evolving strategies in the treatment of peripheral vascular disease ravish sachar md, facc wake...
TRANSCRIPT
Evolving Strategies in the Treatment of
Peripheral Vascular Disease
Ravish Sachar MD, FACC
Wake Heart and Vascular
Disclosures
• Educational Grants: Boston Scientific, Abbott Vascular, ev3
• Consultant: Abbott Vascular, ev3
• Speakers Bureau: Boston Scientific, Abbott Vascular
Atherosclerosis Common Etiology
30-60% of pts with PVD have carotid disease
50-60% of pts with carotid disease have coronary disease
10% of pts with coronary disease have carotid disease
Results of Coronary Angiograms in 634 Patients with PAD
8.5%
Patient Survival by ABI
Newman et al ATVB 1999;19; 538-545
Five year mortality ratesPVD versus Cancer
Breast cancer
PAD
Colon/Rectal
Lung Cancer
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Five Year Mortality Rates
*Criqui M. Presentation: Vascular Medicine of the Lower Extremities at the American Diabetes Association’s Scientific Sessions June 1999
PVD ….What are the goals?
• Asymptomatic – treat risk factors
• Claudication – medical therapy or revascularization to improve symptoms
• Critical Limb Ischemia – prevent amputation and limb loss
Goal…Prevention of Amputation
Diagnosis
• Non-invasive– Bedside Ankle-Brachial Index– Lower extremity Segmental Pressures and PVRs– Arterial Duplex imaging– MRA– CTA
• Invasive– Angiograpy
Magnetic Resonance Angiography
Disease Patterns
Non-Diabetics Diabetics
Aorto Iliac Disease
SFA Disease
SFA OCCLUSION
pre post
Subintimal Angioplasty
Reentry Catheters
• Outback • Pioneer
SFA – PTA/Stenting
Post
Knee Extension Knee Flexion
Problems with SFA Stenting….
With KneeFlexion
Compression
3.
Extension / Contraction 1.
Torsion
2. Flexion 4.
Forces Exerted on Stents in SFA
TypeI
TypeII
TypeIII
TypeIV
Directional Atherectomy
Directional Atherectomy
Atherectomy
AfterBefore
Directional Atherectomy
Orbital Atherectomy
Rotational Atherectomy
Laser Atherectomy
Conclusions
• Peripheral Vascular Disease is very prevalent in patients with cardiac disease
• PVD is underdiagnosed and undertreated
• High Mortality with PVD – usually due to cardiac causes
• There are many revascularization options available to patients to improve quality of life
Thank You!
Thank You!
Percutaneous Surgical
Patient Preference
Treating Critical Limb Ischemia
Primary Treatment for severe PVD in
the 1800’s
Treating Critical Limb Ischemia
In some places Primary Treatment for severe PVD in
2008
Amputations – current data
• Less than 20% get an angiogram • Only 50% get an ABI
• Most of these patients do have limb salvage options
• It is not conservative treatment to amputate!
“For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive
treatment to even do an angiogram”
Amputation (Impact!!)
• Survivors who ambulate (prosthesis) BKA - 40-50%
AKA - 25%
• Psychological testing :“worse than cancer”
Possibilities….
Possibilities….