4/13/11

Case  1  
Peripheral Vascular Disease: •  69  yo  man  referred  for  6.9cm  AAA  found  
An Overview incidentally  on  U/S  for  elevated  LFTs  
•  PMH:    HTN,  HL,  CAD  s/p  PCI,  CRI,  COPD  
•  PSH:    pyloric  stenosis  repair,  4v  CABG  ’03,  B  
Gale Tang, MD IHR  
MS3 Lecture •  NKDA  
•  Meds:    ASA  81  qd,  Metoprolol  50  bid,  Losartan  
100  qd,  SimvastaTn  40  qhs,  Albuterol  MDI  
•  SH:      +TOB  
•  FH:    mother  had  AAA  

Annual  Rupture  Risk   Physical  Exam  

50   •  LaPlace’s  Law   •  PulsaTle  abdominal  mass:    30-­‐40%  
?  
–  T  =  (P*R)/M    
40   –  Limited  by  body  habitus  and  size  of  aneurysm  
•  Increased  Risk   •  Assoc.  Femoral  or  popliteal  aneurysm:    15%  
?  
30  
% Annual – Large  diameter   •  Femoral  aneurysm:    85%  
Risk 20  
?   have  AAA  
– Women   •  Popliteal  aneurysm:    60%  have  AAA  
10   – Low  FEV1   ?  

0   – Current  smoker  
4   5.5   6   7   8   – Elevated  MAP  
Diameter  (cm)  
JVS, 2009;50:880-896

Imaging   Other  Imaging  ModaliTes  

Plain
X-ray
MRA
CTA
Angio
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RecommendaTons  for  U/S  

IndicaTons  for  Repair  
Screening/Surveillance  
•  Size  >5.5  cm  
•  All  men  ≥  65yo  (≥  55yo  if  family  history)  
•  MycoTc  
•  All  women  ≥  65yo  c  family  history  or  +TOB   8.0cm
•  Thrombosis  
•  IdenTfied  AAA:  
•  EmbolizaTon  
–  3-­‐3.4cm      F/U  U/S  in  3  years   6.7cm
–  3.5-­‐4.4cm      F/U  U/S  yearly  
•  Aortocaval  fistula  
–  4.5-­‐5.4cm  F/U  U/S  q6  months   •  Aortoenteric  fistula  
•  Based  on  expected  growth  rate  0.2-­‐0.8cm/yr  

JVS, 2009;50:880-896
Ann Vasc Surg 2010;24:524e1-4

CTA   Management  
•  Open        EVAR  
TeraRecon recon
here

Case  2   Ruptured  AorTc  Aneurysms  (rAAA)  

•  71yo  man  presents  to  ED  with  2  day  h/o   •  Overall  Mortality  85%  (95%  CI  80-­‐91)  
severe  back  pain   –  66%  die  before  reaching  hospital  or  without  
•  PMH:    HTN,  HL,  obesity,  COPD   operaTon   Bengtsson et al. JVS 1993;18:74-80.

•  SH:    +TOB  
–  Peri-­‐operaTve  mortality  open  repair  41-­‐48%  
•  PE:    Vitals  in  ER:    SBP  90’s120  with  2  liters  
NS,  HR  100   Brown et al. Br J Surg 2002;89:714-30.
Visser et al. Eur J Vasc Endovasc Surg 2005
•  Abdomen:    diffusely  distended  
–  Mortality  aker  open  repair  of  rAAA  has  not  
improved  significantly  in  the  past  20  years  
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Modern  Management:    Ruptured  AAA  

AorTc  Occlusion  Balloon  
rAAA  

Hemodynamically  Stable   Hemodynamically  Unstable  

Menta3ng   Not  Menta3ng  
SBP  >80mmHg   SBP  <80mmHg  

Opera3ng  Room  
CTA   Prepped  Awake  
Permissive  Hypotension  
12  Fr  Sheath  and  AOB  +/-­‐  Preclose  
+/-­‐  Angio  and/or  IVUS  

Unsuitable  Anatomy   Suitable  Anatomy  

AOB   Awake  
GETA  and  Open  Repair   EVAR  
Mehta  et  al  JVS  2006;44:1-­‐8  

30-­‐day  Mortality  for  both  Open  

Surgery  and  EVAR  by  Year  
57.1%
60   52.9%

50  
40   26.7%
30  
20   8.3%
10  
0  
         July  07-­‐            July  08-­‐            July  07-­‐            July  08-­‐  
June  08   April  09   June  08   April  09  
Open EVAR

