The Vascular Patient: Diagnosis and Conservative Treatment Ferrell-Duncan Clinic Zachary C. Schmittling, M.D., F.A.C.S. Vascular and General Surgery Ferrell-Duncan Clinic Cox Health Systems Objectives Review diagnosis of aneurysmal disease Review diagnosis of carotid disease Review diagnosis and conservative treatment of peripheral vascular disease Abdominal Aortic Aneuryms Likely the 5 th most common cause of death of men over 60 Missed diagnosis in most cases Highly treatable if found 1
Abdominal Aortic Aneuryms Anatomy of Abdominal Aortic Aneurysms Localized dilatation of the aorta (taken from the Greek meaning widening ) The majority are infrarenal (90%) and over two thirds involve at least some of the iliac arteries Most are fusiform as opposed to saccular (involving only part of the aortic wall) Anatomy of Abdominal Aortic Aneurysms All aneurysms will have some degree of thrombus within the sac the amount does not really matter Aneurysms form due to loss of elastic tissue within the aortic wall the cause of this is unknown Those with some genetic diseases (alpha- 1 antitrypsin) will also have hernias and lung disease 2
Causes of Abdominal Aortic Aneurysms Genetic/hereditary: There is a familial tendency to developing abdominal aortic aneurysms. Individuals with first-degree relatives having abdominal aortic aneurysms have a higher risk of developing abdominal aortic aneurysm than the general population. They also tend to develop the aneurysms at younger ages and have a higher tendency to suffer aneurysm rupture than individuals without family history. Causes of Abdominal Aortic Aneurysms Genetic disease:) such as Ehlers-Danlos syndrome and Marfan's syndrome Post-trauma: After physical trauma to the aorta. Arteritis: Takayasu disease, giant cell arteritis, and relapsing polychondritis. Mycotic infection: salmonella, HIV,, syphilis, fungal Causes of Abdominal Aortic Aneurysms Cigarette smoking Males (70 to 80% of patients) Hypertension Hypercholesterolemia Diabetes mellitus 3
Diagnosis of Abdominal Aortic Aneurysms Very difficult to diagnose the vast majority are asymptomatic With a good examination many can be felt by simple palpation If you can feel the aorta then consider an aneurysm Aneurysms can cause symptoms Diagnosis of Abdominal Aortic Aneurysms Expansion rapid expansion can cause back pain Embolization lower extremities Compression back pain, urinary symptoms, etc Leak or Rupture mortality rate at least 50% 4
Diagnosis of Abdominal Aortic Aneurysms If one suspects an aneurysm the best test is duplex ultrasound Medicare will pay for a screening ultrasound Plain films and MRI have limited usefulness CT angiography the gold standard Angiography can in many cases miss an aneurysm due to thrombus Diagnosis of Abdominal Aortic Aneurysms Once an aneurysm has been diagnosed (3cm or greater) then the patient needs to be followed Duplex ultrasound the test of choice Recommend every 6 months to yearly Once 5 cm reached treatment needs to be considered Peripheral Arterial Aneurysm Diagnosis by physical exam and then duplex ultrasound CT angiography the gold standard Best treatment varies but open surgery still the best Aneurysms in the carotid and upper extremities can occur but are rare 5
Peripheral Vascular Disease Blockages in the arteries Systemic disease if its in one place it likely is everywhere Increasing incidence seen today Those with diabetes and ESRD are living longer Wide variety of opinions in both the open and percutaneous realm Range of disease from asymptomatic to gangrene Diagnosis of Peripheral Vascular Disease Good history from the patient Pulse examination from the head to the toes Auscultation of the carotid, aorta and femoral areas Doppler examination can be useful Look for lose of hair and ulcerations Best treatment remains controversial Diagnosis of Peripheral Vascular Disease Claudication Lower extremity muscular pain (most often calf) induced by exercise and relieved by short periods of rest 1 to 2% of those less than 50, 5% in those 50 to 70 and up to 10% in those greater that 70 Progression in 25% of patients continued tobacco use and diabetes predicators Only 1 to 7% progress to amputation 6
Diagnosis of Peripheral Vascular Disease Rest Pain/Tissue Loss Rest pain is a burning in the foot Aggravated by limb elevation and helped by dependency Tissue loss can be from trauma or spontaneous Asymptomatic Marker for other diseases Work up for carotid and coronary disease may be in order Symptoms in PAD Patients with PAD Symptomatic PAD Asymptomatic PAD ~40% 1 Typical Symptoms (Intermittent Claudication) ~10% 1 Atypical Symptoms ~50% 1 American Heart Association. Heart Disease and Stroke Statistics 2005 Update. 2005. 15 7
Diagnosis of Peripheral Vascular Disease Ankle brachial indices the basic test Less than 0.90 abnormal Waveforms and toe pressures important as well Duplex ultrasound MRA please do not order, most overused test I know of CTA excellent test to plan for therapy Angiography the Gold Standard but usually reserved for treatment 8
