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PAD: Peripheral Arterial Occlusive Disease

PAD: Peripheral Arterial Occlusive Disease. PAD in the United States. Common Manifestation of Atherosclerosis Prevalence: 12% - 14% of the General Population - Up to 20% of Population > 75 Years Old Increased risk from Cerebrovascular & Coronary Disease. PAD: PREVALENCE vs AGE.

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PAD: Peripheral Arterial Occlusive Disease

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  1. PAD: Peripheral Arterial Occlusive Disease

  2. PAD in the United States • Common Manifestation of Atherosclerosis • Prevalence: 12% - 14% of the General Population • - Up to 20% of Population > 75 Years Old • Increased risk from Cerebrovascular & Coronary Disease

  3. PAD: PREVALENCE vs AGE Criqui MH, et al, Circulation, 1985

  4. EPIDEMIOLOGY OF ATHEROSCLEROSIS Incidence Prevalence Mortality (millions) (millions) (%) STROKE .7 4 31 MI 1.1 7 33 PAD - 22 4

  5. PAD: LONG-TERM MORTALITY Criqui MH, et al, Vasc Med, 2001

  6. PATIENTS WITH INTERMITTENT CLAUDICATION Cause of Death Coronary Artery Disease 63% Cerebrovascular Disease 9% All Cardiovascular Diseases 80% Smith DG, et al, Circulation, 1990

  7. INTERMITTENT CLAUDICATION • Exercise-Induced Limb Pain / Weakness • Symptoms Relieved with Rest • Marker for Underlying Systemic Atherosclerosis • Prognosis Worse with Multiple Risk Factors

  8. CLAUDICANTS:LONG-TERM OUTCOME Ouriel K, Lancet, 2001

  9. PAD: NONINVASIVE LAB EVALUATION (PVR)

  10. PAD: ABI PREDICTS SURVIVAL

  11. PAD: Rx of INTERMITTENT CLAUDICATION Symptomatic Rx Exercise Smoking Cessation Pharmacologic Endovascular / Open Surgery Systemic Rx Risk Factor Control - Smoking - Hyperlipidemia - Hypertension - Diabetes Pharmacologic - Antiplatelet - Statins - Beta Blockers

  12. AORTO-ILIAC OCCLUSIVE DISEASE PATIENTS • Younger than Femoral-Popliteal Disease • More Often Hyperlipidemic • Less Often Diabetic • Claudicants

  13. AORTO-ILIAC OCCLUSIVE DISEASE DIAGNOSIS • HISTORY: • - Proximal Claudication +/- • PHYSICAL EXAM: • - Femoral Pulses +/- • NONINVASIVE LABORATORY *** • - Thigh Pressure +/- • - Waveform ***

  14. AORTO-ILIAC OCCLUSIVE DISEASE SURGICAL OPTIONS BILATERAL DISEASE Aorto-Iliac Endarterectomy Aorto-Bifemoral Bypass Axillo-Bifemoral Bypass Thoracic Aorta-Fem-Fem Bypass (PTA & Femoral-Femoral Bypass) UNILATERAL DISEASE Ilio-Femoral Bypass Femoral-Femoral Bypass Axillo-Femoral Bypass

  15. AORTO-ILIAC OCCLUSIVE DISEASE SURGICAL OPTIONS ANATOMIC Aorto-Iliac Endarterectomy Aorto-Femoral Bypass Ilio-Femoral Bypass EXTRA-ANATOMIC Femoral-Femoral Bypass Axillo-Bifemoral Bypass

  16. AORTO-ILIAC ENDARTERECTOMY INDICATIONS: Focal Disease CONTRAINDICATIONS: Aneurysm Disease Extending to Renal Arteries Disease Extending to External Iliac Arteries Largely Replaced Today with Angioplasty

