LowerLower ExtremityExtremity VascularVascular DiseaseDisease LowerLower ExtremityExtremity VascularVascular DiseaseDisease „ PoplitealPopliteal arteryartery „ FibrodysplasiaFibrodysplasia entrapmententrapment „ PseudoxanthomaPseudoxanthoma „ MucinousMucinous cysticcystic elasticumelasticum degenerationdegeneration „ PersistentPersistent sciaticsciatic arteryartery „ Buerger'sBuerger's diseasedisease „ IliacIliac arteryartery syndromesyndrome ofof „ AbdominalAbdominal aorticaortic cyclistcyclist coarctationcoarctation „ PrimaryPrimary arterialarterial tumorstumors „ EmboliEmboli AtherosclerosisAtherosclerosis LowerLower ExtremityExtremity VascularVascular DiseaseDisease

„„ClaudicationClaudication

„„CriticalCritical LimbLimb IschemiaIschemia ClaudicationClaudication

„ ““Doc,Doc, mymy legslegs hurt.hurt.”” „ ClaudereClaudere -- ““toto limp.limp.”” „ Transient,Transient, exerciseexercise inducedinduced ischemicischemic myalgiamyalgia „ TheThe localitylocality ofof painpain usuallyusually correlatescorrelates withwith thethe locationlocation ofof thethe occlusion.occlusion. IntermittentIntermittent ClaudicationClaudication

„ 13%13% ofof patientspatients overover 5050 havehave abnormalabnormal ABIABI - Partner’s Program. Vasc Med 2001 „ ABIABI rangingranging fromfrom 0.50.5 toto 0.950.95 „ RelativelyRelatively fewfew patientspatients whowho presentpresent withwith claudicationclaudication everever requirerequire revascularizationrevascularization toto preventprevent limblimb loss.loss. „ AmputationAmputation raterate ofof 1%1% toto 7%7% atat 55 toto 1010 yearsyears „ RevascularizationsRevascularizations totaledtotaled lessless thanthan 20%20% atat 1010 years.years. IntermittentIntermittent ClaudicationClaudication

„ InterventionIntervention controversialcontroversial „ 233233 consecutiveconsecutive patientspatients (90%(90% endovascular)endovascular) „ MeanMean followfollow--upup ofof almostalmost 77 yearsyears „ PrimaryPrimary patencypatency atat 55 yearsyears waswas 27%27% „ 50%50% secondarysecondary interventionsinterventions „ 12%12% ofof limbslimbs ultimatelyultimately developeddeveloped CLICLI

Jamsen et al. J Vasc Surg 2003 ProsPros andand ConsCons

„ BenignBenign naturalnatural historyhistory „ DiminishedDiminished qualityquality ofof „ GraftGraft failurefailure andand lifelife potentialpotential limblimb threatthreat „ InabilityInability toto rehabrehab „ M&MM&M ofof revascularizationrevascularization SmokingSmoking

„ 8%8% ofof patientspatients whowho diddid notnot smokesmoke oror quitquit smokingsmoking withinwithin 11 yearyear ofof diagnosisdiagnosis ofof PADPAD developeddeveloped restrest painpain „ 21%21% whowho smokedsmoked oror quitquit moremore thanthan 11 yearyear afterafter diagnosisdiagnosis „ DiabetesDiabetes alsoalso hashas beenbeen associatedassociated withwith increasedincreased developmentdevelopment ofof CLICLI CriticalCritical LimbLimb IschemiaIschemia

„ InadequateInadequate arterialarterial bloodblood flowflow toto accommodateaccommodate thethe metabolicmetabolic needsneeds ofof restingresting tissue.tissue. „ RestRest painpain oror pedalpedal necrosisnecrosis „ RiskRisk factorsfactors includeinclude age,age, smoking,smoking, andand diabetesdiabetes CriticalCritical LimbLimb IschemiaIschemia

„ AnkleAnkle pressurepressure lessless thanthan 5050 toto 7070 mmmm HgHg

„ ToeToe pressurepressure lessless thanthan 3030 toto 5050 mmmm HgHg

„ TranscutaneousTranscutaneous partialpartial pressurepressure ofof oxygenoxygen atat thethe footfoot lessless thanthan 3030 toto 5050 mmmm HgHg RestRest painpain

