outcomes (5-year outcomes) morbidity/mortality Stable Worsening Leg bypass Major Nonfatal events Mortality claudication claudication surgery amputation (MI/stroke) 30% 73% 16% 7% 4% 20% Adapted from Weitz JI. Circulation 1996;94:3026-49.

Intervention for Tissue Loss/ Rest Pain, Severe Claudication • Medications • Risk factor assessment & reduction • Exercise program • PTA/Stents • Operation

Aneurysms can occur in these arteries: • Carotid • Hypogastric • Subclavian • Iliac • Thoracic • Femoral • INFRARENAL • Popliteal • Renal

What is an Aortic Aneurysm? Abdominal Aortic Thoracic Aortic Aneurysm Aneurysm (AAA) (front view)

“Endovascular” Aortic Aneurysm Repair Pre-repair Post-repair

Freedom from Re-InterventionDHMC vs EUROSTAR* 1 DHMC, entire series .8 .6 ReIntervention EUROSTAR* .4 from .2 Freedom 0 0 10 20 30 40 50 60 70 Time (months) * Eurostar Data Registry, Jan.2001

First Successful CEA C. Rob F. Eastcott May 19, 1954

Carotid Atherosclerosis

Proven Benefit of CEA Percent 30 Day Stroke, Death + Late Ipsilateral Stroke 30 4 Randomized Trials 25 Medical > 12,000 patients 20 Surgical Relative risk reduction: 15 Symptomatic: 10 50-69% – 25% 70-99% – 61% 5 0 Asymptomatic: NASCET ECST ACAS ACST 60-99% – 48% 2 Year 3 Year 5 Year 5 Year Symptomatic Asymptomatic

Selective carotid injection

Acculink 6-8x40mm

Summary q 3D CTA can be used to screen “high risk” CAS patients better served with modified CAS, CEA, or medical management

Comparison of Carotid Endarterectomy and Stent Dartmouth Experience (2000-Present) Endarterectomy Stent q Number 366 173 q Stroke 0.5% 2.9% q Myocardial Infarct 4% 1.2% q Death 0.8% 0.8%

Conclusions q CEA remains the “gold standard” RX q CAS risk increases with age and requires EPD q Carotid stent treatment of extracranial carotid occlusive disease is safe in selected patients. q ? Asymptomatic medical high risk q 3D CTA can assist in selecting patients for CAS q Need to be prepared to handle technical difficulties q Know when to stop q Long-term durability of the procedure needs to be determined