Atherosclerosis: Atherosclerosis: A Surgical LookA Surgical Look

Badr AljabriBadr Aljabri, , MD, MSc, FRCSCMD, MSc, FRCSC

Associate Professor & ConsultantAssociate Professor & ConsultantVascular Surgery Vascular Surgery

King Saud UniversityKing Saud University

What is Atherosclerosis?What is Atherosclerosis?

Clogging, narrowing, and Clogging, narrowing, and hardening of large and hardening of large and medium-sized arteries medium-sized arteries

What are the risk factors What are the risk factors for Atherosclerosis?for Atherosclerosis?

Non-Modifiable Risk Factors:Non-Modifiable Risk Factors: Male genderMale gender Advanced ageAdvanced age Family historyFamily history

Modifiable Risk Factors:Modifiable Risk Factors: Major Major SmokingSmoking HypertensionHypertension DiabetesDiabetes HyperlipidemiaHyperlipidemia

MinorMinor HomocystenemiaHomocystenemia ObesityObesity Hypercoaguable stateHypercoaguable state Physical inactivityPhysical inactivity

PathogenesisPathogenesis

PathogenesisPathogenesis

Cerebrovascular diseaseCerebrovascular disease

Coronary artery diseaseCoronary artery disease

Renal artery DiseasesRenal artery Diseases

Visceral arterial diseaseVisceral arterial disease

Peripheral arterial diseasePeripheral arterial disease Intermittent claudicationIntermittent claudication Critical limb ischemiaCritical limb ischemia

What is the Clinical Spectrum What is the Clinical Spectrum of Atherosclerosis?of Atherosclerosis?

What is the burden of What is the burden of Atherosclerosis?Atherosclerosis?

Let’s Talk about PADLet’s Talk about PAD

Why it is important to Why it is important to recognize patients with PAD?recognize patients with PAD?

PAD is a marker of PAD is a marker of systemicsystemic atherosclerosis atherosclerosis

Patients with either symptomatic or Patients with either symptomatic or asymptomatic PAD generally have asymptomatic PAD generally have widespread widespread arterial diseasearterial disease

Why it is important to Why it is important to recognize patients with recognize patients with

PAD?PAD?

Coexisting vascular Coexisting vascular Disease:Disease:

CADCAD-- 35 % to 92%-- 35 % to 92%

CVDCVD-- 25 % to 50%-- 25 % to 50%

Why it is important to Why it is important to recognize patients with recognize patients with

PAD?PAD? Cause of death:Cause of death: CADCAD– 40%-60%– 40%-60% CVDCVD– 10%-20% – 10%-20% NNon-cardiovascularon-cardiovascular causescauses----

Only 20% to 30 %Only 20% to 30 % Patients with PAD have a Patients with PAD have a 6 fold6 fold

increased risk of cardiovascular increased risk of cardiovascular disease mortality compared to disease mortality compared to patients without PADpatients without PAD

Natural HistoryNatural History

Annual risk :Annual risk :

- Mortality - Mortality 6.8%6.8%

- MI - MI 2.0%2.0% - Intervention - Intervention

1.0%1.0% - Amputation - Amputation

0.4%0.4%

Ouriel K, Lancet 2001; 358: 1257-64.

How do patients with PAD How do patients with PAD present?present?

AsymptomaticAsymptomatic

SymptomaticSymptomatic

•Intermittent Intermittent claudicationclaudication•Critical Limb IschemiaCritical Limb Ischemia Pain at restPain at rest Tissue lossTissue loss GangreneGangrene

How do patients with PAD How do patients with PAD present?present?

How do we diagnose How do we diagnose PAD?PAD?

SymptomaticSymptomatic

AsymptomaticAsymptomatic

ABI measurementABI measurement Non-invasive tests (arterial Non-invasive tests (arterial duplex, duplex, CTA, MRA)CTA, MRA) Invasive test (Conventional Invasive test (Conventional angiogram)angiogram) ABI ABI measurementmeasurement

HistoryHistoryPhysical ExaminationPhysical Examination

How do we diagnose How do we diagnose PAD?PAD?