  17. AORTO-ILIAC ENDARTERECTOMY

  18. AORTO-FEMORAL BYPASS

  19. AORTO-FEMORAL BYPASS OPERATIVE MORTALITY • 1960s 12% • 1970s 6% • 1980s < 5% • 1990s 2%

  20. AORTO-FEMORAL BYPASS PATENCY PATENCY (%) Source (Yr) # Pts. 5-Yr 10-Yr 15-Yr Brewster (1978) 464 88 75 - Martinez (1980) 376 88 78 - Crawford (1981) 949 87 - - Szilagyi (1986) 1749 85 84 74 Rutherford (1986) 157 86 - - Vantinnen (1991) 177 91 - - Nevelsteen (1991) 912 93 83 77

  21. AORTO-FEMORAL BYPASS COMPLICATIONS • Graft Limb Occlusion • Graft Infection • Graft-Enteric Fistula • Anastomotic Aneurysms • Ureteral Obstruction • Male Sexual Dysfunction

  22. AORTO-FEMORAL GRAFT LIMB OCCLUSION ETIOLOGY EARLY Distal Intimal Flap Kinking / Twisting Incomplete Clot Evacuation Unsuspected Hypercoagulability SEVERE OUTFLOW DISEASE ***

  23. AORTO-FEMORAL GRAFT LIMB OCCLUSION: LATE LATE (> 2 Yr) Progressive Atherosclerosis*** Anastomotic Pseudoaneurysm LATE (< 2 Yr) Anastomotic Hyperplasia ANGIOGRAPHY: Anastomoses Contralateral Limb Run-Off: LYSIS

  24. AXILLO-FEMORAL BYPASS • CANDIDATES: • Severe Comorbidity & Limb-threatened • Infection

  25. AXILLO-FEMORAL BYPASS PATENCY 1- YEAR …………………… 22% - 100% 3-YEAR …………………… 36% - 97% 5-YEAR …………………… 34% - 87%

  26. AXILLO-FEMORAL BYPASS (Oregon HSU) PATENCY % P A T E N C Y Ax-Fem Aorto-Fem YEARS

  27. AXILLO-BIFEMORAL BYPASS

  28. UNILATERAL ILIAC ARTERY OCCLUSION FEMORAL-FEMORAL BYPASS - Extra-Anatomic - Superficial - Less Morbidity - Lower Patency ILIO-FEMORAL BYPASS - Anatomic - Retroperitoneal Dissection - More Morbid - Better Patency vs

  29. FEMORAL-FEMORAL BYPASS PATENCY (13 Series / 919 Patients) 1- YEAR …………………… 74% - 98% (mean, 88%) 3-YEAR …………………… 62% - 85% (mean, 77%) 5-YEAR …………………… 45% - 80% (mean, 67%)

  30. BILATERAL ILIAC ARTERY DISEASE - PTA & FEMORAL-FEMORAL BYPASS - Johns Hopkins % P A T E N C Y 66% 59% PTA & FEM-FEM FEM-FEM J Vasc Surg. 1996 YEARS

  31. ILIO-FEMORAL BYPASS PATENCY INSTITUTION # PTS PATENCY F/U (YRS) Brigham 56 75% 4 U. Toronto 50 92% 3 U. Wisconsin 20 100% 2 Johns Hospkins 22 92% 6

  32. THORACIC AORTA-FEMORAL BYPASS PATENCY (U North Carolina) J Vasc Surg, 1999

  33. ILIAC ANGIOPLASTY: UCLA (1993 – 2004) J Vasc Surg, 2005

  34. ILIAC ANGIOPLASTY: UCLA (1993 – 2004) J Vasc Surg, 2005

  35. AORTOILIAC RECONSTRUCTION SUMMARY • Increasing Endovascular Interventions • Decreasing Open Surgical Procedures • Multiple Surgical Options • - Anatomy • - Comorbidity • Patient Selection Key

  36. INFRAINGUINAL ARTERIAL OCCLUSIVE DISEASE EPIDEMIOLOGY • Lower Extremity Atherosclerosis: 10% > 70 yo • Limb-Threatening Ischemia: 50,000 Individuals / Year • 80,000 Infrainguinal Bypass Grafts / Year • Elderly: Fastest Growing Population Segment

