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swsh 2013

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Michael Costanza

on 2 December 2015

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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
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
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