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 Peripheral Vascular Occlusive Disease

Anthony D. Whittmore , M.D., James M. Seeger , M.D., Jon R. Cohen, M.D.

Includes:

  • Aortoiliac Occlusive Disease
  • Femoral- Popliteal-Tibial Occlusive Disease
  • Upper Extremity Occlusive Disease
  • Combined Aortoiliac and Infrainguinal Occlusive Disease
  • Arterial Bypass Graft Surveillance
  • Failing Arterial Bypass Graft
  • Ischemic Foot Lesions

I. Anatomy & Pathophysiology

1. To define the normal arterial anatomy of the peripheral vascular system including commonly encountered anatomic variations.

2. To recognize the physiologic and pathophysiologic collateral circulatory routes which commonly develop in response to occlusive disease.

3. To understand the neural, humoral and pharmacologic mechanisms which affect peripheral vascular reactivity and auto-regulatory function.

4. To appreciate the multiple etiologies of acute peripheral vascular ischemia including embolism, thrombosis, dissection, venous occlusion, trauma.

5. To appreciate the multiple etiologies of chronic peripheral vascular ischemia including atherosclerosis, aneurysm, entrapment syndromes, trauma, and a variety of non-atherosclerotic occlusive entities.

6. To understand the mechanism of early and late graft failure, fibro- intimal hyperplasia and progression of disease.

II. Diagnostic Evalutation

Acute Peripheral Ischemia

1. To understand the signs and symptoms characteristic of acute arterial ischemia and the differential diagnosis.

2. To understand the importance of assessing the degree of acute ischemia.

3. To appreciate the significance of the duration of acute ischemia.

4. To recognize the importance of antecedent clinical entities which may predispose to acute peripheral ischemia including atrial fibrillation, prior myocardial infarction, aortic dissection and hypercoagulopathies .

5. To appreciate the significance of initial electrolyte, acid base and other laboratory parameters useful in assessing the magnitude of ischemia to define the indications for appropriate therapy.

6. To understand the relative indications for immediate diagnostic angiography versus urgent surgical exploration.

7. To understand the arteriographic findings characteristic of different etiologies and to appreciate the diagnostic imaging options available in addition to arteriography ( MRA , CT , duplex imaging).

Chronic Peripheral Vascular Ischemia

1. To understand the characteristic signs and symptoms of chronic peripheral vascular ischemia relative to the patient's history and physical examination.

2. To understand the importance of appropriate imaging studies prior to formulating a therapeutic management plan.

3. To understand the importance of hemodynamic testing in the formulation of a therapeutic management plan.

4. To appreciate the characteristic angiographic findings in patients with common patterns of peripheral vascular occlusion as well as the importance of assessing available collaterals.

III. Treatment

Acute Peripheral Vascular Ischemia

1. To appreciate the relative indications for immediate angiography, thrombolytic therapy, or urgent surgical exploration relative to the duration of symptoms and magnitude of ischemia.

2. To have a comprehensive understanding of the variety of surgical exposures of the peripheral vasculature.

3. To understand the relative indications for the major surgical options available for peripheral occlusive disease including endarterectomy , patch angioplasty and bypass graft ( autogenous versus prosthetic).

4. To understand the role of intra-operative thrombolytic agents, dosage and mechanisms of action.

5. To appreciate the sequela of reperfusion following acute ischemia in terms of systemic effects as well as local effects warranting fasciotomy including the anatomy and physiology of fasciotomy .

6. To be familiar with endovascular options for the treatment of occlusive disease including atherectomy , laser, balloon angioplasty, stent graft, as well as the role of angioscopy .

7. To understand the importance of completion imaging studies following peripheral arterial reconstruction.

Chronic Peripheral Vascular Ischemia

1. To have a comprehensive understanding of all standard surgical approaches for surgical revascularization including endarterectomy , patch angioplasty and bypass (in -situ and reversed vein grafts, prosthetic grafts).

2. To understand the difference in application of options relative to the degree of ischemia ( claudication versus critical ischemia, with or without tissue necrosis).

3. To understand indications for primary amputation.

4. To have an understanding of the role of endovascular approaches including laser, atherectomy , thrombectomy , balloon dilatation with or without stent , and angioscopy .

5. To have a comprehensive knowledge of popliteal entrapment and advential cystic disease and their treatment.

6. To understand the necessity for post revascularization non-invasive hemodynamic assessment and criteria for reintervention for a failing of failed bypass.

References

1. Boyd, AM: The natural course of arteriosclerosis of lower extremities. Proc R Soc Med 55:591, 1962.

2. Patent FN, Piotrowski JJ, Bernhard VM, et al: Outcome of intraarterial urokinase for acute vascular oclusion . J Cardiovasc Surg 32:680, 1991.

3. Thompson RW, Mannick JA, Whiteemore AD: Arterial reconstruction at diverse sites using nonreversed autogenous vein: An application of venous valvulotomy . Ann Surg 205:747, 1987.

4. Veith FJ, Gupta SK , Ascer E, et al: Six -year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene graft in infrainguinal arterial reconstruction. J Vasc Surg 3:104, 1986.

5. Taylor RS, McFarland RF, Cox MI: An investigation into the causes of failure of PTFE grafts. Eur J Vasc Surg 1:335, 1987.

6. Gilbertson JJ, Walsh DB, Zwolak RM, et al: A blinded comparison of angiography, angioscopy , and duplex csanning in the intraoperative evaluation of in situ saphenous vein bypass grafts. J Vasc Surg 15:121, 1992.

7. Whittemore AD, Clowes AW, Couch NP, Mannick JA: Secondary reconstruction . Ann Surg 193:35, 1981.

8. Bandyk DF, Schmitt DD, Seabrook GR, et al: Monitoring function al patency of in situ saphenous vein bypasses: The impact of a surveillance protocol and elective revision. J Vasc Surg 9:286, 1989.

9. Bergamini TM, Towne JB, Bandyk DF, et al: Experience with in situ saphenous vein bypasses during 1981 to 1989: Determinant factors of long-term patency . J Vasc Surg 13:137, 1991.

10. Donaldson MC, Mannick JA, Whittemore AD: Causes of primary graft failure after in situ saphenous vein bypass grafting. J Vasc Surg 15:113, 1992.

Posted June 2010