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25June2013 c
Common Vascular Disease
常見血管外科疾病
Dr Renny Yien 顏令朱醫生
Specialist in General Surgery 外科專科醫生
MBBS(HK), FRCSEd, FCSHK, FRCSEd (Gen), FHKAM(Surgery)
Vascular Surgeon 血管外科醫生
Vascular Disease 血管疾病
• Venous Disease
– Varicose Veins 靜脈曲張
• Arterial Disease
–
–
–
–
Aortic Dissection 夾層動脈
Aortic Aneurysm 主動脈瘤
Peripheral vascular disease 周邊動脈阻塞疾病
Carotid stenosis 頸動脈狹窄症
What is Varicose Vein?
靜脈曲張
A varicose vein is a Superficial 表面, protruding
dilated vein 擴張 NOT caused by:
•Previous deep vein thrombosis下肢深静脉血栓
•AV malformations
Leg Vein Anatomy 腿部靜脈解剖
• Network of veins to carry
blood to the heart.
• The venous system is
comprised of
• Deep Veins 深靜脈
• Superficial Veins 淺靜脈
• 90% of the blood is returned
to the heart by the deep
system alone
Perforators
交通静脈
Perforating veins connect the deep system
with the superficial system
They pass through the deep fascia at midthigh, knee and ankle
Valves 瓣膜
• Maintain unidirectional flow
– Extremity to heart
– Superficial to deep
• GSV and SSV with terminal
and preterminal valves
• Terminal (sentinel or first)
valve with firm thickened
white cusps different from
the rest of the valves
Etiology 病因
•
•
•
•
•
Pregnancy 懷孕
Pelvic obstruction 盆腔阻塞
Chronic straining
Prolonged standing 長時間站立
Prolonged sitting especially with legs
habitually crossed
• Obesity 肥胖
Why do Varicose Veins Occur?
為什麼?
• Heredity Risk? 遺傳風險
– Both parents = 80%
– 50/50 chance if one parent
– 20% chance of neither parent
• More common in females女性
– Pregnancy (labial varicosities/ Pelvic obstruction?)
– Taking hormones
Symptoms of Varicose Veins
症狀
• Pain 疼痛: sharp, aching, throbbing, tingling
• Cramps抽筋, heaviness, tiredness of legs,
“Restless” legs at night
• 皮膚病 Itching, dermatitis, hyperpigmentation,
ulceration of the skin, bleeding, blood clots
• 外觀 Poor appearance of the legs
Superficial Venous Insufficiency
淺靜脈功能不全
• Abnormal veins
– telangiectasia (spider)
毛細血管擴張症
– Reticular Non-saphenous VV
– Saphenous VV
• Abnormal skin
Superficial Venous Insufficiency
• Abnormal veins
– telangiectasia (spider)
– Reticular 網殼結構
– Non-saphenous VV
– Saphenous VV
• Abnormal skin
Superficial Venous Insufficiency
• Abnormal veins
– telangiectasia (spider)
– Reticular
– Non-saphenous VV 非大
隱靜脈
– Saphenous VV
• Abnormal skin
Superficial Venous Insufficiency
• Abnormal veins
– telangiectasia (spider)
– Reticular
– Non-saphenous VV
– Saphenous VV大隱靜脈
• Abnormal skin
Superficial Venous Insufficiency
• Abnormal veins
• Abnormal skin
– Eczema 濕疹
– Edema
– corona phlebectatica
– Lipodermatosclerosis
– ulceration
Superficial Venous Insufficiency
• Abnormal veins
• Abnormal skin
– Eczema
– Edema 浮腫
– corona phlebectatica
– Lipodermatosclerosis
– ulceration
Superficial Venous Insufficiency
• Abnormal veins
• Abnormal skin
– Eczema
– Edema
– corona phlebectatica
環狀靜脈擴張
– Lipodermatosclerosis
– ulceration
Superficial Venous Insufficiency
• Abnormal veins
• Abnormal skin
– Eczema
– Edema
– corona phlebectatica
– Lipodermatosclerosis
脂性硬皮病
– ulceration
Superficial Venous Insufficiency
• Abnormal veins
• Abnormal skin
– Eczema
– Edema
– corona phlebectatica
– Lipodermatosclerosis
– Ulceration 潰瘍
Classification of CVD (CEAP)
慢性靜脈功能不足
• C - clinical sign
0:
No visible venous disease
無肉眼可見的靜脈疾病
1:
Telangiectasias or reticular
毛細血管擴張或網狀靜脈
2:
Varicose veins
靜脈曲張
3:
Edema
水腫
4:
Skin changes
皮膚變化
5:
Healed ulceration
癒合潰瘍
6:
Active ulceration
潰瘍
Evaluation of Vein Patients
評估
• History and physical examination
–
–
–
–
Coagulation disorders
Thrombophlebitis or deep vein thrombosis
Diabetes or other arterial disorder
Results of previous treatment
• Blood flow tests
Blood flow tests 血流量測試
• Most tests are non-invasive
– Hand-held doppler
多普勒
– Duplex ultrasound
多普勒超聲檢查
– Others
• Patient selection
– Establish anatomy
– Establish function (reflux)
Treatment Goals 治療目標
Cosmetically Acceptable Control of Venous
Reflux 美觀上可接受
•Control of the highest source of backward flow
(reflux) and reduction of venous hypertension
– Great and lesser saphenous veins
– Perforator veins
•Branch varicosities and spider veins
What Treatment Methods are
Available? 治療方法？
• Surgery Stripping 外科手術
– GSV or SSV
– Microincison phlebectomy
• Endovenous ablation therapy
腔內消融治療
– RFA 射頻 or Laser 激光
• Ultrasound guided injection (glue, or sclerosant)
• Compression garments only 壓力縮襪
• No treatment
Surgery 外科手術
•
•
SFJ Flush ligation
Stripping GSV, microphlebectomy
Results of Surgery 結果
Fischer R, et al. The Unresolved Problem of Recurrent
Saphenofemoral Reflux. J Am Coll Surg 2002; 195:80-94.
