peripheral vascular disease

Prof. Bo Yu MDVascular Surgery Department ,Huashan Hospital

Fudan University

2013.12

Peripheral Vascular Disease (PVD) refers to diseases of vessels outside the heart and brain. It's often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys.

* PVD definition is from the American Heart Association

Abdominal Aneurysm Aortoiliac Disease Upper Extremity Disease Carotid Artery Disease Claudication Deep Vein Thrombosis Diabetic Problems Hyperlipidemia Lymphedema

Mesenteric Ischemia Peripheral Aneurysm Peripheral Arterial

Disease Pulmonary Embolism Renovascular

Conditions Thoracic Aneurysm Thoracic Outlet

Syndrome Varicose Veins Venous Insufficiency

Dilation: Aneurysm Stenosis /Obsturction Atherosclerosis obliterans (ASO) Thromboangiitis obliterans(TAO) Acute artery emoblism Polyarteritis(Takayasu Disease) Raynauds syndromeInjury of vessel/Arterio-venous fistulaVenous Diseases

Abdominal Aneurysm Aortoiliac Disease Upper Extremity Disease Carotid Artery Disease Claudication Deep Vein Thrombosis Diabetic Problems Hyperlipidemia Lymphedema

Mesenteric Ischemia Peripheral Aneurysm Arterio-venous fistula

Pulmonary Embolism Renovascular

Conditions Thoracic Aneurysm Thoracic Outlet

Syndrome Varicose Veins Venous Insufficiency

NON-MODIFIABLE RISKS:

Age. The risk of limb loss due to PAD increases with age. People 65 or older are two to three times more likely to have an amputation.

Gender. Men with PAD are twice as likely to undergo an amputation as women. Race/ethnicity. Some racial and ethnic groups have a higher risk of amputation (i.e.,

African Americans, Latino Americans, and Native Americans). This is because they are at increased risk for diabetes and cardiovascular disease.

Family history of heart disease. A family history of cardiovascular disease is an indicator for risk at developing PAD.

MODIFIABLE RISKS:

Cigarette smoking. Smoking is a major risk factor for PAD. Smokers may have four times the risk of PAD than nonsmokers.

Obesity. People with a Body Mass Index (BMI) of 25 or higher are more likely to develop heart disease and stroke even if they have no other risk factors.

Diabetes mellitus. Having diabetes puts individuals at greater risk of developing PAD as well as other cardiovascular diseases.

Physical inactivity. Physical activity increases the distance that people with PAD can walk without pain and also helps decrease the risk of heart attack or stroke. Supervised exercise programs are one of the treatments for PAD patients.

High blood cholesterol. High cholesterol contributes to the build-up of plaque in the arteries, which can significantly reduce the blood's flow. This condition is known as atherosclerosis. Managing cholesterol levels is essential to prevent or treat PAD.

High blood pressure. When blood pressure remains high, the lining of the artery walls becomes damaged. Many PAD patients also have high blood pressure.

High levels of Homocysteine. This is an amino acid found in plasma (blood). Some recent studies show higher levels are associated with PAD.

IIntermittent Painntermittent Pain Postexercise,locomotivePostural change Variation of temperature

Persistent PainPersistent Pain (Rest pain)(Rest pain)

Artery Vein Imflammatory and ischemia and necrosis

I AsymptomaticII Intermittent Claudication

II a Claudication walking > 200mII b Claudication walking < 200m

III Rest/nocturnal painIV Necrosis/gangrene

Venous edemaLymphous edema

HeavyAbnomal sensation:numb 、 paralysis 、 needling 、 formicationSensory deprivation

Up: Venous Obstruction Arterio-venous fistulaDown: Artery Obstruction

Normal and abnormal colorChange of Skin Color after: Finger pressed Locomotive Postual change

Artery Pulse :normal to weaken/disappear to enhance Murmur:trill Apperance and texture: flexion,harder,nodus Vein varicose ,murmur,etc.

