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Common Vascular Pathologies
When to refer to a vascular surgeon?
Ronnie Word, MD, RPVILee Health Vascular Surgery
Vascular Surgery / Medicine
Provide diagnosis and treatment including medical, surgical, or
endovascular therapy for all venous and arterial
pathologies.
Provide surveillance and follow up to arterial and
venous insufficiency.
Arterial PathologiesØ Carotid disease
Ø Aneurysm
Abdominal aorta
Thoracic aorta
Any other arteries popliteal, carotid, etc.
Ø Peripheral arterial disease lower extremity claudication
lower extremity wounds
diabetic foot
Ø Hemodialysis access
Ø Renovascular disease
Ø Mesenteric vascular disease
Ø No intracerebral vascular pathology
Ø No heart pathology
Ø No ascending aortic problems
Venous Pathologies
Varicose veins
Venous ulcers
Help with management of DVT
IVC filters
Carotid artery disease
Carotid Disease
Ø Stroke is the third leading cause of death in the USA
Ø 80% of all strokes are ischemic
Ø 20% of all strokes are hemorrhagic
Ø Over 50% carotid stenosis is found in 12%-20% of all anterior circulation strokes
Ø Only 15%-20% of strokes victims have a warning TIA
(Aboott, Internal J. Stroke, 2007)
Symptomatic Carotid
Common symptoms:
Ø Contralateral weakness (face, arm or leg)
Ø Contralateral sensory deficit / paresthesia (face, arm or leg)
Ø Amaurosis fugaxØ Aphasia
Symptoms not typically associated with carotid stenosis
Ø VertigoØ DizzinessØ DiplopiaØ AtaxiaØ Decreased consciousnessØ Overall weaknessØ Syncope
Carotid Screening
Stroke association / AHA stroke council
Ø Do not recommend carotid ultrasound screening for the general population
Ø Highly selected patients may benefit
(Goldstein, Stroke, 2006)
High Risk Population
Ø Age > 65 yearsØ History of
hypertension Ø CADØ Tobacco abuseØ History of strokeØ History of PADØ History of neck
radiation Ø Carotid bruit
Carotid bruit….What is the significance?
Ø 500 patients with asymptomatic neck bruits
Ø Carotid duplex revealed only 1.2% of severe (>70%) carotid stenosis
Ø Selected high risk patients with carotid bruit 25% had > 60% carotid stenosis
Ø Screening only probably in high risk patients
(Zhucz, Stroke, 1990)
Risk of stroke for
asymptomatic patients with
carotid stenosis
Ø European carotid surgery triallist (ECST)
Ø ECST study of 2295 patients
Ø < 2% annual stroke risk with < 70% carotid stenosis
Ø 14.4% stroke risk with 80 - 99% stenosis (Lancet, 1995)
When should I obtain imaging of the carotidWhich patients should have imaging carotid bifurcation (Duplex ultrasound)?
Ø Symptomatic TIA, amaurosis fugax
Ø Evidence of retinal artery embolization (hollenhorst plaque)
Ø Patients without neurologic symptoms
Consider in
1) Patients with clinical significant PVD
2) 65 year old or older with CAD
3) Tobacco use
4) Diabetes
5) Hypercholesterolemia
6) Stroke history
7) Carotid bruits
What imaging modality should I
choose for carotid
evaluation?
Imaging modalities available for evaluation
Ø Carotid duplex ultrasound
Ø CTAØ MRAØ Subtraction
angiography
Carotid Duplex UltrasoundØ Gold standardØ Non-invasiveØ Technician dependent (accredited vascular lab)
Ultrasound B mode
Duplex ultrasound
Duplex ultrasound consensus criteria for
stenosis
Ø PSV of ICA > 125 cm / second > 50% stenosis
Ø PSV of ICA > 230 cm / second > 70% stenosis
(Grant, Ultrasound Q, 2003)
MRAØ Tendency to
overestimate the degree of stenosis
Ø Very high grade stenosis may result in a loss of signal on MRA
CTA
Ø Pooled sensitivity 85% and specificity 93%
Ø Large calcium burden limits visibility and accurate evaluation
Ø IV contrast (careful with CKD)
CTA
CTA
Carotid disease
Ø First Medical optimization
Control risk factorsØ HTNØ DiabetesØ LipidsØ Antiplatelet therapyØ Statins
Carotid disease
When should I refer to a vascular surgeon?
Ø Symptomatic patients Hospital
Ø Asymptomatic patients• Carotid stenosis with over 70% stenosis• Consider refer patient with > 50% stenosis if
you want us to start surveillance
Carotid interventions,
WHEN?