Surgical Complications 並發症
• Wound Infection 傷口感染
• Hematoma/severe bruising 血腫/
嚴重的瘀傷
• Scarring 疤痕
• DVT 下肢深靜脈血栓
• Recurrence 復發
Endovenous Ablation Therapy
腔內消融治療
– Laser (EVLT) 激光
– Laser precaution
– Higher temperature
– Slightly more burn, numbness, phlebitis,
induration
– Radiofrequency ablation 射
頻
– Vein shrink around the probe, the vein
closes
– Less bruising, pain
– Result same as EVLT
RFA of great saphenous vein
• Local, regional, or general anesthesia
• Access vein
• Insert catheter into the vein and
advance closure catheter tip to SFJ
using US
• Compress saphenous vein and displace
blood away from catheter electrodes
Pre/Post 術前後
Pre/Post 術前後
Treatment of primary varicose veins by
endovenous obliteration with the VNUS
closure system: results of a prospective
multicentre study
RFA saphenous vein obliteration improves
symptoms of varicose veins. Reflux-free rates in
treated veins remain constant over 3 yr f/u.
Eur J Vasc Endovasc Surg. 2005 Apr;29(4):433-9.
Foam Sclerotherapy – Results
泡沫硬化劑
• 1-3% Sodium tetradecyl sulphate (STD)
• Excellent for small veins: reticular,
telangiectasias
• High recanalization rates for larger veins,
GSV: > 50% recurrent
• Complications
•
Ulceration
•
Pain
•
Pigmentation
•
Phlebitis
•
Secondary
telangiectasia
Foam Sclerotherapy - Procedure
• Several injections per visit with small gauge
needles
• Injected areas become reddened and “bee sting”
wheals occur for several hours
• Moderately uncomfortable
• Several treatments
• Compressive bandaging after treatment
• Appearance often “worse before better”
Long Term Results
•
•
•
•
80-90% clearing of treated area
Improvement of symptoms
Cosmetic improvement
Variable rate of recurrence
VenasealTM Sapheon Closure System
• USG guided endovenous medical
adhesive (Glue) to close the abnormal
great saphenous vein without surgery
 VenaSeal does not require
tumescent anesthesia or preprocedure sedatives
 Require minimal posttreatment pain medication or
no compression stockings.
Risk with Glue 膠水
•
•
•
•
•
Allergic reaction to cyanoacrylate
Phlebitis 靜脈炎
DVT, pulmonary embolism
Hematoma
Infection.
eSCOPE European
Observational Trial
• 69 Patients enrolled in a single arm trial
• 7 Centers, UK, Germany, Netherlands,
Denmark
• 9 Investigators (MD)
• Follow-up: 24-48 hr, 1, 3, 6 and 12 months
• Enrollment ended July 31, 2012
• Closure Rate 95% at 3 months
Vascular Emergencies
•
•
•
•
Aortic Dissections 主動脈夾層
Aortic aneurysm 腹主動脈瘤
Lower limb ischaemia 週邊動脈阻塞性疾病
Cerebrovascular Accident
Emergency Condition - 1
• 45 year old man
• Chronic smoker
• Newly diagnosis of
hypertension
• High Stress work
• Sudden onset severe
chest pain, upper
back pain
Not Easy to figure out
• Often worry about
hear attack
• AED shows normal ECG
• Blood cardiac enzyme
normal
• CXR
Aortic Dissection主動脈夾層
• A tear in the inner wall of the aorta
causes blood to flow between the layers
(intimal tear)
• 主動脈壁内膜撕裂, 血液通過內膜的
破口進入主動脈壁內, 導致血管壁夾
層分離
• A medical emergency and can quickly
lead to death
– Rupture (>80% mortality)
– Vital organ ischaemia (Cerebral, coronary,
bowel, kidneys, lower limb)
• ?Begins with an intramural hematoma
Aortic Dissection is NOT Rare
主動脈夾層並不罕見
• Commonest acute aortic disease in the west
• 在西方國家是最常見的一種主動脈急性疾病
• Estimated 5-10 new cases per million per year
• 估計每年、每一百萬人 (年發病率) 中的新症有五至十個
– 60 new case in UK per year
– 在英國會有六十位病人
– 2000 new cases in USA per year
– 在美國每年會有二千多個新症
Chen K. J Emerg Med 1997;15(6):859-67.
