Evolving Strategies in the Treatment of

Peripheral Vascular Disease

Ravish Sachar MD, FACC

Wake Heart and Vascular

Disclosures

• Educational Grants: Boston Scientific, Abbott Vascular, ev3

• Consultant: Abbott Vascular, ev3

• Speakers Bureau: Boston Scientific, Abbott Vascular

Atherosclerosis Common Etiology

30-60% of pts with PVD have carotid disease

50-60% of pts with carotid disease have coronary disease

10% of pts with coronary disease have carotid disease

Results of Coronary Angiograms in 634 Patients with PAD

8.5%

Patient Survival by ABI

Newman et al ATVB 1999;19; 538-545

Five year mortality ratesPVD versus Cancer

Breast cancer

PAD

Colon/Rectal

Lung Cancer

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Five Year Mortality Rates

*Criqui M. Presentation: Vascular Medicine of the Lower Extremities at the American Diabetes Association’s Scientific Sessions June 1999

PVD ….What are the goals?

• Asymptomatic – treat risk factors

• Claudication – medical therapy or revascularization to improve symptoms

• Critical Limb Ischemia – prevent amputation and limb loss

Goal…Prevention of Amputation

Diagnosis

• Non-invasive– Bedside Ankle-Brachial Index– Lower extremity Segmental Pressures and PVRs– Arterial Duplex imaging– MRA– CTA

• Invasive– Angiograpy

Magnetic Resonance Angiography

Disease Patterns

Non-Diabetics Diabetics

Aorto Iliac Disease

SFA Disease

SFA OCCLUSION

pre post

Subintimal Angioplasty

Reentry Catheters

• Outback • Pioneer

SFA – PTA/Stenting

Post

Knee Extension Knee Flexion

Problems with SFA Stenting….

With KneeFlexion

Compression

3.

Extension / Contraction 1.

Torsion

2. Flexion 4.

Forces Exerted on Stents in SFA

TypeI

TypeII

TypeIII

TypeIV

Directional Atherectomy

Directional Atherectomy

Atherectomy

AfterBefore

Directional Atherectomy

Orbital Atherectomy

Rotational Atherectomy

Laser Atherectomy

Conclusions

• Peripheral Vascular Disease is very prevalent in patients with cardiac disease

• PVD is underdiagnosed and undertreated

• High Mortality with PVD – usually due to cardiac causes

• There are many revascularization options available to patients to improve quality of life

Thank You!

Thank You!

Percutaneous Surgical

Patient Preference

Treating Critical Limb Ischemia

Primary Treatment for severe PVD in

the 1800’s

Treating Critical Limb Ischemia

In some places Primary Treatment for severe PVD in

2008

Amputations – current data

• Less than 20% get an angiogram • Only 50% get an ABI

• Most of these patients do have limb salvage options

• It is not conservative treatment to amputate!

“For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive

treatment to even do an angiogram”

Amputation (Impact!!)

• Survivors who ambulate (prosthesis) BKA - 40-50%

AKA - 25%

• Psychological testing :“worse than cancer”

Possibilities….

Possibilities….