family medicine grand rounds vascular surgery...
TRANSCRIPT
May 7 2019 UnityPoint Health Proprietary and Confidentialcopy
Family Medicine Grand Rounds
Vascular Surgery Update
Dr Scott Reid DO FACOS
Clinical Assistant Professor
Department of Surgery
University of Illinois-College of Medicine Peoria
Financial Disclosures
Vascular Surgery Updates
bull Carotid Stenosis
3
Vascular Surgery Updates
bull Abdominal Aortic Aneurysms
4
Vascular Surgery Updates
bull Peripheral Vascular Disease
5
Vascular Disease
bull Younger and younger
bull Diabetes
bull Smokers
bull Sedentary
bull Overweight
6
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Financial Disclosures
Vascular Surgery Updates
bull Carotid Stenosis
3
Vascular Surgery Updates
bull Abdominal Aortic Aneurysms
4
Vascular Surgery Updates
bull Peripheral Vascular Disease
5
Vascular Disease
bull Younger and younger
bull Diabetes
bull Smokers
bull Sedentary
bull Overweight
6
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Vascular Surgery Updates
bull Carotid Stenosis
3
Vascular Surgery Updates
bull Abdominal Aortic Aneurysms
4
Vascular Surgery Updates
bull Peripheral Vascular Disease
5
Vascular Disease
bull Younger and younger
bull Diabetes
bull Smokers
bull Sedentary
bull Overweight
6
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Vascular Surgery Updates
bull Abdominal Aortic Aneurysms
4
Vascular Surgery Updates
bull Peripheral Vascular Disease
5
Vascular Disease
bull Younger and younger
bull Diabetes
bull Smokers
bull Sedentary
bull Overweight
6
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Vascular Surgery Updates
bull Peripheral Vascular Disease
5
Vascular Disease
bull Younger and younger
bull Diabetes
bull Smokers
bull Sedentary
bull Overweight
6
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Vascular Disease
bull Younger and younger
bull Diabetes
bull Smokers
bull Sedentary
bull Overweight
6
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Disease
bull United Statesbull 800000 strokes a year
bull 610000 initial event
bull 142000 deaths a year
bull 5th leading cause of death
bull 20 due to CAS
7
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Disease
bull Risksbull Risks double each ten years after 55bull Men more than women but more
women diebull African American and Hispanics twice
Caucasiansbull HTNbull Family historybull Atrial fibrillationbull Smokingbull Hypercholesterolemiabull Diabetes
8
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Stroke Mortality
bull Following ischemic strokebull 29 recurrence 5 years
bull 53 mortality at 5 years
bull 1 death every 4 minutes
bull Stoke disability after 65 at 6 monthsbull 50 hemiparesis
bull 30 need assistance to walk
bull 26 require care facility
9
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Workup
bull Physical exambull Why are you doing this
bull Nobody has every done this before why
10
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Disease Evaluation
bull Carotid Duplex
bull CT Angiogram
bull MRIbull Over estimates stenosis
bull Catheter based angiography
bull 70 of one doesnrsquot equal 70 in another
11
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Duplex
12
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Duplex
bull Flow velocitybull 100 cars an hour 4 lanes versus 2 lanes
13
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Duplex
bull 0-15
bull 16-49
bull 50-69
bull 70 or more
14
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Duplex
bull 50-69bull More or less than 60
bull External Carotidbull DONrsquoT WORRY IN MOST CASES
bull Common Carotidbull Worry less
bull Internal Carotidbull Now you should worry
15
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Duplex
bull 50-69bull PSV nearing 300cmsecond
bull EDV nearing 125cmsecond
bull GREATER than 60 stenosis
16
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Medical Treatment Carotid Stenosis
bull ACAS and NASCET bull Less than 60 without symptomsbull Less than 70 with symptoms
bull HUHbull 50-70 did better with surgery
bull Singledual antiplatelet therapy
bull Statin therapy
bull Repeat ACAS and NASCETbull Unlikelyhelliphellip
17
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Surgical Treatment of CarotidStenosis
bull Carotid Endarterectomy-Gold standardbull 1953 Dr DeBakey
bull Over 100000 a year in the US
18
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Endarterectomy
19
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Carotid Endarterectomy
