This document discusses cardiovascular risk management from the perspective of a vascular surgeon. It summarizes the author's experience treating patients with chronic myeloid leukemia who developed vascular complications. The main points are: 1) Patients with chronic myeloid leukemia often have multi-level vascular disease involving the carotid, renal, mesenteric, and lower extremity arteries. 2) Endovascular interventions had high restenosis and failure rates, while open surgeries resulted in better mid-term patency but higher amputation rates. 3) An aggressive surgical approach along with intensive medical management and follow-up is needed for these high-risk patients due to their underlying disease and risk factors. A multidisciplinary team approach

1. GESTIONE DEL RISCHIO CARDIOVASCOLARE
IL PUNTO DI VISTA DEL CHIRURGO VASCOLARE
A. Siani
U.O.S.D. Chirurgia Vascolare ed Endovascolare
Resp. Dr S.Bartoli
Ospedale “S.Eugenio” ASL RM2
Roma

2. Chronic L/M Leukemia and Tyrosine Kinase Inibithors
2016-2019 < 50 publications
Crosse sectional or retrospective studies
No meta-analysis
2 Prospective studies (<100pts)
Several statistical bias…..but current clinical practice suggest that
Disease and therapy are collaborative problems in Vascular
disease development

3. Chronic L/M Leukemia and Critical limb ischemia
-23 pubblications (2014-2019) Low statistical power
-) high incidence of evolution
-) high incidence of multilevel disease (visceral,carotid)
-) high incidence of reintervention ( endo or open)
high incidence of leg amputation and low expectancy life
(protrhrombotic state, endotelial dysfunction, apoptosis, high
incidnce of HIM respone…. But really uncelar)
NO good candidates for revascularization

4. Tyrosine Kinase Inibithors and critical limb ischemia
2019 < 20 publications
Crosse sectional or retrospective studies (200 pts)
2 Prospective studies (<100pts)
-) High incidence of progressive disease
-) Multiple involvment ( expecially visceral )
-) high incidence (> 60%) of HIM after endo or open surgery
No good mid and long term results and high mortality rate after
MACE

5. Final angio
Carotid
SFA and POP –distal
Visceral (renal/sma/ct)
Obstructive
HIM +++
Fibrosys
Long lesions
HARD (lipidic, fibrotic)
Chronic
Evolutiv to CLI
Anatomy and Histopatology
Risk Factors
Therapy TKI
L stage

6. LMC-age
18-30 31-40 41-50 51-60 61-70 71-80 81-85
6,3%
(9pz)
18,2%
(26pz)
18,2%
(26pz)
27,3%
(39pz)
12,6%
(18pz)
13,3%
(19pz)
4,2%
(6pz)
143 pts
76 pts 53.1%

7. S.Eugenio experince : 18 pts 2017- 2019
5 >70% Asymptomatic Carotid stenosis
3 > renal artery stenosis with RIN
3 > 50% SMA e CT stenosis
 13 PAD
3 Polyvascular pts
 8 CLI IV
 5 Stage II
HTN 10 100 %
CAD 6 33.4 %
CRF 4
DM 7 11.1%
Dyslipidemia 10
Mean age 72 y
10 male
TKI

8. Final angio
CEA: 2 patch, 3 EV, 3 shunt. No intraprocedural complications
6 months F.U. 30% restenosis
3 Renal Stenting: Renal improvment, 1 occlusion
1 SMA –aorto bypass: 6 months good results
13 PAD
5 stage II : 60% P.patency at 1y, 80% S patency at 1 y, Reintervention 1 y 20%
100% Endo aproach ( iliac / SFA)
8 CLI: 75% P.P at 1y, 15% amputation rate at 1 y
100% open surgey ( fem-pop-distal bypass graft)
Results

9. Final angio
Age
TKI
Multilevel disease
DM
Poor runoff
Dyslipidemia
L-Stage
Results: univariate analisys p<0.5
Restenosis
Occlusion
Failure graft
Amputation
Death

10. Final angio

11. DCB: follow-up a 12 mesi in SFA e BTK

15. Final angio

16. Final angio

17. Final angio
Lesson learned
-) Endo no first approach ( only stage II, short lesions)
-) Operative approach only in symptomatic (visceral)
-) Open approach is the gold standard (always)
-) DAT + Station Therapy (long term)
-) Distal graft AC therapy
-) Intensive F.U. strategy

18. Final angio
Conclusions
-) Aggressive approach ( primary and secondary)
-) R.F. assesment and managment
-) Need of Team with oncologist, angiologist and
cardiologisty

19. Final angio
Grazie per l’attenzione…..