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 ABI < 0.4

> 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) Aortic endarterectomy 3-5% M&M 90% 5 year patency 3-5% M&M 80% 5 year patency Extra-anatomic Bypass Iliac balloon angioplasty Claudication Stenosis 1-2% M&M 60% 5 year patency < 1% M&M 65% 5 year patency Critical ischemia Stenosis Iliac stent Occlusion Occlusion <1% M&M Claudication Stenosis Occlusion Critical ischemia Stenosis Occlusion 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

1-2% M&M 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 77% 5 year patency 40% 5 year patency SFA-pop balloon angioplasty Claudication Stenosis Occlusion Critical ischemia Stenosis Occlusion < 1% M&M 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.