  37. FEMORAL-POPLITEAL-TIBIAL BYPASS - Indications - ****LIMB THREATENING ISCHEMIA - Rest Pain - Nonhealing Ulcers - Gangrene ** CLAUDICATION - 50%-67% Improve Medically - 2% -7% Limb Loss / Year

  38. FEMORAL-POPLITEAL-TIBIAL BYPASS - Operative Mortality - SOURCE (Yr) No. Pts. % Mortality Cleveland Clinic (1987) 932 4.4% Med Coll WI (1987) 192 3.0% Albany Med Coll (1988) 1038 6.7% UCLA (1988) 120 1.2% Brigham (1988) 266 1.4% Oregon U (1990) 564 1.3% Johns Hopkins (1995) 100 2.0% VA Multicenter (2000) 752 0.8% Brigham (2000) 172 2.4%

  39. FEMORAL-POPLITEAL-TIBIAL BYPASS - Wound Morbidity - INCIDENCE: 5% - 30% RISK FACTORS: - Vein Harvesting - Ischemic Limb - Diabetes - Re-Do Procedures - Infected Lesions

  40. FEMORAL-POPLITEAL-TIBIAL BYPASS - Wound Morbidity – Oregon Health Science U • PATIENTS: 112 • Diabetes ……………. 53% • Renal Failure ……… 22% • Limb Salvage ……… 96% • PROCEDURES: • Fem-Pop …………… 52% • Fem-Tib …………… 38% • Pop-Tib …………… 10% • Vein ………………… 91% WOUND COMPLICATIONS: 24% TIME TO HEALING: 0.4 – 10.1 (mean, 1.9) Months J Vasc Surg, 1998

  41. FEMORAL-POPLITEAL-TIBIAL BYPASS REDUCED WOUND MORBIDITY Duplex Vein Mapping Endoscopic Vein Harvest

  42. FEMORAL-POPLITEAL-TIBIAL BYPASS Kent & Queen Anne Hosp METHOD OF VEIN HARVEST ENDOSCOPIC CONVENTIONAL (n=16) (n=16) Wound Complications 0% 31% Mean LOS (days) 3.8 6.2 JACS, 1998

  43. FEMORAL-POPLITEAL-TIBIAL BYPASS PATENCY: KEY VARIABLES ***GRAFT MATERIAL Vein vs Prosthetic **SITE OF DISTAL ANASTOMOSIS Fem-Pop vs Fem-Tib *CLINICAL INDICATION Claudication vs Limb salvage

  44. FEMORAL-POPLITEAL-TIBIAL BYPASS CLINICAL INDICATION CLAUDICATION vs LIMB SALVAGE % P A T E N C Y Claudication Limb Salvage 2,572 PATIENTS 15 YEARS YEARS

  45. FEMORAL-POPLITEAL-TIBIAL BYPASS DISTAL ANATOMOSIS FEM-POP vs FEM-TIB (SAPH. VEIN) % P A T E N C Y Fem-Pop Fem-Tib 2,572 PATIENTS 15 YEARS YEARS

  46. FEMORAL-POPLITEAL-TIBIAL BYPASS GRAFT MATERIAL FEM-POP FEM-TIB % P A T E N C Y % P A T E N C Y p < .025 P< .001 Vein Vein PTFE PTFE 2,572 PATIENTS 15 YEARS 2,572 PATIENTS 15 YEARS YEARS YEARS

  47. FEMORAL-POPLITEAL BYPASS - LONG-TERM 1 0 PATENCY - Randomized Prospective Trial:FEM-POP % P A T E N C Y 68% 38% MONTHS J Vasc Surg, 1986

  48. FEMORAL-TIBAL BYPASS - LONG-TERM 1 0 PATENCY - Randomized Prospective Trial:FEM-TIB % P A T E N C Y 49% 12% MONTHS J Vasc Surg, 1986

  49. FEMORAL-POPLITEAL BYPASS LONG-TERM PATENCY: GRAFT MATERIAL SERIES: 69 YEARS: 15 PROCEDURES: 11,600 % P A T E N C Y 72% 58% 45% YEARS

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