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Arterial disease
- 1. Investigations and Management ofArterial diseases Moderator - Dr Shubhakar Bhandary / Dr Airind Mathai
- 2. Investigations Physiological testing andimaging Non Invasive Invasive
- 3. Non invasive testing •Confirmation • Localise • Demonstrate end points following surgery • Follow up - detect recurrence
- 4. Segmental limb pressure Significantdisease - decrease in pressure of 20 mm of Hg
- 5. Exercise testing Resting pressure walkat 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 usedto 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
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- 10. Catheter Angiography Invasive procedurerequiring 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 vesselpuncture 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 HighOsmolality possible to reduce the osmolality Low Viscosity Increased viscosity Higher Complications Lower Complications
- 13. 1. Abdominal Aortography Multisidecatheter - 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 endovascular 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 isamplified and digitised Initial non contrast image is electronically subtracted
- 16. CT angiography • SingleContrast 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 • Doesnot 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, 360degree 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
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- 21. Aspirin Mechanism of Action Inhibitscyclooxyrgenase- 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
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- 23. Clopidogrel Mechanism of Action InhibitsADP 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 levelsof 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)
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- 28. Problems of classification LifestyleLimiting Claudication
- 29. Trans-Atlantic Inter-Society Consensus Documenton Management of Peripheral Arterial Disease - 2000 Lesion Location Lesion Morphology
- 30. Trans-Atlantic Inter-Society ConsensusDocument 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 AortoiliacLesions 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 AortoiliacLesions 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 AortoiliacLesions 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-AtlanticInter-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-AtlanticInter-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 TYPEB Endovascular - preferred TYPE C open surgery - preferred TYPE D open surgery - recommended
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- 38. Endovascular management Balloon Angioplasty SubintimalAngioplasty Stenting Atherectomy
- 39. Subintimal Angioplasty Arterial dissectiondone using wire to create false tract False Lumen’s diameter is increased by balloon angioplasty
- 40. Balloon Angioplasty Successful - residualstenosis is <30% or there is no pressure gradient across the area treated
- 41. Stenting Balloon-expandable stents Passively enlargedto 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
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- 43. Revascularization Surgical Reconstruction ofAortoiliac Occlusive Disease
- 44. Arterial Substitutes • Arterialautograft – 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 veinPolytetrafluoroethylene
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- 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 endAnastomoses
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- 52. Medical Complications Perioperative myocardialinfarction Respiratory failure Ischemia-induced renal failure Bleeding from IV heparinization Stroke
- 53. Procedure related early complications Declampingshock 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
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