APACVS April 6, 2018

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1 APACVS April 6, 2018 Dejah R Judelson, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery University of Massachusetts Medical School

2 I got a small stipend to be here I think I have the best job in the entire world I m married to the lead tech in our vascular lab so I think our vascular lab is the best one out there No other relevant disclosures

3 Be able to complete a thorough and focused vascular physical exam for pre-operative evaluation Understand appropriate vascular testing including ABIs, carotid duplex Recognize the indications for combined revascularizations (ie CEA-CABG)

4 Cardiothoracic surgery is inherently high risk Reduction of modifiable risk factors improves outcomes Patients with unidentified or untreated concomitant vascular disease can have worse outcomes and complications

5 Healing vein harvest sites Balloon pump placement Risk of stroke on-pump RIMA/LIMA inflow Risk of post-operative renal failure and mesenteric ischemia (Vascular Complications in the ICU, Sunday am)

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8 Carotid Disease Subclavian Disease Peripheral Arterial Disease Mesenteric Disease Renal artery occlusive disease

9 The prevalence of PAD in the lower limbs in a general population >55 years of age is between 10% and 25% and it increases with age Majority of affected population have asymptomatic disease. Peripheral arterial disease, whether symptomatic or asymptomatic, is a risk factor for non-fatal and fatal coronary disease and cerebrovascular events. Patients with PAD alone have the same relative risk of death from cardiovascular cause as those with coronary or cerebrovascular disease Circulation Research. 2015;116:

10 Circulation Research. 2015;116:

11 The burden and progression of coronary atherosclerosis was investigated in 3,479 patients with coronary artery disease with (n = 216) and without (n = 3,263) concomitant PAD who participated in 7 clinical trials that employed serial intravascular ultrasound imaging JACC Vol. 57, No. 10, 2011

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14 Global Registry of Acute Coronary Events (GRACE) increase of in-hospital mortality from 4.5 to 7.2% and a 6- month mortality from 3.9 to 8.8% in patients with lower extremity PVD CASS Registry 30 days post-cabg, patients with lower extremity PVD exhibited higher rates of mortality BARI: Bypass Angioplasty Revascularization Investigation Five-year mortality rates after CABG were five times higher in patients with symptomatic or asymptomatic ABI <0.9 compared with patients without PVD

15 Targeted History Vascular specific physical exam Pulses Skin changes Non-invasive vascular testing

16 Focus on what you need to get the patient through surgery safely and to reduce modifiable risk factors You probably aren t a vascular surgeon/vascular PA. And if you want to be one come talk to me later!

17 Few notable exceptions

18 Focus on symptoms! Be systematic Head to toe By organ system

19 What questions to ask/what are we focused on? Stroke symptoms Upper extremity symptoms Lower extremity symptoms Mesenteric ischemia symptoms Previous vascular procedures

20 Have they had a recent stroke or TIA (within the last 6 months)? Amaurosis fugax Expressive aphasia Lateralizing weakness/paresthesias Facial droop

21 Do they have a known history of different blood pressures in each arm? Most patients with subclavian stenosis are asymptomatic

22 Upper extremity fatigue can be very vague Early exhaustion when using one arm Upper extremity claudication History of syncope when using one arm Subclavian steal from reversal of flow in vertebral

23 3 classifications of symptoms Asymptomatic Claudication Critical Limb Ischemia Rest Pain Non-healing ulceration or lesion

24 Cramping when ambulating a set distance Discomfort relieved when patient stops moving (does not need to sit down) **It is (almost) always the same distance and occurs every time they walk** Pain occurs one level BELOW the level of disease Calf cramping femoral disease Thigh cramping aortoiliac disease

25 Leriche syndrome Specific constellation of symptoms associated with aortoiliac occlusive disease Men Buttock and thigh claudication Erectile dysfunction

26 Aka METATARSALGIA Pain that occurs while sleeping Across the metatarsal bones Often hard to describe Relieved by dangling their leg off the side of the bed Not the same as charley horse!

27 Have they had a history of non-healing or slow to heal ulcerations or lesions on their feet?

28 Post prandial abdominal pain Unintentional weight loss Food fear

29 Focus on reversible disease renal artery stenosis Difficult to control blood pressure on 4+ antihypertensives? Without another etiology

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31 VITALS ARE VITAL Must get bilateral upper extremity blood pressure measurements High sensitivity for determining hemodynamically significant subclavian stenosis If SBP <20 point difference unlikely to have significant disease

32 4 Key things: 1. Pulses 2. Pulses 3. Pulses 4. Skin changes

33 Brachial Radial Femoral Dorsalis Pedis/Posterior Tibial If they have equal and palpable radial and pedal pulses unlikely significant disease!

