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Modern Management of Vascular Disease

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    1. Modern Management of Vascular Disease Marco Baroni Consultant Vascular Surgeon York Hospital, Harrogate District Hospital and BMI The Duchy Hospital

    2. Local Vascular Provision Four Vascular Surgeons Generic referral Contact via York Switchboard Inpatient care York Weekly Clinics Harrogate Wetherby Selby York (Daily)

    3. Whats New? Vascular Specialist RF modification Endovascular Intervention Endovenous Intervention Preoperative assessment

    4. Management of. Vascular Risk Factors Aortic Aneurysms Peripheral Vascular Disease Carotid disease Venous Disease

    5. Risk Factor Management

    6. Smoking cessation

    7. Cholesterol

    8. 8 Anti-platelets

    9. 9 DM

    10. 10 Hypertension

    11. 11 Obesity

    12. Aortic Aneurysms

    13. What is an Aneurysm? Abnormal dilatation of an Artery All layers of arterial wall involved Intima, Media Adventitia Mostly Atherosclerosis Other Causes Inflammatory Mycotic Aneurysm Connective Tissue Disease Eg Marfans Ehlers Danlos

    14. AAA Aortic diameter >3cm M:F 4:1 75% asymptommatic at presentation Prevalence 5% in UK 1.5% deaths in >55 yo Males Most Infrarenal Common ward referral.Common ward referral.

    15. Who gets Aneurysms? Men Old Hypercholesterolaemia Hypertension Smokers Familial

    16. Why Worry? Rupture Cardiovascular Risk MI, TIA, CVA, PVD Distal Embolisation Thrombosis Rareties

    17. Ruptured Aneurysm Risk of rupture (5year) 5-5.9cm 25% 6-6.9cm 35% >7cm 75% 50% prehospital mortality 50% perioperative mortality 25% of rAAA will survive How do we improve this?

    18. UK small Aneurysms trial UK small aneurysm trial 1090 Asx patients randomised to either early surgery or observation Rupture rate of <2%/yr less than 5cm diameter No evidence for survival benefit with diameter <5.5cm

    19. Screening Several trials Gloucester Cambridge Chichester 55% reduction in ruptures in screened population vs controls Favourable results with single US at 65 National programme Prevent upto 80% of ruptures Implementation in progress

    21. Methods of Presentation Incidental finding AXR US CT Clinical Examination Screening Collapse with known Aneurysm A&E and call Vascular surgeon Incidental AAA <5cm Routine OPA >5cm Urgent OPA >7cm Discuss with Vascular surgeon for inpatient work up

    22. Treatment for AAA Open Repair Endovascular Repair (Laparoscopic) Total Hand Assisted None + RISK FACTOR MANAGEMENT

    23. History Aneurysm Ligations Antyllus 200AD Astley Cooper 1700s (ruptured iliac) 1st Graft: Dubost 1951 1st EVAR 1994 Einstein: celophane reinforcement lived for 5 years more

    24. Open Repair Incision Proximal & Distal Control Open & empty Sac Oversew Lumbars +/- IMA Graft Tube Bifurcated Close up

    27. Complications Early Bleeding MI Chest Infection Respiratory Failure Bowel Ischaemis Renal Failure Loss of Limb DEATH 5-10% Late Incisional Hernia Erectile Dysfunction Aorto-enteric Fistula Graft Infection

    28. EVAR Bilateral or Unilateral groin cut down CFA, SFA & PFA controlled Stent insertion Bifurcated, AUI Crossover if required Arterial repair Closure

    31. EVAR

    32. An avulsed iliac artery after removal of a 22-F sheath for endograft deployment

    33. EVAR 1 1100 patients Open vs EVAR in patients fit for surgery No change in all cause mortality despite promising 30d decrease mort in EVAR Cost roughly equal for procedure but much higher ongoing cost in EVAR

    34. EVAR I Trial

    36. EVAR 2 Small 388pts >60, aaa >5.5cm unfit 30day op mortality EVAR 9% No diff in all cause or AAA related mortality Overall mortality at 4yrs=64% Flawed trial. Evidence currently s that if pt is unfit for open surg should not have EVAR.Flawed trial. Evidence currently s that if pt is unfit for open surg should not have EVAR.