„ BurningBurning dysesthesiadysesthesia ofof thethe foot.foot. „ AggravatedAggravated byby elevationelevation andand relievedrelieved withwith dependencydependency „ IncreaseIncrease inin arterialarterial pressurepressure fromfrom gravitygravity „ NonfunctioningNonfunctioning venoarteriolarvenoarteriolar reflexreflex TissueTissue LossLoss

„ IschemicIschemic ulcerationsulcerations oror gangrenegangrene „ SpontaneousSpontaneous „ AfterAfter minorminor traumatrauma oror surgicalsurgical incisionsincisions CriticalCritical LimbLimb IschemiaIschemia

„ EstimatedEstimated 500,000500,000 toto 11 millionmillion newnew casescases perper yearyear „ CLICLI progressesprogresses directlydirectly fromfrom FontaineFontaine II toto stagestage IIIIII oror IVIV „ 50%50% ofof patientspatients werewere asymptomaticasymptomatic 66 monthsmonths beforebefore majormajor amputationamputation forfor CLICLI - Dormandy. Br J Surg 1994 „ CoCo--morbiditiesmorbidities maskmask symptomssymptoms ofof claudicationclaudication.. CriticalCritical LimbLimb IschemiaIschemia

„ Major risk factors - age, smoking, and diabetes. „ The incidence of major amputation increases with age. „ Smoking:PAD > Smoking: CAD „ Major amputation is 10 times more frequent in diabetic patients „ Diabetic smokers need amputation earlier in life than nondiabetic smokers EvaluationEvaluation RelevantRelevant HistoryHistory

„ ElapsedElapsed timetime afterafter exerciseexercise isis stoppedstopped beforebefore thethe painpain isis relievedrelieved „ TypeType ofof restrest oror positionposition ofof patientpatient (standing(standing atat rest,rest, sitting,sitting, lying)lying) necessarynecessary toto relieverelieve thethe painpain „ WhetherWhether thethe painpain returnsreturns afterafter thethe samesame timetime andand distancedistance ifif exerciseexercise isis thenthen resumedresumed

TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 31(Pt 2):S56, 2000 RelevantRelevant HistoryHistory

„ LocationLocation ofof thethe painpain oror discomfortdiscomfort „ DurationDuration ofof thethe symptomsymptom „ WhetherWhether itit worsensworsens oror improvesimproves withwith timetime andand whetherwhether conservativeconservative therapytherapy hashas hadhad anan effecteffect „ DistanceDistance thethe patientpatient cancan nownow walkwalk beforebefore (1)(1) experiencingexperiencing thethe discomfortdiscomfort andand (2)(2) beingbeing forcedforced toto stopstop

TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 31(Pt 2):S56, 2000 SymptomSymptom PatternPattern

„ ClaudicationClaudication generallygenerally resultsresults fromfrom aa singlesingle levellevel ofof arterialarterial occlusionocclusion „ ThreeThree majormajor patternspatterns ofof arterialarterial obstructionobstruction 1)1) InflowInflow obstructionobstruction 2)2) OutflowOutflow obstructionobstruction 3)3) CombinationCombination „ LocationLocation ofof symptomssymptoms correlatescorrelates withwith levellevel ofof obstruction.obstruction. InflowInflow ObstructionObstruction

„ AorticAortic andand IliacIliac stenosisstenosis oror occlusion.occlusion. „ ButtockButtock andand thighthigh claudicationclaudication „ VasculogenicVasculogenic erectileerectile dysfunctiondysfunction „ MayMay exhibitexhibit classicclassic symptomssymptoms ofof intermittentintermittent calfcalf claudicationclaudication resultingresulting fromfrom inadequateinadequate perfusionperfusion ofof thethe entireentire legleg OutflowOutflow ObstructionObstruction „ SuperficialSuperficial femoralfemoral arteryartery stenosisstenosis oror occlusionocclusion isis thethe mostmost commoncommon lesionlesion associatedassociated withwith intermittentintermittent claudicationclaudication „ NoNo specificspecific thighthigh oror footfoot symptoms.symptoms. „ PoplitealPopliteal andand tibialtibial arterialarterial occlusionsocclusions areare associatedassociated moremore commonlycommonly withwith limblimb--threateningthreatening ischemiaischemia owingowing toto thethe paucitypaucity ofof collateralcollateral vascularvascular pathwayspathways beyondbeyond thesethese lesions.lesions. MultilevelMultilevel ObstructionObstruction