Symptomatic 10%

Asymptomatic 90%

Ankle Brachial IndexAnkle Brachial Index

ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

Ankle Brachial IndexAnkle Brachial Index

ABI valueABI value IndicatesIndicates

<0.9<0.9 AbnormalAbnormal

0.8- 0.90.8- 0.9 Mild PADMild PAD

0.5- 0.80.5- 0.8 Moderate PADModerate PAD

<0.5<0.5 Severe PADSevere PAD

<0.25<0.25 Very Severe PADVery Severe PAD

The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics

Arterial Arterial duplexduplex

CTACTA

AngiogramAngiogram

What are the Goals of What are the Goals of treating patients with treating patients with

PAD?PAD? Relief symptomsRelief symptoms Improve quality of lifeImprove quality of life Limb salvageLimb salvage Prolong survival Prolong survival

Risk Factors Modification

Improve Lower Limb Circulation

Strategies in treating Strategies in treating patients with PADpatients with PAD

Risk Factors Modification• Diet and weight controlDiet and weight control• ExerciseExercise• Antiplatlets Antiplatlets • Hypertension controlHypertension control• Diabetes controlDiabetes control• Lipid controlLipid control• Smoking CessationSmoking Cessation

Improve Lower Limb Circulation• Conservative (Exercise Program)Conservative (Exercise Program)• Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting- Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass

Strategies in treating Strategies in treating patients with PADpatients with PAD

Percutanous Transluminal Percutanous Transluminal AngioplpastyAngioplpasty

PTAPTA

Surgical BypassSurgical Bypass

Major amputation• Primary vs SecondaryPrimary vs Secondary• Minor vs BKA vs AKA Minor vs BKA vs AKA

Last Strategy in treating Last Strategy in treating patients with PADpatients with PAD

NOWNOW

Let’s Talk about Let’s Talk about Carotid Artery DiseaseCarotid Artery Disease

Why it is important to Why it is important to recognize patients with recognize patients with

CAS?CAS? Stroke is the Stroke is the

third third leading leading cause of death cause of death and a principal and a principal cause of long-cause of long-term disabilityterm disability in much of the in much of the western countrieswestern countries

How do patients with CAS How do patients with CAS present?present?

AsymptomaticAsymptomatic

SymptomaticSymptomatic

•Transient Ischemic Attacks Transient Ischemic Attacks (TIA)(TIA)•Amurosis Fugax Amurosis Fugax (Transient Visual Loss) (Transient Visual Loss)

•StrokeStroke

How do we diagnose How do we diagnose CAS?CAS?

SymptomaticSymptomatic

AsymptomaticAsymptomatic

Non-invasive tests (arterial Non-invasive tests (arterial duplex, duplex, CTA, MRA)CTA, MRA) Invasive test (Conventional Invasive test (Conventional angiogram)angiogram) Carotid Bruit Carotid Bruit Arterial duplexArterial duplex

HistoryHistoryPhysical ExaminationPhysical Examination

Arterial Arterial duplexduplex

•Stenosis is determined by Stenosis is determined by measuring Velocities measuring Velocities NOT NOT anatomical diameteranatomical diameter

AngiogramAngiogram

What are the Goals of What are the Goals of treating patients with treating patients with

CAD?CAD?Prevent StrokePrevent StrokeProlong survivalProlong survival

Risk Factors Modification

Improve Brain Circulation

Strategies in treating Strategies in treating patients with CADpatients with CAD

Risk Factors Modification• Diet and weight controlDiet and weight control• AntiplatletsAntiplatlets• Exercise Exercise • Hypertension controlHypertension control• Diabetes controlDiabetes control• Lipid controlLipid control• Smoking CessationSmoking Cessation

Improve Brain Circulation• Intervention ( Revascularization)Intervention ( Revascularization) - Carotid Endarterectomy - Carotid Endarterectomy - Angioplasty +/- Stenting- Angioplasty +/- Stenting

Strategies in treating Strategies in treating patients with CASpatients with CAS

Symptomatic• > 70% stenosis- NACET > 70% stenosis- NACET Decrease Stroke at 2 years from 26% to Decrease Stroke at 2 years from 26% to

9%9%• 50-69% stenosis- marginal benefit, 50-69% stenosis- marginal benefit,

greater for malegreater for male• Recovered Ischemic Stroke PatientsRecovered Ischemic Stroke Patients

What are the indications to What are the indications to intervene?intervene?