Case  3   Epidemiology  
•  66yo  man  presents  with  bilateral  lower  
extremity  calf  cramping  with  walking  600k   •  11.6%  US  populaTon  >60  (5  million  people)  
–  ABI  <0.9  
•  PMH:    DM,  afib,  HTN,  CAD,  LLE  DVT  
–  29.6%  symptomaTc  (at  least  calf  claudicaTon)  
•  PSH:    s/p  R  SFA  stent  ‘99    
–  7%  age  60-­‐69  to  23%  age>80  
•  All:    codeine-­‐>itching   •  19%  non-­‐Hispanic  black,    15.6%  Mexican-­‐
•  Meds:    ASA,  simvastaTn,  lisinopril,  meoormin,   American  
glyburide   •  Risk  factors:    +TOB,  HTN,  DM,  CRI,  moderate-­‐
•  SH:    +TOB  (1.5-­‐2ppd  x  45y)   high  level  of  CRP  

Ostchega et al, J Am Geriatr Soc. 2007;55:583-9

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Physical  Exam   Intermiqent  ClaudicaTon  

•  Complete  pulse  exam:  
•  Muscular  ache  or  cramp  
–  Abdomen:    AAA?  
with  walking  
–  Femoral,  popliteal,  pedal  pulses  
•  Major  muscle  group  
–  Findings  consistent  with  chronic  ischemia?   below  occlusion  (calf,  
thigh,  buqock)  
•  Relieved  by  a  brief  period  
of  standing  rest  
•  Walk-­‐pain-­‐rest-­‐relief  cycle  
is  repeated  over  and  over  

Workup  
Intermiqent  ClaudicaTon   •  DiagnosTc  
–  Clinical  history  
1500  paTents  followed  longitudinally   –  Physical  exam  

5 years 10 years •  Confirmatory  

–  ABI:  ankle  brachial  index  (or  ankle  arm  index)  
–  Treadmill  ABI  if  resTng  ABI  normal  
Limb Survival 93% 88% –  Imaging,  only  for  planning  procedures  
•  Duplex  
•  CTA  
Patient Survival 73% 39% •  MRA  
•  Angiogram  

Ankle-­‐Brachial  Index  (ABI)  

false elevation due to vascular calcification (DM, CRF)

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Treatment:    Risk  Factor  ModificaTon   Exercise  Treatment  for  ClaudicaTon  

•  Smoking  CessaTon   •  Many  studies  

have  shown  
•  DM  control:  HgbA1c  <  7  
benefit  of  
•  Control  HTN:  SBP  <130,  DBP  <85     structured  
•  StaTn:  LDL  <  70,  HDL  >  45,  TG  <  200   exercise  in  
paTent  with  
•  BMI  <  25,  waist  <  40  inches   mild-­‐moderate  
•  ASA  for  CAD,  stroke  prevenTon   claudicaTon  

Case  3  ConTnued  
Drug  Therapy  
•  Pentoxifylline  (Trental)   •  PaTent  followed  in  clinic  for  10  years  with  
–  Early  controlled  trials  showed  improvement   intermiqent  claudicaTon  
in  walking  distance,  but  more  recent  studies   •  Now  presents  with  5th  toe  ulcer  draining  pus  
show  quesTonable  benefit  
•  Cilostazol  (Pletal)  
–  Phosphodiesterase  inhibitor  
–  Improves  walking  distance  and  QOL  
•  Expensive,  marginal  benefit  

CriTcal  Limb  Ischemia   Management  

•  Rest  pain   •  Risk  factor  modificaTon  

•  Tissue  loss   •  RevascularizaTon  if  possible  
– Endovascular  (angioplasty/
stenTng)  
– Open  (bypass)  
•  AmputaTon  if  necessary  
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Case  4   Epidemiology  
•  57yo  man  present  with  L  great  toe  gangrene  
•  PMH:    DM,  HTN,  HCV  
•  15%  lifeTme  risk  of  foot  ulcer  
•  PSH:    R  BKA   •  57,000  amputaTons/year  
•  NKDA   – Leading  cause  of  nontraumaTc  amputaTons  
•  Meds:    ASA,  Meoormin,  glyburide,  HCTZ   •  50-­‐80%  all  amputaTons  are  diabetes  
•  SH:    qTOB   related  
•  USA  Annual  cost  $5  billion  

