Peripheral Vascular Surgery

Shahriar Alizadegan, MDVascular Services

Professional Background Tabriz University of Medical Sciences (MD), 1988

to 1995 General practitioner, 1995 to 1998 General surgery residency, 1998 to 2003 General surgery practice, 2003 to 2006 General surgery residency (UIC-MGH),

2009 to 2014 Vascular surgery fellowship (MCW) 2014-2016

Scope of Vascular Surgery Practice

ArteriesVeinsLymphaticsVascular accessVascular compression syndromes

Peripheral Arterial Disease

Atherosclerosis: Risk FactorsConventional Smoking Diabetes mellitus Hyperlipidemia Hypertension

PredisposingAdvanced ageOverweight/obesityPhysical inactivityGender: male, postmenopausal

women Insulin resistanceFamily history/geneticsBehavioral/socioeconomic

factors

AtherosclerosisConditionalHomocysteineC-reactive protein

(high-sensitivity CRP)FibrinogenLipoprotein (a)Hypertriglyceridemia

EmergingInflammatory markersInfectious agentsVascular calcification

markersHemostatic factorsMMP

Arterial Disease: Atherosclerosis

Cerebrovascular DiseaseCarotid stenosisFibromuscular dysplasia (FMD)AneurysmsDissections

Carotid StenosisAsymptomatic Symptomatic

- TIA- Stroke

Carotid Endarterectomy

Carotid Stenting

Inability to tolerate general anesthesia for CEA

History of damage to the contralateral vocal cord (previous CEA or neck surgery)

Previous neck surgery on the ipsilateral side Neck irradiation Restenosis after CEA

Indications for Carotid Artery Stenting

Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction or death did not differ significantly in the group undergoing carotid-artery stenting and the group undergoing carotid endarterectomy.

During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy.

Carotid Artery Endarterectomy Versus Stenting

Fibromuscular Dysplasia (FMD)

Carotid Artery Aneurysm

Pulsating Neck MassMost common cause of pulsating neck mass

Carotid Dissection

Carotid Dissection, cont.The carotid artery is compressed by blood

dissecting upward from a tear with aortic dissection. Blood may also dissect to coronary arteries. Thus patients with aortic dissection may have symptoms of severe chest pain (for distal dissection) or may present with findings that suggest a stroke (with carotid dissection) or myocardial ischemia (with coronary dissection).

Brachiocephalic and Subclavian Artery

Severe Multivessel Disease of Aortic Arch Branches

Subclavian Steal Syndrome

Carotid Subclavian Bypass

Subclavian Carotid Transposition

Hybrid Repair of Distal Arch and Descending Thoracic Aortic Aneurysm

Endovascular Treatment With Brachial Access

Intermittent Claudication Most common reason for referral to vascular

surgeon Calf, thigh or buttock pain after certain distance of

walking Symptoms of intermittent claudication are

alleviated by a brief period of rest Abnormal ankle brachial indexes No constant pain, no tissue loss Inflow diseaseOutflow disease

Inflow Disease Outflow Disease

Critical Limb Ischemia Common major manifestations of CLI are rest pain

and ischemic ulceration or gangrene of the forefoot or toes, representing a reduction in distal tissue perfusion below resting metabolic requirements.

Ankle pressure less than 50 mm Hg Toe pressure to less than 30 mm Hg

or ABI to less than 0.40

Natural History of IC versus Critical Limb Ischemia

The risk of major amputation is small; over a five-year period, the rate of amputation was less than five percent (IC)

Only insulin-requiring diabetes, low initial ABI, and high pack-years of smoking predicted progression to ischemic rest pain and ischemic ulceration

Natural history of CLI is grim, remarkable for the high risk of major amputation and death

AneurysmsAneurysms can be categorized according to

their anatomic, pathologic or etiologic characteristics.

Ectasia: Intermediate stage of enlargement when an artery is less than 50 percent enlarged, whereas

Arteriomegaly: Diffuse, continuous enlargement of multiple arterial segments dilated to greater than 50 percent of normal.

Aneurysms, cont.

Aneurysms, cont.Degenerative InflammatoryPost dissectionTraumaticDevelopmental Infectious

Endovascular RepairTAAAAA Iliac aneurysmVisceral aneurysms

Endovascular Repair of Abdominal Aortic Aneurysm

(EVAR)

Open Versus Endovascular Repair CRT has shown no significant survival benefit at any

time-point for an endovascular strategy (using a standard EVAR device whenever anatomically and operationally possible, with open repair as a default option) versus open repair.

In contrast, there were gains for the endovascular strategy versus the open repair group with respect to patient-preferred outcomes: faster discharge, more often to home, and QoL and overall the endovascular strategy was cost-effective.

Open vs. Endovascular Repair, cont.Follow-up:One imaging after five years for open repairEVAR requires imaging on a yearly basisRisk of endo leak after EVARRisk of limb occlusion, slippage of the graft, limb separation

Endoleak

Harvard Report on Cancer Prevention, Cancer Causes and Control 1999;10:167.

Visceral Interventions

Venous Diseases Deep vein thrombosis Venous insufficiency and stasis ulcer Superficial thrombophlebitis Differentiation of venous stasis ulcer versus

arterial insufficiency

Venous Stasis Ulcer Knowing the underlying pathophysiologyCompression therapyReflux studies (venous duplex)Arterial flow Ablation of incompetent veins if indicatedLocal wound care and hygiene

Treatment Options for Venous Disease

Laser or RFA ablation( for larger veins GSV)Sclerosing agent

Polidecanol Hypertonic NACL Varithena(injectable foam)

MicrophlebectomyLigation and divisionStripping

Thank YouQuestions?