„ BroadBroad symptomssymptoms ofof intermittentintermittent claudicationclaudication affectingaffecting thethe buttock,buttock, hip,hip, thigh,thigh, andand calf.calf. „ CLICLI requiresrequires atat leastleast twotwo oror moremore levelslevels „ PatternPattern ofof occlusionocclusion isis usuallyusually inin adjacentadjacent vascularvascular beds,beds, butbut maymay bebe inin parallelparallel bedsbeds „ LimitLimit flowflow throughthrough thethe collateralcollateral bedsbeds RiskRisk FactorFactor AssesmentAssesment

„ HTNHTN –– riskrisk ofof ICIC 2.5x2.5x inin men,men, 3.9x3.9x inin womenwomen „ DiabetesDiabetes „ SmokingSmoking -- severityseverity ofof arterialarterial occlusiveocclusive diseasedisease proportionalproportional toto thethe numbernumber ofof cigarettescigarettes smokedsmoked „ EachEach additionaladditional riskrisk factorfactor independentlyindependently increasesincreases thethe riskrisk ofof developingdeveloping symptomaticsymptomatic PADPAD RiskRisk FactorsFactors

Downloaded from: Vascular Surgery 6/e (on 20 April 2006 01:40 AM) © 2 005 El se vie r PhysicalPhysical ExamExam

„„ LossLoss ofof hairhair „„ Thin,Thin, drydry skinskin „„ ThickenedThickened nailsnails „„ UlcersUlcers „„ EdemaEdema „„ GangreneGangrene PhysicalPhysical ExamExam „„ PulsesPulses

„„ BruitsBruits

„„ PulsatilePulsatile massesmasses HematologicHematologic EvaluationEvaluation

„ CompleteComplete bloodblood count,count, includingincluding whitewhite bloodblood cellscells andand plateletsplatelets „ FastingFasting bloodblood glucoseglucose „ SerumSerum creatininecreatinine „ FastingFasting lipidlipid profileprofile „ FibrinogenFibrinogen levellevel „ UrinalysisUrinalysis

TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 31(Pt 2):S59, 2000. HypercoaguableHypercoaguable StateState

„ Thrombin/Thrombin/prothrombinprothrombin timetime „ ActivatedActivated partialpartial thromboplastinthromboplastin timetime „ ProteinProtein S/proteinS/protein CC assaysassays „ FactorFactor VV LeidenLeiden assayassay „ LupusLupus anticoagulantanticoagulant assayassay „ HeparinHeparin--inducedinduced plateletplatelet antibodiesantibodies „ PlateletPlatelet adhesiveness/adhesiveness/aggregabilityaggregability „ Fibrinogen/Fibrinogen/plasminogenplasminogen levelslevels „ AntithrombinAntithrombin activityactivity „ AnticardiolipinAnticardiolipin antibodyantibody assayassay HomocysteineHomocysteine

„ Young patients with PAD, no other risk factors „ Toxic to endothelial cells „ Reduced ability to generate and release nitric oxide . „ Smooth muscle cell proliferation „ Arterial wall inflammation „ Increased levels of plasminogen activator inhibitor CardiacCardiac EvaluationEvaluation CardiacCardiac EvaluationEvaluation inin CLICLI

„ AssumeAssume thatthat theythey allall havehave significantsignificant CADCAD „ PerioperativePerioperative bloodblood pressurepressure control,control, antianginalantianginal regimens,regimens, andand treatmenttreatment forfor CHFCHF areare optimizedoptimized „ DelayDelay interventionintervention onlyonly forfor thethe presencepresence ofof frequentfrequent oror unstableunstable angina,angina, recentrecent myocardialmyocardial infarction,infarction, poorlypoorly controlledcontrolled CHF,CHF, oror symptomaticsymptomatic oror untreateduntreated arrhythmia.arrhythmia. „ EvenEven inin thesethese instances,instances, cardiaccardiac evaluationevaluation shouldshould bebe focusedfocused andand expeditiousexpeditious CarotidCarotid DiseaseDisease