20
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Treatment of Carotid Disease
bull Carotid Stentingbull Poor early results
bull ldquoHigh risk patientsrdquobull Arenrsquot they already
bull Femoral versus Carotid approach
bull Transcarotid Artery Revascularizationbull TCAR
21
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Treatment of Carotid Disease
22
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysms
bull Aneurysm 15 times normal sizebull ldquonormalrdquo aorta 2cm
bull 3cm size means AAA
23
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysm
bull Risk Factorsbull Male
bull Smoking
bull Increased Age
bull Hypertension
bull Caucasian
bull Peripheral aneurysm
bull Decreased riskbull Female
bull Diabetes
24
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysm
bull 7000 deaths a year
bull Approximately 1000000 AAA in the US
bull Over age 50bull 4-8 of men
bull Just over 1 of women
25
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysms
bull 1951 first open repair by Dr Dubost
bull 1991 first EVAR by Dr Parodi
26
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysm
27
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysm
bull Not all sizes the samebull APDiameter
bull Smaller threshold for women
bull UK small AAA trial
bull Society for Vascular Surgery 55cm
bull EVAR fails to show earlier repair is indicated
28
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysm
bull Diagnosisbull ldquowerdquo fail
bull Often found by accident
bull Physical Exambull Often misses even large AAA
29
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Abdominal Aortic Aneurysm
bull Diagnostic optionsbull Physical Exam
bull Ultrasound
bull CT scanning
bull MRI
bull Catheter based angiography
30
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
AAA Medicare Screening
bull Abdominal aortic aneurysm screenings
bull Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if yoursquore at risk Yoursquore considered at risk if you have a family history of abdominal aortic aneurysms or yoursquore a man age 65-75 and have smoked at least 100 cigarettes in your lifetime
bull Your costs in Original Medicare
bull You pay nothing for this test if the doctor or other qualified health care provider accepts Assignment
31
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
32
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
bull A good history and physical examhellip
bull ABI of 09 or less
bull Symptoms are not part of the diagnosis
33
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
bull Asymptomatic diseasebull 13rd mortality at 5 years
bull CVAMI
bull Claudicationbull 42-65 mortality 5-10 years
bull Critical ischemiabull 20 mortality at 6 months
34
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
bull Amputationbull BKA 40 5 year mortality
bull AKA 60 5 year mortality
35
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Diseasebull $50000 for an amputation
bull J Am Podiatr Med Assoc 2017 Sep107(5)355-364 doi 10754716-073
bull Rate of and Factors Associated with Ambulation After Unilateral Major Lower-Limb Amputation at an Urban US Tertiary-Care Hospital with a Multidisciplinary Limb Salvage Team
bull Sansosti LE Crowell A Choi ET Meyr AJ
bull Abstract
bull BACKGROUND
bull One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis This retrospective observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital
bull METHODS
bull A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation
bull RESULTS
bull The overall rate of ambulation in a prosthesis was 2994 (500 of those with unilateral below-the-knee amputation [BKA] and 200 of those with unilateral above-the-knee amputation [AKA]) In 2481 of patients with unilateral BKA or AKA a secondary surgical procedure of the amputation site was required
36
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
37
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
bull Treatmentbull Observation
bull Lifestyle changesbull 13 13 13
bull Medicalbull Pletal
bull Trental
bull Endovascular
bull Open repair
38
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
39
bull ABI
bull Waveforms
bull Post exercise ABI
bull Toe pressures
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
bull Pletalbull Smooth muscle relaxation
bull Contraindicated CHF
bull Headaches
bull Diarrhea
bull 50100mg dose
bull 2-3 month trial
40
Peripheral Vascular Disease
41
42
43
Peripheral Vascular Disease
41
42
43
42
43
43