WHEN TO REFER A PATIENT TO A VASCULAR SURGEON · Ø Symptomatic TIA, amaurosis fugax Ø Evidence of...

Common Vascular Pathologies

When to refer to a vascular surgeon?

Ronnie Word, MD, RPVILee Health Vascular Surgery

Vascular Surgery / Medicine

Provide diagnosis and treatment including medical, surgical, or

endovascular therapy for all venous and arterial

pathologies.

Provide surveillance and follow up to arterial and

venous insufficiency.

Arterial PathologiesØ Carotid disease

Ø Aneurysm

Abdominal aorta

Thoracic aorta

Any other arteries popliteal, carotid, etc.

Ø Peripheral arterial disease lower extremity claudication

lower extremity wounds

diabetic foot

Ø Hemodialysis access

Ø Renovascular disease

Ø Mesenteric vascular disease

Ø No intracerebral vascular pathology

Ø No heart pathology

Ø No ascending aortic problems

Venous Pathologies

Varicose veins

Venous ulcers

Help with management of DVT

IVC filters

Carotid artery disease

Carotid Disease

Ø Stroke is the third leading cause of death in the USA

Ø 80% of all strokes are ischemic

Ø 20% of all strokes are hemorrhagic

Ø Over 50% carotid stenosis is found in 12%-20% of all anterior circulation strokes

Ø Only 15%-20% of strokes victims have a warning TIA

(Aboott, Internal J. Stroke, 2007)

Symptomatic Carotid

Common symptoms:

Ø Contralateral weakness (face, arm or leg)

Ø Contralateral sensory deficit / paresthesia (face, arm or leg)

Ø Amaurosis fugaxØ Aphasia

Symptoms not typically associated with carotid stenosis

Ø VertigoØ DizzinessØ DiplopiaØ AtaxiaØ Decreased consciousnessØ Overall weaknessØ Syncope

Carotid Screening

Stroke association / AHA stroke council

Ø Do not recommend carotid ultrasound screening for the general population

Ø Highly selected patients may benefit

(Goldstein, Stroke, 2006)

High Risk Population

Ø Age > 65 yearsØ History of

hypertension Ø CADØ Tobacco abuseØ History of strokeØ History of PADØ History of neck

radiation Ø Carotid bruit

Carotid bruit….What is the significance?

Ø 500 patients with asymptomatic neck bruits

Ø Carotid duplex revealed only 1.2% of severe (>70%) carotid stenosis

Ø Selected high risk patients with carotid bruit 25% had > 60% carotid stenosis

Ø Screening only probably in high risk patients

(Zhucz, Stroke, 1990)

Risk of stroke for

asymptomatic patients with

carotid stenosis

Ø European carotid surgery triallist (ECST)

Ø ECST study of 2295 patients

Ø < 2% annual stroke risk with < 70% carotid stenosis

Ø 14.4% stroke risk with 80 - 99% stenosis (Lancet, 1995)

When should I obtain imaging of the carotidWhich patients should have imaging carotid bifurcation (Duplex ultrasound)?

Ø Symptomatic TIA, amaurosis fugax

Ø Evidence of retinal artery embolization (hollenhorst plaque)

Ø Patients without neurologic symptoms

Consider in

1) Patients with clinical significant PVD

2) 65 year old or older with CAD

3) Tobacco use

4) Diabetes

5) Hypercholesterolemia

6) Stroke history

7) Carotid bruits

What imaging modality should I

choose for carotid

evaluation?

Imaging modalities available for evaluation

Ø Carotid duplex ultrasound

Ø CTAØ MRAØ Subtraction

angiography

Carotid Duplex UltrasoundØ Gold standardØ Non-invasiveØ Technician dependent (accredited vascular lab)

Ultrasound B mode

Duplex ultrasound

Duplex ultrasound consensus criteria for

stenosis

Ø PSV of ICA > 125 cm / second > 50% stenosis

Ø PSV of ICA > 230 cm / second > 70% stenosis

(Grant, Ultrasound Q, 2003)

MRAØ Tendency to

overestimate the degree of stenosis

Ø Very high grade stenosis may result in a loss of signal on MRA

CTA

Ø Pooled sensitivity 85% and specificity 93%

Ø Large calcium burden limits visibility and accurate evaluation

Ø IV contrast (careful with CKD)

Carotid disease

Ø First Medical optimization

Control risk factorsØ HTNØ DiabetesØ LipidsØ Antiplatelet therapyØ Statins

Carotid disease

When should I refer to a vascular surgeon?

Ø Symptomatic patients Hospital

Ø Asymptomatic patients• Carotid stenosis with over 70% stenosis• Consider refer patient with > 50% stenosis if

you want us to start surveillance

Carotid interventions,

WHEN?