„ 225225 patients,patients, screenedscreened forfor carotidcarotid arteryartery diseasedisease withwith duplexduplex imagingimaging „ HemodynamicallyHemodynamically significantsignificant stenosesstenoses inin 28.4%28.4% „ 4%4% hadhad aa greatergreater thanthan 80%80% stenosisstenosis requiringrequiring surgerysurgery „ 12%12% withwith symptomaticsymptomatic lowerlower extremityextremity hadhad greatergreater thanthan 75%75% diameterdiameter reductionreduction -Gentile et al. Arch Surg;1995 - De Virgilio et al. AnnVasc Surg;1997 AssesmentAssesment

„ IsIs significantsignificant arterialarterial occlusiveocclusive diseasedisease present?present? „ IfIf so,so, howhow severesevere isis thethe physiologicphysiologic impairment?impairment? „ WhereWhere areare thethe responsibleresponsible lesionslesions located?located? „ InIn multilevelmultilevel disease,disease, whichwhich arterialarterial segmentssegments areare mostmost severelyseverely involved?involved? ABIABI’’ss andand SegmentalSegmental PressuresPressures „ SegmentalSegmental arterialarterial pressurepressure measurement,measurement, withwith thethe calculationcalculation ofof thethe ABIABI „ IdentifyingIdentifying thethe presencepresence ofof arterialarterial occlusiveocclusive diseasedisease andand locatinglocating thethe segmentsegment involvedinvolved „ ToeToe pressurespressures usefuluseful inin diabeticsdiabetics „ ShouldShould includeinclude excerciseexcercise PulsePulse VolumeVolume RecordingsRecordings

„ DetectDetect changeschanges inin thethe volumevolume ofof bloodblood flowflow „ RapidRapid systolicsystolic upstrokeupstroke andand aa rapidrapid downstrokedownstroke withwith aa prominentprominent dicroticdicrotic notchnotch „ WithWith increasingincreasing severityseverity ofof PAD,PAD, thethe waveformswaveforms becomebecome moremore attenuatedattenuated withwith aa widewide downslopedownslope ScreeningScreening

„ BB--modemode ultrasoundultrasound andand pulsedpulsed wavewave dopplerdoppler „ NonNon--invasiveinvasive „ NoNo contrastcontrast „ HighHigh sensitivitysensitivity andand specificspecific forfor stenosisstenosis >50%>50% „ HighlyHighly techtech dependantdependant EvaluationEvaluation

„ GadoliniumGadolinium--enhancedenhanced MRIMRI „ NoNo arterialarterial puncturepuncture oror standardstandard ionicionic contrastcontrast „ CanCan identifyidentify patentpatent pedalpedal vesselsvessels „ ClaustrophobiaClaustrophobia „ ArtifactArtifact EvaluationEvaluation

„ CTCT angiographyangiography „ EasilyEasily toleratedtolerated „ NonNon--invasiveinvasive „ GreatGreat visualizationvisualization „ StillStill requiresrequires ionicionic contrastcontrast „ UnderestimatesUnderestimates stenosisstenosis TreatmentTreatment NonNon--operativeoperative TreatmentTreatment

„ RiskRisk--factorfactor modificationmodification „ WalkingWalking onon treadmilltreadmill ofof 6060 minutesminutes oror more,more, atat leastleast threethree timestimes aa week.week. - meanmean improvementimprovement inin absoluteabsolute claudicationclaudication distancedistance ofof almostalmost 200200 mm - improvesimproves qualityquality ofof lifelife - improvesimproves oxygenoxygen extractionextraction inin thethe lowerlower extremitiesextremities NonNon--operativeoperative TreatmentTreatment

„ PentoxifyllinePentoxifylline -- nono sustainedsustained improvementsimprovements inin walkingwalking distancedistance „ CilostazolCilostazol -- improveimprove overalloverall walkingwalking distancedistance andand qualityquality ofof life.life. „ NaftidrofurylNaftidrofuryl,, BlufomedilBlufomedil,, CarnitineCarnitine,, Prostaglandins,Prostaglandins, VascularVascular EndothelialEndothelial GrowthGrowth Factor,Factor, ll--ArginineArginine OperativeOperative TreatmentTreatment

