Atherosclerosis: A Surgical Look Mohammed Al-Omran, MD, MSc, FRCSC Associate Professor & Consultant...

Atherosclerosis: Atherosclerosis: A Surgical LookA Surgical Look

Mohammed Al-OmranMohammed Al-Omran, , MD, MSc, FRCSCMD, MSc, FRCSC

Associate Professor & ConsultantAssociate Professor & Consultant

Vascular Surgery Vascular Surgery

King Saud UniversityKing Saud University

11428 surgery team428 surgery team

Done by: 428 surgery team

What is Atherosclerosis?What is Atherosclerosis?

•It as an inflammatory process It as an inflammatory process that causes clogging, that causes clogging, narrowing, and hardening of narrowing, and hardening of large large and and mediummedium-sized -sized arteries arteries


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



• Fat deposits accumulate and will cause Fat deposits accumulate and will cause endothelial injury that will initiate the endothelial injury that will initiate the inflammatory processinflammatory process

• Formation of fibrous plaque by platelets Formation of fibrous plaque by platelets

• Calcification of the arterial wall Calcification of the arterial wall (this is the (this is the cause of atherosclerosis)cause of atherosclerosis)

• Fat by itself is Fat by itself is NOT NOT harmfulharmful

• Rupture of the wall will cause Rupture of the wall will cause clotting(atherothrombosis) clotting(atherothrombosis) >> this what we >> this what we are worrying about are worrying about


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

• Cerebrovascular diseaseCerebrovascular disease

• Coronary artery diseaseCoronary artery disease

• Renal artery DiseasesRenal artery Diseases

• Visceral Visceral (mesenteric) (mesenteric) arterial arterial disease disease

• Peripheral arterial disease Peripheral arterial disease (Aorto-iliac & upper and (Aorto-iliac & upper and lower limb) is a lower limb) is a marker for marker for atherosclerosisatherosclerosis

• Intermittent claudicationIntermittent claudication• Critical limb ischemiaCritical limb ischemia


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


Let’s Talk about Peripheral Let’s Talk about Peripheral Arterial DiseaseArterial Disease


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



• Coexisting vascular Disease:Coexisting vascular Disease:

CAD*CAD*-- 35 % to 92%-- 35 % to 92%

CVD*CVD*-- 25 % to 50%-- 25 % to 50%

Coronary Arterial diseaseCoronary Arterial disease

Cerebrovascular diseaseCerebrovascular disease



•Cause of death:Cause of death: CADCAD– 40%-60% – 40%-60% main cause of deathmain cause of death

CVDCVD– 10%-20% – 10%-20% NNon-cardiovascularon-cardiovascular causescauses--Only --Only

20% to 30 %20% to 30 %•Patients with PAD have a Patients with PAD have a 6 fold 6 fold

increased risk of cardiovascular increased risk of cardiovascular disease mortality compared to disease mortality compared to patients without PADpatients without PAD even the even the patient with or without symptomspatient with or without symptoms


Natural HistoryNatural History

• 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: 1257-64.1313428 surgery team428 surgery team

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

AsymptomaticAsymptomatic

SymptomaticSymptomatic

•Intermittent Intermittent claudicationclaudication•Critical Limb Ischemia Critical Limb Ischemia ((limb-limb-threating condition)threating condition) Pain at restPain at rest Tissue loss Tissue loss (Ulcers)(Ulcers) GangreneGangrene


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


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



ABI measurementABI measurement Non-invasive tests (arterial duplex, Non-invasive tests (arterial duplex, CTA, MRA)CTA, MRA) Invasive test Invasive test ((Conventional angiogramConventional angiogram) ) (the gold standard)(the gold standard) ABI measurementABI measurement

HistoryHistoryPhysical ExaminationPhysical Examination

Investigation usually to : 1-confirm the diagnosis (NOT for

diagnosis)2-to inform us about the severity


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

Symptomatic 10%

Asymptomatic 90%

Even Asymptomatic patients Carrie the same risks of

symptomatics1717428 surgery team428 surgery team

Ankle Brachial IndexAnkle Brachial Index

ABI= Highest Ankle Systolic BP (PT or DP) / Highest Arm Systolic BP

PT : posterior tibial arteryDP : dorsalis pedis artery 1818428 surgery team428 surgery team