Ø Neurologically asymptomatic patients with > 70% internal carotid stenosis if life expectancy is expected over 3-5 years and perioperative stroke death < 3%
Ø Neurologically symptomatic patients with > 50% internal carotid artery stenosis
(Ricotta, JVS, 2001)
Carotid Interventions
Ø
Ø
Ø
TCAR
Peripheral Vascular Disease (PVD)
Anatomy
•Upper extremity•Lower extremity
Pathology
•Claudication •Limb threatening
ischemia
Peripheral vascular disease affects the blood vessels outside the heart where plaques build up inside the lumen of the vessels obstructing the
arteries (atherosclerosis)
Peripheral Vascular Disease (PVD)
Scope of problemØ 8 – 12 millions of Americans are
affected by PVD
Ø Prevalence of 14.5% patients aged > 65 years
Ø Relative in PAD prevalence of 23.5% worldwide
Ø US Medicare program spent 4.3 billions in 2001
(Selvin, Circulation, 2004)
PVD RISK
FACTORS
Ø SmokingØ DiabetesØ Hypertension Ø Renal
insufficiencyØ AgeØ Male genderØ Hyperlipidemia
PVD ( lower extremity)
Clinical presentation ØAsymptomaticØIntermittent claudication ØCLI ( critical limb ischemia)
➢Rest pain ➢Ischemic ulcer
IntermittentClaudication
Reproducible discomfort in a specific muscle group that is induced by exercise and relieved by rest.
Ø Cramping / aching discomfort at calf muscle
Ø Quickly relieved by restØ No effect on position
Differential Diagnosis
Ø Neurogenic claudication
Ø Hip arthritisØ Venous
claudication Ø Spinal stenosisØ Foot / ankle
arthritis
Neurogenic Claudication (nerve root
compression)
Ø Pain radiates down the leg
Ø Sharp, lacerating pain (electric shocks)
Ø Induced by sitting, walking or standing
Ø Improved by changing positions
Spinal Stenosis
Ø Often bilateral buttocks /posterior leg
Ø Often pain present with weakness
Ø Relief by lumbar spine flexion
Ø Worse with standing and spine extension
Hip Arthritis
Ø Lateral hip and thigh pain
Ø Symptoms after variable degree of exercise
Ø Improved when not weigh bearing
Ø Not relieved quickly
Natural history of patients with claudication
5 year outcomes
Limb morbidity CV morbidity
Stable claudication 70%-80%
Worsening claudication20%-30%
CLI1%-5%
MI or stable20%
Mortality10%-15%
Screening for PVD
SVS recommends against routine screening for PAD in absence of risk factors, history or symptoms
(Conte, Journal of Vascular Surgery, 2015)
Screening for PVD
SVS suggests screening for patients with several risk factors (Diabetes, smoking, age, CAD) and those with
abnormal pulse examination
(Conte, Journal of Vascular Surgery, 2015)
Screening for PVD
SVS suggests that screening for PAD is reasonable if used to
improve risk stratification,
preventive care and medical management
(Conte, Journal of Vascular Surgery, 2015)
PAD + leg / foot wound =CLI
(critical limb ischemia)
Chronic CLI
Leg ulcer or ischemic foot pain for > 2 wks
ABI < 0.4
Ankle pressure < 50 mmHg
Arterial ulcer
Peripheral Vascular Disease (PVD)
Test of choice to diagnose PVDØPhysical examØAnkle – brachial index (ABI)ØWhere? Vascular laboratoryØShould I get CT scans, MRI? NO
Vascular lab
Ankle –brachial index
Peripheral Vascular Disease (PVD)
Management of PVD (SVS recommendations)Ø Recommend antiplatelet therapy (ASD 75 – 325 mg)Ø Suggest 3 month trial of Cilostazol (patients without
CHF)Ø Recommend smoking cessation Ø Optimizing diabetes controlØ Exercise program 30 minutes of walking 5 times a
week
(Conte, Journal of Vascular Surgery, 2015)
Peripheral Vascular Disease (PVD)When to refer patients with lower extremity PVD
Ø All patients with limb threatening symptoms (all lower extremity wounds without palpable pedal pulses –VASCULAR SURGEON FIRST)
Ø Severe intermittent claudication
Ø Unclear leg pain …. Obtain ABI first.
Ø All patients needing a work up evaluation
Peripheral Vascular Disease (PVD)
Recommendations for vascular intervention
All patients with limb threatening ischemia (CLI)
IC patients only with lifestyle limiting disability when pharmacologic or exercise therapy have failed.