„ CriticalCritical LimbLimb IschemiaIschemia „ AA predictedpredicted oror observedobserved lacklack ofof adequateadequate responseresponse toto exerciseexercise therapytherapy andand riskrisk factorfactor modificationmodification „ TheThe patientpatient mustmust havehave aa severesevere disability,disability, eithereither beingbeing unableunable toto performperform normalnormal workwork oror havinghaving veryvery seriousserious impairmentimpairment ofof otherother activitiesactivities importantimportant toto thethe patientpatient

TASC Work Group. J Vasc Surg; Jan 2001 OperativeOperative TreatmentTreatment

„ AbsenceAbsence ofof otherother diseasedisease thatthat wouldwould limitlimit exerciseexercise eveneven ifif thethe claudicationclaudication waswas improvedimproved ((egeg,, anginaangina oror chronicchronic respiratoryrespiratory disease)disease) „ TheThe individual'sindividual's anticipatedanticipated naturalnatural historyhistory andand prognosisprognosis „ TheThe morphologymorphology ofof thethe lesionlesion mustmust bebe suchsuch thatthat thethe appropriateappropriate interventionintervention wouldwould havehave lowlow riskrisk andand highhigh probabilityprobability ofof initialinitial andand longlong--termterm successsuccess

TASC Work Group. J Vasc Surg; Jan 2001 AortoiliacAortoiliac OcclusiveOcclusive DiseaseDisease

„ ButtockButtock andand ThighThigh claudicationclaudication „ ErectileErectile dysfunctiondysfunction „ ProgressesProgresses toto calfcalf claudicationclaudication „ Chronic,Chronic, rarelyrarely causecause ofof limblimb--threateningthreatening ischemia.ischemia. MorphologyMorphology

„ TypeType AA -- SingleSingle stenosisstenosis <3<3 cmcm ofof thethe CIACIA oror EIAEIA (unilateral/bilateral)(unilateral/bilateral) „ TypeType BB -- SingleSingle stenosisstenosis 33––1010 cmcm inin length,length, notnot extendingextending intointo thethe commoncommon femoralfemoral arteryartery (CFA)(CFA) -- TotalTotal ofof twotwo stenosisstenosis <5<5 cmcm longlong inin thethe CIACIA and/orand/or EIAEIA andand notnot extendingextending intointo thethe CFACFA -- UnilateralUnilateral CIACIA occlusionocclusion MorphologyMorphology

„ TypeType CC -- BilateralBilateral 55––1010--cmcm--longlong stenosisstenosis ofof thethe CIACIA and/orand/or EIA,EIA, notnot extendingextending intointo thethe CFACFA -- UnilateralUnilateral EIAEIA occlusionocclusion notnot extendingextending intointo thethe CFACFA -- UnilateralUnilateral EIAEIA stenosisstenosis extendingextending intointo thethe CFACFA -- BilateralBilateral CIACIA occlusionocclusion MorphologyMorphology „ TypeType DD -- Diffuse,Diffuse, multiplemultiple unilateralunilateral stenosesstenoses involvinginvolving thethe CIA,CIA, EIA,EIA, andand CFACFA (usually(usually >10>10 cm)cm) -- UnilateralUnilateral occlusionocclusion involvinginvolving bothboth thethe CIACIA andand EIAEIA -- BilateralBilateral EIAEIA occlusionsocclusions -- DiffuseDiffuse diseasedisease involvinginvolving thethe aortaaorta andand bothboth iliaciliac arteriesarteries -- IliacIliac stenosesstenoses inin aa patientpatient withwith anan abdominalabdominal aorticaortic aneurysmaneurysm oror otherother lesionlesion requiringrequiring aorticaortic oror iliaciliac surgerysurgery TASCTASC RecommendationsRecommendations

„ TypeType AA ““EndovascularEndovascular proceduresprocedures areare treatmenttreatment ofof choicechoice”” „ TypeType DD ““SurgerySurgery isis thethe procedureprocedure ofof choicechoice”” „ TypeType BB andand CC -- InsufficientInsufficient datadata toto makemake recommendationsrecommendations Timaran C, Prault TL et al. Iliac artery stenting versus surgical reconstruction for TASC type B & C lesions. J Vasc Surg 2003;38:272-8

