presentation on investigations and management of atherosclerosis and Chronic ischemic disease

1. Investigations and
Management of Arterial
diseases
Moderator - Dr Shubhakar Bhandary / Dr Airind Mathai

2. Investigations
Physiological testing and imaging
Non Invasive
Invasive

3. Non invasive testing
• Confirmation
• Localise
• Demonstrate end points following surgery
• Follow up - detect recurrence

4. Segmental limb pressure
Significant disease - decrease in pressure of 20 mm of Hg

5. Exercise testing
Resting pressure
walk at a set speed (5km/hr)
with fixed inclination (12
degree) for 5 mins or until
forced to stop due to
symptoms
Arm and ankle pressure
measured immediately and
every 2 mins for 10 mins
Patients with more than 20 mm of Hg pressure drop at ankle in comparison to upper
extremity significantly benefit from vascular reconstruction

6. Photoplethysmography
Photo electrode is
used to detect
changes in
cutaneous blood flow
Particularly useful in patients with pedal artery occlusive disease or
highly calcified vessels.

7. Duplex scanning
Pulsed Doppler + B mode imaging
Detect and quantitate PVD
Color duplex scanner Carotid vessels - stenosis at bifurcation

8. Vascular Imaging

9. Vascular Imaging
Angiography
DiagnosticTherapeutic and

10. Catheter Angiography
Invasive procedure requiring catheter placement in the
area of interest of the vascular system, iodine-based
contrast media injection and ionising radiation based
images.
Indications
Diagnostic
Emergency
Guidance in elective
procedures

11. 1. Percutaneous vessel puncture with a
puncture needle
Seldinger Technique
2. Backflow is observed
3. Guidewire is advanced through the needle
4. Pressure is held over the puncture site
while the needle is pulled out with the guide
wire in place
5 - 6. a diagnostic catheter or an introducer
sheath may be advanced over the wire
7. the wire is removed and percutaneous
intravascular access is obtained

12. Contrast Media
Ionic Non-ionic
High Osmolality
possible to reduce
the osmolality
Low Viscosity Increased viscosity
Higher
Complications
Lower
Complications

13. 1. Abdominal Aortography
Multiside catheter - side of
diaphragm
• Abdominal aorta
• Celiac
• Superior mesenteric
• Inferior mesenteric
• Aortic bifurcation
2. Pelvic angiography
Multiside hole catheter - at the
aortic bifurcation
• Bilateral common iliac
• External Iliac
• Common femoral
• Proximal Superficial femoral
• Profunda Femoral
4. Ipsilateral Common Iliac artery
Access sheath is pulled back to
visualise the ipsilateral limb
3. Contralateral Common Femoral
artery
End Hole catheter
• SFA
• Profunda
• Popliteal
• Tibial
• pedal vessels

14. Risks of endo vascular
procedures
Groin Hematoma
Retroperitoneal bleeding
Pseudoaneurysm
Arterial dissection
Brachial sheath hematoma - Neural compromise
Contrast Nephropathy
Increase Oral hydration prior and following procedure
Metformin, ACE inhiitors and Diuretics are avoided
Acetylcysteine - 1200mg PO BID
IVF - 1/2 NS with 1.5 ampules of Sodium Bicarbonate

15. Digital
Subtraction
Angiography
Fluoroscopic image is amplified
and digitised
Initial non contrast image is
electronically subtracted

16. CT angiography
• Single Contrast bolus
• Depiction of the entire vessel,
appreciate thrombus and
calcification
• Three dimensional reconstruction
and multiplanar reformatting
• Iodinized contrast agents
complications - Nephrotoxicity
Significant radiation exposure

17. MR angiography
• Does not require iodine based
contrast agents
• Contrast - Gadolinium
• Contraindicated - Pts with
pacemakers, defibrillatorrs, spinal
cord simulators, intracerebral shunts,
cochlear implants and cranial clips
• Limitations - slow and expensive

18. Intravascular Ultrasound
Transverse, 360 degree
image of the lumen of the
vessel
Provides qualitative data
about the wall anatomy
Virtual histology
Diagnostic tool - assess and measure
the severity
Measure the completeness of the
treatment

19. Medical Management

20. Aspirin and Clopidogrel

21. Aspirin
Mechanism of Action
Inhibits cyclooxyrgenase-
mediated production of
thromboxane A2
Side Effects
Gastrointestinal
Dosages
75 to 325 mg once daily
Indications
Secondary prevention of
vascular events in patients
with established coronary,
cerebrovascular or peripheral
arterial disease

22. Clopidogrel

23. Clopidogrel
Mechanism of Action
Inhibits ADP induced platelet
aggregation
Side Effects
Rashes, diarrhoea and
pruritus
Dosages
75 mg once daily
Indications
Reduce risk for
Cardiovascular death, MI and
stroke - marginally more
effective than aspirin

24. Cilostazol
↑ cellular levels of cAMP
Inhibits platelet aggregation and thrombus formation
↓vascular smooth muscle cell proliferation
Oxypentifylline
Reduces blood viscosity
↑Red cell deformablity
↓plasma fibrinogen levels
Side effects - Headache and GI disturbance

25. • Antioxidants
• Prostaglandins
Prostaglandin E1 and prostacyclin
derivatives - iloprost and beraprost

26. Risk factors modification
• Smoking Cessation
• Hyperlipidemia (LDL < 100mg/dl)
• Statins
• Hypertension (systolic < 140 and diastolic < 90)
• Beta blockers
• ACE inhibitors
• Diabetes (HbA1c - < 7)