UK Hosp admission data 1999-2003(ICD10:I71.0)
China中國
• Statistics in 2009二零零九年估計
• Population of 1.3 billion 十三億人口
Underestimated annual incidence rate ‧
年發病率可能被低估
Estimated Annual incidence rate 4-5 /million /year
估計每年、每一百萬人 (年發病率)中的新症有四
至五個
• Trend to increase
• 有增加的傾向
•
•
•
•
National Health Insurance Databases from 1996 to 2001.
Chan GQ, Li ZL. Eur J Vasc Endovasc Surg. 2009 Mar 26
Hong Kong Information
香港資料
• During 2006-2008, there have been 858 patients was
admitted into HA hospitals because of aortic dissection
(CDARS)
• 在二零零六至二零零八年期間, 曾經有八百五十八位病人
因為主動脈夾層而進入醫管局轄下醫院 (CDARS)
• Each year, about 30-40 patients had emergency open surgical
repair in Grantham Hospital for Type A aortic dissection
(Cheng LC HKMJ 2007; 13:. 332)
• 每年大約有三十至四十位病人在葛量洪心臟外科中心進行
近端型主動脈夾層緊急傳統開胸手術(Cheng LC. HKMJ 2007;
13: 332)
Etiology of Aortic Dissection
•
•
•
•
•
Degenerative
Hypertension
Pregnancy
Skeletal (scoliosis)
Connective tissue
(Marfan’s)
• Mycotic aneurysm
• Takayasu arteritis
• Aortic laceration
•
•
•
•
•
•
•
•
退化性
高血壓
懷孕
骨骼（脊柱側彎）
結締組織（馬凡氏）
感染性動脈瘤
多發性大動脈炎
主動脈撕裂傷
Anatomical Classification
Percentage
60%
10-15%
25-30%
DeBakey
I
II
III
Stanford
A (Proximal)
升主動脈受累者:近端型
B (Distal)
遠端型
Signs and Symptoms
• Sudden onset severe pain 96%
– Anterior chest pain - Ascending
– Interscapular back pain descending
• Pericardial Tamponade
(commonest cause of death)
•
•
•
•
•
•
Congestive Heart Failure 7%
Syncope 9%
Cerebrovacular accident 3-6%
Paraplegia
Cardiac Arrest
Sudden death
• 突然發生劇烈疼痛96％
– 前胸部疼痛
– 肩胛背部疼痛
•
•
•
•
•
•
•
心包填塞（死亡的常見原因）
充血性心力衰竭7％
暈厥9％
腦中風3-6％
截癱
心臟驟停
猝死
Abdominal aortic dissection
• Both renal arteries 58%
• Mesenteric ischemia
3-5%
• Ischemic peripheral
neuropathy
• Acute limb ischaemia
Blood Pressure
• Variable, higher with more distal dissection
Hypertension
Hypotension
Proximal dissection
36%
25%
Distal dissection
70%
4%
• Severe hypertension at presentation
is a grave prognostic indicator
– Pericardial temponade, severe aortic insufficiency or
aortic rupture
Aortic insufficiency
• AI ½ to 2/3 ascending aortic dissection
• Dissection dilate the annulus of the
aortic valve, so that the leaflets of the
valve cannot coapt
• Dissection may extend into the aortic
root and detach the aortic valve
leaflets
• With extensive intimal tear, the flap
prolapses into the outflow tract,
causing intimal intussusception into
the aortic valve, preventing proper
closure
Myocardial infarction
• 1-2%
• Involvement of the coronary
arteries in the dissection
• Right coronary artery is
involved more commonly than
the left coronary artery
• If the myocardial infarction is
treated with thrombolytic
therapy, the mortality increases
to over 70%, hemorrhage
causes pericardial temponade
Pleural effusion
• Left
• Blood due to transient
rupture of aorta
• Fluid due to
inflammatory reaction
around the aorta
Diagnosis
• D-dimer (less than 500mcg/ml making
diagnosis of acute dissection unlikely)
• CXR –
– Widening of the mediastinum in
ascending aortic dissection
(sensitivity 67%, low specificity)
– Calcium sign (separation of the intimal calcification from the outer aortic soft
tissue border by 10 mm)
–
–
–
–
–
Pleural effusions
Obliteration of the aortic knob
Depression of the left mainstem bronchus
Loss of the paratracheal stripe
Tracheal deviation
Computed tomography
• Fast non-invasive, threedimensional view
• sensitivity of 96 to 100%
• specificity of 96 to 100%
• Iodinated contrast
• Inability to diagnose the
site of the intimal tear
Magnetic resonance imaging
•
•
•
•
•
•
sensitivity of 98%
specificity of 98%
location of the intimal tear
limited availability
time consuming
contraindicated in
individuals with metallic
implants
Transesophageal
echocardiography
•
•
•
•
sensitivity of up to 98%
specificity of up to 97%
non-invasive test
evaluation of AI in the setting of
ascending aortic dissection
• inability to visualize the distal ascending aorta
and the descending abdominal aorta that lies
below the stomach
Treatment of acute aortic
dissection
• Stanford type A (ascending aortic) dissection, surgical
management is superior to medical management.