„ PrimaryPrimary patencypatency ratesrates atat 1,1, 3,3, andand 55 yearsyears werewere 85%,85%, 72%,72%, andand 64%64% afterafter iliaciliac stentingstenting,, andand 89%,89%, 86%,86%, andand 86%86% afterafter surgicalsurgical reconstructionreconstruction „ PoorPoor infrainguinalinfrainguinal runoffrunoff isis thethe mainmain riskrisk factorfactor forfor decreaseddecreased primaryprimary patencypatency,, howeverhowever lessless soso forfor thosethose undergoingundergoing surgery.surgery. EndovascularEndovascular TherapyTherapy

„ ““KissingKissing StentsStents”” „ TechnicalTechnical successsuccess -- 95%95% „ PrimaryPrimary patencypatency atat 33 yearsyears waswas 79%79% „ 55 yryr patencypatency 8585--45%45% -- locationlocation -- discretenessdiscreteness -- runoffrunoff -- ClinicalClinical stagestage EndovascularEndovascular TherapyTherapy

„ PatencyPatency ofof endovascularendovascular therapytherapy inin thethe EIAEIA isis likelylikely asas goodgood asas thatthat inin thethe CIACIA „ SimilarSimilar factorsfactors thatthat affectaffect patencypatency SurgicalSurgical ReconstructionReconstruction

„ EndEnd –– toto –– endend „ HemodynamicallyHemodynamically moremore soundsound „ BetterBetter flowflow characteristicscharacteristics „ LessLess chancechance ofof competitivecompetitive flowflow „ BetterBetter longlong--termterm patencypatency „ LowerLower incidenceincidence ofof aorticaortic anastomoticanastomotic aneurysmsaneurysms SurgicalSurgical ReconstructionReconstruction „ EndEnd--toto--sideside „ CertainCertain anatomicanatomic patternspatterns ofof diseasedisease „ HigherHigher riskrisk ofof dislodgmentdislodgment ofof intraintra-- aorticaortic thrombusthrombus oror debrisdebris „ DifficultDifficult toto covercover ResultsResults

„ 85%85% toto 90%90% graftgraft patencypatency raterate atat 55 yearsyears andand 70%70% toto 75%75% atat 1010 years.years. „ PerioperativePerioperative mortalitymortality ratesrates wellwell belowbelow 3%3% „ MorbidityMorbidity 2020--30%30% „ 25%25% toto 30%30% ofof patientspatients areare deaddead atat 55 years,years, andand 50%50% toto 60%60% willwill havehave dieddied atat 1010 yearsyears ExtraExtra--anatomicanatomic bypassbypass

„ AxillofemoralAxillofemoral oror axillobifemoralaxillobifemoral bypassbypass „ FemoralFemoral--FemoralFemoral bypassbypass „ ObturatorObturator bypassbypass InfrainguinalInfrainguinal DiseaseDisease

„ SFASFA occlusionocclusion oror stenosisstenosis „ NoNo thighthigh oror footfoot symptomssymptoms „ DeepDeep femoralfemoral arteryartery „ TibialTibial diseasedisease mostmost commonlycommonly associatedassociated withwith limblimb--threateningthreatening ischemiaischemia MorphologyMorphology

„ TypeType AA -- SingleSingle stenosisstenosis upup toto 33 cmcm long,long, notnot atat originorigin ofof superficialsuperficial femoralfemoral arteryartery oror distaldistal poplitealpopliteal arteryartery „ TypeType BB -- SingleSingle stenosisstenosis oror occlusionocclusion 33--55 cmcm long,long, notnot involvinginvolving distaldistal poplitealpopliteal arteryartery -- MultipleMultiple stenosesstenoses oror occlusions,occlusions, eacheach lessless thanthan 33 cmcm longlong MorphologyMorphology

„ TypeType CC -- SingleSingle stenosisstenosis oror occlusionocclusion longerlonger thanthan 55 cmcm -- MultipleMultiple stenosesstenoses oror occlusions,occlusions, eacheach 33--55 cmcm longlong „ TypeType DD -- CompleteComplete commoncommon femoralfemoral arteryartery oror superficialsuperficial arteryartery occlusionsocclusions oror completecomplete poplitealpopliteal andand proximalproximal trifurcationtrifurcation occlusionsocclusions TASCTASC RecommendationsRecommendations