Physical  Exam   Workup  

•  Neuropathy  
•  SympatheTc  dysfuncTon  
•  Intrinsic  muscle  atrophy  
– Hammertoes  
– Claw  toes  
•  Peripheral  vascular  diseae  
       ULCERATION  

OsteomyeliTs   Management  

•  Probe  to  bone  test   •  DiabeTc  foot  care  instrucTon  

•  Plain  X-­‐ray   •  Pressure-­‐relief/off-­‐loading  
•  MRI   •  RevascularizaTon  if  necessary  
•  Debridement/local  wound  care  
•  Bone  scan  
•  AmputaTon  if  necessary  
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Case  5   CaroTd  Pathophysiology  

•  76yo  man  undergoing  preoperaTve  workup   •  Symptoms  are  secondary  to  
for  CABG  s/p  NSTEMI  noted  to  have  high   emboli  from  ruptured  plaque,  not  
grade  R  ICA  stenosis   reduced  flow  
•  Focal,  hemispheric  neurologic  
•  PMH:    afib,  HTN,  HLD,  OSA,  Parkinson’s,  BPH   deficits  
•  PSH:    none  
•  NKDA  
•  Meds:    Carbidopa/Levodopa,  lisinopril,  
simvastaTn,  ASA  
•  SH:    qTOB  25  years  ago  (25pkyrs)  

Epidemiology   Diagnosis  

•  Hemodynamically  significant  caroTd  

stenosis  
– 0.5%  age  50-­‐60,  10%  age  >80  
•  ~600,000  CVA/year  in  US  
– 30%  from  caroTd  disease   Duplex Scan

MRA
Angio

AsymptomaTc  PaTents   Case  3  ConTnued  

•  Good  risk  paTents  with  >  80%  stenosis   •  POD  #4-­‐5  from  CABG,  paTent  complains  of  
several  episodes  of  transient  right  eye  vision  
•  11%  vs  5  %  5-­‐year  stroke  rate  
loss  
•  Not  for:  
•  MRI  Brain:  
– age  over  80  years  
– symptomaTc  coronary  artery  disease  
– severe  COPD  
– unfavorable  caroTd  anatomy    

ACAS. JAMA 1995; 273:1421-8

ACST. Lancet 2004;363:1491–1502
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Posterior  CirculaTon  Symptoms  

CaroTd,  Anterior  CirculaTon  Symptoms  
Decreased  Flow:  Both  CaroTds  and  Vert’s  
•  Focal,  hemispheric  neurologic  deficits  
–  Contralateral  numbness   •  Dizziness  
–  Contralateral  Weakness   •  Ataxia  
–  Aphasia   •  Diplopia  
•  Ipsilateral  amaurosis  fugax  (monocular   •  Bilateral  visual  loss  
blindness)   •  Crossed  deficits  
•  Transient  (TIA),  permanent  (CVA)   •  Cerebellar  symptoms  
•  Not:  dizziness,  lightheadedness,  headache,   •  Drop  aqacks  
blurred  vision,  and  syncope     •  Syncope  

SymptomaTc  Disease   CaroTd  Endarterectomy  

•  >  70%  stenosis:  intervenTon  
–  26%  vs  9%  2-­‐year  stroke  risk  
•  50  -­‐  70%  stenosis  
–  Surgery  if  symptomaTc  on  anTplatelet  agents  
–  22%  vs  17%  5-­‐year  stroke  risk  
•  <  50%  stenosis:    conTnue  neurologic  workup,  
anTplatelet  therapy,  angiography  if  symptoms  
persist  

NASCET. NEJM 1991;325:445-53

NASCET. NEJM 1998;339:1415-25

CaroTd  Artery  StenTng   Case  6  

•  56yo  man  with  recurrent  lek  calf  ulceraTon  
•  PMH:    Obesity,  LLE  DVT,  HTN,  CHF  
•  PSH:    CABG,  L  TKA  
•  NKDA  
•  Meds:    Lasix,  simvastaTn,  ASA,  metoprolol  
•  SH:    qTOB  (30  pkyrs)  
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Epidemiology   Physical  Exam  