34 But if you aren t completely sure. Do the complete pulse exam Strongly palpable brachial pulse that is symmetric unlikely to have significant subclavian stenosis (unless the patient is hypertensive or has bilateral disease) Strongly palpable femoral pulses unlikely to have aorto-iliac disease IABP can likely safely be placed Likely to heal vein harvest incisions

35 Skin changes Loss of hair on legs distally Lighter coloring of feet/toes Delayed capillary refill Be concerned for underlying PAD that may complicate healing of vein harvest

36 Things that I don t even do: Listen for carotid bruit Can be confused with aortic stenosis Neither sensitive nor specific for carotid stenosis Listen for abdominal bruit My patients are never skinny enough to appreciate RAS **for the record I do own and always use my stethoscope!**

37 Now you think there might be a vascular problem based on your history and exam what tests do you order to confirm it?

38 Lots of variability: tech dependent Radiology vs Vascular Surgery Registered Vascular Technicians vs Ultrasound Technicians Ask your vascular surgeons! Assuming you are at a place with an amazing reliable vascular lab like University of Massachusetts.

39 Direct Indirect

40 Doppler Duplex ultrasonography Laser doppler and skin perfusion Not used as frequently

41 Velocities are detected as frequency shifts in reflected ultrasound from the flowing red blood cells Arterial narrowing causes an increase in velocity at the site of the stenosis and dampening of the velocity waveform beyond

42 Handheld devices at the bedside transmit between 5-10MHz can only penetrate a few cm below the skin Probes have a receiving and transmitting piezoelectric crystal at the tip. Doppler output is a sound signature tells you if there is flow but not what direction it is going in

43 Normal peripheral arteries have a triphasic quality: brisk upstroke of forward flow in systole brief reversal in early diastole forward flow in late diastole Arterial obstruction leads to dampening of the waveforms with a monophasic output

44 Developed under Dr. Eugene Strandness at University of Washington 1967: Ultrasonic Flow Detection: A Useful Technic In The Evaluation of Peripheral Vascular Disease 1970s: combined B-mode with Doppler to create Duplex imaging Non-invasive and cost effective Pulsed doppler spectral analysis flow velocity distribution at a selected sample volume Provides information about peak velocity in sample

45 Combination of B mode (black and white) with color flow and doppler waveforms

46 ABI/TBI Segmental Pressures Pulse Volume Recording Transcutaneous Oxygen tissue measurement

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48 ABI also has been shown to be linked to cardiovascular morbidity and mortality - ABI <0.5 found to have 5 yr survival of only 63% - ABI <0.67 independently associated with cardiac events and increased the risk for cardiac death by 2/3.

49 Useful in diabetics where ABI is non-compressible due to extensive calcifications of tibial vessels Normal >0.7 Toe pressure > 50 Interpretation Able to heal wounds CLI < 30 CLI with inability to heal wounds

50 Allows for identification of levels of disease Pressure gradients >20mmHg are significant and indicate disease at the level above Segmental pressure measurements also do not detect disease in nonaxial vessels, such as the profunda femoris Inaccurate in patients with calcification

51 Records volume changes in leg and thigh with arterial pulse - blood moves into microcirculation during systole, leading to increased tissue perfusion and limb volume Air-containing cuffs are applied to legs as leg volume increases, air in cuff gets displaced and is recorded by a transducer Allows for noninvasive evaluation even in patients with significant calcification

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53 An oximetry probe is used to measure tissue oxygen perfusion Reports absolute oxygen pressure and ratio of oxygen pressures Normal wound healing requires TcpO2 > 40 TcpO2 < 20 indicates critical ischemia with need for revascularization

54 Cerebrovascular Disease: Carotid Duplex Subclavian Disease: Carotid Duplex, Upper Extremity Arterial Duplex Peripheral Arterial Disease: ABIs Chronic Mesenteric Ischemia: Mesenteric Duplex Renal Artery Stenosis: Renal Artery Duplex

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56 Most common clinical application is for the detection of proximal ICA atherosclerotic plaque and estimation of stenosis severity Can also identify subclavian stenosis (by retrograde flow in the vertebral) Huge variety in diagnostic criteria, no set standards Visualizes: Common carotid arteries Internal carotid arteries External carotid arteries Proximal Vertebral arteries

57 Inability to examine supraaortic trunks and distal cervical portions Quality and reliability is operator dependent Additional imaging may be indicated to visualize high bifurcations, tandem stenoses, proximal common or distal carotid disease May overestimate degree of stenosis if contralateral side occluded - elevated velocities as compensatory mechanism to maintain perfusion

58 Stenoses reported in decile ranges 1-29% 30-49% 50-69% 70-79% 80-99% Occluded Stenosis determined by PSV, EDV, ratio

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61 Used infrequently Direct visualization of subclavian, axillary, brachial, radial, ulnar arteries Looks at peak systolic velocity with focal increases to determine areas of stenosis Limitation: proximal left subclavian stenosis not visualized

62 ABIs/TBIs are sufficient to determine if there is significant PAD

63 Patient must be fasting ~90% accurate to detect >70% stenosis Visualizes celiac, SMA, IMA Criteria for >70% stenosis Celiac: PSV >200 cm/sec SMA: PSV >275 cm/sec IMA: no set criteria Must be accompanied by post stenotic turbulence and decreased velocities distal to the area of stenosis

64 >70% in 2+ mesenteric vessels Typically celiac and SMA Can be seen with SMA and IMA stenosis Isolated single mesenteric stenosis should not give you chronic mesenteric ischemia Acute mesenteric ischemia is a different story come back Sunday am!

