[os 213] lec 15 surgery for peripheral vascular diseases i (b)

OS 213: Human Disease and Treatment 3 (Circulation and Respiration)LEC 15: SURGERY FOR PERIPHERAL VASCULAR DISEASES I

Quiz 02 | Dr. Leoncio L. Kaw | July 30, 2012

OUTLINE I. Aneurysmal Diseases

A. AneurysmB. Risk FactorsC. Natural HistoryD. DiagnosisE. Indications of RepairF. Treatment Options

II. Carotid Artery DiseasesA. IntroductionB. Clinical SyndromesC. Natural HistoryD. DiagnosisE. Indications of RepairF. Treatment G. ComplicationsH. InterventionI. Summary

III. Renovascular HypertensionA. IntroductionB. PathophysiologyC. Clinical CluesD. DiagnosticsE. TreatmentF. Surgery vs. StentingG. Summary

Objectives: To discuss the clinical presentation, diagnosis and treatment of

common diseases involving the aorta and its branches, as seen in clinical practice

To review clinical data supporting use of these diagnostic strategies

This trans is copied entirely from Class 2015 trans and edited to our class trans format. Suspension of classes ang salarin!!!

ANEURYSMAL DISEASESANEURYSM

Defined as a pathologic dilatation of a segment of a blood vessel (from Harrison’s)

Most commonly located in the abdominal aorta (71%) specifically aorto-iliac area

75% of atherosclerotic aneurysms occur in the distal abdominal aorta below the renal arteries.

The focus of this discussion will be on abdominal aortic aneurysms (AAA), also called aorto-iliac aneurysms

Figure 1. Abdominal aortic aneurysm (AAA).

True aneurysm: involves all three layers of the vessel wall Pseudoaneurysm: intimal and medial layers are disrupted and the dilatation is lined by adventitia only and sometimes by perivascular clot

RISK FACTORS Atherosclerosis is the leading cause of aneurysms.

1. Age : increased incidence in elderly population usually due to atherosclerosis; in young patients – think of other etiology such as Marfan syndrome and syphilis

2. Smoking : Incidence increases much higher with age in smokers

3. Family history : 15-20% of patients have a family history of aortic aneurysm

4. COPD : Associated elastin degradation and smoking5. High Cholesterol 6. High Blood Pressure (BP): Can accelerate known

aneurysms and contribute to formation of new ones

NATURAL HISTORYINTRODUCTION The average growth rate of an AAA is 3.3 to 4 mm every year. UK AAA screening (1984-2007)○ Median AAA diameter= 35 mm○ Median growth (3.2 yrs)= 9 mm

Aneurysms are like balloons; as the diameter increases, the wall becomes thinner and weaker.

The increase in diameter will increase the risk of rupture. In practice, when the aneurysm is <5 cm in diameter, surgery

can be indicated. This value is true for Filipinos (2014).

MORTALITY

62% of patients with ruptured AAA never reach the hospital alive;

48% of those who reach the hospital don’t get out of the hospital alive (Operative Mortality);

Without surgery, the overall mortality rate is roughly 80%; Mortality for elective repair is 2-5%; Thus, Early Diagnosis and expeditious elective repair of intact

AAA provides the best chance for good outcome.

DIAGNOSIS

HISTORY frequently asymptomatic • Symptoms which may be signs of beginning rupture include:o abdominal mass or fullnesso Pain/ tenderness radiating to the groin, back legso Low back paino Abdominal rigidityo Fainting/ light-headednesso Excessive thirst and vomiting

PHYSICAL EXAMINATION

Usually presents as a pulsatile mass on abdominal examination (Difficult to diagnose in obese patients. May be confused with a transmitted pulse.)