    37. EVAR 2 Trial

    38. NICE

    39. Who gets what? ???

    40. Not for Open Medically Unfit Morbidly Obese Multiple Previous Surgery Co-morbidity with limited life expectancy Not for EVAR Unsuitable neck Short Diseased Angulation Small Distal aorta Unsuitable iliacs Diseased Small Tortuosity

    41. Bottom line Seen by Vascular Surgeon Appropriate Imaging Full Work up including CPX MDT discussion

    42. Late complications requiring surgical management Graft limb occlusion Persistent endoleaks with continued aneurysm expansion Graft failure Endotension AAA rupture Miscellaneous (graft infection, aortoduodenal fistula)

    44. The Future?

    45. Day 1 post op

    46. The Future Screening More EVAR Currently 30-40% in York More complex EVAR Branched Fenestrated Less Open Surgery But More Complicated

    47. Acute Limb Ischaemia Aetiology: emboli thrombosis trauma iatrogenic drug abuse venous outflow blockade low flow states

    49. Acute Limb Ischaemia Embolus vs Thrombosis

    50. Acute Limb Ischaemia Incidence of embolic occlusion : femoral 36% aortoiliac 22% popliteal 15% upper extremity 14% visceral 7% other 6%

    51. Acute Limb Ischaemia Signs of acute ischaemia : pale extremity temperature change - sharp demarcation pain paraesthesia paresis mottled or cyanotic limb

    53. Acute Limb Ischaemia clinical categories

    54. Clinical scenarios of acute limb ischaemia Sudden onset in previously asymptomatic individual History: age, PMH, co morbidity Remember POPLITEAL ANEURYSM Sudden deterioration in a patient with PVD Recurrence of symptoms in a patient with a previous bypass graft All Require urgent referral

    56. Management of acute limb ischaemia Diagnosis of underlying pathology Prevention of deterioration whilst awaiting Rx Avoidance of complications Preparation for theatre Management of thrombus

    57. Acute Limb Ischaemia Definitive measures embolectomy thrombectomy bypass procedure Thrombolysis +/- fasciotomy

    58. Thrombolysis Catheter directed Potentially a high-risk strategy Complications include CVA, GI bleeds, bleeding from puncture sites and compartment syndrome Usually reserved for limb-threatening ischaemia; but remember contraindications Monitor for development of complications

    61. Claudicants Risk Factor Management Smoking cessation Anti platelet Statin Routine referral for consideration of intervention No defined distance for treatment

    62. Critical Ischaemia PVD + Tissue loss Rest pain Urgent outpatient referral Next available clinic Fax referral to Harrogate/York Secretaries If concern regarding infection or viability refer to on call vascular team

    63. Carotid Disease

    64. Surgery For Symptomatic Stenoses ECST/NASCET: similar results Stenosis* <70% conservative management >70% CEA & medical treatment 6-10x decreased risk of stroke compared to best medical treatment alone *Using ECST measurement criteria 2 large studies in symptomatic patients, European and North American. Used different measurement criteria. Best medical therapy was antiplatelet plus risk factor management.2 large studies in symptomatic patients, European and North American. Used different measurement criteria. Best medical therapy was antiplatelet plus risk factor management.

    65. ACST Conclusions Patients under 75 with ASx Stenosis >70% and best medical therapy who are offered immediate CEA half their 5 year stroke risk (from 12% to 6%) Outside trials patient selection, poor surgery or delay could obviate benefits No reason to scan over 75s who are asymp.No reason to scan over 75s who are asymp.

    66. What to do? Symptomatic Patients TIA clinic urgently A&E Incidental Asymptommatic stenosis Vascular opinion Carotid territory symptoms ie hemimotor/sens signs, dysphasia, visuospatial neglect. Investigate as quickly as possible as benefit tails off after event.Carotid territory symptoms ie hemimotor/sens signs, dysphasia, visuospatial neglect. Investigate as quickly as possible as benefit tails off after event.

    67. Venous Disease

    68. DVT Mostly Medical Mx Iliofemoral or upper limb Consider early vascular referral Admission for elevation ?Thrombolyis Caval Filters

    69. Varicose Veins Happy to assess eligibility Helpful if PCT guidelines have been raised Currently eligible: Skin changes Ulceration Recurrent bleeding Proximal GSV thrombophlebitis

    70. Tretment Offered Conservative Mx Open Surgery EVLA VNUS Foam sclerotherapy Endovenous options may require MSAs or Sclerotherapy

    71. VNUS: Radiofrequency Ablation Local Anaethetic Outpatient procedure Rapid return to work Comparable early results to surgery

    75. Questions? Contact: Marco.baroni@york.nhs.uk 01904 726737