• For uncomplicated Stanford type B (distal aortic) dissections,
medical management is preferred over surgical
Suzuki T, Mehta RR, Ince H, Nagai R, Sakomura Y, Weber F, Sumiyoshi T, Bossone E, Trimarchi S, Cooper J, Smith
D, Isselbacher E, Eagle K, Nienaber C (2003). "Clinical profiles and outcomes of acute type B aortic dissection
in the current era: lessons from the International Registry of Aortic Dissection (IRAD)".Circulation 108 (Suppl 1):
II312–7
Modality of Medical Treatment
• Systemic pressure
• Beta-blockers and/or ACEI
• Vasodilators, Ca channel blockers
and /or diuretcis
• Refractory hypertension
• Indirect sign of impending rupture or
renal malperfusion
• Thoracic or back pain
• Usually sensitive to analgesic drugs
• Severe hypotension or shock
• High risk of death
Suzuki T, Mehta RR, Ince H, Nagai R, Sakomura Y, Weber F, Sumiyoshi T, Bossone E, Trimarchi S, Cooper J,
Smith D, Isselbacher E, Eagle K, Nienaber C (2003). "Clinical profiles and outcomes of acute type B aortic
dissection in the current era: lessons from the International Registry of Aortic Dissection
(IRAD)".Circulation 108 (Suppl 1): II312–7
Complicated Type B dissection
•
•
•
•
Rupture
Impending rupture
Intractable pain
Refractory
hypertension
• Visceral ischemia
• Spinal ischemia
• Limb ischemia
->Surgery or TEVAR (Thoracic EndoVascular Aortic
Replacement)
Progression of disease
• Uncomplicated
•
Complicated
Patient who survive the acute uncomplicated phase
often suffer late complication
• New dissection with related complications
• Aneurysmal degeneration
What are the current evidence?
• Role of TEVAR?
• Minimal invasive method
• Avoid thoracotomy
• How does it affect our
decision making?
TEVAR
• From the first procedure, the
subsequent use of TEVAR for this
indication had grown without
comprehensive evaluation of the
evidence for its benefits and risks:
• Only one randomized trial of TEVAR
versus BMT
• No randomized trials of TEVAR versus
open repair
INSTEAD trial
• 140 patients with stable type B
dissection
TEVAR + BMT
BMT
Nienaber CA, Kische S, Akin I, Rousseau H, Eggebrecht H, Fattori R, Rehders TC, Kundt G,
Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Ince H. Strategies for subacute/chronic
type B aortic dissection: the Investigation Of Stent Grafts in Patients with type B Aortic Dissection
(INSTEAD) trial 1-year outcome. J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S101-8;
discussion S142-S146. doi: 10.1016/j.jtcvs.2010.07.026.
Results INSTEAD
• No difference in all-cause mortality
• Cumulative survival
– BMT 97.0% ± 3.4%
– TEVAR 91.3% ± 2.1% (P = .16)
• Aorta-related mortality was not different (P = .42)
• Combined end point of aorta-related death (rupture) and
progression was similar (P = .86)
• Aortic remodeling (with true-lumen recovery and thoracic
false-lumen thrombosis)
– TEVAR 91.3%
– BMT 19.4% (P < .001)
Nienaber CA, Kische S, Akin I, Rousseau H, Eggebrecht H, Fattori R, Rehders TC, Kundt G,
Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Ince H. Strategies for subacute/chronic
type B aortic dissection: the Investigation Of Stent Grafts in Patients with type B Aortic Dissection
(INSTEAD) trial 1-year outcome. J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S101-8;
discussion S142-S146. doi: 10.1016/j.jtcvs.2010.07.026.
Aortic Remodeling
• Recovery of the true lumen
• Thrombosis of the false lumen
• Does it translate to reduced aneurysmal
degeneration?
INSTEAD-XL
• Amended FU to five years
• BMT group experienced further rate
complications and fatalities
• Stented group stable long-term course, no fatalities
up to 5 years
• Only cases with remodeling guaranteed uneventful
long-term course
• With technology advance, dissection specific stents
are now available
Recommendations
• Complicated acute type B aortic dissections ->
TEVAR
• Uncomplicated type B dissection, a primary
conservative approach
• PAU when symptomatic or ulcer demonstates
expansion and IMH -> TEVAR
Martin Grabenwoger, Fernando Alfonso, Jean Bachet, Robert Bonser, Martin Czerny,
Holger Eggebrecht, Arturo Evangelista, Rossella Fattori, Heinz Jakob, Lars Lonn, Christoph A.
Nienaber, Guido Rocchi, Herve Rousseau, Matt Thompson, Ernst Weigang, Raimund Erbel.
Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position
statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the
European Society of Cardiology (ESC), in collaboration with the European Association of
Percutaneous Cardiovascular Interventions (EAPCI). European Heart Journal May 4, 2012
Contraindications for TEVAR
• Must have suitable anatomy
• Appropriate landings zones
– 2 cm of suitable aortic diameter on either side of the
pathology
• Branch vessels occluded by stent-graft may not be
candidate (celiac, subclavian or carotids)
– Hybrid techniques (bypass)
– Chimney/snorkel techniques (extra stents)
• Marfan disease (further tissue degeneration
highly likely.
Recommendation
• Early Diagnosis
• Consider early TEVAR even in uncomplicated
cases
腹主動脈瘤
ABDOMINAL AORTIC ANEURYSM
Emergency Case
•
•
•
•
Male
65 year old
Chronic smoker
Hypertension on
medication
• Sudden onset severe
abdominal pain or back pain
• Pulsatile abdominal mass
(Heart in abdomen)
• Shock
•
•
•
•
•
男
65年歲
長期吸煙者
高血壓
突然發生劇烈腹痛或腰背
痛
• 腹部搏動性腫塊（心在腹
部）
• 休克
What is an Abdominal Aortic
Aneurysm (or AAA)? 腹主動脈瘤
•
•
•
•
•
•
An Abdominal Aortic Aneurysm (AAA) is a permanent localized dilatation
of the abdominal aorta.
腹主動脈瘤是腹主動脈的永久局部擴張。
The disorder is defined as the aortic diameter is 30 mm or more.
該病症被定義為主動脈直徑為30毫米或更多。
If a AAA goes undetected and untreated, it can
rupture 破裂 and lead to massive internal
bleeding and death
如果腹主動脈瘤未被發現和未經處理的，它
可以破裂，並導致大量內出血而死亡
Why are AAAs a serious healthcare
issue? 嚴重的醫療問題
• AAA is the 10th
leading cause of
death in men in HK.
• A silent killer 沉默的殺
手 because there are
often no symptoms
that an aneurysm is
developing in the
abdominal aorta.
Why is early diagnosis of AAA so important?
早期診斷為什麼非常重要
• The operative mortality 手術死亡率 of treating a
ruptured aneurysm is 30-70%.
• For elective 非緊急擇期手術 AAA cases, the
operative mortality rate is drastically reduced,
approximately only 2-5% of cases result in death.
• AAA ruptures can be avoided by identifying the
population at risk and conducting simple and
inexpensive ultrasound examinations.
Epidemiology 流行病學
(1999-2000 HK)
•
•
•
•
•
Annual incidence of AAA in HK: 13.7 per 100,000 population,
105 per 100,000 for those aged 65 and above
Mean age: 74, 84% > 65
Operative repair rate:- 8% for intact, 54% for rupture, 45%
overall
Territory-wide operative mortality rates:- 10% (4-24%) for
intact, 70% (38-100%) for rupture
Low repair rates for intact AAA, high proportion for ruptured> AAA under treatment in HK
SWK CHENG ET AL. EPIDEMIOLOGY AND OUTCOME OF AORTIC ANEURYSM IN
HONG KONG. WORLD JOURNAL OF SURGERY VOL 27, NO 2/ FEB 2003
How to prevent?預防
• No AAA screening program 篩選程序 is in
place in HK today
• A simple ultrasound examination 超聲檢查
easily detects aneurysms
Types of AAA
• Morphological Classification
• Fusiform aneurysms 梭形動脈瘤
• Saccular aneurysms 囊狀動脈瘤
• Dissecting aneurysms夾層動脈瘤
• Pseudo-aneurysms 假性動脈瘤
 Segments involved





Thoracic
Thoraco-abdominal
Abdominal
Main branches of the aorta
Iliac arteries
Ruptured AAAs are fatal in 82% of cases
• Mortality is high due to
rapid circulatory
collapse.
• Up to 50% of patients with
untreated aneurysms >
5.5 cm will die of rupture
within 5 years.
• Less than 50% of
emergency cases arrive
at the hospital live; out of
those, only 50% survive
conventional AAA repair.
How can you diagnose a AAA?
• AAA is an asymptomatic disease.
• AAA是一種無症狀的疾病。
• Physical examination:
– Palpation, you may notice or feel
a throbbing, tender mass the
patients abdomen.
• However, you may miss up to
80% of AAA if the diagnosis is
limited to physical examination.
• Most of the time, AAAs are
diagnosed too late, i.e. when
they rupture.
How can you diagnose a AAA?
你如何診斷AAA
 Ultrasound scan has proven to be
a reliable and cost-effective way
to diagnose a AAA.
 超聲掃描已被證明是一個可靠和
具有成本效益的方式來診斷AAA。
• It is an
extremely
sensitive test
for all AAA
sizes.
• It is painless
and
non-invasive.
• It is costeffective.
What if a AAA>5cm is diagnosed?
