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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?