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Peripheral Vascular Disease

Erin Bolken, PA-C

Vascular Surgery

October 15, 2016

Pacific Vascular Specialists9155 SW Barnes Road, #321 Portland, OR

503-292-0070

pacificvascularspecialists.com

Overview

� Goals◦ Insight into the Vascular Surgery specialty

◦ Geared toward the PCP � When do you need to refer to a Vascular Surgeon?

� What information will help with a referral and what can the patient expect?

� Venous disease

� Arterial disease

What do we do?

� Offer comprehensive medical, surgical and endovascular treatment for:◦ Abdominal and Thoracic Aortic Aneurysms

◦ Peripheral Artery disease

◦ Carotid artery disease

◦ Varicose Veins & Venous Ulcers

◦ Deep Vein Thrombosis

◦ Dialysis and Vascular Access

◦ Aortic Dissection

◦ Other Complex Vascular Diseases

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Peripheral Venous Disease

Anatomy

Varicose Veins

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VV Risk factors

� Age

� Gender

� Obesity

� Pregnancy

� Family hx

� Lifestyle

� Prolonged standing

Signs and Symptoms

� Edema or swelling ◦ Improved with elevation and/or compression

� Discomfort◦ Pain, ache, itching

� Especially after long periods of standing

� Bulging superficial veins◦ Swollen, twisted, dilated, superficial bleeding

◦ Cosmetic concern

Diagnosis

� History

� Physical exam

� Ultrasound

◦ Checking for reflux (blood flow in the wrong direction)

� Antegrade flow

� Retrograde flow

Telangectasia (spider veins)

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Treatment

� Conservative

◦ Compression*

� Various grades

� Rx for >20mmHg

� Helps with decreasing pressure in the tissues

◦ Elevation

◦ Exercise

◦ Hydration

Treatment� Invasive

◦ Sclerotherapy� Hypertonic solution used to create inflammatory response along with compression

� Small, spider veins

◦ Stripping of veins � Superficial varicosities

◦ Endovenous radiofrequency ablation (GSV)

◦ Laser ablation

Chronic Venous Insufficiency(Venous stasis disease)

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Venous Stasis

� High pressure in veins

� Incompetent valves◦ retrograde flow and pooling due to gravity.

� Usually noted around the ankles ◦ Feet dependent

Venous Stasis risk factors

� Age

� Obesity

� Pregnancy

� Family hx

� Sedentary Lifestyle

� Prolonged standing

� Injury or prior surgery of the leg/foot

� Post-thrombotic Syndrome (hx of DVT)

VS Signs and Symptoms

� Heaviness, aching

� Edema/swelling in lower extremities

� May also have varicose veins

� Skin changes (thin, discolored, flakey, leathery)

� Venous stasis ulcerations (non-healing)

◦ May involve cellulitis

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VS Diagnosis

� History ◦ Investigate origin of the ulcer� What are the 4 top reasons people have staged/non-

healing ulcers??*� Pressure, infection, arterial or venous problem

� Physical exam◦ What are the signs and symptoms?

◦ Rule out ischemic ulcer (why?)

� Pulses, doppler signals (hx of claudication?)

� Important information to know (pt can have both)

� Chronic venous ultrasound

VS Treatment

� Compression*

◦ Stockings to prevent ulceration

◦ Unna Boot – open/active ulcers

� Elevation

� Exercise

� Vein stripping

� Venous ablation (GSV)

Venous Thrombosis

� Blood clot in the veins

� SVT vs. DVT

� Pulmonary embolism (lung)

� May-Thurner syndrome (iliofemoral v.)

� Paget-Schroetter syndrome (subclavian v.)

� Thrombophlebitis (inflammation of vein)

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Superficial thrombophlebitis

Superficial Thrombophlebitis

� Blood clot in vein just under the skin

� Erythema, tenderness, palpable cord

� Low risk, patients need reassurance (but watch for progressive sxs)

� Often due to peripheral IV catheter, procedure

� Treatment: Warm compresses, NSAIDs, elevation, rest, TIME

Complications of DVT• DVT and PE are common, accounting for up to 300,000 deaths per year

� Post-operative initiatives

◦ LMWH (Lovenox), SCDs, compression stockings, mobility, etc.

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DVT risk factors� Surgery, immobilization, trauma

� Hypercoaguable (Coagulopathy)◦ Factor V Leiden, neoplasm, etc

� Smoking

� Prolonged travel

� Pregnancy/hormonal contraception

� Intravascular catheters

� History of DVT

� Dehydration

Virchow’s Triad

DVT Signs and Symptoms

� Up to 40% of people will not have symptoms!◦ Low threshold for getting an ultrasound if concern is present

� Pain

� Swelling

� Discoloration of affected leg

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Pulmonary Embolus: Signs and Symptoms

• Sudden feeling of impending doom

• Shortness of Breath (increased respirations)

• Decreased SpO2

• Elevated Heart Rate

• Current or Hx of LE DVT

• Hemoptysis

DVT Diagnosis

• Physical exam is unreliable• Begins with suspicion / recognition of increased risk

• Duplex ultrasound study• CT scan (for PE)• With or without contrast?