• The patient should be referred to a vascular surgeon
• 患者應被轉介血管外科醫生
Open Surgery
開放性手術
Endovascular Stent Grafting
血管內支架置入術
•
Open surgical repair:
advantages
開放性手術:優點
Aneurysm opened,
graft sewn in, aorta
wrapped and
closed around graft
• Established
procedure (with
more than 40 years
of clinical
experience)
• Excludes aneurysm
Open surgical repair:
drawbacks
開放性手術:缺點
• Significant incision in
the abdomen 顯著手
術切口
• 30–90 minute crossclamp
• Up to 4-hour
procedure
• Contraindicated in
some patients
•
Endovascular stent :
advantages
血管內支架置入術:優點
Benefits
– Minimally invasive 微創
– Reduced risk of death
死亡的風險降低
– Faster recovery 術後恢復
快
– Improved functional
outcomes 功能性結果
Endovascular stent
grafting: drawbacks
血管內支架置入術:缺點
• Complications and re-interventions:
– Endoleaks
– Stent graft migration
– Modular dislocation
• Most complications are benign and
treatable by endovascular techniques.
• New stent graft generations are
associated with fewer complications.
Open Vs EVAR
Take Home Messages
•
•
Who are the patients at risk of AAA?
– Predominantly males
– 60 years old or older
– Smoking history
– Hypertension
– Family history of AAA
What should I do with a patient at risk?
– An ultrasound examination may be
performed to check the presence
of a AAA. Palpation is not effective
with all patients.
•
What is the main risk associated AAA?
• The risk of rupture
• Only 18% of patients with a
ruptured AAA survive.
• Operative mortality in elective
cases is less than 5% with open
surgery and less than 2% with
endovascular repair.
• It is important to diagnose AAA as
early as possible.
Peripheral
Vascular Disease
週邊動脈阻塞性疾病
Emergency Case
•
•
•
•
•
•
Male
Chronic smoker
Diabetes, hypertension
Pain in calf after walking
Relief by standing
Severe foot pain at
night
• Foot ulceration
• Toes gangrene
•
•
•
•
•
•
•
•
男
長期吸煙者
糖尿病，高血壓
行走後小腿疼痛
站立緩解疼痛
晚上嚴重的足部疼痛
足部潰瘍
腳趾壞疽
Peripheral Vascular Disease
週邊動脈阻塞性疾病
• Atherosclerosis 粥樣動脈硬化
– Hardening of the arteries affects
blood flow to the legs
– Depending on a patient's
severity of PVD, it can cause pain
or even gangrene of a limb
Epidemiology 流行病學
• Demographic and biochemical risk factors
–
–
–
–
–
–
–
–
smoking 吸煙 (59%)
Hypertension 高血壓 (55%)
diabetes mellitus 糖尿病 (42%)
Hypercholesterolemia 高膽固醇 (55%)
elevated low density lipoprotein (LDL) 60%)
triglycerides (31%)
Hyperfibrinogenemia 纖維蛋白原血症 (62%)
Hyperglycemia 高血糖 (49%)
Cheng SW. Epidemiology of atherosclerotic peripheral arterial occlusive disease in Hong Kong.
World J Surg. 1999 Feb;23(2):202-6.
Classification of PVD:
Fontaine’s Stages and
Rutherford’s Categories
Fontaine
Rutherford
Stage
Clinical
Grade
Category
I
Asymptomatic 無症狀
0
0
Asymptomatic
Mild claudication
間歇性跛行
Moderate-severe
claudication
I
1
Mild claudication
I
2
Moderate claudication
I
3
Severe claudication
IIa
IIb
Clinical
III
Ischaemic rest pain
II
4
Ischaemic rest pain
IV
Ulceration 潰瘍 or
gangrene 壞疽
III
5
Minor tissue loss
III
6
Major tissue loss
How do they present?
• Can be asymptomatic 無症狀 for long
time
• Primary symptom (early stage):
Intermittent claudication (IC)
間歇性跛行
• Secondary symptom (late stage):
Critical Limb Ischemia (CLI)
重症肢體缺血
• necrosis, gangrene, ulceration
Apelquist J et al.: Long-term costs for foot ulcers in diabetic patients in a
multidisciplinary setting. Foot and Ankle International 1995;16:388
Inspection 檢查
• Particular in advanced chronic stages, trophic
disturbances are notices which may include:
–
–
–
–
reduced hair growth on the legs
slow nail growth
Livedo
thinning of the skin
Vascular Medicine - Therapy and Practice - ABW Wissenschaftsverlag GmbH 2010; 140
Palpation 觸診
Jonathan D Beard, BMJ 2000;320:854-857
•
Method of palpating the
femoral pulse in the skin
crease of groin
•
Method of palpating
dorsalis pedis and posterior
tibial
Ankle-Brachial Index (ABI)
踝臂指數
• ABI is the ratio of the ankle to
brachial systolic blood pressure
• Measured using a blood pressure
cuff and handheld Doppler
device (continuous wave doppler probe)
• ABI measurement is calculated by
dividing the highest pressure at the
ankle by the higher systolic
pressure of the right and left
brachial arteries
www.tasc-2-pad.org - Management of IC;
Techniques for Peripheral Interventions, Urban & Vogel GmbH, 2007; 11
Ankle-Brachial Index (ABI)
踝臂指數
<0.9 at rest
Sensitivity 95%; Specificity 100% compared with angiography
Positive predictive value 90%; negative predictive value 99%
Ankle-Brachial Index (ABI)
踝臂指數
ABI value
Diagnosis
What It Means
1.00 to 1.29
Normal
Normal range and patient is not likely to have PVD
0.91-0.99
Borderline
Lower than normal, but not enough to diagnose PVD
ABI might be measured again after exercise
0.41 to 0.90
Mild-to-moderate
PVD
Patient has PVD
Control risk factors
Antiplatlet agent for cardiovascular risk reduction
0.40 or less
Severe PAD
May need immediate treatment to relieve symptoms and
prevent serious complication
Patients with very high ABI (>1.30) may have calcified arteries and require further assessment
Hirsch, ACC/AHA Practice Guidelines, 2006 - J Am Coll Cardiol;
www.tasc-2-pad.org - Management of IC
Duplex ultrasonography
多普勒超聲
• B-mode Ultrasound +
Doppler waveform
• Normal triphasic
–Cardiac systole results in
the initial forward flow
–A brief period of flow
reversal in early diastole
–Subsequent forward flow in
late diastole
Manual of Carotid and Peripheral Vascular Interventions, T.