65 Patient must be fasting PSV >180 cm/sec suggestive of >60% stenosis Renal/Aortic Velocity Ratio (RAR) RAR = PSV of renal artery/psv of suprarenal aorta <3.5 = normal >3.5 = Abnormal (>60% stenosis) Resistive Index = PSV-EDV/PSV <0.7 = normal 0.7= renal parenchymal disease

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67 One of the most hotly debated topics in cardiac/vascular literature

68 Everyone s favorite vascular consult How many of you get carotid duplexes for: Every CABG and valve? All ascending aneurysms? Every open heart case?

69 Typically well tolerated vascular procedure Only moderate risk open vascular intervention At centers of excellence, stroke rates Asymptomatic disease: <1-3% Symptomatic disease: <3-5% Biggest complication: MI

70 Symptomatic disease (stroke or TIA within past 6 months) and stenosis >50% Asymptomatic disease >80% Some providers will perform CEA for low risk patients at stenosis >70%

71 Favored more by interventional radiologists and interventional cardiologists Vascular surgeons preferer CEA and reserve CAS for appropriate populations Biggest complication: risk of stroke Reduced cardiovascular complications

72 Case by case situation Is the risk of two surgeries greater than the risk of a combined case?

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74 Should be performed if the risk of stroke during CABG is prohibitively increased if carotid revascularization isn t done in the same setting Symptomatic Disease Bilateral 80-99% stenosis (typically left) Unilateral occlusion and contralateral 80-99% Any other carotid stenosis >50% refer to vascular surgeon for outpatient evaluation

75 To heal a vein harvest site: need palpable femoral pulse and reasonable outflow To place an IABP: need palpable femoral pulse

76 Concern for symptomatic disease: claudication, rest pain, ulcers Non palpable femoral pulse Non palpable pedal pulse ABIs concerning for significant PAD

77 If you are planning on using a LIMA and there is a concern for subclavian stenosis Retrograde flow of vertebral on CDS Unequal upper extremity BP >20mm Hg Coronary angiogram concerning for subclavian stenosis

78 Patient endorses symptoms consistent with chronic mesenteric ischemia Mesenteric duplex with>70% in 1+ vessels

79 Worsening HTN refractory to 4+ meds Renal duplex with >60% stenosis

80 PAD case study Subclavian stenosis/carotid case study

81 61 male with history of hypertension, coronary artery disease s/p RCA plasty hyperlipidemia, ESRD on HD presented with chest pain during hemodialysis Coronary angiogram: severe three vessel coronary disease On preoperative evaluation patient endorses bilateral claudication, left >right

82 Vein mapping: Chronic superficial thrombophlebitis was found in the right great saphenous vein at the proximal calf. The left great saphenous vein was patent and continuous from the saphenofemoral junction to the ankle (0.09cm-0.57cm). Carotid Ultrasound: 30-49% stenosis of the right internal carotid artery % stenosis of the left internal carotid artery. STS mortality risk for an isolated CABG is 2.879

83 Emergent 4-vessel coronary artery bypass grafting Left endoscopic vein harvest LIMA to the mid LAD, GSV to RCA, GSV to ramus, GSV as a Y-graft off of the ramus graft going to D1 Immediate post op course uneventful

84 2 week post op with clear serous fluid draining from vein harvest site erythematous within a week or two started on PO ABx Presented one week later with small dehiscence at vein harvest site Duplex negative for fluid collection Sent out on antibiotics with HD

85 Two weeks later returned to the ED with increasing erythema at wound, unable to bear weight, contracture at knee CT leg showed air around the knee joint and significant vascular calcifications

86 Patient extensively debrided by plastic surgery

87 Post op noted foot was cool comparable to contralateral leg CT angiogram: common and external iliac occlusion, reconstitution of femoral artery

88 BEFORE AFTER Vascular surgery consult: Given extensive tissue loss, no option for limb salvage but needed revascularization to heal major amputation Underwent iliac stenting and then AKA Left common/external iliac occlusion Stenting left common/external iliac

89 If patient endorses lower extremity symptoms, work them up for PAD to determine extent of disease His leg pain was less significant (to him) than his chest pain and was hiding his rest pain!

90 73F with HTN, HLD had syncopal event positive stress test Cardiac cath: 3 vessel disease, arch branch disease, aorto-iliac occlusive disease Worked up for CABG CDS: bilateral 80-99% CAS with L CCA stenosis CTA findings: high grade innominate lesion moderate-severe L CCA stenosis high grade L SCA stenosis Celiac stenosis aorto-iliac occlusive disease

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94 Left subclavian stent to preserve LIMA inflow Combined L CEA and L CCA stent with CABG Why left? Patient right handed speech center on the left Asymptomatic from celiac stenosis Intermittent claudication but weakly palpable femoral pulses

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97 Thank You