Pulsatile mass: usually cephalad to the umbilicus and when fingers are placed on its lateral walls, it will demonstrate lateral and anteroposterior movement to differentiate it from a solid tumor transmitting the pulsation. (De Gowin)o Pulsatile mass exhibits horizontal movement. (Fingers will

move up and down and away from each other)o Transmitted pulses exhibit vertical movement. (Both fingers

will move up and down) Width of the pulsatile mass and not the degree of pulsatility

should be measured

IMPORTANT: No pulsation, however forcible; no thrill, however intense; no bruit, however loud, singly or together can justify the diagnosis of an aneurysm of the abdominal aorta

The presence of a palpable expansile tumor is the only sure indication of an AAA. - Sir William Osler

DIAGNOSTIC TESTS-PLAIN ABDOMINAL X-RAY Most of the time you cannot see aneurysm in CXR. AP and lateral views are taken to see the outline of the aorta. Not routinely done because sensitivity is low May produce several differentials - e.g. intestinal obstruction May be helpful if the aneurysm is calcified - more visible

Bea, Anna, <JC> says UPCM 2016: XVI, Walang Kapantay! 1 of 8



DIAGNOSTIC TESTS-ULTRASOUND (DUPLEX UTZ) Advantages: Highly accurate, cost-effective, no radiation and

is readily available Gives the following information (2014): o Involvement of iliac arteryo Absolute diameter of the aneurysm can be determinedo Effective lumen can be measuredo Thrombi may be visualizedo Relationship of aneurysm with nearby vessels (iliac and renal

arteries), organs and lesions can be visualized - useful for preoperative planning

Disadvantages:o Operator dependento Some aneurysms may be extremely difficult to detecto Contraindicated in obese individuals and patients with a full

stomacho Difficult to get measurements for tortuous vessels

DIAGNOSTIC TESTS-COMPUTER TOMOGRAPHY SCAN (CT SCAN) Gold standard for detecting AAAs Also provides all the information provided by an ultrasound The difference: it can use this information to reconstruct the

aneurysm and its relations in 3D Can also show neighboring structures that can help tell what

the patient is feeling Versus the ultrasound:o Delivers a more anatomically accurate image o Less prone to reader erroro More expensive

INDICATIONS FOR REPAIR Not all AAA patients need surgical repair Decision to intervene is based on randomized controlled trials

(RCT’s) done a few years ago Two predominant studies (RCT’s)o Aneurysm Detection And Management (ADAM) of the USo UK Small Aneurysm Trial (UKSAT) of the UKo RCT Results and Findings

Designs are basically the same Patients employed were diagnosed cases of AAA’s which

are 4.0- 5.4 cm in diameter Patients were randomized into two groups: those who

would have an early surgery and those who would have the surgery later

Found that there was no significant difference in the mortality rates of the two groups after 5 years of follow-up

• In practice:o When AAA is 4.0 - 5.4 cm wide: it can be safely observed

without significant risk of ruptureo When AAA is more than 5.5 cm wide, surgery/repair is

usually indicated• Problems encountered:o 90% of the patients are male: women should have a lower

size thresholdo Rapidly growing aneurysms? (>0.5 cm a year)o 5cm aneurysm has a risk of <1 % of rupture. Other risk

factors include: strong family history irregular shape (saccular/eccentric) hypertension COPD Filipino

o Are these criteria applicable to Filipinos? Tests were done on Caucasians

o In the Philippines, 5 cm is the threshold for surgical intervention

Figure 2. Algorithm for evaluation and management of abdominal aortic aneurysm.

TREATMENT OPTIONS

OPEN SURGERY Midline laparotomy Retroperitoneal Laparoscopy assisted Mini laparotomy Most common forms of surgical intervention (2014) Procedure

1. Starts with a midline laparotomy (most common; incision from xiphoid process to symphysis pubis)

2. Aorta is exposed3. Aneurysm is located4. Aorta is clamped on either end of the aneurysm5. Aorta is opened to expose the aneurysm6. Lesion is taken out and the vessel is repaired with a graft

A major operation done by a vascular surgeon Major operation which entails at least one week in the hospital

and may even involve a stay in the ICU Statisticso 10% morbidity rateo 2-5% mortality rate

Note, however, that most patients who undergo the surgery are elderly; hence, the mortality & morbidity are high

Co-morbidities if present, will complicate the surgery Provide proximal control of the AAA Blood loss in surgery – 2 Liters Hospital stay- 1 week Two options: GRAFT or CLAMP replacement

Figure 3. Open Surgery

ENDOVASCULAR SURGERY Relatively novel way of treating AAA’s




No midline incision; only 2 small incisions Has been increasingly used in the past 10 years Talent graft – most commonly used in the Phils.