Asymptomatic• > 60% stenosis- ACAS> 60% stenosis- ACAS Decrease Stroke at 4 years from 11% to Decrease Stroke at 4 years from 11% to

5%5% (should be done in high volume centers (should be done in high volume centers

only)only)

Carotid Endarterectomy: The Carotid Endarterectomy: The Standard of CareStandard of Care

Carotid Angioplasty and Carotid Angioplasty and StentingStenting

This interventional procedure is This interventional procedure is currently under investigationcurrently under investigation

Relative Indications• Hostile NeckHostile Neck• Hostile Carotid DiseaseHostile Carotid Disease• As part of a Randomized Clinical As part of a Randomized Clinical

TrialTrial

Carotid Angioplasty and Carotid Angioplasty and StentingStenting

Carotid Angioplasty and Carotid Angioplasty and StentingStenting

Acute Limb Acute Limb IschemiaIschemia

What is an Acute Limb What is an Acute Limb Ischemia?Ischemia?

Sudden decrease or worsening in Sudden decrease or worsening in the limb perfusion causing a the limb perfusion causing a potential threat to the limb viability potential threat to the limb viability resulting from a sudden obstruction resulting from a sudden obstruction of the arterial system of the arterial system

What are the causes of acute What are the causes of acute arterial occlusion ?arterial occlusion ?

EmbolusEmbolus ThrombosisThrombosis OthersOthers

TraumaTrauma

IatrogenicIatrogenic

Arterial dissectionArterial dissection

What is the possible source for What is the possible source for an embolus? an embolus?

Spontaneous (80%) Cardiac source arrhythmias, MI, prosthetic valve, endocarditis

Non-Cardiac source Proximal AS plaque, Proximal Aneurysm,

Paradoxical emboli

Iatrogenic (20%) Angiographic manipulation Surgical manipulation

What are the common sites for What are the common sites for embolus lodgment in the arterial embolus lodgment in the arterial

tree?tree?

How do patients with acute How do patients with acute limb ischemia present?limb ischemia present?

Sudden onset of diffuse and poorly Sudden onset of diffuse and poorly localized leg pain localized leg pain

6 Ps6 Ps Paresthesias Paresthesias Pain Pain Poikilothermia (coolness) Poikilothermia (coolness) Pallor Pallor Pulselessness Pulselessness ParalysisParalysis

InvestigationsInvestigations

Acute Limb Ischemia is aAcute Limb Ischemia is a

CLINICAL DIAGNOSISCLINICAL DIAGNOSIS If time allows, especially if If time allows, especially if

atherosclerotic thrombosis is atherosclerotic thrombosis is suggested, preoperative suggested, preoperative angiographyangiography is often wise is often wise

Goal of treating patients Goal of treating patients with Acute Limb Ischemiawith Acute Limb Ischemia

Rapid restoration of adequate Rapid restoration of adequate arterial perfusion without the arterial perfusion without the development of morbid local development of morbid local or systemic complicationsor systemic complications

TreatmentTreatment

EMEGENCY (Golden time is 6 EMEGENCY (Golden time is 6 hours)hours)

ABCABC

IV Heparin (anticoagulation)IV Heparin (anticoagulation)

Rapid surgical Rapid surgical thromboembolectomythromboembolectomy

+/ - surgical bypass+/ - surgical bypass

+/- thrombolytic therapy+/- thrombolytic therapy

+/- primary amputation+/- primary amputation

Surgical Thrmboemblectomy Surgical Thrmboemblectomy ProcedureProcedure

ThrombolysisThrombolysis

What do we worry about What do we worry about after revascularization?after revascularization?

Reperfusion InjuryReperfusion Injury Local Local Compartment SyndromeCompartment Syndrome Systemic Systemic HyperkalemiaHyperkalemia AcidosisAcidosis MyoglobulinuriaMyoglobulinuria

Compartment SyndromeCompartment Syndrome

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