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  • Left: Lateral view of infarenal aortic aneurysm (AAA) with a saggital “DropSlice” shown for context. bloodflow (red) thrombus and non-calcified plaque (yellow) plaque (white) Right AP view of thoraco-abdominal aortic aneurysm (TAA) with a coronal “DropSlice” shown for context
  • The freedom from reintervention for the overall series is obviously affected by grafts that ultimately did not gain FDA approval. However, our secondary intervention rate is equal to or better than other series with a similar mix of approved and non-approved grafts. This is illustrated by a lifetable comparison to the Eurostar registry over a similar time period.
  • Slide 1 The diagnosis and management of peripheral arterial disease (PAD) and its symptoms in the office setting can present many challenges to the physician. However, if primary care practitioners accept these challenges, they can play an extremely important role in identifying PAD, reducing PAD-related morbidity and mortality, favorably impacting symptoms, and improving patients’ quality of life (QOL). This presentation will help provide some critical information about detection and therapy that will help ensure successful interventions and outcomes for PAD patients.
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    1. 1. What Is Peripheral Vascular Disease? Daniel B. Walsh, M.D. Professor of Surgery, Section of Vascular Surgery Vice-Chair, Department of Sugery Dartmouth-Hitchcock Medical Center
    2. 2. Perhipheral vascular disease is considered to be any abnormality of the arteries and veins outside of the skull and the heart.
    3. 3. Differences Between Arteries & Veins
    4. 4. Components <ul><li>Problems with veins </li></ul><ul><ul><li>Varicose veins </li></ul></ul><ul><ul><li>Blood clots and sequelae </li></ul></ul><ul><li>Arterial Aneurysms </li></ul><ul><ul><li>Aorta and branches </li></ul></ul><ul><li>Arteries blocked by atherosclerosis </li></ul><ul><ul><li>Carotid, Legs. Kidneys, GI tract </li></ul></ul>
    5. 5. Risk Factors for Atherosclerosis Age Diabetes Obesity Genetics Dyslipidemia Hypertension Hyperhomocysteinemia Atheroscleroris Atherosclerotic Disease and Complications (coronary, cerebrovascular, peripheral arterial events Smoking
    6. 8. Natural History of PAD in US Population Adapted from Weitz JI. Circulation 1996;94:3026-49. Population Aged >55y Asymptomatic ABI <0.9 10% Intermittent claudication 5% Critical leg ischemia 1% PAD outcomes (5-year outcomes) Cardiovascular morbidity/mortality Stable claudication 73% Worsening claudication 16% Leg bypass surgery 7% Major amputation 4% Nonfatal events (MI/stroke) 20% Mortality 30%
    7. 9. Intervention for Tissue Loss/ Rest Pain, Severe Claudication <ul><li>Medications </li></ul><ul><li>Risk factor assessment & reduction </li></ul><ul><li>Exercise program </li></ul><ul><li>PTA/Stents </li></ul><ul><li>Operation </li></ul>
    8. 11. Aneurysms can occur in these arteries: <ul><li>Carotid </li></ul><ul><li>Subclavian </li></ul><ul><li>Thoracic </li></ul><ul><li>INFRARENAL </li></ul><ul><li>Renal </li></ul><ul><li>Hypogastric </li></ul><ul><li>Iliac </li></ul><ul><li>Femoral </li></ul><ul><li>Popliteal </li></ul>
    9. 12. What is an Aortic Aneurysm? Abdominal Aortic Aneurysm (AAA) Thoracic Aortic Aneurysm (front view)
    10. 21. “ Endovascular” Aortic Aneurysm Repair Pre-repair Post-repair
    11. 22. Freedom from Re-Intervention DHMC vs EUROSTAR* * Eurostar Data Registry, Jan.2001 Freedom from Re-Intervention 0 .2 .4 .6 .8 1 0 10 20 30 40 50 60 70 Time (months) DHMC, entire series EUROSTAR*
    12. 23. First Successful CEA F. Eastcott May 19, 1954 C. Rob
    13. 24. Carotid Atherosclerosis
    14. 25. Proven Benefit of CEA Percent 30 Day Stroke, Death + Late Ipsilateral Stroke 2 Year 3 Year 5 Year 5 Year Symptomatic Asymptomatic <ul><li>4 Randomized Trials </li></ul><ul><li>> 12,000 patients </li></ul><ul><li>Relative risk reduction: </li></ul><ul><li>Symptomatic: </li></ul><ul><ul><li>50-69% - 25% </li></ul></ul><ul><ul><li>70-99% - 61% </li></ul></ul><ul><ul><li>Asymptomatic: </li></ul></ul><ul><ul><li>60-99% - 48% </li></ul></ul>
    15. 26. Selective carotid injection
    16. 30. Acculink 6-8x40mm
    17. 31. Summary <ul><li>3D CTA can be used to screen “high risk” CAS patients better served with modified CAS, CEA, or medical management </li></ul>
    18. 32. Comparison of Carotid Endarterectomy and Stent Dartmouth Experience (2000-Present) <ul><li>Number 366 173 </li></ul><ul><li>Stroke 0.5% 2.9% </li></ul><ul><li>Myocardial Infarct 4% 1.2% </li></ul><ul><li>Death 0.8% 0.8% </li></ul>Endarterectomy Stent
    19. 33. Conclusions <ul><li>CEA remains the “gold standard” RX </li></ul><ul><li>CAS risk increases with age and requires EPD </li></ul><ul><li>Carotid stent treatment of extracranial carotid occlusive disease is safe in selected patients. </li></ul><ul><ul><ul><li>? Asymptomatic medical high risk </li></ul></ul></ul><ul><li>3D CTA can assist in selecting patients for CAS </li></ul><ul><li>Need to be prepared to handle technical difficulties </li></ul><ul><ul><ul><li>Know when to stop </li></ul></ul></ul><ul><li>Long-term durability of the procedure needs to be determined </li></ul>