Vascular Diseases

Idar Mappangara
Department of Cardiology

Hasanuddin University
 •Acute Limb Ischemia
•Chronic Limb Ischemia
•Critical Limb Ischemia
•Aneurysma & Disection Aortic
•Renal Stenosis
•Pulmonal Embolism
•Deep Vein Thrombosis
•Vein Insufisiensi
The Overlap of Atherosclerotic Disease

CAD CVD

PAD

Patients with one manifestation often have

coexistent disease in other vascular beds
Global Diagnosis & Global Intervention

Carotid Systemic Atherosclerosis

Subcla & vertebra

Coronary
Renal Aortoiliac

SFA

Infrapop
 Risk Factors for PAD
Reduced Increased
Smoking
Diabetes
Hypertension
Hypercholesterolemia
Hyperhomocysteinemia
Fibrinogen
C-Reactive Protein
Alcohol

Relative Risk .5 1 2 3 4 5 6
Newman AB, et al. Circulation. 1993;88:837-845. Hiatt WR, et al. Circulation. 1995;92:614-621.
Graham IM, et al. JAMA. 1997;277:1775-1781.TASC Working Group. J Vasc Surg.
2000;31(1, pt 2):S1-S288. Ridker PM, et al. Circulation. 1998;97:425-428.
 PAD Evaluation
• Asymptomatic, IC or CLI
• Fontaine and Rutherford class
• Echo and ABI
• Treadmill ABI: Bruce modified :ⅠX 5 min
• Identify level of stenosis
 Fontaine Classification
Claudication Critical limb ischemia

Fontaine Ⅰ,Ⅱ 　　　　　 Ⅲ ,Ⅳ

Pentecost MJ, Circulation 89:51, 1994
 Rutherford Classification
Stage Stage Clinical Claudication

0 Asymptomatic
1 Mild claudication
2 Moderate claudication
3 Severe claudication
Critical limb ischemia
4 Ischemic rest pain
5 Minor tissue loss
6 Major tissue loss

Rutherford RB, et al, J Vasc Surg 1986;4:80-94

Rutherford
Rutherford44
Ischemic
Ischemicrest
restpain
pain

Rutherford
Rutherford55
Minor
Minortissue
tissueloss
loss

Rutherford
Rutherford66
Major
Majortissue
tissueloss
loss
 Spectrum of
Peripheral Arterial Disease

Claudication Limb-Threatening Ischemia

Poor Impending
Fatigue, wound or overt
"Normal” Heaviness Mild Moderate- Severe Rest pain healing gangrene
       

Worsening flow limitation

Vascular Echo and ABI for PAD
 Ankle-Brachial Index

Above 0.90 Normal

0.71 – 0.90 Mild
0.41 – 0.70
Moderate
0.00 – 0.40 Severe
• The objective way to diagnose limb ischemia
• To evaluate long term prognosis

Newman AB, et al. Circulation. 1993;88:837-845.

Duplex in SFA Disease
浅大腿動脈閉塞
How many tests do we need to evaluate PVD ?

TCD

Duplex
Duplex MRA

CTA ABI
DSA

ABI Segmental pressure Treadmill ABI

Pulse volume
Toe pressure
tPO2
 Medical Therapy of PAD
•• Smoking
Smoking cessation
cessation
•• Exercise
Exercise
•• Control
Control of
of hypertension
hypertension
•• Reduction
Reduction of
of LDL
LDL
•• DM
DM control
control
•• Antiplatelet
Antiplatelet therapy
therapy
•• Cilostazol
Cilostazol
•• Foot
Foot care
care
 PAD Risk Reduction Therapies

• Smoking
– Complete cessation
• Diabetes mellitus
– HbA1c <7.0%, treat other risk factors
• Dyslipidemia
– LDL <100 mg/dL, modify HDL and TG
• Hypertension
– BP <140/90 or <130/80 in diabetes
• ACE Inhibitors
• Antiplatelet therapy
– Aspirin, Pletal, Clopidogrel?
 Summary of PAD

• PAD is a common disorder

– Occurs in ~1/3 of patients
>70 y/o or 50 y/o with history of Tobacco and/or DM
• Strong association between PAD, CAD, CVD
– Marked Risk of MI and CVA
• Progressive in ~50% of patients with IC
• Most of the lesions are Infrainguinal diseases
• Outcomes:
– Impaired Quality of Life
– Limb Loss
– Premature Mortality (Vascular death)
Indication of PTA for PAD
• Claudication
• Lim threatening ischemia
• Rest pain
• Non-healing ulcer
• Gangrene
• Acute limb ischemia
Iliac Artery Intervention
76 y/o Female
Rutherford 4
 TASC D lesions of the Pelvic Artery:
Is there still a role for Aorta-Femoral bypass ?
71 y/o Male
CAD, HTN, DM
Rutherford 5
Pre 71 y/o Male
CAD, HTN, DM
Rutherford 5

2 weeks

2 mo
 SFA Intervention: Why so many?
• Balloon angioplasty
• Cutting balloon
• Non-Nitinol stent
• Nitinol stent
• Rotational atherectomy
• Endoluminal grafts ?
• Brachytherapy ?
• Laser angioplasty ?
• Cryoangioplasty ?
• Drug eluting stent
 Fem-Pop Bypass
F-P bypass is not a primary mode of therapy
Infrapopliteal Intervention for CLI
Infrapopliteal Angioplasty: Principles

Success is measured by:

– Relief of rest pain
– Healing of ulcers
– Avoidance of amputation
• Not by long-term vessel patency!
 Lt critical limb ischemia
Pre 1 mo

2mo
 Lt critical limb ischemia
pre 1 mo

2 mo
Infrapopliteal Intervention: Conclusions
• Indicated in CLI and limb salvage
• Relatively few contraindications for limb salvag
e
• Most limbs have the dilatable lesions
• Similar technique to coronary intervention
• Not only for limb salvage, but also for severe cl
audication

Most limbs can be salvaged if a dilatable lesion is found