Procedure1. A small incision is made in the groin area2. The femoral artery is located and punctured3. A catheter which contains the graft in an enclosed vessel is

inserted through the femoral artery. 4. Guided by an angiogram, the catheter enters the site of the

aneurysm. 5. The graft is deployed and the catheter is taken out.

Figure 4. Endovascular SurgeryNote the site of catheter insertion. Exclude the aneurysm sac.

Figure 5. Endovascular Surgery IIThe catheter has now reached the AAA and the graft is deployed.

Figure 6. Common Grafts in Current UseDifferent mechanisms entail variations in

characteristics and specifications In Phil., Talent graft most commonly used

Advantages (Short Term Outcome)o Less blood losso Faster recovery, shorter ICU stayo Reduction in early major adverse eventso Significantly reduced 30 day mortality (usually due to cardiac

problems)EVAR 1 Trial Lancet 2004DREAM Trial N Eng J Med 2004OVER Trial JAMA 2009

Long Term Outcomeo Median follow-up: 1.8 yrs (OVER) 6.0 yrs (EVAR 2)o No significant difference in major morbidity and mortalityo Higher graft related complications and reinterventions with

endovascular repairOVER Trial JAMA 2009EVAR 2 Trial N Eng J Med 2010

Early Repair for Small AAA?o AAA 4.0-5.0 cm in diameter?

PIVOTAL trial (Ouriel et al., 2010(Positive Impact of EndoVascular Options for Treating Aneurysm earLy)

CAESAR trial (Cao et al., 2011)(Comparison of Surveillance vs Aortic Endografting for Small Aneurysm Repair)

No significant difference in mortality 1/6 patients lose feasibility for EVAR (Endovascular repair)Not all patients with AAA are candidates for EVAR (10,000 dollars – cost of endovascular repair graft)

Anatomic Criteriao Not all patients are candidates for EVARo A criterion is used to ascertain whether a person is a possible

candidate for EVAR. Access

- Smallest graft has French 18, whose outer diameter is 6 mm

- Hence, vessel must be at least 7 mm for the device to enter (because a very thick delivery sheath is going to be used into the aorta, 6 mm vessel to accommodate delivery vessel)

- Not for kids and women- No calcified or stenotic arteries

Iliac Vessels- The angle between aorta and common iliac arteries

should be at least 90º, if less than it is a relative contraindication

Presence of aberrant vessels- Large Inferior Mesenteric Artery (IMA) - Accessory Renal Artery (if there are accessory renal

arteries and you block the aortic aneurysm, you will also exclude blood flow to these arteries and cause infarcts - colonic ischemia - to areas supplied by them, 2013)

Neck angulated - Difficult to maneuver the device if less than <60°, also

another relative contraindication.- 60° angle is necessary to create a good proximal seal- Length should be at least 1.5 cm- Diameter should be at least 28 mm- Having a reversed cone shape neck is also a RC- No thrombus, atheroma, or calcifications (to allow the

graft to attach and to avoid leakage into the aneurysm)

SUMMARY Early diagnosis is beneficial


<2014> says: Anatomic and device constraints

o Diameter (Depending on the neck of aneurysm, graft is oversized by 10-15% = can be a floating graft)

o Radial force Mechanism

o Since aneurysm is due to systolic flow, if you block the flow above the aneurysm, it will eventually shrink

o Instances when the aneurysm doesn’t shrink: Blood flow from lumbar vessels is not excluded (usually this is

somehow blocked in open surgeries) - type II endoleak Poor seal - type I endoleak

Relative Contraindicationso Young patients (because after Endovascular Surgery, there must be

regular surveillance, annual CT scans. So if the patient is young, the patient will have more years to spend having CT scans, very expensive).