27. Surgical revascularization
procedures

28. Problems of classification
Lifestyle Limiting Claudication

29. Trans-Atlantic Inter-Society Consensus
Document on Management of Peripheral
Arterial Disease - 2000
Lesion Location
Lesion Morphology

30. Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral
Arterial Disease - II, 2007
Classification of Aortoiliac Lesions
TYPE - A
• Unilateral / Bilateral
stenosis of CIA
• Unilateral / Bilateral single
short (< 3 cms) stenosis of
EIA

31. Classification of Aortoiliac Lesions
TYPE - B
• Short (< 3 cms) stenosis of
infrarenal aorta
• Unilateral CIA occlusion
• Single or Multiple stenosis
totalling 3 - 10 cms
involving the EIA not
extending into the CFA
• Unilateral EIA occlusion not
involving the origins of
internal iliac artery or CFA
Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral
Arterial Disease - II, 2007

32. Classification of Aortoiliac Lesions
TYPE - C
• Bilateral CIA occlusions
• Bilateral EIA stenosis 3 - 10
cms long not extending into
the CFA
• Unilateral EIA occlusion that
involves the origins of internal
iliac artery and/or CFA
• Heavily calcified unilateral EIA
occlusion with or without
involvement of origins of
internal iliac artery and/or CFA
Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral
Arterial Disease - II, 2007

33. Classification of Aortoiliac Lesions
TYPE - D
• Infra renal aortic occlusion
• Diffuse disease involving the
aorta and both iliac arteries
requiring treatment
• Diffuse multiple stenosis involving
the unilateral CIA, EIA and CFA
• Unilateral occlusion of both CIA
and EIA
• Bilateral occlusion of EIA
• Iliac Stenosis in patients with AAA
requiring treatment and not
amenable to endograft placement
or other lesions
Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral
Arterial Disease - II, 2007

34. Classification of Femoropopliteal
Lesions
Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral
Arterial Disease - II, 2007
• single stenosis < 10 cms in length
• single occlusion < 5 cms in length
• Multiple lesions (stenosis or occlusions)
each <5 cms
• Single stenosis or occlusion <15 cms not
involving the intrageniculate popliteal
artery
• SIngle or multiple lesions in the absence
of continuous tibial vessels to improve
inflow for a distal bypass
• Heavily calcified occlusion <5 cm in
length
• Single popliteal stenosis

35. Classification of Femoropopliteal
Lesions
Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral
Arterial Disease - II, 2007
• Multiple stenosis or occlusion tattling >15 cms
with or without heavy calcification
• Recurrent stenosis or occlusion that need
treatment after two endovascular
interventions
• Chronic total occlusion of CFA or SFA (>20
cms involving the popliteal artery )
• Chronic total occlusions of popliteal artery
and proximal bifurcation vessels

36. TYPE A
Endovascular -
recommended
TYPE B Endovascular - preferred
TYPE C open surgery - preferred
TYPE D
open surgery -
recommended

37. Endovascular
management

38. Endovascular management
Balloon Angioplasty
Subintimal Angioplasty
Stenting
Atherectomy

39. Subintimal Angioplasty
Arterial dissection done
using wire to create
false tract
False Lumen’s diameter is
increased by balloon
angioplasty

40. Balloon Angioplasty
Successful -
residual stenosis is
<30% or there is no
pressure gradient
across the area
treated

41. Stenting
Balloon-expandable stents
Passively enlarged to a desired diameter
at the site of implantation by dilatation
of the balloon
Self Expanding stents
Open actively after being released from
a dedicated delivery system

42. Atherectomy

43. Revascularization
Surgical Reconstruction of Aortoiliac
Occlusive Disease

44. Arterial Substitutes
• Arterial autograft – Internal mammary artery (common), internal iliac
artery.
• Venous autograft – Long saphenous vein (common), small saphenous
vein, basilic vein, cephalic vein.
• Venous allograft – Umbilical vein graft.
• Prosthetic grafts:
• Textile grafts -Dacron graft and Teflon graft – Knitted or woven types.
• Non-textile semi-inert polymer graft - -ePTFE graft – Expanded
polytetrafl uoroethylene graft.

45. Conduits
Great saphenous vein Polytetrafluoroethylene

46. Aortoiliac diseases

47. • Indications - disease involving the external iliac artery /
extending to common femoral artery
• Transabdominal or Retroperitoneal approach
• Proximal anastomosis
• End to End
• End to side
Aortobifemoral Bypass

48. End to end Anastomoses

49. Aortobifemoral Bypass

50. Aortoiliac endartectomy

51. Axillobifemoral bypass

52. Medical Complications
Perioperative myocardial infarction
Respiratory failure
Ischemia-induced renal failure
Bleeding from IV heparinization Stroke

53. Procedure related early
complications
Declamping shock
Graft thrombosis
Retroperitoneal bleeding
Groin hematoma
Bowel ischemia/infarction
Peripheral embolization
Erectile dysfunction
Lymphatic leak
Chylous ascites
Paraplegia

54. Graft infection
Anastomotic pseudoaneurysm
Aortoenteric fistula Aortourinary fistula
Graft thrombosis
Procedure related late
complications

55. Lower extremity
occlusive disease

56. Femoropopliteal Bypass

57. Profundaplasty

58. Thank you