Dystrophia skin changeUlcer,gangreneLonger , bigger extremity

Apperance:Varicose Color:PigmentationTexture:HarderUlcer

Gangrene

Non-invasiveABIsSegmental limb pressuresLimb plethysmographyExercise testingDoppler & duplex

ultrasoundCT angiographyMR angiography

InvasiveContrast arteriography

Comparison of ankle pressure to brachial SBP

Reproducible, useful for long term surveillance

Normal 0.85-1.2Claudicants 0.5-0.7Critical ischemia < 0.4May be falsely elevated in

calcified vessels (DM)

Simple, reliable means for diagnosing PAD. Blood pressure measurements are taken at the arms and ankles using a Doppler.

The ABI test is simple enough to be performed in any doctor's office.

Inexpensive equipment and reimbursable tests.

Similar to the ABI plus 2 or 3 additional blood pressure cuffs. These additional cuffs are placed just below the knee and one large cuff or two narrow cuffs are placed above the knee and at the upper thigh. These cuffs are then inflated above your normal systolic blood pressure, and then slowly deflated.

Using the Doppler instrument, a significant drop in pressure between two adjacent cuffs indicates a narrowing of the artery or blockage along the arteries in this portion of your leg. This allows the physician to identify more precisely the location of such blockages in the arteries of your leg.

Duplex Scanning = a combination of real-time and Doppler ultrasonography

Purpose: to evaluate arterial and venous disorders noninvasively.

The most common application for the examination is to determine the presence of deep vein thrombosis (DVT) in the extremity, usually because of leg swelling.

The deep veins are examined every 1-2 cm and gentle pressure is applied with the scan head to demonstrate that the walls of the vein can be easily collapsed. When thrombus is present there is little if any compressibility. The flow patterns are also assessed with Doppler recording. The presence or absence of venous valve insufficiency is assessed with compression maneuvers of the extremity.

TYPES OF DUPLEX SCANS:

• Extracranial Cerebrovascular

• Abdominal– Renal– Aortoiliac – Mesenteric

Arterial • Venous Duplex

Scan Upper and Lower Extremities

Risk factor managementLipid-lowering therapySmoking cessation

Exercise regimenAntiplatelet therapy - ASA, clopidogrelVasoactive - Cilostazol (Pletal), pentoxyfilline

(Trental)

Bypass Endarterectomy PTA/Stenting

Stenosis vs.Occlusion

Either Stenosis > occlusion Stenosis >occlusion

Length of segment Not a factor Preferably short Preferably short

Vessel caliber > 2 mm Preferably > 5-6 mm Preferably > 4 mm

Most suitableanatomic sites

Aortic arch throughdistal femoral

Carotid bifurcation Distal abdominalaorta and iliacs

Gray’sAnatomy: The Anatomical Basis of Clinical Practice, 40th edition (2008), Churchill-Livingstone, Elsevier

http://www.bartleby.com/107/148.html

http://en.wikipedia.org/wiki/File:Carotid_Plaque.jpg

Predilection Sites: •Bifurcation of Common Carotid Artery (CCA)•Origin of Common Carotid Artery•Carotid Siphon•Middle Cerebral Artery (MCA) and Anterior Cerebral Arteries (ACA)

Bilateral Lesion is mostly Seen

Atherosclerosis , >90% Takayasu Disease, Fibromuscular

Dysplasia Rare:Trauma, Artery Reversion,

Congenital Artery Atresia, Tumors, Inflammation around the artery , Fibrosis after Radiotherapy 。

Stroke is the first cause of disability and death in China, the incidence has increased every year

150-200 million new cases in China, the recurrence rate is more of an average annual rate of 7.6%

China has 700 million existing patients with cerebrovascular disease, of which about 70% of Ischemic Stroke.

