PAD: Pills, stents & bypasses. - Wheatcroft Presentation including ARS.pdf¢  PAD:...

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Transcript of PAD: Pills, stents & bypasses. - Wheatcroft Presentation including ARS.pdf¢  PAD:...

  • PAD: Pills, stents & bypasses. ��� (Pick one and then keep walking)

    Dr Mark Wheatcroft

    Vascular Surgeon

    St Michael’s Hospital

  • Introduction

    •  PAD: demographics, natural history

    •  Best medical therapy

    •  Further investigation

    •  Intervention - endovascular vs open

    • Outcomes / Follow-up

  • Disclosure

    • No conflict of interest

  • PAD: A definition

    •  What ankle brachial index (ABI) defines

    PAD?

    a). More than 1.0

    b). Less than 1.0

    c). Less than 0.9

    d). Less than 0.5

  • Answer

    c). ABI < 0.9

  • The burden of PAD

    •  27m people in N. America & Europe with PAD

    •  4.3% > 40 years

    •  14.5% >70 years

    •  2 - 3% per annum non-fatal MI

    •  CVS mortality rates:

    1yr 12%

    5yr 42%

    10yr 65%

  • Natural history

    PAD

    ABI < 0.9

    Asymptomatic

    Intermittent Claudication (IC)

    Short distance IC

    Rest pain

    Tissue loss / ulcer /

    gangrene

    Limb loss / death

    Primary

    presentation

  • Natural history

    Intermittent

    Claudication

    50% Stable

    25% Improve

    25% Deteriorate

    1 - 5% Amputation

  • PAD risk factors

    •  The BIG FOUR:

    SMOKING

    X 4

    DIABETES

    X 2

    HYPERTENSION

    X < 2

    DYSLIPIDEMIA

    X 2

  • Best Medical Therapy

    •  Smoking cessation

    •  Statin therapy (even if lipids normal)

    •  Glycemic control in DM

    •  Antihypertensives - ACE-I

    •  ASA 81mg / clopidogrel 75mg

    •  Exercise program

  • Management

    •  All PAD (inc. asymptomatic): BMT +

    Exercise

    •  Symptomatic: Refer to vascular surgery

    Intermittent claudication - routine

    Critical limb ischemia - urgent

    “rest pain”, “tissue loss”,

    “ulcer”, “gangrene”.

    • 

    •  Need for arterial duplex prior to Vasc Surg

    questionable

  • Management - Vasc. Clinic

    •  Full Hx, Exam.

    •  Blood work (creat, lipids)

    •  Arterial duplex with resting ABI +/- post

    exercise ABI

    •  Assessment of severity, risks, benefits

    •  Address risk factors

    •  CTA, MRA, TFA.

  • Intervention: Medication

    •  Pentoxifylline -

    12% improvement in WD,

    not clinically significant

    •  Cilostazol -

    approx 25% improvement in WD

    NOT available in Canada

    •  Ramipril -

    studied for yrs, recent +ve trial

    JAMA 2013; 309 (5): 453 - 460

  • Intervention: ��� Revascularisation

    •  Is patient suitable? - risks vs benefits

    •  Is pathology suitable? location, severity, plaque morphology, distal run-off, conduit available?

  • Intermittent claudication

    • Life-style limiting symptoms

    • No imminent threat to life or limb

    • Period of BMT + Exercise

    • Intervention must be low risk

    • MIMIC trial supports angioplasty for IC

    • Improved WD (but not QoL)

    Eur. J. Vasc. Surg. 2008 Dec; 36(6): 660 - 668

  • Intermittent Claudication

    •  Open procedures (more short dist IC):

    Common femoral endarterectomy +/-

    profundaplasty - PTA resistant

    •  NOT fem-pop / fem-distal bypass

    - Only exceptional cases.

    - Too risky for IC.

  • Critical ischaemia

    • Urgent!

    • Angioplasty / stent vs open bypass

    • Depends on lesion and patient fitness /

    prognosis

    • BASIL 2: Primary bypass better if life expectancy > 2yrs

    J. Vasc. Surg. 2010; 51: 5S - 17S

  • Endovascular

    •  Minimally invasive - day case procedure

    •  Well tolerated

    •  Good for short lesions

    •  Subintimal angioplasty and stenting for occlusions

    •  Excellent results with iliac stents

    (70 - 80%)

    •  SFA stents for longer lesions / occlusions

    (65% 3yr)

    •  Tibial PTA less successful, but possible

  • Angioplasty

  • TASC II Classification of aorto-iliac disease

  • TASC II Classification of femoro-popliteal disease

  • Pre

    Post

  • Subintimal Angioplasty

    •  Technique for crossing chronic occlusions

  • Endovascular

    • Often requires multiple procedures

    •  Close duplex follow up

    •  High re-intervention rate

    • Need anti-platelet and statin life long

  • Open Surgery

    •  Iliac disease:

    Aorto-bi-iliac / femoral* (>80%)

    Ilio-femoral*

    Fem-fem X over (75%)

    Axillo-bifemoral (71%)

    Axillo-unifem (51%)

    * rare due to stent success

  • •  CFA / PFA disease: Endarterectomy + patch plasty +/- PFA plasty

    Refractory to PTA / stent

    •  Ilio-femoral disease: Hybrid procedure

  • •  Infra-inguinal Bypass (5yr):

    Vein Prosthetic

    Fem - AK pop

    >85% 75%

    Fem - BK pop

    75% 65%

    Fem - distal

    70% 25%

  • Patency

  • Follow-up

    •  Lifelong BMT + exercise

    •  Duplex surveillance

    •  Endovascular reintervention

    •  Redo bypass

  • Worthy of a read......

  • Vascular Surgery at��� St Mikes

    •  Dr Mark Wheatcroft

    •  Dr Tony Moloney

    •  Dr Wayne Tanner

    •  Dr Mohammed Al Omran (Chief - Sept 2013)

    •  Fax referrals to: 416 864 6012