Paul Anain, MD, FACS, RPVI Vascular & Endovascular Center of WNY Medical Director of Vascular Service Line, Catholic Health Major Manifestations of Arterial Disease • Ischemic stroke • Transient ischemic attack • Myocardial infarction • Angina pectoris (stable, unstable) • Peripheral arterial disease • Critical limb ischemia, rest pain, gangrene, necrosis Risk Profile of PAD • The REACH (REduction of Atherothrombosis for Continued Health) Registry studied 7,013 patients with symptomatic PAD Key Finding 63% of PAD patients had polyvascular* disease Polyvascular disease = 63% CVD CAD 14.2% 39.4% 9.5% PAD * PAD patients with polyvascular disease had concomitant symptomatic cerebrovascular or cardiovascular disease or both. Bhatt DL, et al. American College of Cardiology Scientific Session. March 8, 2005. Presentation        Asymptomatic Cerebral Vascular Accident Transient Ischemic Attack Rupture Claudication Rest pain Gangrene/Tissue loss Relative 5-Year Mortality Rates 100 86 80 Patients 60 (%) 40 20 39 32 18 23 8 0 Prostate Hodgkin's Cancer* Disease* Breast Cancer* PAD † *American Cancer Society. Cancer Facts and Figures, 2000. †Criqui MH et al. N Engl J Med. 1992;326:381-6. Colorectal Lung Cancer* Cancer* Medical Management Best Medical Treatment for arterial disease: Antiplatelets • Plavix • Aspirin Anticoagulants Statins Diet/exercise/weight loss SMOKING Cessation Medical management of HTN and DM LT2924151 Rev. B 5/9/2014 6 Anatomy and Pathology AAA — Working Definition Pathologic, focal dilatation of the aorta > 1.5X “normal” diameter Normal aortic diameter: 20-mm (range, 14-30 mm) (M > F) Increases with age Fusiform Saccular Anatomy and Pathology Demographics Prevalence: 5-7% in > 65 years old 2000 US Census  2.7 million Americans 15,000 deaths from aneurysm rupture per year 10th leading cause of death in US Americans with AAA are under‐diagnosed & under‐treated The prevalence of AAA is 4.5% in men and 1.0% in women (data from SAVE screenings) • AAA increases in frequency after 6th decade ‾ 5% of men over 65 years ‾ 10% of men over 75 1,152,294 Americans living with AAA 15% are diagnosed 6% are treated Risk Factors Risk Factors for AAA Age: > 65 years Gender: M > F (4:1) Family history (1° male relatives): 20% Smoking: > 10 pack-years Peripheral aneurysms femoral, popliteal, thoracic Hypertension Absence of diabetes Race: Caucasian > African-American AAA‐Concomitant Disease • Unselected screened patients 3.2% • Selected patients with CAD 5.0% • Selected patients with PVD 10.0% • With femoral/popliteal aneurysm 50.0% Clinical Presentation and Diagnosis Abdominal Ultrasound Safe, non-invasive Widely available Rapid Inexpensive Normal Accurate (> 90%) longitudinal axial Clinical Presentation and Diagnosis CT Scan Gold standard: Timed-bolus, intravenous contrast-enhanced, thin-cut, spiral technique Advantages • Rapid (16 / 64 multi-row detector arrays, 15-30 sec, single breath-hold) • < 1-mm spatial resolution, 3-D reconstructions • Usually operator-independent • Accurate: sizing, anatomy (dimensional / conformational) Disadvantages • Radiation • Contrast nephropathy Natural History Natural History Natural history of AAA: To EXPAND and RUPTURE > 80% of small aneurysms grow Pattern of growth is unpredictable and staccato (i.e., stop-and-go) Past growth does NOT predict future growth 50% die from other causes (mostly cardiovascular) 50% die from aneurysm rupture Natural History Risk of Rupture Estimated risk of rupture (per year) 4.0-5.4 cm 5.5-6.4 cm 6.5-6.9 cm 7.0-7.9 cm ≥8.0 cm 0.6% 10% 19% 35% 51% Risk of Rupture Rate of Expansion Estimated rate of expansion (per year) < 4 cm 4-5 cm > 5 cm 0.2-0.4 cm 0.2-0.5 cm 0.3-0.7 cm Aneurysm Size