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Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities CURTIS W

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Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities CURTIS W C.Atherosclerotic W. Bakal and Disease J. Cynamon of the Aorta, Pelvis, and Lower Extremities 20 ■■■ Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities CURTIS W. BAKAL and JACOB CYNAMON Diagnostic arteriography for atherosclerotic disease of liteal bypass grafts, if vein is available, most vascular sur- the aorta, pelvis, and lower extremities is performed af- geons will use it, especially if the graft has to cross the ter the decision to treat has been made. Clinical history knee joint; otherwise, PTFE is used (surgical bypasses and noninvasive studies that precede the angiogram al- are usually named by their proximal and distal anasto- most always can make the diagnosis of chronic moses; see Table 20-1.) atherosclerotic occlusive disease and often will be able to define the levels at which critical stenoses occur. The purpose of the angiogram is to define specifically the ■ anatomy to plan interventional or surgical therapy. Mul- Chronic Occlusive Disease tiple views are often necessary to define the anatomy clearly (Fig. 20-1). Thus, a thorough knowledge of po- Arteriosclerosis obliterans tential available therapies is important to obtain an ade- Arteriosclerosis is a chronic disease that is progressive quate study. and usually symmetric. Patients present with gradual on- Traditional vascular surgical techniques require that set or worsening of symptoms. Most patients with arterio- three things be defined. The first is the status of the sclerosis obliterans present with claudication. Risk factors “inflow,” that is, the arteries upstream of the target le- for arteriosclerosis obliterans include advanced age, hy- sion. (Because atheroocclusive disease is almost always pertension, smoking, diabetes, hypercholesterolemia, infrarenal, the infrarenal aorta and the common iliac hypertriglyceridemia, and male sex. In the United States, and external iliac arteries serve as the inflow for the the most commonly accepted categorization of chronic infrainguinal arteries, as an example.) The second is the limb ischemia is the Rutherford Criteria, which is listed status of the “outflow,” the vascular segment or segments in Table 20-2.1 downstream of the occlusive lesion. (For example, for popliteal occlusion at Hunter’s canal, the outflow is the Rutherford criteria popliteal artery and trifurcation vessels.) These two ves- sel sets define where the proximal anastomosis and distal Category 0 anastomosis of a bypass graft are placed. The third pa- Asymptomatic patients in this category include those with rameter is the type of conduit, for example, autologous occlusive disease and congenital variants. The dorsal vein versus polytetrafluoroethylene (PTFE). Synthetic pedal pulse can be absent in about 12% of patients, conduits are used exclusively in the aortoiliac distribu- although the posterior tibial pulse is rarely absent in tion, whereas an autologous vein is much preferred for normal patients. Asymmetric pulse decrement alone is bypass to the tibial and pedal vessels. For femoropop- not an indication for intervention in chronic disease. 211 212 C. W. Bakal and J. Cynamon A–C FIGURE 20-1. (A). An arteriogram was performed to evaluate a failing left common femoral to peroneal artery vein graft. The proximal portion of the graft is not seen secondary to the overlapping superficial femoral artery (arrow). (B). An oblique view demonstrates severe narrowing of the proximal portion of the vein graft (straight arrow). The superficial femoral artery (arrowhead) is seen better; the left deep femoral artery is visualized (curved arrow). (C). After balloon angioplasty of the proximal graft, flow and lumenal patency (arrow) are improved. Categories 1–3 and with normal peripheral pulses. Claudication and Patients with intermittent claudication usually have single- pseudoclaudication can coexist. The prevalence of inter- segment stenosis or occlusion (80% of cases). In these pa- mittent claudication increases with age and is present in tients, the level of claudication usually develops distal to 3% of the population under 60 years of age and in 20% of the level of stenosis. Claudication is a reproducible pain or the population older than 75 years of age. It is relatively soreness brought on by a defined amount of exercise and stable in 60% of patients, with 15% actually improving relieved by rest. (The term is derived from (Latin “to with conservative therapy such as exercise and cessation of limp,” after the Roman Emperor Claudius, who limped smoking. Twenty-five percent of claudicators progress to across Europe as his armies conquered the continent). critical ischemia. Amputation is done in only 5 to 6% of