Peripheral Vascular Disease (PVD)Upper extremity PVDØ Most common pathology: Subclavian artery stenosis
Ø Usually asymptomaticØ Symptoms Arm claudication
Subclavian steal
When to referØ Only symptomatic patientsØ If previous coronary bypass and angina
Ø Varicose veins
Ø Spider veins
Ø Leg swelling
Ø Leg ulcers
Chronic Venous
Insufficiency(CVI)
Chronic venous insufficiency (CVI)
Condition that occurs when the venous valves or wall of the leg veins are not working effectively causing reflux and
blood pooling in the legs
Varicose VeinsScope of the problemØPrevalence of varicose veins between 20-
30%
Ø20 million women and 11 million menages 40 to 80 have varicose veins in the USA
ØActive venous ulcers 0.5% population
(O’Donnel, et al., Journal of Vascular Surgery, 2014)
Anatomy of the Leg Venous SystemTibial
Ø Deep venous system PoplitealFemoral
Ø Superficial venous system GSVSSV
Ø Iliac veins
Ø Perforators
Risk factors to develop CVIØ Age over 50Ø Female sexØ Family history of varicose veinsØ PregnancyØ Episode of deep venous thrombosis
(DVT)Ø Extended periods of standing or
sittingØ Obesity and inactivity
PATHOPHYSIOLOGY OFCHRONIC VENOUS INSUFFICIENCYØ Primary reflux deep – only 8%
superficial perforator
Ø Secondary reflux post DVT (common in deep system)
Ø Obstruction residual thrombus is replaced and fibrous tissue valve damage
Ø Mixed etiology obstruction / reflux
CVI Manifestations
C1 Spider veins
C2 Varicose veins C3 Edema
C4 Chronic skin
changes
C5 Healed venous ulcer
C6 Active venous ulcer
Spider veins TelangiectasiasReticular veins
No underlying pathologyØNo need for further work upØCosmetic
Spider veins
Varicose veinsDilated subcutaneous veins that are > 3 mm in
diameter measured in the upright position
Varicose VeinsPathology of venous insufficiencyØ Primary versus secondary
Ø 70-80% of varicose veins originate of primary venous insufficiency
Ø 40% of advance chronic venous insufficiency (venous ulcers) pathology is isolated saphenous vein reflux
Varicose Veins
Varicose veins symptomsØAchingØHeavy legs and tirednessØThrobbingØItchingØMuscle crampsØSwelling
DIAGNOSIS
Gold standard Duplex Ultrasound
Society of vascular surgery recommends all patients with advance CVI (C2-C6) must
have a diagnostic work up (Duplex))
Duplex Evaluation Reflux or obstruction Deep veins
Superficial (GSV, SSV) Perforator veins
DUPLEX ULTRASOUND
Venous reflux defined by reversal flow of > 0.5 seconds in leg veins
Edema
More often multifactorial (CHF, CKD, obesity, inactivity, leg dependency)
Be suspicious of non venous etiology if no history of DVT or varicose veins
Severe leg swelling without venous stasis changes ………… think other causes.
Venous stasis
Leg venous ulcers
Varicose Veins/CVI
Medical therapy
Ø Compression therapy (20-30 mmHg) knee high (not recommended as the primary treatment modality)
Ø Venoactive drugs (Diosmin, purified flavonoid fraction –not available)
Ø Exercise
Varicose Veins
When to refer to vascular surgery officeØAny patient with spider / varicose veins that
desires treatmentØAll symptomatic patientsØAll patients with advance venous
insufficiency C4 - C6ØVenous ulcers word of caution with
wound healing centers
Varicose Veins
Endovenous thermal ablation
Sclerotherapy
Phlebectomies
Iliac venogram / stenting?
Stripping
What to expect for therapy
Aortic AneurysmsDefinition: Aorta > 3 cms
Types1. Thoracic aorta Ascending
Descending
2. Abdominal aorta3. Thoracoabdominal aneurysm4. Iliac aneurysm
Aortic AneurysmsØ Symptoms
• Usually none• Abdominal /
back pain• Embolization
Ø Diagnosis• Abdominal
ultrasound• CT scan
Abdominal ultrasoundØ Gold standard for initial diagnosisØ Non invasive Ø Accuracy as good as CT scan Ø Limitations in severe obesity
CTAØ Gold standard prior to surgeryØ Axial cuts should be 2 mm cuts Ø Best study if rupture suspectedØ Limitations in CKD
Aortic AneurysmsØScreening recommendations (SVS)
ØU/S for all men > 65 y/o
ØU/S for men > 55 y/o with a positive family history
ØU/S for women > 65 y/o with history of smoking with a positive family history
(Chaikof, Journal of Vascular Surgery, 2017)
Recommendations for Aneurysms Surveillance
AAA 3.0 to 3.9 cm u/s every 3 years
AAA 4.0 to 4.9 cm u/s every 12 months
AAA 5.0 to 5.4 cmu/s every 6 months
(Chaikof, Society of Vascular Surgery, 2017)
Aortic Aneurysms
Who do I need to refer to a vascular surgeon?
Ø Any thoracic / abdominal aortic aneurysm > 5 cms
Ø Any iliac artery aneurysm > 2.5 cms
Ø Any patient that desires further discussion and easy access to regular surveillance
Aneurysm RepairØ Thoracic Endovascular with stent graft
Ø Abdominal aorta Endovascular repair (EVAR)
Open traditional repair
Ø Endovascular repairMinimally invasive
- Percutaneous approach- Local anesthesia- 24 hours hospital stay
What about other aortic pathologies?
Aortic dissection
Aortic penetrating ulcer
Aortic stenosis
Mural thrombus in presence of an aneurysm (no concern)
What about other
aneurysms?
Popliteal artery aneurysms
Carotid artery aneurysms (not in brain)
Visceral and renal artery aneurysms
Questions?