•  5%  lifeTme  risk  venous  thromboembolism  
(VTE)   •  Check  peripheral  
pulses  
•  VTE  responsible  for  >600,000  hospital  
admissions  per  year   •  Moist  ulceraTon  
with  granulaTon  bed  
•  PE  is  3rd  most  common  cause  of  hospital  death  
•  Leg  edema  common  
•  >6  million  people  in  US  have  severe  symptoms  
from  chronic  venous  insufficiency   •  Other  signs  of  
— Skin  changes,  chronic  ulceraTon   venous  
hypertension/stasis  
•  >24  million  US  with  varicose  veins  

McLafferty et al. JVS. 2007;45:142-148

CEAP  ClassificaTon   Workup  

Grade   Descrip3on  
C  0     No  evidence  of  venous  disease.     •  Rule  out  concomitant  arterial  disease  
•  Advanced  imaging:  
C  1   Superficial  spider  veins  (reTcular  veins)  
–  Reflux  venous  duplex  
only  
C  2   Simple  varicose  veins  only    
C3   Ankle  edema  of  venous  origin  (not  foot  
edema)    
C  4   Skin  pigmentaTon  in  the  gaiter  area  
(lipodermatosclerosis)    
C  5   A  healed  venous  ulcer    
C  6   An  open  venous  ulcer  

Management   Case  7  
•  Compression,  compression,  compression!   •  83yo  woman  presents  with  cold,  pulseless  lek  
•  Weight  loss   foot  
•  Local  wound  care   •  PMH:    afib,  HTN,  HL  
•  Treatment  of  contribuTng  refluxing  veins   •  PSH:    none  
–  Sclerotherapy   •  NKDA  
–  Radiofrequency  or  Laser  ablaTon   •  Meds:    HCTZ,  ASA,  simvastaTn  
–  Stripping   •  SH:    no  TOB  
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Epidemiology   Physical  Exam  –  6  P’s  

•  Incidence  ~14/100,000   •  Pulselessness  
•  30-­‐day  amputaTon  rate:    10-­‐30%   •  Pain  
•  30-­‐day  mortality  rate:    15%   •  Pallor  
•  Thrombosis  vs  Embolism  
•  Poikilothermia  
•  Paresthesias  
•  Paralysis   Impending limb loss!!!

Rutherford  SVS  Acute  Limb  

Acute  Ischemia  
Ischemia  ClassificaTon  
•  Emboli:  Cardiac,  atheroscleroTc  plaque  
Category    DescripTon    Neuromuscular  Findings    Doppler    
•  Thrombosis  of  exisTng  plaque    I    Viable    No  sensory  or  muscle    Audible  arterial  
•  Severity      weakness  &  venous    
 IIa    Threatened    Minimal  Oken  inaudible  
–  Level  of  occlusion  
   (marginally)      arterial,  audible  
–  Collateral  development        venous    
–  Venous  and  sok  Tssue  injury    IIb    Threatened    Mild  to  moderate    Usually  inaud.    
–  InfecTon        (immediately)    assoc  with  pain    arterial,  audible  
–  Temperature        venous      
 III    Irreversible    Profound  deficit    No  signals  

Acute  Ischemia  
Workup  
•  Expedited  for  Rutherford  class  IIa,  IIb  
•  Advanced  imaging  if  Tme  permits  
–  Duplex  
–  MRA  
–  CTA  
–  Angio  
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Management   Other  CondiTons  Treated  by  

Vascular  Surgeons  
•  AnTcoagulaTon  
•  Complicated  type  B  dissecTon  
•  Thrombolysis  
•  Descending  thoracic  aorTc  aneurysms  
–  Rutherford  Class  I,  IIa,  ?IIb  
•  Thoracoabdominal  aneurysms  
•  Thrombectomy/Open  Revision  
•  Acute/chronic  visceral  ischemia  
–  Rutherford  Class  IIb  
–  Fasciotomies  if  necessary   •  Renal  artery  stenosis  
•  AmputaTon   •  Dialysis  access  
–  Rutherford  Class  III   •  Upper  extremity  occlusive  disease  

Vascular  Surgery  at  UW  

•  Training  5/2  +  0/5  
•  Ben  Starnes,  MD,  Division  Chief,  
starnes@uw.edu    
•  Ted  Kohler,  MD      kohler@uw.edu    
•  Gale  Tang,  MD      gtang@uw.edu