„ TypeType AA ““EndovascularEndovascular proceduresprocedures areare treatmenttreatment ofof choicechoice”” „ TypeType DD ““SurgerySurgery isis thethe procedureprocedure ofof choicechoice”” „ TypeType BB andand CC -- InsufficientInsufficient datadata toto makemake recommendationsrecommendations EndovascularEndovascular TherapyTherapy –– femoralfemoral poplitealpopliteal segmentsegment

„ 44 RandomizedRandomized TrialsTrials –– 33 PTAPTA vs.vs. routineroutine stentstent 11 routineroutine vs.vs. selectiveselective stentstent „ ImprovedImproved technicaltechnical successsuccess withwith stentingstenting „ ImprovedImproved primaryprimary patencypatency withwith stentingstenting atat 11 yearyear –– 85%85% vs.vs. 74%74% „ PatencyPatency equalizedequalized afterafter ~~ 22 yrsyrs „ AllAll usedused balloonballoon expandableexpandable stentsstents EndovascularEndovascular TherapyTherapy –– femoralfemoral poplitealpopliteal segmentsegment

„ DynamicDynamic anatomicanatomic positionposition „ SelfSelf--expandingexpanding stentsstents usedused momostst oftenoften „ HaveHave betterbetter performanceperformance inin thethe flexibleflexible femoropoplitealfemoropopliteal segmentsegment „ 33--yearyear patencypatency rangingranging fromfrom 70%70% toto 76%76% EndovascularEndovascular TherapyTherapy ––tibialtibial segmentssegments

„ earlyearly clinicalclinical successsuccess rangesranges fromfrom 71%71% toto 93%93% „ 11--yearyear limblimb salvagesalvage ratesrates rangingranging fromfrom 60%60% toto 88%88% „ 22--yearyear limblimb salvagesalvage ratesrates rangingranging fromfrom 50%50% toto 83%83% „ HardwareHardware inin thethe infrageniculateinfrageniculate arteriesarteries isis badbad OtherOther EndovascularEndovascular OptionsOptions

„„ PeripheralPeripheral atherectomyatherectomy „„ LaserLaser AtherectomyAtherectomy „„ CryoplastyCryoplasty „„ SubintimalSubintimal AngioplastyAngioplasty InfrainguinalInfrainguinal bypassbypass

„ DefineDefine thethe inflowinflow sourcesource withwith selectedselected alternativealternative originsorigins „ CorrectionCorrection ofof significantsignificant deepdeep femoralfemoral diseasedisease atat thethe timetime ofof bypassbypass isis clinicallyclinically important;important; shouldshould thethe bypassbypass everever failfail „ BypassBypass allall hemodynamicallyhemodynamically significantsignificant diseasedisease andand toto insertinsert thethe bypassbypass toto thethe mostmost proximalproximal limblimb arteryartery thatthat hashas atat leastleast oneone continuouscontinuous runoffrunoff arteryartery toto thethe foot.foot. „ PedalPedal arteryartery overover peronealperoneal.. ChoiceChoice ofof ConduitConduit

„ IpsiIpsi--,, contralateralcontralateral GSVGSV „ DacronDacron „ LesserLesser SaphenousSaphenous „ HeparinHeparin bondedbonded DacronDacron „ SuperficialSuperficial femoralfemoral veinvein „ PTFEPTFE „ ArmArm veinvein ((basillicbasillic andand „ PTFEPTFE withwith veinvein cuffcuff cephalic)cephalic) „ CryopreservedCryopreserved veinvein „ EndarterectomizedEndarterectomized SFASFA „ HumanHuman umbilicalumbilical veinvein „ RadialRadial arteryartery VeinVein CuffsCuffs PatencyPatency

