Boca Raton Regional Hospital Grand Rounds September 13, 2016
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1 Boca Raton Regional Hospital Grand Rounds September 13, 2016 W. Anthony Lee, MD, FACS Chief, BocaCare Vascular Surgery Christine E. Lynn Heart and Vascular Institute Boca Raton, Florida
2 Disclosures No disclosures relevant to this presentation
3 Q1. 79 yo M, R calf cramping at 100 feet, relieved with rest and palpable R pedal pulse. The patient 1. does not have vasculogenic claudication 2. may have vasculogenic claudication 3. definitely has vasculogenic claudication
4 Q2. 79 yo M, h/o CAD, HTN with 6m h/o constant calf pain and numbness relieved with walking. ABI 0.6/0.7. Next step should be 1. immediate referral to vascular surgeon 2. immediate angiogram and intervention 3. initiate w/u for non-vasculogenic etiologies of leg pain
5 Q3. 79 yo M, with 1 block thigh/calf claudication. The NEXT diagnostic test should be 1. ABI w/ exercise 2. arterial duplex ultrasound only 3. angiogram
6 Q4. 79 yo M, severe COPD/DOE, home O2/steroids, ambulates 5 steps w walker, c/o calf-ankle swelling/redness/pain. Arterial/venous leg dopplers show no DVT, SFA occlusion and ABI 0.6/0.7. Treatment options may include all of the following EXCEPT: 1. compression stockings for lymphedema and/or venous insufficiency 2. antibiotics for cellulitis 3. angioplasty and/or stent for SFA occlusion
7 Scope of Peripheral Vascular Disease
8 Peripheral Vascular Disease Aortic Aneurysms Carotid Stenosis Lower Extremity Occlusive Disease Venous Thrombosis
9 Brief Anatomic Review Internal iliac artery External iliac artery
10 Peripheral Vascular Disease Progressive process of stenosis and acute-onchronic occlusion (typically from atherosclerosis) in the major and mediumsized arteries
11 Lesion Types Focal vs. diffuse Stenosis Chronic total occlusion (CTO) Soft plaque Calcific disease Intimal hyperplasia Acute thrombosis Embolic
12 Demographics Prevalence 8-10 million people in US 12-20% of adults over the age of 65 75% (50% asymptomatic + 25% atypical leg pain) require NO treatment Don t look for it!!!
13 Spectrum of Clinical PVD Claudication: ~20-25% Critical limb ischemia: ~1-2% Untreated CLI: ~25% amputation, ~25% CVrelated 6- months
14 MODIFIABLE Risk Factors Age >70 years CAD/Stroke Smoking Diabetes Hyperlipidemia Hypertension Antiplatelet tx Sedentary lifestyle
15 Classifications for LE Ischemia
16 Critical Limb Ischemia (CLI) Rest pain (Fontaine III, Rutherford Grade II- Category 4) Tissue loss (Fontaine IV, Rutherford Grade III-Categories 5, 6)
17 TASC Classification Trans-Atlantic Inter-Societal Consensus SURGERY ENDOVASCULAR
18 Examples TASC A TASC B TASC B TASC C TASC D
19 Infrainguinal PAD Normal Claudication Rest Pain Tissue Loss Rutherford Fontaine I II III IV ABI TASC N/A A-B C-D
20 Diagnosis: Symptoms Reproducible pain ( crampy ) and/or fatigue with walking, relieved with rest (intermittent claudication) Numbness, pain, paresthesia localized to the toes (esp. 1 st toe) and/or the instep at night, relieved with dependent positioning (metatarsalgia/rest pain)
21 Diagnosis: Signs None Mild muscle wasting Hair loss Shiny skin Dependent rubor Coolness Pallor Tissue loss Sensory change Motor change
22 Diagnostic Studies: Physiologic Vascular Lab ICAVL accreditation ( Good Housekeeping seal) ACCEPT NO SUBSTITUTES Validation garbage in, garbage out The most important diagnostic tool (2 nd to a careful H&P) May be the ONLY preoperative diagnostic study required
