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What Is Peripheral Vascular Disease?

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What Is Peripheral Vascular Disease?

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  1. 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

  2. Perhipheral vascular disease is considered to be any abnormality of the arteries and veins outside of the skull and the heart.

  3. Differences Between Arteries & Veins

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

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

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

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

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

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

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

  11. 1 DHMC, entire series .8 .6 EUROSTAR* .4 .2 0 0 10 20 30 40 50 60 70 Time (months) Freedom from Re-InterventionDHMC vs EUROSTAR* Freedom from Re-Intervention * Eurostar Data Registry, Jan.2001

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

  13. Carotid Atherosclerosis

  14. Proven Benefit of CEA Percent 30 Day Stroke, Death + Late Ipsilateral Stroke • 4 Randomized Trials • > 12,000 patients • Relative risk reduction: • Symptomatic: • 50-69% - 25% • 70-99% - 61% • Asymptomatic: • 60-99% - 48% 2 Year 3 Year 5 Year 5 Year Symptomatic Asymptomatic

  15. Selective carotid injection

  16. Acculink 6-8x40mm

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

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

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