Ankle Brachial IndexAnkle Brachial Index

ABI valueABI value IndicatesIndicates

<0.9<0.9 Abnormal [MCQ]Abnormal [MCQ]

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


Arterial Arterial duplexduplexDoppler

Anatomical function


CTACTA


Angiogram Angiogram


What are the Goals of treating What are the Goals of treating patients with PAD?patients with 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 patients Strategies in treating patients with PADwith PAD


Risk Factors Modification• Diet and weight controlDiet and weight control• ExerciseExercise• Antiplatlets Antiplatlets (to prevent the thrombus (to prevent the thrombus

when the artery is ruptured) when the artery is ruptured)

• Hypertension controlHypertension control• Diabetes control Diabetes control H1c < 6H1c < 6

• Lipid control Lipid control < 2.5 < 2.5

• Smoking CessationSmoking Cessation2525428 surgery team428 surgery team

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

the artery) the artery)

- Surgical Bypass - Surgical Bypass (outside the artery) (outside the artery)

Strategies in treating Strategies in treating patients with PADpatients with PAD


Percutanous Transluminal Percutanous Transluminal AngioplpastyAngioplpasty

PTAPTA


Surgical BypassSurgical Bypass


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


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



•Transient Ischemic Attacks (TIA) Transient Ischemic Attacks (TIA) less than less than 24 hours24 hours•Amurosis Fugax (Transient Visual Loss) Amurosis Fugax (Transient Visual Loss) •Stroke Stroke more than more than 24 hours 24 hours


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



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 plz use ur stethoscope plz use ur stethoscope 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 treating What are the Goals of treating patients with CAD?patients with CAD?

•Prevent StrokePrevent Stroke

•Prolong 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 (the (the

best method to increase the brain best method to increase the brain circulation) circulation)

- 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


Acute Limb IschemiaAcute Limb Ischemia


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

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


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

• EmbolusEmbolus the commonest cause the commonest cause [MCQ][MCQ]

• ThrombosisThrombosis

• OthersOthers

TraumaTrauma

IatrogenicIatrogenic

Arterial dissectionArterial dissection


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

Spontaneous (80%) Cardiac source commonest cause

[MCQ] 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 limb How do patients with acute limb ischemia present?ischemia present?

• Sudden onset of diffuse and poorly localized leg Sudden onset of diffuse and poorly localized leg pain 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 CLINICAL DIAGNOSIS (coz there is no time to do DIAGNOSIS (coz there is no time to do investigation) investigation)

• If time allows, especially if atherosclerotic If time allows, especially if atherosclerotic thrombosis is suggested, preoperative thrombosis is suggested, preoperative angiography angiography is often wise is often wise


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

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


TreatmentTreatment

• EMEGENCY EMEGENCY (Golden time is 6 hours from the (Golden time is 6 hours from the appearance of symptomappearance of symptoms)s)

ABCABC

IV Heparin (anticoagulation)IV Heparin (anticoagulation)

Rapid surgical thromboembolectomyRapid surgical thromboembolectomy

+/ - surgical bypass+/ - surgical bypass

+/- thrombolytic therapy+/- thrombolytic therapy

+/- primary amputation+/- primary amputation


Surgical Thrmboemblectomy ProcedureSurgical Thrmboemblectomy Procedure


ThrombolysisThrombolysis


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

•Reperfusion InjuryReperfusion Injury-Local -Local

Compartment Syndrome Compartment Syndrome we should do we should do fasciotomyfasciotomy

-Systemic -Systemic

Hyperkalemia leads to cardiac arrest Hyperkalemia leads to cardiac arrest we we should give Calcium Gluconateshould give Calcium Gluconate

AcidosisAcidosis we should give bicarbonate we should give bicarbonate

Myoglobulinuria leads to acute renal Myoglobulinuria leads to acute renal injure injure we should give a lot of fluids we should give a lot of fluids


Compartment SyndromeCompartment Syndrome


Thank Thank YouYou


Atherosclerosis: A Surgical Look Mohammed Al-Omran, MD, MSc, FRCSC Associate Professor & Consultant...

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