Tomáš Novotný II. chirurgická klinika LF MU a FN u sv. Anny Chronic arterial occlusions [USEMAP] • •a chronic systemic disease leading to development of characteristic atherosclerotic plaques • •asymptomatic until – –significant narrowing of an artery (>70%) – –rupture generating thrombus and/or thrombemboli – Arterial disease: atherosclerosis [USEMAP] Arterial disease: atherosclerosis http://upload.wikimedia.org/wikipedia/commons/9/9a/Endo_dysfunction_Athero.PNG Source: wikimedia.org (cc) [USEMAP] •Conventional –Smoking –Diabetes mellitus –Hyperlipidemia –Hypertension – • •Conditional –e.g. homocysteine, CRP – •Emerging •Predisposing –Advanced age –Overweight and obesity –Physical inactivity –Gender: male sex, postmenopausal women –Insulin resistance –Family history and genetics –Behavioral and socioeconomic factors • Atherosclerosis risk factors [USEMAP] •Predilection arterial beds • –coronary arteries – –carotid arteries – –lower limb arteries – –mesenteric arteries Arterial disease: atherosclerosis [USEMAP] Cerebrovascular disease https://www.myhealth.london.nhs.uk/wp-content/uploads/2019/02/FAST.png [USEMAP] Epidemiology – prevalence of stroke Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •Risk –of recurrence 29% at 5 years –of death 53 % at5 years – •Stroke survivors 65+ after 6 months –50% - hemiparesis –30% - unable to walk without assistance –26% - dependent in daily activities –19% - aphasia –26% - institutionalized Epidemiology – stroke [USEMAP] Types of stroke TOAST (Trial of ORG 10172 in Acute Stroke) [USEMAP] Pathogenesis source: http://www.brain-aneurysm.com http://www.brain-aneurysm.com/images/cad_images/Slide2.jpg http://www.brain-aneurysm.com/images/cad_images/Slide3.jpg http://www.brain-aneurysm.com/images/cad_images/Slide6.jpg [USEMAP] Pathogenesis source: http://www.brain-aneurysm.com http://www.brain-aneurysm.com/images/cad_images/Slide2.jpg http://www.brain-aneurysm.com/images/cad_images/Slide3.jpg http://www.brain-aneurysm.com/images/cad_images/Slide6.jpg [USEMAP] •Transient ischemic attack (TIA) – –stroke-like symptoms lasting less than 24 hours –the vast majority last for only a few minutes – –30% of patients will suffer a stroke within 5 years – –is a clinical diagnosis •brain infarction on computed tomography (CT) in circa 25% of patients Clinical presentation [USEMAP] •Stroke – –an acute neurologic dysfunction of vascular etiology –signs and symptoms lasting more than 24 hours –resulting from infarction of focal areas of the brain • •Typical signs • –sudden contralateral motor-sensory loss –speech deficit (dysarthria, dysphasia, aphasia) –ipsilateral monocular blindness / field cuts Clinical presentation [USEMAP] Clinical presentation [USEMAP] •History – •clinical presentation of present illness – •atherosclerosis –risk factors •Physical findings – •vital signs –blood pressure, heart rate, rhythm • •alertness, orientation •speech, basic motor and sensory deficits •carotid pulse palpation and auscultation • Clinical assessment [USEMAP] •carotid duplex ultrasonography with transcranial Doppler • •carotid CT angiography • •magnetic resonance angiography –price, imaging limitations – •digital subtraction angiography –specific indications (CT/MRI artifacts, planned endovascular intervention) Diagnostic evaluation [USEMAP] CT angiography [USEMAP] • • •„best“ medical therapy (BMT) • •carotid endarterectomy (CEA) • •carotid stenting (CAS) Treatment [USEMAP] •symptom status (within last 6 months) • •degree of stenosis –at present, the most reliable imaging predictor of stroke risk – •plaque progression; plaque character („vulnerable plaque“); evidence of clinically silent emboli • •2017 Clinical Practice Guidelines of the European Society for Vascular Surgery • How do we choose the proper treatment? [USEMAP] Symptomatic patient •Carotid endarterectomy –is recommended - 70%-99% stenosis [I,A] –should be considered - 50-69% stenosis [IIa,A] – – –The perioperative stroke/death rate should be <6% – –should be performed within 2 weeks of the last symptoms [I,A] • Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) [USEMAP] Symptomatic patient •Carotid stenting –might be considered in symptomatic patients aged <70 years with 50-99% stenosis as an alternative to CEA [IIb,A] –is recommended that in patients 70+ CEA should be preferred