Limpijankit, Beyond Enterprise Co., Ltd, 2008, 17
Magnetic Resonance angiography (MR)
磁共振血管造影
• Allows three-dimensional (3-D) imaging of all vessels at any
level
• Problem:
–Overestimation of stenosis
–Calcified structures are not identified
–Patients with metallic implants cannot be examined (e.g.
defibrillators, intracerebral shunts)
Vascular Medicine - Therapy and Practice - ABW Wissenschaftsverlag GmbH 2010; 141-142
Magnetic Resonance angiography (MR)
磁共振血管造影
Supra-aortic, carotids and
cerebral vessels
AV shunt and multiple stenoses of
the brachial vein
Visualization of lower leg vessels, collaterals in a
patient with stenoses and occlusions
Computed tomography angiography (CTA)
電腦斷層掃描血管造影
• Minimally invasive
• Requires an intravenous (IV) and contrast injection
• Use of radiation
• Shows remarkable detail of the vessels
• Costly
Computed tomography angiography (CTA)
• Disadvantage:
– High level of radiation exposure
– Need large amount of contrast agent
– Difficulties to distinguish between calcified, occluded
lumen and a perfused lumen in lower leg areas
Vascular Medicine - Therapy and Practice - ABW Wissenschaftsverlag GmbH 2010; 142
Computed tomography angiography (CTA)
Treatment options
• In 1980’s 4 Words
• Keep Walking
保持行走
• Stop Smoking
停止吸煙
Treatment options
Exercise Therapy
運動療法
Lifestyle Modifications
生活方式的改變
Medication
藥物治療
Diet
飲食
Smoking Cessation
戒菸
Diabetes management
糖尿病管理
Blood pressure control
血壓管理
Foot Care
足部護理
Revascularization
血運重建
Vary and depend on
the overall health of
the patient and the
severity of the
diagnosis
Treatment Mnemonic
治療助記符
•
•
•
•
•
•
•
•
Anti-platelet (aspirin) 抗血小板（阿司匹林）
Blood pressure control 血壓控制
Cessation of smoking 停止吸煙
Diet, to avoid overweight and have a low fat diet
飲食，避免超重和低脂肪的飲食
Exercise therapy 運動療法
Foot care 足部護理
Glucose control for diabetes 血糖控制
HMG CoA reductase inhibitor i.e. statin 他汀類藥
Walking Training 步行訓練
• Exercise therapy [ Grade A evidence]
– Treadmill 跑步機
• Sufficient intensity to bring on
claudication
• Followed by rest
• Over 30-60mins
• 3x/ week for 3 months
• Improving walking distance  greater
mobility, improvement in Quality of life
生活質量
Medication 藥物治療
• Naftidrofuryl
– 5-hydroxytrptamine type 2
antagonist
– Improve muscle
metabolism
– Reduce erythrocyte and
platelet aggregation
• Cilostazol
– Phosphodiesterase III inhibitor
– Vasodilator, metabolic and
antiplatelet activity
– 3-6 month course of cilostazol
should be the first line
treatment for the relief of
claudication symptoms
Revascularization- Indication
血運重建術
•
•
Critical limb ischaemia 嚴重肢體缺血
Life style limiting Intermittent Claudication
有生活方式受限制的間歇性跛行
Revascularization options
• Endovascular Treatment
• Surgical bypass 搭橋手術
– Prosthetic graft
血管內治療
– Autogenous vein graft
–Balloon Angioplasty 球囊血管成
形術
–Cutting Balloon
–Stents - BMS, DES, Covered
stents 支架
–Atherectomy
–Cryoplasty
How to Choose?