Risk for rupture when the AAA (<5 mm) is low. Mortality of elective repair is low (3-5% in Phils) Decision for repair must be individualized EVAR is a viable alternative treatment of AAA (Always take note

of the anatomical criteria.) Anatomic selection criteria absolutely important for EVAR

Not all patients with AAA are candidates for EVAR

ADDITIONAL INFO Is the 5 mm threshold applicable for all aneurysms? NO. o 5 mm – just for abdominal aortao Popliteal: 2.5 mmo Iliac: 2.5 mmo Thoracic: 6 mm

Stroke, or a cerebrovascular accident, is defined by this abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. The definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis. (Harrison’s)

Stroke is the leading cause of serious long-term disability; it is a very costly disease.

The risk of getting stroke increases with a history of stroke incidents

Mortality from initial stroke is 15-35%. Carotid artery atherosclerosis is a major factor in carotid artery

disease Risk for recurrence is 4.8 – 20% 30% of patients die 30% survive without sequelae 30% survive and are left with a disability that amounts to a high

cost

CLINICAL SYMPTOMS Generally, patients are asymptomatic Transient Ischemic Attacks (TIA’s) are commono Definition: focal neurologic deficit which disappears within 24

hourso Pathophysiology: TIA results from a failure of perfusion due to

hemodynamic causes or microembolism. Less common causes are in situ arterial thrombosis, arterial dissection and venous sinus thrombosis. The symptoms reflect the area of ischemia. (De Gowin)

o The patient returns to pre-TIA neurological state within the day Reversible Ischemic Neurologic Deficit (RIND) o Lasts more than 24 hours o Takes at least a week for the patient to return to his or her pre-

ischemic neurological state Crescendo TIAo Multiple TIA’s occurring in a short period of timeo Connotative of high grade stenoses

Amaurosis fugax o Pathophysiology: Cholesterol emboli from ruptured

atherosclerotic plaques in the common or internal carotid artery transiently occlude flow to the retinal artery (De Gowin)

o Evidence of ischemia seen in the ophthalmic arterieso Presents as fleeting blindness or monocular loss of vision;

described as “curtain fall” over eyeso Due to emboli (usually cholesterol emboli) which go into

ophthalmic artery and may cause calcification Stroke

NATURAL HISTORY

Risk of Stroke

Presence of symptoms Degree of stenosis (higher degree of stenosis, the higher risk of

stroke) Plaque densityo For asymptomatic patients, risk increases with the plaque

densityo According to increased risk of TIA & stroke: Calcified < Dense <

Soft PlaqueTherefore: soft plaque is WORSE than calcified plaque

o There is always forward blood flow. Soft plaques may be dislodged and embolize.

Risk of neurologic event and carotid plaque characteristicsDuplex charc. Stenosis n TIA StrokeCalcified >75% 37 4(11%) 1(3%)

< 75% 53 0 0Dense >75% 42 23 (55%) 4 (10%)

<75% 76 7 (9%) 1 (1%)Soft >75% 42 32 (76%) 9 (21%)

<75% 46 10 (21%) 4 (9%)

For symptomatic patients (risk increases with increasing severity of stenosis) has:o Intraplaque hemorrhageo Large superficial lipid coreo Low intraplaque calcification

Those who have intraplaque hemmorhage, calcification, lipid core, soft and ulcerated plaques have higher risk.

DIAGNOSIS

Goals To ascertain whether or not carotid disease is present To asses the severity of the disease To determine whether or not the carotid lesion is responsible for

the pt’s symptoms To assess the potential for operability

Remember!Stroke in Filipinos stems from intracranial carotids, while in Caucasians it is from the extracranial carotids

History and Physical ExaminationThere are three main foci in doing the PE: bruits, absence of carotid pulse, and embolic material Bruito An obstruction causes turbulent blood flow that is heard as a

bruit upon auscultationo Extends into diastole in high-grade lesions; when there is high

grade stenosis, there is almost no flow, and therefore, no bruito PE must be thorough: examine all arteries, pulses and pressureso Make sure that the bruit is not an extension of a cardiac

murmur into the carotids If the bruit is loudest in the precordial area and diminishes as

you approach the carotids of the neck area, then the bruit is just an extension of the precordial murmur.

o Degree of bruit ≠ degree of stenosis


<2014> says: Anatomic and device constraints

o Diameter (Depending on the neck of aneurysm, graft is oversized by 10-15% = can be a floating graft)

o Radial force Mechanism

o Since aneurysm is due to systolic flow, if you block the flow above the aneurysm, it will eventually shrink

o Instances when the aneurysm doesn’t shrink: Blood flow from lumbar vessels is not excluded (usually this is

somehow blocked in open surgeries) - type II endoleak Poor seal - type I endoleak

Relative Contraindicationso Young patients (because after Endovascular Surgery, there must be

regular surveillance, annual CT scans. So if the patient is young, the patient will have more years to spend having CT scans, very expensive).