over CAS [I,A] – –The periprocedural stroke/death rate should be <6% – –should be performed within 2 weeks of the last symptoms [I,A] –CEA should be preferred over CAS within 2 weeks of symptoms [I,A] Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) [USEMAP] Asymptomatic patient •Carotid endarterectomy –should be considered in asymptomatic patient with 60-99% stenosis and life expectancy exceeding 5 years [IIa,B]. – –The perioperative stroke/death rate should be <3% – Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) [USEMAP] Asymptomatic patient •Carotid stenting –might be considered in asymptomatic patients with 60-99% stenosis and life expectancy exceeding 5 years [IIb,B]. – –The periprocedural stroke/death rate should be <3% – –might be considered in „high-risk for surgery“ patients [IIb,B] Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) [USEMAP] •Risk factor reduction and medical management – –antiplatelet therapy •anticoagulation (if indicated for other condition) –statin therapy – •risk factor reduction –hypertension –diabetes mellitus –smoking cessation –alcohol cessation „Best“ medical therapy [USEMAP] Carotid endarterectomy - conventional Public domain image(s) and selected text provided courtesy of The National Heart, Lung, and Blood Institute (NHLBI) http://www.nhlbi.nih.gov Source: https://thoracickey.com/carotid-surgery-interpositionendarterectomy-including-eversionligation/ The illustration shows the process of carotid endarterectomy. Figure A shows a carotid artery with plaque buildup. The inset image shows a cross-section of the narrowed carotid artery. Figure B shows how the carotid artery is cut and how the plaque is removed. Figure C shows the artery stitched up and normal blood flow restored. The inset image shows a cross-section of the artery with plaque removed and normal blood flow restored. [USEMAP] Carotid endarterectomy - conventional E:\Archiv\OperFotoUsable\klasCEA\004.JPG [USEMAP] Carotid endarterectomy - conventional E:\Archiv\OperFotoUsable\klasCEA\010.JPG [USEMAP] Carotid endarterectomy - conventional E:\Archiv\OperFotoUsable\klasCEA\014.jpg [USEMAP] Carotid endarterectomy - conventional E:\Archiv\OperFotoUsable\klasCEA\028.jpg [USEMAP] Carotid endarterectomy - shunting nik42896 [USEMAP] Carotid endarterectomy - eversion Source: https://thoracickey.com/carotid-surgery-interpositionendarterectomy-including-eversionligation/ [USEMAP] Carotid endarterectomy - eversion E:\Archiv\OperFotoUsable\everzCEACI\DSC_0004.JPG [USEMAP] Carotid endarterectomy - eversion E:\Archiv\OperFotoUsable\everzCEACI\DSC_0012.JPG [USEMAP] Carotid artery stenting Public domain image(s) and selected text provided courtesy of The National Heart, Lung, and Blood Institute (NHLBI) http://www.nhlbi.nih.gov http://www.checkbook.org/sitemap/health/Carotid_Endarterectomy/..%5CGraphics%5Ccarotid_stent.jpg [USEMAP] Carotid artery stenting [USEMAP] Peripheral artery disease (PAD) [USEMAP] Epidemiology •Prevalence of PAD based on ABI • •0.9% in <50yo •14.5% in >70yo National Health and Nutrition Examination Survey (NHANES) from 1999 to 2000 •Prevalence of intermittent claudication •symptomatic to asymptomatic ratio is 1:3-4 [USEMAP] Pathogenesis •narrowed arteries (most commonly due to atherosclerosis) limit blood flow to extremities • •extremities (usually legs) don't receive enough blood to keep up with demand, especially during physical exertion Source: https://www.nhlbi.nih.gov/health/health-topics/topics/pad The illustration shows how P.A.D. can affect arteries in the legs. Figure A shows a normal artery with normal blood flow. The inset image shows a cross-section of the normal artery. Figure B shows an artery with plaque buildup that's partially blocking blood flow. The inset image shows a cross-section of the narrowed artery. [USEMAP] Clinical presentation • •I. Asymptomatic • •II. Intermittent claudication (IC) • • •Critical limb threatening ischemia (CLTI) • •III. Ischemic rest pain • •IV. Ulceration or gangrene [USEMAP] Claudication •described as pain, discomfort, numbness, or tiredness in the legs that occurs during walking •relieved by rest (minutes) •in the –calf –buttocks –hips –thighs –feet Source: https://guysandgoodhealth.com/2017/05/20/fruits-and-veggies-may-lower-risk-of-blockages-in-leg-arte ries-aha/ Výsledek obrázku pro