2 / 3 of ischemic stroke is caused by Carotid Artery Atherosclerosis Stenosis

Carotid plaques mainly caused by cerebral ischemia in two ways ：①Severe stenosis of the carotid artery caused hemodynamic changes, leading to the corresponding parts of the brain hypoperfusion ；②Micro-emboli or plaques in the plaque surface micro-thrombosis leading to cerebral embolism

Symptomatic Carotid Stenosis——I.Brain ischemic symptoms: Tinnitus, Vertigo, Amaurosis, Blurred vision, Dizziness, Headache, Insomnia, Memory loss, dreams and Ocular ischemic manifestations.II.TIA (transient ischemic attack): clinical manifestation is one side of limb sensory or motor function disorders, transient monocular blindness, or aphasia, etc., generally lasted only a few minutes, within 24h after the onset of full recovery. Imaging without focal lesions. III.Ischemic stroke: common clinical symptoms limb sensory disturbances, hemiplegia, aphasia, brain damage, coma and other serious and nervous system with the appropriate signs and imaging featuresAsymptomatic Carotid Stenosis —— Patients with carotid stenosis without any clinical signs or symptoms

Asymptomatic Vs Symptomatic 3-4 ： 1

BUS,TCD ： Convenient and easy to repeatCTA: Accurate and important tool for screeningCTP ： Assess cerebral ischemia and vascular reserveMRDWI/PWI: Assess indications for thrombolysisMRA: TOF/PC MRA ， 3D-CEMRADSA: Gold Standard

Blackshear WM,….,Strandness DE.Stroke 1980; 11:67.

VR MPR MIP

CT Angiogram

DSA:Gold Standard

NASCET Standard*:(1 － A/B)×100%

ECST Standard:(1 － A/C)×100%

Mild Moderate

Severe

NASCET ＜ 50% 50-69% 70-99%

Medical Treatment—Basic Carotid Endarterectomy(CEA) － Gold

StandardCarotid Angioplasty and Stenting (CAS)

Prevent Risk FactorsAnti-platelet Drugs Statins

British Heart Protection Study Collaboration Group.Lancet 2002; 360:7-22Naylor AR et al.Eur J Vasc Endovasc Surg 2009; 37:625.

Prevent StrokePrevent Stroke Prevent Nerve InjuryPrevent Nerve Injury

1953 ， first successful CEA case was performed by

DeBakey 1956 ， Cooley first reported CEA and using a shunt

during operation. 1958 ， DeBakey Utilize Dacron Material in CEA. 1985, Professor Wang Zhonggao performed CEA

operation in China firstly. 1979 ， First PTA in Carotid Artery performed by

Mathias 1991 ， NACET and ACAS’s result established an

era of CEA 1994 ， Marks and Palmaz performed first Carotid

Artery Stenting. The treatment of carotid artery entered an era of CEA and CAS.

Symtomatic Patients: >50% Stenosis of Carotid Artery

Asymtomatic Patients: >70% Stenosis of Carotid Artery

Lancet.2010;375(9719):985-997

CEAEEA

Techniques

PTFE patch Vein Vein interposition PTFE

CAS Pro-CASM.O.M.A

Pro-CAS

Carotid Angioplasty and Stenting(CAS)

61

Distal ICA Occlusion

Proximal Occlusion:CCA/ECA Occlusion

Distal ICA Filter Proximal Occlusion / Reverse Flow

Carotid Endarterectomy

Carotid Artery Stenting

Long-term efficacy has been confirmed

Minimally invasive

Removal of atherosclerotic plaque

No cranial nerve injury

No intravascular foreign body

Long lesion of CA

Avoid the risk of angiography

For a history of neck surgery or

radiotherapy in patients

Craig R. Narins, et al. Patient selection for carotid stenting versus endarterectomy: A systematic review. J Vasc Surg 2006;44:661-72.

Summary Carotid Artery Atherosclerosis Stenosis is the primary

cause of ischemic stroke, which is the only stroke type can be prevented by surgical intervention

Stenosis of carotid atherosclerosis can be divided into symptomatic and asymptomatic, the most common clinical manifestations of transient ischemic attack (TIA)

Surgical Indication: Severe carotid artery stenosis (symptomatic stenosis> 50%, asymptomatic> 70%)

The Gold Standard Treatment of Severe Stenosis of carotid artery carotid endarterectomy(CEA), carotid angioplasty and stenting(CAS) is an alternative for patients at high surgical risk

Vessel wall of abdominal aorticPermanent and localized dilationDiameter of AAA's 〉 2 times normal's

Male （ >60Y ）： 4 ％～ 9 ％ Female （ >60Y ）： 1 ％ Diameter>5cm: about 0.5% in male Almost all rupture of AAA occur in males aged 65 or above.