<2014> says:OUTCOMES

Progression of the Diseaseo Increase in the degree of stenosis which may lead to full

occlusion of the artery Ruptureo Embolization of thrombosis may ensue causing transient

ischemic attack and strokeo Neurologic deficits may also present as a consequence of

emboli reaching the brain Healing & Repair

CAROTID ARTERY DISEASESINTRODUCTION



o No correlation between bruit volume or intensity and severity of the disease - Some presentations with very tight stenosis have almost no flow, so the bruit can’t be heard anymore; severe stenosis but no bruits

Absence of Carotid Pulseo Rare - the external carotid artery is almost always patent o Occurs only when there is common carotid artery occlusion

Embolic Materialo Often found in the retinal artery and its brancheso Hollenhorst plaque - cholesterol embolus

Diagnostics Carotid Duplexo Measures the degree of blood flow (velocity) going through the

artery (e.g. carotid)o Combines the ultrasound with the Doppler to produce a 3D

image with soundo Has two components:

B Mode- provides anatomic information; shows flow irregularities and evidences of blockage

Doppler- derived Data- provides functional informationo Data obtained:

degree of stenosis, plaque density, other morphological characteristics (like ulcerations)

To determine the plaque density (i.e. degree of stenosis), we look at the velocity of blood flow through the vessel not at how broad the lesion appears on the ultrasound (not at anatomic criteria, University of Washington Criteria) Determined by the Doppler component If there is increased velocity in the area proximal to the

carotid bulb, there is a significant lesion in the area of the carotid artery

Able to help the examiner visualize other morphologic characteristics of the lesion

o Limitations: Operator dependent Cannot provide an image of the carotid arch and the

intracranial circulation (recall how important this is for the unique pathophysiology of stroke in Filipinos)

Different labs have different parameters Hence, request for an MRI or CT Angiography Largely operator-dependent Limited access area

Magnetic Resonance Imaging (MRI) and CT Angiographyo Able to display anatomical information about the lesiono Also able to let the examiner visualize the relationship of the

disease with other organs or vesselso Compensate for shortcomings of Duplex

CT angiography Contrast Angiographyo Gold Standardo Examiner is able to visualize the degree of the stenosiso Also provides comparisons and percentages

INDICATIONS FOR REPAIR Based on RCT’s Form the basis for the treatment guidelines being implemented

Symptomatic NASCET data is used as gold standard.o Patients all had more than 70% stenosiso The patients were divided into two groups: Medical

management vs surgeryo The incidence of stroke, TIA’s and death (mortality) was noted

NASCET Findingso Surgery: mortality rate was 7%o Medical management: mortality rate was 24%o Mortality rate: Surgery < medical mgto Hence, 71% risk reduction

o Ipsilateral stroke was also noted Therefore, in practice, if the patient is symptomatic and the

stenosis is greater than 70%, surgery is recommended

Asymptomatic Carotid Artery Stenosis with Asymptomatic Narrowing: Operation

vs Aspirin (CASANOVA) ACAS (Asymptomatic Carotid Artery Study) data is used as gold

standard.o 5.1% vs 11% incidence of ipsilateral stroke at 5 yrs in pts w/ 60-

99% stenosis (53% risk reduction)o Mortality rate: Surgery < medical mgt

ACST (Asymptomatic Carotid Surgery Trial) data: o 6.4 % stroke risk in medical arm vs 11.8% in combined CEA +

best medical treatment

TREATMENTIron Man (irony of treatment): the means by which stroke is prevented can also trigger stroke.