peripheral artery disease symptoms [USEMAP] Clinical presentation • •I. Asymptomatic • •II. Intermittent claudication • • •CLTI • •III. Ischemic rest pain • •IV. Ulceration or gangrene R:\DistCOVID\pics\006.JPG R:\DistCOVID\pics\003.JPG [USEMAP] Fontaine vs. Rutherford classification [USEMAP] Fate of the leg •Asymptomatic – –progression of PAD is identical to patients with intermittent claudication – –symptomatology depends on the level of activity of the subject – –should be managed medically in the same way as those with symptoms of intermittent claudication [USEMAP] Fate of the leg •Intermittent claudication / asymptomatic – –PAD is progressive –clinical course is surprisingly stable – –only 25% of patients with IC deteriorate – –major amputation is a relatively rare outcome •less than 5% over a 5-year period. [USEMAP] Fate of the leg Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG; TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007 Jan;45 Suppl S:S5-67. [USEMAP] •History – •clinical presentation of illness –claudication –rest pain –ulcers – •atherosclerosis –risk factors •Physical findings – •lower limb examination –pulses (bruits & thrills ) –sensory and motor functions –ulcers / gangrenes / infection –foot color and temperature –capillary refill –Buerger's test – •ABI measurement • Clinical assessment [USEMAP] Ankle-brachial index - ABI European Stroke Organisation, Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, Cremonesi A, De Carlo M, Erbel R, Fowkes FG, Heras M, Kownator S, Minar E, Ostergren J, Poldermans D, Riambau V, Roffi M, Röther J, Sievert H, van Sambeek M, Zeller T; ESC Committee for Practice Guidelines. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011 Nov;32(22):2851-906. doi: 10.1093/eurheartj/ehr211. Epub 2011 Aug 26. [USEMAP] Ankle-brachial index - ABI [USEMAP] •duplex ultrasonography • •CT angiography • •magnetic resonance angiography –price, availability, imaging limitations – •digital subtraction angiography –specific indications (CT/MRI artifacts, below the knee arteries, planned endovascular intervention) Diagnosis [USEMAP] CT angiography [USEMAP] • • •„best“ medical therapy • •endovascular interventions • •surgical procedures • Treatment [USEMAP] •symptoms – significant disability, presence of critical ischemia •functional status of the patient •comorbid conditions • •favorable risk-benefit ratio (anatomical pattern of disease, target vessel, conduit availability) • •patient preferences •expected durability of offered procedures!!! • • • • • How do we choose the proper treatment? [USEMAP] •2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery • How do we choose the proper treatment? [USEMAP] Intermittent claudication •Supervised exercise training is recommended [I,A] •Unsupervised exercise training is recommended when supervised exercise training is not feasible or available. [I,C] •When daily life activities are compromised despite exercise therapy, revascularization should be considered. [IIa,C] •When daily life activities are severely compromised, revascularization should be considered in association with exercise therapy. [IIa,B] [USEMAP] Chronic limb-threatening ischemia •for limb salvage, revascularization is indicated whenever feasible [I,B] • •for infra-popliteal revascularization –bypass using the great saphenous vein is indicated [I,A] –endovascular therapy should be considered [IIa,B] • •stem cell/gene therapy is not indicated [III,B] [USEMAP] •Risk factor reduction and medical management – –antiplatelet therapy •anticoagulation (if indicated for other condition) –statin therapy –exercise therapy !!! –vasodilators – •risk factor reduction –hypertension –diabetes mellitus –smoking cessation –alcohol cessation „Best“ medical therapy [USEMAP] Structured exercise therapy •involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest •is performed for a minimum of 30–45 min/session; sessions are performed at least 3 times/wk for a minimum of 12 wk • •two options –Supervised exercise program –Structured community- or home-based exercise program [USEMAP] •PTA or PTA + stenting Endovascular interventions Zilver 518 Vascular Self-Expanding Stent Advance 18LP Low-Profile PTA Balloon Dilatation Catheter http://www.cookmedical.com/di/content/lg_thumbnail/di_atb5.jpg [USEMAP] PTA [USEMAP] PTA (Stenting) [USEMAP] Surgical procedures • •Endarterectomy •Patch angioplasty • •Bypass –anatomic –extraanatomic – •Hybrid procedures [USEMAP] Endarterectomy & patch angioplasty E:\Archiv\OperFoto\Dr.Krejčí\Makovický Štefan, 1949 plastika tepen pr. třísla\2015-02-04\004.JPG [USEMAP] E:\Archiv\OperFotoUsable\FPBproxDistAna.JPG Proximal femoropopliteal bypass E:\Archiv\OperFotoUsable\FPBproxAP.JPG E:\Archiv\OperFotoUsable\FPBArteriotomietříslo.JPG E:\Archiv\OperFotoUsable\FPBprox.JPG [USEMAP] Bypass extranatomic Source: Ruhterford‘s Vascular Surgery 8th Edition, edited [USEMAP] Hybrid procedure = E:\Archiv\OperFoto\Dr.Krejčí\Makovický Štefan, 1949 plastika tepen pr. třísla\2015-02-04\004.JPG [USEMAP] Chronic mesenteric ischemia (CMI) [USEMAP] •asymptomatic occlusive disease of the visceral arteries is a common finding in elderly patients • •estimated the prevalence 6 to 10 % • •the exact incidence of chronic mesenteric ischemia is not known Epidemiology [USEMAP] •atherosclerosis is the most common cause • •median arcuate ligament syndrome –a separate entity that may lead to symptoms of CMI –compression of the celiac artery by the median arcuate ligament – •majority of patients with symptoms of CMI have significant stenosis or occlusion of at least two of the three mesenteric arteries • Pathophysiology [USEMAP] •20% of the cardiac output goes through the mesenteric arteries under normal conditions • •after the ingestion of a meal blood flow is elevated during the next 3 to 6 (up to 2000 mL/min) • •duration of these responses depend on the type and quantity of a meal Pathophysiology [USEMAP] •postprandial abdominal pain –often occurs 15 to 45 minutes after a meal –patients typically develop “food fear” – •progressive weight loss –is a common finding –changes in bowel habits, nausea, and vomiting are less common Clinical presentation [USEMAP] •physical examination is usually nonspecific –undernourishment or cachexia –an abdominal bruit can sometimes be auscultated –bowel sounds are frequently hyperactive –guarding and rebound tenderness are usually absent – •typical patient –female with a median age 65 (40-90) –3-4 : 1 female-to-male ratio – Clinical presentation [USEMAP] •History – •clinical presentation of present illness – •atherosclerosis –risk factors •Physical findings – •cachexia •abdominal bruit (up to 50 % of patients • •female with a median age 65 (40-90) • Clinical assessment [USEMAP] •DUS –useful tool for diagnosis of visceral ischemic syndromes –excellent for median arcuate ligament syndrome as well – •CT –accurate imaging modality –can rule out other diagnoses –important for intervention planning • •MRI Diagnosis [USEMAP] •digital subtraction angiography –usually for planned endovascular intervention • •endoscopy • •gastric tonometry Diagnosis [USEMAP] •conservative –no role in symptomatic mesenteric artery disease • •endovascular interventions • •surgical procedures • •2017 Clinical Practice Guidelines of the European Society of Vascular Surgery •2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery • • Treatment [USEMAP] •In patients with suspected CMI, occlusive disease of a single mesenteric artery makes the diagnosis unlikely and a careful search for alternative causes should be considered. [IIa,C] •In patients with symptomatic multivessel CMI, revascularization is recommended [I,C/B] •In patients with symptomatic multivessel CMI, it is not recommended to delay revascularization in order to improve the nutritional status. [III,C] Treatment [USEMAP] •In patients with CMI, needing revascularization, the superior long term results of open surgery must be offset against a possible early benefit of endovascular intervention with regard to peri-procedural mortality and morbidity. [I,B] Treatment [USEMAP] PTA + stenting Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •Antegrade Mesenteric Bypass • •Retrograde Mesenteric Bypass – •Mesenteric bypass offers •improved patency •lower rates of re-interventions •better freedom from recurrent symptoms – •Transaortic endarterectomy – rare – Surgical procedures [USEMAP] Antegrade mesenteric bypass Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] Retrograde mesenteric bypass Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] Thank you for your attention! Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP]