Update On Advances In Vascular Disease And Peripheral Artery Disease

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Update on Advances in Vascular Diseaseand Peripheral Artery DiseaseMehdi H. Shishehbor, DO, MPH, PhDProfessor of Medicine, Case Western Reserve UniversitySchool of MedicinePresident, Harrington Heart and Vascular InstituteUniversity Hospitals, Cleveland, Ohio

Atherosclerotic Disease is a Pan Vascular ProcessCoronary Artery Disease (CAD)Non-coronary Atherosclerosis–Peripheral Artery Disease (PAD)–Lower extremity–Upper extremity (subclavian stenosis)Vascular disease isthere –Renal artery diseasebut it may need to be–Mesentericartery diseasediscovered–Carotid artery disease–Aortic aneurysm–Vasculogenic Erectile Dysfunction

Rutherford 4-6Critical LimbIschemiaAsymptomaticPADRutherfordClass INon-life stylelimitingclaudicationRutherfordClass IILife style limitingclaudicationRutherfordClass IIIAcute LimbIschemia

Intermittent ClaudicationRecurring burning,aching, fatigue, orheaviness in the legmuscles with predictablelevel of walking, thatresolves with apredictable duration ofrest ( 10 minutes)

Simple Screening Tool for Claudication#1 Do you get pain in either leg when youwalk?#2 Does the pain go away when you stopwalking (within 10 minutes)?If answers are “Yes” toboth questions, thelikelihood of PAD is 95%Adapted from Rose, FA. Bulletin of the WHO. 1962;27:645

Claudication is the Exception Rather thanthe Rule: PARTNERS Study11%N 1857 Patients with ABI 0.934%No PainAtypical Leg PainClassicClaudication55%Hirsch, et al. PARTNERS Study. JAMA 1999; 286:1317

Question?69 yo male with know CAD presents with severebilateral calf pain. An exercise ABI revealssevere PAD. After endovascularrevascularizations 6 months ago he feels better.At this point you recommend?a) Aspirin aloneb) Aspirin plus high dose statin therapyc) Aspirin plus Ticagrelord) Aspirin plus Clopidgrele) Aspirin plus Cilostazol

4 major medical therapy recommendations toreduce CV events:–Statins (Class I)–Smoking cessation (Class I)–Antiplatelet therapy (Class I)–ACE inhibitors (Class IIa)–Supervised exercise

Screening for Claudication Alone isInadequate to Detect PADIntermittent ClaudicationAtypical or No Symptoms

The Ankle-Brachial IndexABI Cornerstone of PADDiagnosisAnkle systolic pressureBrachial systolic pressure

Critical Limb Ischemia Rutherford 4-6or Fontaine III, IVRest PainTissue Loss or Gangrene

Critical Limb Ischemia68 year old man with ischemiccardiomyopathy, CHF, MI, A-fib, CAD s/pCABG x 4, and mitral valve diseasepresented with painful ulcers on the L footfor 2 yearsPain attributed to multifactorial lowerextremity edemaOn exam, cool skin temperature andabsent pulses

Aortoiliac Reconstruction16

Always Assume There is an Underlying Arterial Component

Critical Limb Ischemia (CLI)

Knowledge20

PUBLISHED BY 40ABSTRACTNationwide Trends of Hospital Admissionand Outcomes Among Critical LimbOBJECTIVES The study sought to characterize the trends in hospitalization of U.S. patients with CLI from 2003 to 2011,using theNationwide InpatientPatientsSample. We comparedthe cost utilizationand in-hospital outcomes of endovascular andIschemiaDuring2003–2011BACKGROUND Critical limb ischemia (CLI) continues to be a major cause of vascular related morbidity and mortality inthe United States.surgical revascularization procedures for CLI.Shikhar Agarwal, MD, MPH, Karan Sud, MD, Mehdi H. Shishehbor, DO, MPH, PHDMETHODS CLI and revascularization procedures were identified using International Classification of Diseases-NinthEdition-Clinical Modification codes. In-hospital mortality and amputation were coprimary outcomes. Length of stay (LOS)ABSTRACTand cost of hospitalization were secondary outcomes.BACKGROUNDlimbischemiaadmissions(CLI) continuesbeacrossa major2003cause toof 2011.vascularrelatedmorbidityinRESULTSWe included aCriticaltotal of642,433withtoCLITheannualrate ofandCLImortalityadmissionsUnited States.has beentherelativelyconstant across 2003 to 2011 (w150 per 100,000 people in the United States). There has been asignificant reduction in the proportion of patients undergoing surgical revascularization from 13.9% in 2003 to 8.8% inOBJECTIVES The study sought to characterize the trends in hospitalization of U.S. patients with CLI from 2003 to 2011,2011, while endovascular revascularization has increased from 5.1% to 11.0% during the same time period. This wasusing the Nationwide Inpatient Sample. We compared the cost utilization and in-hospital outcomes of endovascular andaccompaniedby a steady reduction in the incidence of in-hospital mortality and major amputation. Compared to surgicalsurgical revascularization procedures for CLI.revascularization, endovascular revascularization was associated with reduced in-hospital mortality (2.34% vs. 2.73%,642,433 patients with CLIp 0.001),mean LOSdays vs. 10.7 days,p 0.001),and meancostInternationalof hospitalization( 31,679vs. 32,485,METHODSCLI (8.7and revascularizationprocedureswere identifiedusingClassificationof typ 0.001)despite similarrates ofcodes.majorIn-hospitalamputation(6.5% andvs. amputation5.7%, p ¼ were0.75).coprimary outcomes. Length of stay (LOS)and cost of hospitalization were secondary outcomes.CONCLUSIONS While CLI admission rates have remained constant from 2003 to 2011, rates of surgical reva-RESULTS We included a total of 642,433 admissions with CLI across 2003 to 2011. The annual rate of CLI admissionsscularizationhave significantly declined and endovascular revascularization procedures have increased. This has beenhas been relatively constant across 2003 to 2011 (w150 per 100,000 people in the United States). There has been aassociated with decreasing rates of in-hospital death and major amputation rates in the United States. Despitesignificant reduction in the proportion of patients undergoing surgical revascularization from 13.9% in 2003 to 8.8% inJACC mortalityMarch 2016multiple adjustments, endovascular revascularization was associated with reduced in-hospitalcompared to2011, while endovascular revascularization has increased from 5.1% to 11.0% during the same time period. This wassurgical revascularization during 2003 to 2011. (J Am Coll Cardiol 2016;-:-–-)accompanied by a steady reduction in the incidence of in-hospital mortality and major amputation. Compared to surgical 2016 bythe American College of Cardiology Foundation.revascularization, endovascular revascularization was associated with reduced in-hospital mortality (2.34% vs. 2.73%,

