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swsh 2013

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by

Michael Costanza

on 19 January 2017

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Transcript of swsh 2013

vascular
CARDIO
vascular
Peripheral Arterial Disease
Blocked or narrowed arteries
From build up of plaque on inside of vessel
"Poor circulation"
PAD: Symptoms
Cold feet
Pain in legs with walking
Slow healing wounds
Burning pain in feet
Gangrene
Peripheral Arterial Disease
Who get's it?
Why do they get it?
How is it diagnosed?
Increases with age
Gender differences
Risk factors: smoking, cholesterol, high lipids, hypertension, diabetes
Physical exam: pulses
Ankle brachial index
Ankle Brachial Index
Ankle pressure divided by brachial pressure
Should be >1.0
PAD defined: ABI <0.9
Objective, correlates with severity
Norgren L, Hiatt WR, Dormandy MR et al. TASC II J Vasc Surg 2007;45: Supplement
PAD: Consequences
Disability
Walking limitation
Gait disturbance
Fall risk
Cardiovascular Risk
6.6x increase in myocardial infarction
Only 10% have normal coronary arteries
Women and PAD
Women more likely to have atypical symptoms; less active
Prevalence of PAD is equal to or higher than men
Decreased screening and less aggressive risk factor treatment in women
PAD Treatment
Women: higher percentage present with critical limb ischemia
Women have higher rate of wound infections after bypass; smaller caliber arteries
Women may not discuss circulation problems with their doctor
Women may have greater impairment in lower extremity function
Less aggressive screening for PAD in women
Women less likely to receive pharmacologic risk modification
Aneurysms in Women
Present at older age (after menopause)
Strong association with smoking
More likely to have occlusive disease
Less frequently detected (older age; live alone; less medical care)
Higher risk of rupture (3x higher than men)
Rupture at smaller size
Prevalence increases with cardiovascular risk factors
More access related complications with EVAR
More endoleaks
Faster sac shrinkage
Improvements in AAA mortality only affected men
PAD associated with osteoporosis?
Narrowing in arteries going to brain

Build up of atherosclerotic plaque

Stroke risk: clot or plaque breaks off and goes into brain
Carotid Artery Stenosis
Symptoms
Usually none

Temporary weakness in one arm or leg; blindness in one eye: "mini stroke"

Major stroke: permanent damage
Diagnosis
Duplex ultrasound

Non -invasive and accurate

Measures velocity of blood flow; range of percent narrowing
Women and Stroke
Women more likely to have atypical symptoms: pain, altered consciousness
Stroke causes more death and disability in women
Women less likely to get carotid duplex exam
Carotid Treatment
Women: under represented in studies on surgery and medical therapy
Lose benefit if surgery delayed more than 2 weeks after stroke
Smaller arteries
More stenosis for amount of plaque
Higher recurrence (especially if patch not used)
More post-op complications
Gender not a risk factor for surgery
Outcome depends on surgeon and technique
Symptomatic (stroke)
Severe narrowing
Medical problems
Anatomic challenges
Carotid Stenting
Abdmoninal Aortic Aneurysm (AAA)
Aneursym: abnormal enlargement
Aorta: largest blood vessel
Normal size: 2cm
Aneurysm: Greater than 3cm
AAA Danger
Larger diameter = more pressure on weaker walls
When pressure exceeds wall strength: rupture
>80% of patients with rupture did not know they had an aneurysm
AAA: Diagnosis
Physical exam: insensitive
Ultrasound: good for screening
CT scan: often an incidental finding
Women and AAA
3x higher risk of rupture
Rupture at smaller size
Present at older age
Strong association with smoking and cardiovasc. risk factors
Less likely to be detected (older age; live alone)
No screening program
AAA Treatment
Goal: repair when risk of rupture exceeds risk of surgery
Guideline: diameter >5.5cm
Size threshold based on studies that included a small number of women
Older age
More occlusive disease
Higher rate of complications and mortality for any vascular surgery procedure
More access complications
Higher rate of endoleak
Reduced mortality in men only
Varicose Veins
Enlarged, redundant, tortuous veins near the skin surface
Tributaries of superficial venous system
Causes of Varicose Veins
Floppy vein walls
Incompetent valves
Superficial venous reflux
Varicose Veins: Symptoms
Aching
Fatigue
Swelling
Itching
Bleeding
Clot
Varicose Veins: Diagnosis
Physical exam
Ultrasound
Varicose Vein Treatment
Initial therapy: compression stockings
Knee high; worn daily
Treats symptoms; veins still present
Can be difficult to put on
Surgical removal of great saphenous vein ("vein stripping")
Effective and durable
Longer recovery
Radiofrequency ablation
Minimally invasive
Faster recovery
Stab phlebectomy for varicose vein clusters
Women and AAA
No proven association with deep venous thrombosis (DVT)
Higher prevalence compared to men
Risk increases with pregnancy
More likely to seek treatment at younger age
Division of Vascular Surgery
and Endovascular Services
Full transcript