agnesian healthcare know & go friday, february 2017: vascular surgery
TRANSCRIPT
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Peripheral Vascular Surgery
Shahriar Alizadegan, MDVascular Services
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Professional Background Tabriz University of Medical Sciences (MD), 1988
to 1995 General practitioner, 1995 to 1998 General surgery residency, 1998 to 2003 General surgery practice, 2003 to 2006 General surgery residency (UIC-MGH),
2009 to 2014 Vascular surgery fellowship (MCW) 2014-2016
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Scope of Vascular Surgery Practice
ArteriesVeinsLymphaticsVascular accessVascular compression syndromes
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Peripheral Arterial Disease
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Atherosclerosis: Risk FactorsConventional Smoking Diabetes mellitus Hyperlipidemia Hypertension
PredisposingAdvanced ageOverweight/obesityPhysical inactivityGender: male, postmenopausal
women Insulin resistanceFamily history/geneticsBehavioral/socioeconomic
factors
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AtherosclerosisConditionalHomocysteineC-reactive protein
(high-sensitivity CRP)FibrinogenLipoprotein (a)Hypertriglyceridemia
EmergingInflammatory markersInfectious agentsVascular calcification
markersHemostatic factorsMMP
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Arterial Disease: Atherosclerosis
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Cerebrovascular DiseaseCarotid stenosisFibromuscular dysplasia (FMD)AneurysmsDissections
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Carotid StenosisAsymptomatic Symptomatic
- TIA- Stroke
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Carotid Endarterectomy
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Carotid Stenting
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Inability to tolerate general anesthesia for CEA
History of damage to the contralateral vocal cord (previous CEA or neck surgery)
Previous neck surgery on the ipsilateral side Neck irradiation Restenosis after CEA
Indications for Carotid Artery Stenting
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Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction or death did not differ significantly in the group undergoing carotid-artery stenting and the group undergoing carotid endarterectomy.
During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy.
Carotid Artery Endarterectomy Versus Stenting
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Fibromuscular Dysplasia (FMD)
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Carotid Artery Aneurysm
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Pulsating Neck MassMost common cause of pulsating neck mass
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Carotid Dissection
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Carotid Dissection, cont.The carotid artery is compressed by blood
dissecting upward from a tear with aortic dissection. Blood may also dissect to coronary arteries. Thus patients with aortic dissection may have symptoms of severe chest pain (for distal dissection) or may present with findings that suggest a stroke (with carotid dissection) or myocardial ischemia (with coronary dissection).
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Brachiocephalic and Subclavian Artery
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Severe Multivessel Disease of Aortic Arch Branches
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Subclavian Steal Syndrome
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Carotid Subclavian Bypass
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Subclavian Carotid Transposition
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Hybrid Repair of Distal Arch and Descending Thoracic Aortic Aneurysm
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Endovascular Treatment With Brachial Access
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Intermittent Claudication Most common reason for referral to vascular
surgeon Calf, thigh or buttock pain after certain distance of
walking Symptoms of intermittent claudication are
alleviated by a brief period of rest Abnormal ankle brachial indexes No constant pain, no tissue loss Inflow diseaseOutflow disease
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Inflow Disease Outflow Disease
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Critical Limb Ischemia Common major manifestations of CLI are rest pain
and ischemic ulceration or gangrene of the forefoot or toes, representing a reduction in distal tissue perfusion below resting metabolic requirements.
Ankle pressure less than 50 mm Hg Toe pressure to less than 30 mm Hg
or ABI to less than 0.40
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Natural History of IC versus Critical Limb Ischemia
The risk of major amputation is small; over a five-year period, the rate of amputation was less than five percent (IC)
Only insulin-requiring diabetes, low initial ABI, and high pack-years of smoking predicted progression to ischemic rest pain and ischemic ulceration
Natural history of CLI is grim, remarkable for the high risk of major amputation and death
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AneurysmsAneurysms can be categorized according to
their anatomic, pathologic or etiologic characteristics.
Ectasia: Intermediate stage of enlargement when an artery is less than 50 percent enlarged, whereas
Arteriomegaly: Diffuse, continuous enlargement of multiple arterial segments dilated to greater than 50 percent of normal.
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Aneurysms, cont.
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Aneurysms, cont.Degenerative InflammatoryPost dissectionTraumaticDevelopmental Infectious
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Endovascular RepairTAAAAA Iliac aneurysmVisceral aneurysms
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Endovascular Repair of Abdominal Aortic Aneurysm
(EVAR)
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Open Versus Endovascular Repair CRT has shown no significant survival benefit at any
time-point for an endovascular strategy (using a standard EVAR device whenever anatomically and operationally possible, with open repair as a default option) versus open repair.
In contrast, there were gains for the endovascular strategy versus the open repair group with respect to patient-preferred outcomes: faster discharge, more often to home, and QoL and overall the endovascular strategy was cost-effective.
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Open vs. Endovascular Repair, cont.Follow-up:One imaging after five years for open repairEVAR requires imaging on a yearly basisRisk of endo leak after EVARRisk of limb occlusion, slippage of the graft, limb separation
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Endoleak
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Harvard Report on Cancer Prevention, Cancer Causes and Control 1999;10:167.
Visceral Interventions
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Venous Diseases Deep vein thrombosis Venous insufficiency and stasis ulcer Superficial thrombophlebitis Differentiation of venous stasis ulcer versus
arterial insufficiency
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Venous Stasis Ulcer Knowing the underlying pathophysiologyCompression therapyReflux studies (venous duplex)Arterial flow Ablation of incompetent veins if indicatedLocal wound care and hygiene
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Treatment Options for Venous Disease
Laser or RFA ablation( for larger veins GSV)Sclerosing agent
Polidecanol Hypertonic NACL Varithena(injectable foam)
MicrophlebectomyLigation and divisionStripping
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Thank YouQuestions?