AAA‐Recommended Management • • • • 3‐4 cm follow‐up one year 4‐5 cm follow‐up six months > 5 cm‐ repair Rapidly expanding >2mm per 6 months Normal rate of expansion 2mm/year Endovascular Repair Thoracic Endograft Popliteal Aneurysm Endovascular Repair Functional Description of Intermittent Claudication • Symptoms – Exertional aching pain, cramping, tightness, fatigue – Occur in muscle groups, not joints (buttocks, hips, legs, calves) – Are reproducible from one day to the next on similar terrain – Resolve completely with 2-5 minutes of rest Prevalence of PAD/Intermittent Claudication in Smokers • Severity of PAD increases with number of cigarettes smoked • Diagnosis is made a decade earlier • Intermittent claudication is 3 times more common in smokers • Smoking is the most powerful modifiable risk factor for PAD TASC Working Group. J Vasc Surg. 2000;31(1 suppl):S1-S296. Kannel WB et al. J Am Geriatr Soc. 1985;33:13-8. How to Perform and Calculate the ABI PARTNERS Program ABI Interpretation Right Arm Pressure: Above 0.90 — Normal Left Arm Pressure: 0.71‐0.90 — Mild Obstruction 0.41‐0.70 — Moderate Obstruction 0.00‐0.40 — Severe Obstruction Pressure: PT DP Pressure: PT DP Right ABI Left ABI Higher Right Ankle Pressure = Higher Arm Pressure mm Hg Example mm Hg = = ____ Higher Ankle Pressure Higher Brachial Pressure Higher Left Ankle Pressure = Higher Arm Pressure mm Hg 92 mm Hg = mm Hg 164 = 0.56 mm Hg = ____ = See ABI Chart PAD Disease Management Symptomatic Treatment Prevention of Ischemic Events Exercise1 Smoking cessation1,2 Pharmacologic therapy – Clopidogrel5 – Cilostazol3 • Selective use of interventional therapy4 • Control of risk factors4 – Smoking – Hyperlipidemia – Hypertension – Diabetes • Antiplatelet therapy2 • • • 1. McDermott MM, McCarthy W. Surg Clin North Am. 1995;75:581‐591. 2. Clagett GP, Krupski WC. Chest. 1995;108 (4 suppl):431S‐443S. 3. Pletal (cilostazol) Prescribing Information. 4. Kempczinski RF, Bernhard VM. In: Rutherford RB, ed. Vascular Surgery. 1989: chap 53. 5. Plavix (Clopidogrel) prescribing information. Risk‐Factor Modification • Smoking cessation • LDL cholesterol <100 mg/dL, recent literature < 70 mg/dl • Glycosylated hemoglobin <7.0% • Blood pressure <130/85 mm Hg Hiatt WR. N Engl J Med. 2001;344:1608‐1621. Surgical and Endovascular Treatment Options • Surgical – endarterectomy – bypass • Endovascular – percutaneous transluminal angioplasty – percutaneous transluminal angioplasty with stent placement Creager M. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000. Indication for surgical intervention  Clinical Limb ischemia  Gangrene  Non‐healing ulcers  Ischemic rest pain  Claudication causing life style deterioration refractory to pharmacologic intervention and behavioral modification Right Iliac Stenosis Pre- and Post-PTA SFA Angioplasty and Stent Peripheral Arterial Disease • • • • 80 y.o. Hypertension High Cholesterol 2 week history of progressive toe pain Total Occlusion The PAD Guideline is Intended to Guide Lifelong Primary to Specialty PAD Care Population at risk: (Age and risk factors) Establish the PAD diagnosis Population with symptoms: Improve limb outcomes Prevent CV ischemic events Population remains at risk: Primary care management of legs and life, in collaboration with vascular specialists •ABI •TBI •Duplex US •MRA Medical Therapy Endovascular Therapy Surgical Therapy •CTA •Angiography Integrated care requires a partnership of vascular specialists (vascular medicine, cardiology, interventional radiology, nursing, podiatry, and others) ABI=ankle-brachial index; CTA=computed tomographic angiography; CV=cardiovascular; MRA=magnetic resonance angiography; TBI=toe-brachial index; US= ultrasound.