Ø Neurologically asymptomatic patients with > 70% internal carotid stenosis if life expectancy is expected over 3-5 years and perioperative stroke death < 3%

Ø Neurologically symptomatic patients with > 50% internal carotid artery stenosis

(Ricotta, JVS, 2001)

Carotid Interventions

Ø

Ø

Ø

Peripheral Vascular Disease (PVD)

Anatomy

•Upper extremity•Lower extremity

Pathology

•Claudication •Limb threatening

ischemia

Peripheral vascular disease affects the blood vessels outside the heart where plaques build up inside the lumen of the vessels obstructing the

arteries (atherosclerosis)


Scope of problemØ 8 – 12 millions of Americans are

affected by PVD

Ø Prevalence of 14.5% patients aged > 65 years

Ø Relative in PAD prevalence of 23.5% worldwide

Ø US Medicare program spent 4.3 billions in 2001

(Selvin, Circulation, 2004)

PVD RISK

FACTORS

Ø SmokingØ DiabetesØ Hypertension Ø Renal

insufficiencyØ AgeØ Male genderØ Hyperlipidemia

PVD ( lower extremity)

Clinical presentation ØAsymptomaticØIntermittent claudication ØCLI ( critical limb ischemia)

➢Rest pain ➢Ischemic ulcer

IntermittentClaudication

Reproducible discomfort in a specific muscle group that is induced by exercise and relieved by rest.

Ø Cramping / aching discomfort at calf muscle

Ø Quickly relieved by restØ No effect on position

Differential Diagnosis

Ø Neurogenic claudication

Ø Hip arthritisØ Venous

claudication Ø Spinal stenosisØ Foot / ankle

arthritis

Neurogenic Claudication (nerve root

compression)

Ø Pain radiates down the leg

Ø Sharp, lacerating pain (electric shocks)

Ø Induced by sitting, walking or standing

Ø Improved by changing positions

Spinal Stenosis

Ø Often bilateral buttocks /posterior leg

Ø Often pain present with weakness

Ø Relief by lumbar spine flexion

Ø Worse with standing and spine extension

Hip Arthritis

Ø Lateral hip and thigh pain

Ø Symptoms after variable degree of exercise

Ø Improved when not weigh bearing

Ø Not relieved quickly

Natural history of patients with claudication

5 year outcomes

Limb morbidity CV morbidity

Stable claudication 70%-80%

Worsening claudication20%-30%

CLI1%-5%

MI or stable20%

Mortality10%-15%

Screening for PVD

SVS recommends against routine screening for PAD in absence of risk factors, history or symptoms

(Conte, Journal of Vascular Surgery, 2015)

Screening for PVD

SVS suggests screening for patients with several risk factors (Diabetes, smoking, age, CAD) and those with

abnormal pulse examination


Screening for PVD

SVS suggests that screening for PAD is reasonable if used to

improve risk stratification,

preventive care and medical management


PAD + leg / foot wound =CLI

(critical limb ischemia)

Chronic CLI

Leg ulcer or ischemic foot pain for > 2 wks

ABI < 0.4

Ankle pressure < 50 mmHg

Arterial ulcer


Test of choice to diagnose PVDØPhysical examØAnkle – brachial index (ABI)ØWhere? Vascular laboratoryØShould I get CT scans, MRI? NO

Vascular lab

Ankle –brachial index


Management of PVD (SVS recommendations)Ø Recommend antiplatelet therapy (ASD 75 – 325 mg)Ø Suggest 3 month trial of Cilostazol (patients without

CHF)Ø Recommend smoking cessation Ø Optimizing diabetes controlØ Exercise program 30 minutes of walking 5 times a

week


Peripheral Vascular Disease (PVD)When to refer patients with lower extremity PVD

Ø All patients with limb threatening symptoms (all lower extremity wounds without palpable pedal pulses –VASCULAR SURGEON FIRST)

Ø Severe intermittent claudication

Ø Unclear leg pain …. Obtain ABI first.

Ø All patients needing a work up evaluation


Recommendations for vascular intervention

All patients with limb threatening ischemia (CLI)

IC patients only with lifestyle limiting disability when pharmacologic or exercise therapy have failed.

Peripheral Vascular Disease (PVD)Upper extremity PVDØ Most common pathology: Subclavian artery stenosis

Ø Usually asymptomaticØ Symptoms Arm claudication

Subclavian steal

When to referØ Only symptomatic patientsØ If previous coronary bypass and angina

Ø Varicose veins

Ø Spider veins

Ø Leg swelling

Ø Leg ulcers

Chronic Venous

Insufficiency(CVI)

Chronic venous insufficiency (CVI)

Condition that occurs when the venous valves or wall of the leg veins are not working effectively causing reflux and

blood pooling in the legs

Varicose VeinsScope of the problemØPrevalence of varicose veins between 20-

30%

Ø20 million women and 11 million menages 40 to 80 have varicose veins in the USA

ØActive venous ulcers 0.5% population

(O’Donnel, et al., Journal of Vascular Surgery, 2014)

Anatomy of the Leg Venous SystemTibial

Ø Deep venous system PoplitealFemoral

Ø Superficial venous system GSVSSV

Ø Iliac veins

Ø Perforators

Risk factors to develop CVIØ Age over 50Ø Female sexØ Family history of varicose veinsØ PregnancyØ Episode of deep venous thrombosis