Treatment of Peripheral Vascular Disease REMEMBER: PALPABLE PULSES DO NOT RULE OUT PERIPHERAL VASCULAR DISEASE NORMAL ANKLE BRACHIAL INDICES DO NOT RULE OUT PERIPHERAL VASCULAR DISEASE AS WELL Treatment of Peripheral Vascular Disease Lifestyle modification STOP SMOKING Exercise program Walk every day for 20 minutes and push yourself, you cannot hurt your legs Pletal or related drugs (at most 25% response) Aspirin in all patients (if possible) Control of medical problems (diabetes, hypertension, hypercholesterolemia) Smoking Cessation Smoking cessation the number one modification Chantix in my experience not all that helpful Smoking is an addiction AND a habit Nicotine replacement cannot be the only treatment Cognitive therapy, biofeedback, etc Vapor type devices are an option but controversial 9
Exercise Therapy Patient must be motivated however SUPERVISED exercise much more helpful Patient must be encourage to push themselves Those with severe arthritis and other medical conditions (CHF, COPD) may not be the best candidates Exercise therapy Exercise Therapy Patient must be motivated however SUPERVISED exercise much more helpful Now covered by Medicare Patient must be encourage to push themselves Those with severe arthritis and other medical conditions (CHF, COPD) may not be the best candidates Exercise Therapy Extend pain free walking distance Strengthen the lower extremities Improve balance and coordination Promote overall general fitness Improve quality of life Defer invasive treatment or prevent the need for surgical therapy 10
Exercise Therapy Study comparing supervised walking versus resistance training over 12 weeks Increased time and amount of exercise by 5% every week After 12 weeks results were: Improvement in ABI by 15% Increase in walking distance by up to 500 feet Equal results in both groups Biomed Res Int: Szymczak et al 2016: Oct 19: 545-560. Medical Treatment of Peripheral Vascular Disease In most cases for intermittent claudication There are therapies in trial (i.e. stem cell treatment) for ulcerations/rest pain that show some promise Aspirin in most cases however Plavix and thrombin inhibitors do not help Trental (Pentoxifylline) versus Pletal (Cilostazol) 11
Pletal Therapy Inhibition of phosphodiesterase (camp) Inhibition of platelet activation and aggregation Inhibition of vascular smooth muscle cell proliferation Improvement in lipids (increases HDL) Vasodilation Promotes neovasculariztion 12
Treatment of Peripheral Vascular Disease Decision to proceed with invasive treatment is multi-factorial Operative Endartectomy Bypass operation Endovascular Balloon angioplasty with or without stenting Athrectomy and other procedures 13
Diagnosis of Carotid Disease Carotid stenosis is one of the major causes of stroke (up to 10% of ischemic strokes) Secondary to embolization of particulate matter into the cerebrovascular system Cholesterol emboli or platelet emboli can occur Leads to stroke or transient ischemic attack (TIA) or amaurosis fugax Diagnosis of Carotid Disease Carotid stenosis is one of the major causes of stroke Secondary to embolization of particulate matter into the cerebrovascular system Cholesterol emboli or platelet emboli can occur Leads to stroke or transient ischemic attack (TIA) Diagnosis of Carotid Disease History and physical listen for carotid bruit Only 10% of patients with a bruit carotid will have a significant stenosis First test should be ultrasound No risks and easy on the patient Low cost Can be used to follow patient long term 14
Diagnosis of Carotid Disease In some ultrasound is all that is needed: Minimal disease High grade stenosis To confirm MRA or CTA At our system CTA is the test of choice Angiography used in selected cases: Risk of stroke (1-2%) and local complications Can be done with minimal contrast Disagreement between tests Treatment of Carotid Disease (Symptomatic) NASCET Trial In those patients with a 30 to 69% stenosis there was no benefit with surgery In those with a 70% or greater stenosis at two year medically treated patients had a 26% risk compared to 9% in the surgical group For a fatal or major stroke rates were 13.1% compared to 2.5% Treatment of Carotid Disease (Asymptomatic ACAS Trial Followed 1662 from 1987 to 1993 All patients had a greater than 60% stenosis Divided into medical and surgical groups Stroke rates at 2.7 years of follow up were 5.1% in the surgical patients and 11% in the medically treated patients This included angiography strokes 15
Treatment of Carotid Disease Medical therapy very important Plavix is my drug of choice no studies however have proven that this is better than aspirin or aggrenox Treat maximally hypertension and diabetes Cholesterol must be treated statin drugs are the best we will treat with these drugs even borderline cholesterol with known disease 16