23 Diagnostic Studies: Physiologic Single most important study ABI (resting) ankle-brachial index Segmental pressures False negative (decreased arterial compressibility) Diabetes CKD/HD Calcinosis
24 ABI The higher of the 2 ratios obtained by dividing the calf pressure required to occlude either DP or PT doppler signal by the higher of 2 brachial pressures
25 When ABI s Fail PVR (pulse volume recording) waveform analysis TBI (toe brachial indices) Exercise ABI Increased sensitivity for hemodynamically significant lesion
26 Diagnostic Studies: Anatomic Do NOT order if you are going consult vascular surgery Optimal study dependent on clinical presentation Non-Invasive Arterial duplex ultrasound CT angiography (CTA) MR angiography (MRA) Angiography
27 Non-Invasive Imaging Optimal approach to lesion (L vs. R, brachial vs. femoral, etc.) Technical risk assessment (single vs. multi-vessel runoff) Endovascular vs. surgical candidacy Limitations Complex/multisegmental lesions low flow Duplex: Quality dependent on flow characteristics (eg. proximal lesions underestimate severity of distal lesions) CT & MR: Quality dependent on contrast delivery and bolus timing Pseudo-stenosis/occlusion
28 Contrast Angiography The Gold Standard Allows simultaneous diagnosis and catheter-based intervention Limitations Contrast nephropathy (1-8%) Anaphylaxis ( %) Puncture site related complications (4-7%)
29
30 Treatment Medical Surgery Endovascular (angioplasty/stenting) Goals Improve quality of life Relieve pain Heal ischemic ulcers/wounds Prevent limb loss
31 Medical Management Risk factor modification Drug ASA Statin Pletal (cilostazol) Exercise Min: 30 min x 5x/week Weight loss
32 Surgery Bypass/Endarterectomy Salvage therapy for Failed endovascular treatment Unfavorable lesion types Unfavorable lesion locations Pros: Durable, Low-Cost Cons Maximally-invasive Conduit-limited
33 Endovascular Evidence-based/ textbook vs. real-world First line (invasive) treatment Pros: Minimally-invasive Outpatient, low morbidity, rapid recovery Cons: Durability, Cost Favorable lesions: short, stenotic, non-calcified, large vessel, good outflow, non-diabetic, non-ckd
34 Tools & Techniques Angiosculpt Intraluminal PTA +/- stent Subintimal PTA Cutting balloon PTA Cryoplasty Laser Directional atherectomy DES (drug-eluting stent) Absorbable stent Silverhawk Cutting Balloon Polar-Cath Subintimal Laser
35 Stents Bare Metal Drug-Eluting Spiral (coil) stent Absorbable Balloon-expandable NiTi stent
36 Covered Stents PTFE + BE (icast) PTFE + SE (Viabahn) Spiral covered stent PTFE + BE (Jostent) Dacron + SE (Wallgraft) PTFE + SE (Fluency)
37 Chronic Total Occlusions (CTO) 70-80% overall success Recanalization tools and techniques Intraluminal Subintimal Re-entry Spectranetics Safe-Cross Front-Runner Outback Pioneer
38 Aspiration/Thrombus Management Thrombo- vs. atheroemboli Recognized complication in all interventional procedures Mechanical Aspiration Fragmentation Pharmaco-lysis Possis Angiojet Possis Fetch tpa Medtronic Export
39 Challenges to SFA Intervention Diffuse disease more common (vs. focal) Occlusions more common (vs. stenoses) Adductor canal (repetitive flexion motion) Small diameter, low flow, high resistance Frequent outflow disease
40 66F, DM, ESRF, HTN, L great toe ulcer and rest pain
41 82 yo M w/ HTN, R LE short distance claudication
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45 PVD Management N DDx Exp Mgmt Clinical PVD? Symptoms N DDx Exp Mgmt Y Physiology N Y Anatomy H & P Vascular Lab Y Angiogram DDx Exp Mgmt Intervention
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