Main ： Age ： >65Y Gender ： Male>Female Cigerattes

Minor ： Family history Coronary disease Hypercholesteremia Hypertension Cerebral vascular disease

Genetic inheritance Genetic susceptibility Atherosclerosis Medial cystic necroses or degeneration Cogenital AAA Infection:staphylococci ,saimonella,etc.

Infrarenal aorta aneurysm:95 ％ Thoracic-abdominal aneurysm ： 5 ％（ both thoracic and abdomianl aorta involved ）

http://www.zjmedical.cn/Html/anatomy/0710701540359290284.html

True aneurysm ： Whole aortic vessel and aortic aneurysm expand pathologically 。 Pseudoaneurysm(false aneurysm) ： Actual perforation and tearing of one or more layers of aortic vessel wall,from which hemorrhage to be surrounded by adjacent tissue and become hematoma ,mostly due to trauma. Dissecting aneurysm: It occurs when a tear in the aorta intima causes blood to flow between the layers of the wall of the aorta and force the layers apart.

A B CA ： True aneurysm B ： Pseuoaneurysm C ： Dissecting aneurysm

Always untypcial Founded by physical examinations occasionally

Abdominal pain ： from discomfortable to severe upper adominal pain Pulsating mass ： most unique sign, periumbilical Vascular murmur ： systolic phase Symptoms of compression ： obstruction of digestion and ureter ,etc.

Rupture Embolism of peripheral artery Acute complete thrombosis Infection Chronic disturbance of blood coagulation due to consuming Aortoenteric fistula Arteriovenous fistula （ blood flow into inferior vena cava ）

Abdominal radiography ： Calcified vessel wall of AAA (which looks like eggshell) Ultrasound CT MRI Angiography

23/5/1华山血管外科网 www.vascularcenter.cn 80

23/5/1华山血管外科网 www.vascularcenter.cn 84动脉造影 DSA

Indication ： Diameter>5.5cm (<5.5cm Ultrasound follow up regularly) Continuing dilation with abdominal pain Tend to rupture Hematoma in dissecting which causes severe abdominal pain With infection Compress adjacent organs and other important tissues Mural thrombosis in aneurysm clot off and lead to embolism of distal artery

Incision

Anastomosis


Artificial Veseel

EndoVascular AAA Repair

(EVAR)

Indication ： Conventional resection of AAA No allergic response to contrast medium Creatinine level ＜ 2.5mg ／ dl

Contraindication ： Length from inferior renal artery ＜ 1.5cm Diameter of AAA ＞ 2.8cm Diameter of common iliac artery ＞ 11.5mm Diameter of external iliac artery ＜ 6mm Angle of proximal aneurysm neck ＞ 60° Severe atherosclerosis of iliac artery,buckling vessel (>90°),especially with extensive calcification Only inferior mesenteric artery supply left hemicolon (superio and inferior mesentenci artery lack of communication)

Before-EVAR After-EVAR

Reference Books and Literatures

1. Rutherford: Vascular Surgery, 7th ed. 2010

2. 2011 ASA ACCF AHA AANN AANS ACR ASNR CNS SAIP SCAI SIR SNIS SVM SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. Journal of the American College of Cardiology, Vol. 57,No. 8, 2011

3. C.D. Liapis, Sir P.R.F. Bell ESVS Guidelines. Invasive Treatment for Carotid Stenosis -- Indications, Techniques Eur J Vasc Endovasc Surg (2009) 37, S1-S19

The only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do.

——Steve Jobs

[email protected] Julian

mailto:[email protected]

peripheral vascular disease

Health & Medicine