Carotid Endarterectomy Gold Standard Patients under general anesthesia Process: create a long cervical incision expose carotid arteries

extract plaque close with a patch Risk of stroke Difference in risk reduction not significant

Figure 7. Carotid endarterectomy.Note the process mentioned above. Heparin is used in order to

prevent immediate coagulation and risk of post-surgical embolism


<2014> says: Problem: only the 5-year risk was assessedo Risk of stroke with regard to the procedure is estimated to

be 5%o This large risk invalidates the advantage presented by the

study Therefore, in clinical practice, when the patient is

asymptomatic, medical management is indicated for stenoses which are 80% or less; for those which are greater than 80%, surgery is indicated.



Figure 8. Carotid endarterectomy: plaque excision

Carotid Artery Stenting (CAS) Fluoroscopic guide is used, embolic protection device Distal filter – most common For symptomatic, high risk patients Procedureo The vessel is accessed via the femoral arteryo A catheter is inserted towards the common carotid arteryo A balloon or stent is used to open the stenosis

No incision needed, only a puncture wound Main Problem: there is no long-term data (e.g. risk of restenosis)

since the modality is young Risk if soft plaque strokeo Higher risk – because of continuous poking with the wire, the

plaque might become dislodged Modificationso Balloon – serves as blockade to possible embolio Basket – used to catch particles that might dislodge

Reversal of flow is possible, instead of a forward flow, blood will flow backward and towards the external carotid artery, hence emboli may block ECA – this is alright because ECA is dispensable according to sir since it only supplies the face (vs. brain supplied by ICA)

COMPLICATIONS Strokeo The means to prevent stroke can cause a stroke o The surgeon should, then, be aware of his stroke risk. So that, if

his stroke risk is greater than the mortality from the procedure, he should not perform the procedure.

Surgicalo Bleeding, infectionso Cranial nerve injury (esp. CN IX and XII)

Endovascularo Dissectionso Common vessel occlusiono Bleeding

Being studied EVA3s, SPACE and CREST CREST, higher risk of stroke CAS is usually indicated for high-risk patients only High Risk Patients are those who had:o severe co-morbidities (e.g. COPD)o Previous CEA with restenosiso previous neck surgerieso prior neck irradiation with skin changeso presence of tracheostomyo contralateral vocal cord paralysis

CEA is usually indicated for patients who have unstable plaques which might embolize if a catheter is used

More benefit: CEA > CAS

INTERVENTIONS

SymptomaticExtent of Stenosis Intervention<70% stenosis Optimal medical tx≥ 70% Stenosis CEA + medical tx≥ 70% stenosis and high operative risk

CAS + medical tx

AsymptomaticExtent of Stenosis Intervention≤ 60% Stenosis Optimal medical tx≥ 60% stenosis and low operative risk

CEA + medical tx

The table shows the type of intervention relative to the degree of stenosis among asymptomatic and symptomatic patients.

SUMMARY Coronary artery disease is a major risk factor for stroke Surgical intervention in symptomatic patients prove to decrease

the risk Carotid artery stenting is emerging as a viable alternative to CEA, esp. in symptomatic, high risk patients

RENOVASCULAR HYPERTENSIONINTRODUCTION (2014)

This is a syndrome of decreased kidney perfusion due to increased arterial blood pressure

Also known as renal artery occlusive disease and fibrodysplastic disease of the renal arteries

Most common form of secondary hypertension 80% of cases is caused by atherosclerosis

PATHOPHYSIOLOGY (2014) The hypoperfused kidney responds as though under conditions

of low blood pressure, releasing renin and activating the Renin-Angiotensin-Aldosterone System (RAAS)

o The RAAS will induce sodium and water retentiono This retention may induce other forms of hypertension

CLINICAL CLUES

ONSET

Onset before age 30 without risk factors or onset of sig. HTN after age 55

Presence of an abdominal bruit Accelerated HTN over prev. stable baseline or resistant HTN

despite multidrug therapy Renal failure of uncertain etiology Recurrent flash edema Coexisting diffuse atherosclerotic vascular disease ARF precipitated by ACEI or ARBs

HYPERTENSION

A lot of hypertension <HPN> idiopathic, small % HPN is because of renovascular disease

DIAGNOSTICS History and Physical Examination Anatomic studieso Renal duplex USo MRI/MRA (magnetic resonance angiography)o Angiography