(DVT)Ø Extended periods of standing or

sittingØ Obesity and inactivity

PATHOPHYSIOLOGY OFCHRONIC VENOUS INSUFFICIENCYØ Primary reflux deep – only 8%

superficial perforator

Ø Secondary reflux post DVT (common in deep system)

Ø Obstruction residual thrombus is replaced and fibrous tissue valve damage

Ø Mixed etiology obstruction / reflux

CVI Manifestations

C1 Spider veins

C2 Varicose veins C3 Edema

C4 Chronic skin

changes

C5 Healed venous ulcer

C6 Active venous ulcer

Spider veins TelangiectasiasReticular veins

No underlying pathologyØNo need for further work upØCosmetic

Spider veins

Varicose veinsDilated subcutaneous veins that are > 3 mm in

diameter measured in the upright position

Varicose VeinsPathology of venous insufficiencyØ Primary versus secondary

Ø 70-80% of varicose veins originate of primary venous insufficiency

Ø 40% of advance chronic venous insufficiency (venous ulcers) pathology is isolated saphenous vein reflux

Varicose Veins

Varicose veins symptomsØAchingØHeavy legs and tirednessØThrobbingØItchingØMuscle crampsØSwelling

DIAGNOSIS

Gold standard Duplex Ultrasound

Society of vascular surgery recommends all patients with advance CVI (C2-C6) must

have a diagnostic work up (Duplex))

Duplex Evaluation Reflux or obstruction Deep veins

Superficial (GSV, SSV) Perforator veins

DUPLEX ULTRASOUND

Venous reflux defined by reversal flow of > 0.5 seconds in leg veins

Edema

More often multifactorial (CHF, CKD, obesity, inactivity, leg dependency)

Be suspicious of non venous etiology if no history of DVT or varicose veins

Severe leg swelling without venous stasis changes ………… think other causes.

Venous stasis

Leg venous ulcers

Varicose Veins/CVI

Medical therapy

Ø Compression therapy (20-30 mmHg) knee high (not recommended as the primary treatment modality)

Ø Venoactive drugs (Diosmin, purified flavonoid fraction –not available)

Ø Exercise

Varicose Veins

When to refer to vascular surgery officeØAny patient with spider / varicose veins that

desires treatmentØAll symptomatic patientsØAll patients with advance venous

insufficiency C4 - C6ØVenous ulcers word of caution with

wound healing centers

Varicose Veins

Endovenous thermal ablation

Sclerotherapy

Phlebectomies

Iliac venogram / stenting?

Stripping

What to expect for therapy

Aortic AneurysmsDefinition: Aorta > 3 cms

Types1. Thoracic aorta Ascending

Descending

2. Abdominal aorta3. Thoracoabdominal aneurysm4. Iliac aneurysm

Aortic AneurysmsØ Symptoms

• Usually none• Abdominal /

back pain• Embolization

Ø Diagnosis• Abdominal

ultrasound• CT scan

Abdominal ultrasoundØ Gold standard for initial diagnosisØ Non invasive Ø Accuracy as good as CT scan Ø Limitations in severe obesity

CTAØ Gold standard prior to surgeryØ Axial cuts should be 2 mm cuts Ø Best study if rupture suspectedØ Limitations in CKD

Aortic AneurysmsØScreening recommendations (SVS)

ØU/S for all men > 65 y/o

ØU/S for men > 55 y/o with a positive family history

ØU/S for women > 65 y/o with history of smoking with a positive family history

(Chaikof, Journal of Vascular Surgery, 2017)

Recommendations for Aneurysms Surveillance

AAA 3.0 to 3.9 cm u/s every 3 years

AAA 4.0 to 4.9 cm u/s every 12 months

AAA 5.0 to 5.4 cmu/s every 6 months

(Chaikof, Society of Vascular Surgery, 2017)

Aortic Aneurysms

Who do I need to refer to a vascular surgeon?

Ø Any thoracic / abdominal aortic aneurysm > 5 cms

Ø Any iliac artery aneurysm > 2.5 cms

Ø Any patient that desires further discussion and easy access to regular surveillance

Aneurysm RepairØ Thoracic Endovascular with stent graft

Ø Abdominal aorta Endovascular repair (EVAR)

Open traditional repair

Ø Endovascular repairMinimally invasive

- Percutaneous approach- Local anesthesia- 24 hours hospital stay

What about other aortic pathologies?

Aortic dissection

Aortic penetrating ulcer

Aortic stenosis

Mural thrombus in presence of an aneurysm (no concern)

What about other

aneurysms?

Popliteal artery aneurysms

Carotid artery aneurysms (not in brain)

Visceral and renal artery aneurysms

Questions?

WHEN TO REFER A PATIENT TO A VASCULAR SURGEON · Ø Symptomatic TIA, amaurosis fugax Ø Evidence of...

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