„ 44 yearyear patencypatency AKAK poppop veinvein –– 7575--85%85% PTFEPTFE –– 4040--50%50% HUVHUV –– 5050--55%55% „ 44 yearyear patencypatency BKBK--poppop veinvein –– 7575--80%80% PTFEPTFE –– 3535--45%45% „ 44 yearyear patencypatency infrageniculateinfrageniculate veinvein –– 5050--60%60% PTFEPTFE –– 1212--15%15% Goshima KR, Mills JL, Hughes JD: A new look at outcomes following infrainguinal bypass surgery: Traditional reporting standards systematically underestimate the expenditure of

effort required to attain limb salvage. J Vasc Surg 39:330-335, 2004. „ UniversityUniversity ofof ArizonaArizona -- 318318 patientspatients undergoingundergoing infrainguinalinfrainguinal bypass,bypass, 72%72% forfor CLICLI „ mortalitymortality << 1%,1%, meanmean LOSLOS -- 99 days,days, 3030--dayday graftgraft patencypatency -- 96.9%,96.9%, andand 33--monthmonth limblimb salvagesalvage waswas 96.5%.96.5%. „ 49%49% -- atat leastleast oneone reoperationreoperation withinwithin 33 months,months, 50%50% requiredrequired readmissionreadmission withinwithin 66 months.months. TheThe cumulativecumulative LOSLOS waswas 1111 days.days. „ >> 50%50% CLICLI patientspatients requiredrequired moremore thanthan 33 monthsmonths ofof postoperativepostoperative carecare toto achieveachieve woundwound healing.healing. PostPost--operativeoperative carecare

„ ToTo anticoagulateanticoagulate oror notnot toto anticoagulateanticoagulate.. „ MeticulousMeticulous woundwound carecare „ PressurePressure releaserelease „ DelayDelay amputation/amputation/debridementdebridement forfor 44--1010 daysdays „ GraftGraft surveillencesurveillence withwith inin 11 month,month, thenthen everyevery 33 monthsmonths xx 11 year,year, thenthen biannuallybiannually forfor 22 years,years, thenthen annuallyannually thereafter.thereafter. TakeTake HomeHome PointsPoints „ AtherosclerosisAtherosclerosis isis aa systemicsystemic disease.disease. „ ControlControl ofof riskrisk factorsfactors isis mostmost importantimportant determinantdeterminant ofof successsuccess „ EndovascularEndovascular optionoption isis generallygenerally thethe bestbest firstfirst optionoption inin aortoiliacaortoiliac diseasedisease „ EndovascularEndovascular therapytherapy isis probablyprobably asas goodgood asas prostheticprosthetic bypassbypass inin femoralfemoral poplitealpopliteal segmentsegment „ HardwareHardware isis bad.bad. „ VeinVein betterbetter thanthan prostheticprosthetic DifferentialDifferential DiagnosisDiagnosis

„ ChronicChronic compartmentcompartment „ SpinalSpinal cordcord syndromesyndrome compressioncompression „ VenousVenous claudicationclaudication „ HipHip arthritisarthritis „ NerveNerve rootroot „ InflammatoryInflammatory arthritisarthritis compressioncompression „ SymptomaticSymptomatic BakerBaker’’ss cystcyst

TreatmentTreatment

„ ReferralReferral toto vascularvascular surgeon.surgeon. „ ModificationModification ofof riskrisk factorsfactors „ ExerciseExercise rehabilitationrehabilitation „ AntiplateletAntiplatelet therapytherapy „ PentoxifyllinePentoxifylline „ CilostazolCilostazol „ Naftidrofuryl,Naftidrofuryl, Blufomedil,Blufomedil, Carnitine,Carnitine, prostaglandins,prostaglandins, VEGF,VEGF, LL--argininearginine SurvivalSurvival

„ TheThe severityseverity ofof systemicsystemic atherosclerosisatherosclerosis isis accuratelyaccurately reflectedreflected byby thethe severityseverity ofof thethe lowerlower extremityextremity disease.disease. „ 55 andand 1010 yearyear mortalitymortality forfor ICIC –– 30%30% andand 50%50% „ 55 andand 1010 yearyear mortalitymortality forfor CLICLI –– 70%70% andand 85%85% „ 80%80% fromfrom vascularvascular eventevent –– 60%60% CAD,CAD, 10%CVA,10%CVA, 10%10% otherother

-Muluk et al. JVasc Surg 33:2001 - Walker et al. Eur J Vasc Endovasc Surg 15:1998 TakeTake HomeHome PointsPoints

„ EarlyEarly referralreferral

„ ScreeningScreening forfor otherother manifestationsmanifestations ofof atherosclerosis.atherosclerosis.

„ RiskRisk factorfactor modification.modification.