What Is Peripheral Vascular Disease

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What Is Peripheral Vascular Disease?
Daniel B. Walsh, M.D. Professor of Surgery,
Section of Vascular Surgery Vice-Chair,
Department of Sugery Dartmouth-Hitchcock Medical
Center
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Perhipheral vascular disease is considered to be
any abnormality of the arteries and veins outside
of the skull and the heart.
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Differences Between Arteries Veins
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Components

• Problems with veins
• Varicose veins
• Blood clots and sequelae
• Arterial Aneurysms
• Aorta and branches
• Arteries blocked by atherosclerosis
• Carotid, Legs. Kidneys, GI tract

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Risk Factors for Atherosclerosis
Dyslipidemia
Hyperhomocysteinemia
Diabetes
Hypertension
Smoking
Obesity
Age
Atheroscleroris
Genetics
Atherosclerotic Disease and Complications (coronar
y, cerebrovascular, peripheral arterial events
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Natural History of PAD in US Population
Population Aged gt55y
Asymptomatic ABI lt0.9 10
Intermittent claudication 5
Critical leg ischemia 1
Cardiovascular morbidity/mortality
PAD outcomes
(5-year outcomes)
Stable claudication 73
Leg bypass surgery 7
Major amputation 4
Worsening claudication 16
Nonfatal events (MI/stroke) 20
Mortality 30
Adapted from Weitz JI. Circulation
1996943026-49.
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Intervention for Tissue Loss/Rest Pain, Severe
Claudication

• Medications
• Risk factor assessment reduction
• Exercise program
• PTA/Stents
• Operation

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Aneurysms can occur in these arteries

• Carotid
• Subclavian
• Thoracic
• INFRARENAL
• Renal

• Hypogastric
• Iliac
• Femoral
• Popliteal

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What is an Aortic Aneurysm?
Abdominal Aortic Aneurysm (AAA)
Thoracic Aortic Aneurysm (front view)
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Endovascular Aortic Aneurysm Repair
Pre-repair
Post-repair
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Freedom from Re-InterventionDHMC vs EUROSTAR
Freedom from Re-Intervention
Eurostar Data Registry, Jan.2001
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First Successful CEA
C. Rob
F. Eastcott
May 19, 1954
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Carotid Atherosclerosis
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Proven Benefit of CEA
Percent 30 Day Stroke, Death Late Ipsilateral
Stroke
4 Randomized Trials gt 12,000 patients Relative
risk reduction Symptomatic 50-69 -
25 70-99 - 61 Asymptomatic 60-99 - 48
2 Year
3 Year
5 Year
5 Year
Symptomatic
Asymptomatic
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Selective carotid injection
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Acculink 6-8x40mm
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Summary

• 3D CTA can be used to screen high risk CAS
  patients better served with modified CAS, CEA, or
  medical management

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Comparison of Carotid Endarterectomy and
StentDartmouth Experience (2000-Present)
Endarterectomy Stent

• Number 366 173
• Stroke 0.5 2.9
• Myocardial Infarct 4 1.2
• Death 0.8 0.8

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Conclusions

• CEA remains the gold standard RX
• CAS risk increases with age and requires EPD
• Carotid stent treatment of extracranial carotid
  occlusive disease is safe in selected patients.
• ? Asymptomatic medical high risk
• 3D CTA can assist in selecting patients for CAS
• Need to be prepared to handle technical
  difficulties
• Know when to stop
• Long-term durability of the procedure needs to be
  determined

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