pa- These patients usually should be treated conservatively. tients within 10 years of presentation of peripheral vascu- Claudication must be differentiated from pseudoclaudica- lar disease (PVD); the amputation rate is higher in smok- tion caused by spinal stenosis. Pseudoclaudication pre- ers and diabetics. Intervention should be reserved for sents with variable onset relieved by a change in position patients with debilitating or lifestyle-limiting claudication TABLE 20-1. Typical Surgical Procedures Operation Indication Aortoaortic bypass Abdominal aortic aneurysm, without iliac extension Aortoiliac bypass Abdominal aortic aneurysm extending to common iliac arteries Aorto bifemoral bypass Aortoiliac occlusive disease involving both iliac arteries Femoral–femoral bypass Unilateral severe iliac disease ipsilateral to symptoms; needs intact donor iliac artery contralateral (“cross-femoral” bypass) to symptomatic side Axillofemoral bypass Used in high-risk patients with bilateral severe iliac disease; generally, axillary artery to femoral artery bypass (ipsilateral side), combined with cross-femoral bypass Femoropopliteal bypass Long-segment superficial femoral artery stenosis/occlusion; typically, common femoral artery serves as proximal anastomosis Femorotibial bypass Combined superficial femoral and popliteal artery stenosis/occlusion; (“fem-distal” bypass) occlusive disease frequently extends into proximal/midtibial arteries Profundaplasty Surgical revision of focal profunda femoris origin stenosis; often done in conjunction with femoropopliteal bypass Iliac endarterectomy Rarely used Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities 213 TABLE 20-2. Clinical Categories of Chronic Limb Ischemia Grade Category Clinical Description Objective Criteria 0 0 Asymptomatic: no hemodynamically Normal treadmill or reactive hyperemia testb significant occlusive disease 1 Mild claudication Completes treadmill exercise, AP after exercise Ͼ 50 mm Hg but at least 20 mm Hg lower than resting value I 2 Moderate claudication Between categories 1 and 3 II 3 Severe claudication Cannot complete standard treadmill exercise and AP after exercise Ͻ 50 mm Hg IIa 4 Ischemic rest pain Resting AP Ͻ 40 mm Hg, flat or barely pulsatile ankle or metatarsal PVR; TP Ͻ 30 mm Hg IIIa 5 Minor tissue loss: nonhealing ulcer, Resting AP Ͻ 60 mm Hg, ankle or metatarsal focal gangrene with diffuse pedal PVR flat or barely pulsatile; TP Ͻ 40 mm Hg ischemia 6 Major tissue loss extending above Same as category 5 TM level, functional foot no longer salvageable AP, ankle pressure; PVR, pulse volume recording; TP, toe pressure; TM, transmetatarsal. aGrades II and III, categories 4, 5, and 6, are embraced by the term chronic critical ischemia. bFive minutes at 3 mph on 12% incline. From Rutherford RB, Baker JD, Ernest C, et al. Recommended Standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26:517–538. With permission. and for patients with critical ischemia. It is important to re- serve as much of the lower limb as possible because member that claudication is a marker for coronary artery amputation sites may not heal in the face of vascular disease, which is prevalent in nearly all PVD patients. insufficiency. Categories 4–6 Angiographic findings Patients with critical ischemia have a threatened extrem- Atherosclerotic plaque is usually irregular and eccentric ity that requires intervention. Diagnostic studies such but may also be smooth and concentric (Fig. 20-2). as angiography should be performed to plan treatment. Plaques may be ulcerated. Rarely, they are weblike. Col- Percutaneous and surgical interventions generally are lateral development is the hallmark of chronic arterial directed at restoring continuous or “straight-line” flow occlusive disease, developing over time (weeks to to the foot. The purpose of such intervention is to main- months) (Fig. 20-3). Collateral arteries can partially com- tain a functional foot and allow ambulation. Critically pensate for occlusion of major vessels. Acute occlusion of ischemic patients usually have multilevel occlusive dis- normal vessels generally yields rapid, profound, limb- ease. Symptoms from perfusion deficit develop in the threatening ischemia. This typically occurs with trauma end organ, that is, the skin of the foot. Ischemic rest or arterial emboli in young patients. In patients with pain (category 4) usually develops in the forefoot be- underlying occlusive disease, chronic collaterals may re- cause resting-limb blood flow is insufficient to meet ba- duce the effect of an acute occlusion. (Fig. 20-4). sal metabolic demand, causing pain in the cutaneous PVD can occur in focal and diffuse patterns. A critical nerves. It is often nocturnal, aggravated by elevation and stenosis can undergo in situ thrombosis and convert to relieved by dependency. Dependent
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