• Endovascular Method
• Surgical Bypass
– Less invasive compared
– Better patency rates
to open surgery
– Less reinterventions due
– The patient is normally
to restenosis
treated while under local
– Useful in multiple-level
anaesthesia
stenoses
– Hospital stay is reduced
– Better cost-benefit ratio
Endovascular
First Approach
compared
to open
particularly in severe
surgery
advanced PVD
Balloon angioplasty for
Aorto-iliac Disease
主髂動脈疾病- 球囊血管成形術
Aortobifemoral Bypass
Iliac-femoral / Iliac-popliteal
Bypass
PTA + Cross femoral Bypass
Take home messages
• Early Index of
suspicion 懷疑
• ABI for diagnosis踝
臂指數診斷
• Aspirin 阿司匹林
• Find a vascular
surgeon 血管外科醫
生
Carotid Stenosis
頸動脈狹窄
Emergency Case
• 60 year old
• Hypertensive
• Sudden onset of left eye
blindness that lasted for
one hour
• Now vision is normal
• Slurring of speech for
two to three hours
• 60多歲
• 高血壓
• 突發的左眼失明，持
續一小時
• 現在的視力是正常
• 不清講話為兩到三個
小時
What Is Carotid Artery
Disease?
•
•
•
Narrowing of the carotid arteries, caused by
atherosclerosis on the inside of the vessels,
decreasing blood flow to the brain and increasing
the risk of a stroke
Brain cells deprived of the oxygen and glucose for
more than 3 to 6 hours, the damage is usually
permanent
A stroke 中風 can occur if:
– The artery becomes extremely narrowed.
– A piece of plaque breaks off and travels to the smaller
arteries of the brain.
– A blood clot forms and blocks a narrowed artery.
What Are the Risk Factors?
風險因素
•
Family history of atherosclerosis (either coronary artery disease
or carotid artery disease) 家史
•
•
•
•
•
Age (men under age 75 have a greater risk of developing the
disease than women, but the risk is higher in women after age
75) 年老
Smoking 抽煙
Hypertension 高血壓
Diabetes 糖尿病
Obesity 肥胖
•
Lack of exercise
Typically, the carotid arteries become diseased a few years later than
the coronary arteries.
What Are the Symptoms of
Carotid Artery Disease?
• Asymptomatic 無症狀
• Warning signs of
impending stroke
– Transient Ischaemic
Attack (TIA) 短暫性腦缺血
• a blood clot briefly
blocks an artery that
supplies blood to the
brain
• temporary and may last
a few minutes or a few
hours
• Sudden loss of vision 喪
失視力 or blurred vision
in one or both eyes.
• Weakness and/or
numbness on one side
of the face or in one
arm or leg.
• Slurred speech 說話含糊
• Loss of coordination,
• Dizziness or confusion
• Difficulty swallowing
Transient Ischaemic Attack
短暫性腦缺血發作: "小中風"
• A TIA is a medical emergency since it is
impossible to predict if it will progress into
a major stroke.
• Immediate treatment can save your life
or increase your chance of a full
recovery.
• TIAs are strong predictors of future strokes
• about 10 times more likely to suffer a
How Is Carotid Artery
Disease Diagnosed? 診斷
• Carotid artery disease may not have
symptoms
• At risk should have regular physical exams
定期身體檢查
• A doctor will listen to the arteries in your
neck with a stethoscope for bruit
• Bruits are not always present when
blockages are present
• Tell your doctors your symptoms
Carotid duplex ultrasound
頸動脈多普勒超聲
• Simple, non-invasive
• Accurate anatomical
localization
• Peak systolic velocity
• Degree of narrowing
• Extent of stenosis
• Valuable information
for planning for
treatment
Computer Tomogram
電腦斷層掃描血管造影
How Is Carotid Artery Disease
Treated? 治療
• Carotid artery disease is treated by:
– Making lifestyle changes 改變生活方式
– Medications 藥物治療
– Having procedures as recommended 外科手
術
Lifestyle Changes
改變生活方式
Quit smoking
戒菸
Control blood pressure,
cholesterol, diabetes
控制高血壓，膽固醇，
糖尿病
Have regular check-ups
定期檢查
Diet
吃低脂肪的食物
Weight Control.
保持理想體重
Limit the amount of alcohol
限制你喝的酒精含量
Medications 藥物治療
•
•
•
•
Aspirin 阿司匹林
Warfarin 華法林
Plavix 氯吡格雷
Statin 他汀類藥物
Procedures 外科手術
• Carotid artery
stenting (CAS)
頸動脈支架置入術
• Carotid
endarterectomy
(CEA)
頸動脈內膜切除術
Carotid Artery Stenting
頸動脈支架置入術
• Small puncture in groin
• Stent is guided to the carotid
artery with wire and catheter
• Stent is deployed permanently
Carotid Endarterectomy
頸動脈內膜切除術
• proven to benefit
patients who have a
50 percent or greater
blockage in the
carotid artery
Summary 總結
• Indication for CEA
– Symptomatic >50% NNT
1:5
– Asymptomatic >60% NNT
1:15
– Higher Risk of MI
• Indication for CAS
– Symptomatic >50% with
hostile anatomy
– Asymptomatic – no
indication
– High Risk of Stroke
• Prophylactic 預防性
procedure
• Simple Duplex
assessment
– stroke with good
recovery
– TIA
– Amaurosis fugax
• Aspirin
• Statin
Life Long