Functional studieso Captopril renography o Renal vein rennin assay

TREATMENT Goals


CEA vs CAS

<2014> says:SIGNS AND SYMPTOMS

Abdominal bruit Signs of renal failure of uncertain etiology No proteinuria No sediments in urine Recurrent flush edema

ACUTE RENAL FAILUREAcute Renal Failure (ARF) precipitated by ACE (Angiotensin Converting Enzyme) Inhibitors or Angiotensin Receptor Blockers (ARB’s)

If there is compromised blood flow to the kidneys, suspect renal stenosis if after administering ACE inhibitors, the patient developed acute renal failure (ARF)



o Control HPN (hypertension)o Preserve renal function

Optionso Medical treatment to control hypertensiono Percutaneous Transluminal renal Angioplasty without

stentingo Surgical to draw renal inflow from aorta/splenic artery

Aortorenal bypass Splenorenal bypass

- Laparotomy expose renal vessels aortorenal/ splenorenal bypass take out plaque close up with patch- Very good response to surgery

o Endovascular (Endarterectomy) Treatment Used to repair obstructed/stenosed renal arterial supply Uses a stent- or balloon catheter (if balloon: Fogarty

catheter) Stenting is safer, has lower mortality and is prescribed by

most doctors Guided by either duplex ultrasound or angiogram Results: rare cure of hypertension, reduction in number of

medications to be takeno Transaortic Endarterectomy (recommended for extensive

aortic lesions)

Endovascular and Med Treatmento Hypertension

Slight reduction in BP or drug medication is the best that can be hoped for

Hypertension is rarely curedo Renal Function

Evidence less clear cuto Angioplasty vs Medical treatment for Hypertension

(Dutch Renal Artery Stenosis Cooperative Study) no significant difference in systolic and diastolic blood

pressures, daily drug doses, and renal functiono Revascularization vs Medical treatment for RAS

(Angioplasty and Stenting for Renal Artery Lesions) revascularization carried substantial risks but had NO

benefit in renal function and blood pressureo Stent vs Medical treatment for Renal Function

primary endpoint is 20% or greater decrease in creatinine clearance

Conclusion: stent placement had no clear effect on progression of impaired renal function but was associated with significant procedure related complications

Recommendation: focus on cardiovascular risk factor management and avoid stenting

<jc> says:

Hi everyone! No greetings from my trans-mates, so ako na lang!

Una sa lahat, I wanna invite you all to Agape’s Series on It’s Not About Me (Max Lucado), every Tuesdays starting this August 7 until September 25, 2012, 5-7pm at MSU 2nd flr. This is open to ALL UPCM students, and it’s FREE! We hope to see you.

Gusto ko rin i-greet ang aking mga research groupmates (Ho-Sia group), Tricia Isada to Alex Martinez. Salamat at hindi na ako (pati si Ruby) mag-isa sa pananaliksik >hehe<

Hello rin sa Class 2017! God bless everyone!

Figure 19. Splenorenal bypass (venous in this case)

SURGERY VS STENTING Surgical interventions are really superior and very effective but

the mortality & morbidity very high Surgery has more complications Therefore, if given the option, one should really consider doing an

endovascular intervention instead.

SUMMARY Renovascular diseases are a known cause of hypertension and

renal insufficiency Revascularization is an option to cure or better control the

renovascular disease

END

“NBA championship teams have something in common: they play with one goal in mind. Each player contributes his own gifts and efforts so that the greater goal – winning – can be reached. But players who seek their own glory at the sacrifice of the team’s glory drive the team away from success. So it is with life. The goal is not our own glory. In fact, trying to make life “all about us” pushes happiness further out of reach.

The Bible is full of men and women who struggled with “me-centric” thinking, so our generation is not alone. If we would learn from them, we could live in freedom. We would be able to enjoy




successes without taking the credit. We could bear up under troubles with confidence in God. By letting go of our own agendas and time-tables, we would discover that God’s plans are mind-blowing. In the end, a “God-centric” lifestyle would free us to live life to the fullest!”

[David Robinson, former NBA player]


[os 213] lec 15 surgery for peripheral vascular diseases i (b)

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