what is peripheral vascular disease? daniel b. walsh, m.d. professor of surgery, section of vascular...
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What Is Peripheral Vascular Disease?What Is Peripheral Vascular Disease?What Is Peripheral Vascular Disease?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
Perhipheral vascular disease is Perhipheral vascular disease is considered to be any abnormality considered to be any abnormality of the arteries and veins outside of of the arteries and veins outside of
the skull and the heart.the skull and the heart.
Perhipheral vascular disease is Perhipheral vascular disease is considered to be any abnormality considered to be any abnormality of the arteries and veins outside of of the arteries and veins outside of
the skull and the heart.the skull and the heart.
Differences Between Differences Between
Arteries & VeinsArteries & Veins
Differences Between Differences Between
Arteries & VeinsArteries & Veins
ComponentsComponentsComponentsComponents Problems with veinsProblems with veins
Varicose veinsVaricose veins
Blood clots and sequelaeBlood clots and sequelae
Arterial AneurysmsArterial Aneurysms
Aorta and branchesAorta and branches
Arteries blocked by atherosclerosisArteries blocked by atherosclerosis
Carotid, Legs. Kidneys, GI tractCarotid, Legs. Kidneys, GI tract
Risk Factors for AtherosclerosisRisk Factors for AtherosclerosisRisk Factors for AtherosclerosisRisk Factors for Atherosclerosis
AgeAge
DiabetesDiabetes
ObesityObesity
GeneticsGenetics
DyslipidemiaDyslipidemia
HypertensionHypertension
HyperhomocysteinemiaHyperhomocysteinemia
Atheroscleroris
Atherosclerotic Disease and Complications(coronary, cerebrovascular, peripheral arterial events
SmokingSmoking
Natural History of PAD in US PopulationNatural History of PAD in US PopulationNatural History of PAD in US PopulationNatural History of PAD in US Population
Adapted from Weitz JI. Circulation 1996;94:3026-49.
Population Aged >55y
AsymptomaticABI <0.9
10%
Intermittentclaudication
5%
Critical leg ischemia1%
PADoutcomes (5-year outcomes)
Cardiovascularmorbidity/mortality
Stableclaudication
73%
Worseningclaudication
16%
Leg bypasssurgery
7%
Majoramputation
4%
Nonfatal events(MI/stroke)
20%
Mortality30%
Intervention for Tissue Loss/Intervention for Tissue Loss/Rest Pain, Severe ClaudicationRest Pain, Severe Claudication
Intervention for Tissue Loss/Intervention for Tissue Loss/Rest Pain, Severe ClaudicationRest Pain, Severe Claudication
• Medications
• Risk factor assessment & reduction
• Exercise program
• PTA/Stents
• Operation
Aneurysms can occur in these arteries:Aneurysms can occur in these arteries:Aneurysms can occur in these arteries:Aneurysms can occur in these arteries:
• Carotid
• Subclavian
• Thoracic
• INFRARENAL
• Renal
• Hypogastric
• Iliac
• Femoral
• Popliteal
What is an Aortic Aneurysm?What is an Aortic Aneurysm?
Abdominal Aortic Aneurysm (AAA)
Thoracic Aortic Aneurysm(front view)
““Endovascular” Aortic Aneurysm RepairEndovascular” Aortic Aneurysm Repair““Endovascular” Aortic Aneurysm RepairEndovascular” Aortic Aneurysm Repair
Pre-repair Post-repair
Freedom from Re-InterventionFreedom from Re-Intervention
DHMC vs EUROSTAR*DHMC vs EUROSTAR*
Freedom from Re-InterventionFreedom from Re-Intervention
DHMC vs EUROSTAR*DHMC vs EUROSTAR*
* Eurostar Data Registry, Jan.2001
Fre
ed
om
fro
m R
e-I
nte
rven
tion
0
.2
.4
.6
.8
1
0 10 20 30 40 50 60 70
Time (months)
DHMC, entire series
EUROSTAR*
First Successful CEAFirst Successful CEA First Successful CEAFirst Successful CEA
F. EastcottF. EastcottMay 19, 1954May 19, 1954
C. RobC. Rob
Carotid AtherosclerosisCarotid Atherosclerosis
Proven Benefit of CEAProven Benefit of CEAProven Benefit of CEAProven Benefit of CEA
0
5
10
15
20
25
30
NASCET ECST ACAS ACST
Medical
Surgical
Percent 30 Day Stroke, Death + Late Ipsilateral Stroke
2 Year 3 Year 5 Year 5 YearSymptomatic Asymptomatic
4 Randomized Trials
> 12,000 patients
Relative risk reduction:
Symptomatic:50-69%50-69% - -
25%25%70-99%70-99% - -
61%61%
Asymptomatic:Asymptomatic:60-99%60-99% - -
48%48%
Selective carotid Selective carotid injectioninjection
Selective carotid Selective carotid injectioninjection
Acculink 6-8x40mm
SummarySummarySummarySummary
3D CTA can be used to screen 3D CTA can be used to screen “high risk” CAS patients better “high risk” CAS patients better served with modified CAS, CEA, served with modified CAS, CEA, or medical managementor medical management
Comparison of Carotid Endarterectomy and StentComparison of Carotid Endarterectomy and StentDartmouth Experience (2000-Present)Dartmouth Experience (2000-Present)
Comparison of Carotid Endarterectomy and StentComparison of Carotid Endarterectomy and StentDartmouth Experience (2000-Present)Dartmouth Experience (2000-Present)
NumberNumber 366 366 173173
StrokeStroke 0.5% 0.5% 2.9%2.9%
Myocardial Infarct 4%Myocardial Infarct 4% 1.2%1.2%
DeathDeath 0.8% 0.8% 0.8%0.8%
Endarterectomy StentEndarterectomy Stent
ConclusionsConclusionsConclusionsConclusions CEA remains the “gold standard” RXCEA remains the “gold standard” RX CAS risk increases with age and requires EPDCAS risk increases with age and requires EPD Carotid stent treatment of extracranial carotid occlusive Carotid stent treatment of extracranial carotid occlusive
disease is safe in disease is safe in selectedselected patients. patients. ? Asymptomatic medical high risk? Asymptomatic medical high risk
3D CTA can assist in selecting patients for CAS3D CTA can assist in selecting patients for CAS Need to be prepared to handle technical difficultiesNeed to be prepared to handle technical difficulties
Know when to stopKnow when to stop Long-term durability of the procedure needs to be determinedLong-term durability of the procedure needs to be determined