• D-dimer (sensitive but not specific)• Breakdown products of thrombosis• More useful when suspect PE (and patient has not had recent surgery/trauma)

• Venography

DVT/PE Treatment and Prevention• Treatment must begin immediately

• Anticoagulation*• heparin (IV)

• LMWH (enoxaparin, dalteparin) –subQ injection

• warfarin (Vit. K antagonists)

• Factor Xa inhibitors (rivaroxaban, apixaban)

• Direct thrombin inhibitor (dabigatran)

• IVC Filter• Useful if not a candidate for anticoagulation

• Most are placed for temporary treatment, should be removed after 6-8 wks.

• Endovascular lysis of the clot• Evidence shows minimal benefit unless symptoms are severe (and acute)

• Prevention: Compression stockings, LMWH prophylaxis, SCDs, ambulation

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Peripheral Arterial Disease

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Anatomy

Peripheral Arterial Disease

� Insufficient blood flow to a limb or organ system

◦ Atherosclerosis (plaque formation)� Carotid stenosis� Mesenteric ischemia (Celiac, SMA, IMA)� Aortic, iliac, femoral, popliteal, and tibial artery disease� Other: renal a. stenosis, anything else requiring blood flow

◦ Arterial Embolism causing occlusion� Patent foramen ovale� Atrial fibrillation� Hypercoagulable pathology

Who is at risk for atherosclerosis?

� Smokers!

� Hypertension

� Hyperlipidemia

� Family History

� Diabetes

� Poor exercise

� Poor Diet

� Age

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Symptoms of LE PAD

� Claudication◦ Vascular vs. neurogenic

� What’s the difference?

◦ What is their baseline activity?

� Hair loss� Non-healing ulcers◦ Arterial vs. venous

� Numbness◦ Does the pt have peripheral neuropathy due to diabetes?

� Rest pain◦ Classic sign “hangs foot off edge of bed at night”

� Gangrene (tissue death)

Diagnosis of LE PAD� History� Presence of above symptoms� Ankle-brachial index (ABI)◦ Easy to do, good information (need a doppler)

◦ Systolic ankle mmHg/systolic brachial mmHg

◦ >1 considered normal, abnormal if less than 1.

� Peripheral arterial exam*◦ Provides waveforms of the LE blood flow

◦ At rest or with treadmill exercise

� Doppler ultrasound (arteries)*� CTA (contrast needed)� Angiography (contrast needed)

� * = Performed in a vascular lab

Ankle-brachial index (ABI)

ABI = Ankle SBP/Brachial SBP>1 = normal<1 = abnormal (severity is based on clinical picture)

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Peripheral arterial exam (PAE)

CT Angiogram

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Angiogram

PAD Treatment

� Conservative measures (non-invasive)◦ Exercise (try to improve endurance)◦ Risk factor control

� Smoking cessation, HLD, HTN, diet, etc.

◦ Daily Aspirin◦ Pletal (cilostazol) –

� Helpful for some, but if no benefit noted, then discontinue

◦ Lipid lowering medications (statin*)

� Surgical interventions◦ Endovascular - Angioplasty/stent◦ Direct/open repair - Endarterectomy or arterial bypass◦ Amputation (no revascularization options)

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Arterial bypass surgery

� Most common in the lower extremities

� When to proceed with surgery?◦ Limited function/mobility

� Affecting quality of life, debilitating symptoms� Treat the patient, not the numbers…surgery comes with risk too.

◦ Non-healing ulcers or gangrene◦ Rest pain in the foot (limb threatening)

� Conduit:◦ Pt’s greater saphenous vein (arm veins if big enough)◦ PTFE graft (synthetic)◦ Cryovein (preserved and frozen cadaver vein)

Carotid Occlusive Disease� Plaque build-up at the bifurcation of the common carotid artery

� Increased risk of stroke as the stenosis becomes more severe

� Stenosis based on internal carotid artery (ICA) measurements

� Intervention recommended when stenosis is:◦ Greater than 80% (asymptomatic)

◦ Greater than 50% with active TIA/stroke sxs

� Interventions◦ Carotid endarterectomy (CEA) vs. carotid stent

� Recommend CEA if patient is a good surgical candidate� Carotid stent has a ~1% higher perioperative risk of stroke, selected patients

◦ Only to reduce the risk of further stroke

◦ Does not improve symptoms that have already occurred!

Carotid Endarterectomy

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Carotid Endarterectomy

Carotid Plaque

Carotid Endarterectomy

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Carotid Stenting

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Aneurysms

� AAA

◦ Congenital

◦ Found by US screening, PE, incidental

◦ Repair: Endograft placement vs. open repair

◦ Risks:

� Rupture (risk when >5-5.5cm)

AAA Endograft

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Post-op AAA endograft

Dialysis access

� Arteriovenous Fistula (vein)

� Arteriovenous graft (synthetic)

Questions?