Very Sick Group of PatientsT A B L E 1 Trend of Cardiovascular Risk Factors in the Study Cohort Across2003 to 2011YearHypertensionObesityDiabetesChronic 354.336.016.2201175.215.056.737.817.8

CLI is a Deadly Disease100806040200BAPBSX012345Time After Randomization, (Years)

CLI is Associated with the Highest Rates ofReadmission46.5%READMIT IN 90DAYS POSTDISCHARGE* 15KINPATIENTHOSPITAL SPENDPERREADMISSION*Reed and Shisheebor, J Am Heart Assoc. 2016 May 20;5(5).

CLI is Extremely Under TreatedCirc Cardiovasc Qual Outcomes. 2012;5:94-102.EN-1630.A

Significant Disparities in Outcomes(Amputations)

ArticleArticleRacial/Ethnic DisparitiesinRacial/Ethnic DisparitiesinRevascularization for Limb Salvage: AnRevascularizationfor Limb Salvage: AnAnalysis of the National Surgical QualityAnalysis of theImprovementNational SurgicalQualityProgram DatabaseImprovement Program Database404Vascular andEndovascularSurgeryVascularand EndovascularSurgeryVol. 48(5-6)402-4052014, Vol. 2014,48(5-6)402-405ª The Author(s)ª The Author(s)2014 2014Reprints and permission:Reprints agepub.com/journalsPermissions.navDOI: 10.1177/1538574414543276ves.sagepub.comDOI: 10.1177/1538574414543276ves.sagepub.comKakra Hughes, MD, FACS1, Christopher Boyd, MD1,Tolulope Oyetunji, MD1, Daniel Tran, MD1, David Chang, MD2,1David 1Rose, MD1, Suryanarayan Siram,1 MD ,FACS, CornwellChristopherBoyd, MD ,3EdwardIII, MD1,1and Thomas Obisesan, MD12Kakra Hughes, MD,Tolulope Oyetunji, MD , Daniel Tran, MD , David Chang, MD ,David Rose, MD1, Suryanarayan Siram, MD1,1, and Thomas Obisesan, MD3Edward Cornwell III, MDAbstractHadvIntroduction: Previous reports have suggested that black patients have a higher rate of major lower extremity amputation and alower rate of revascularization for limb salvage when compared to white patients. Objective: We undertook this study todetermine the extent of this ethnic disparity in recent years and to evaluate whether the widespread adoption of endovascularulatechniques has had an impact on this disparity. Methods: The American College of Surgeons’ National Surgical QualityImprovement Program (NSQIP) database was queried to identify all patients who had undergone an above- or below-knee ampu-moAbstracttationas wellas all patientswhohad undergoneopenaorendovascularfor criticallimb ischemiaIntroduction: Previous reportshavesuggestedthatblackpatients anhavehigherrate ofrevascularizationmajor lowerprocedureextremityamputationand aforthe years 2005 to 2006. Patient demographics and 30-day outcomes were recorded, and comparisons were made among thelower rate of revascularizationfor limbwhen comparedwhitepatients.We undertookthis studyto leaddifferentethnicsalvagegroups. Results:There were to1568patientsidentifiedObjective:in the NSQIP databaseas having undergonea majordetermine the extent of this ethnicdisparityin recentyearswhetherthewhite,widespreadlower extremityamputationin 2005andand2006.toOfevaluatethese patients,54% were29% black, adoption8% Hispanic,ofandendovascular0.7% Asian. 1%)a meannifitechniques has had an impact on this disparity. Methods: The American College of Surgeons’ National Surgical withQualityage of 65. Median length of stay was 11 days, and 30-day mortality was 9% following amputation. During this same time period,Improvement Program (NSQIP)database was queried to identify all patients who had undergone an above- or below-knee ampu4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes ofcontation as well as all patients whohadundergonean openor endovascularrevascularizationprocedurecritical 0.4%limbAsian,ischemiafordidlimb salvage.Of those patientsundergoingan open procedure,74% were white,12% black, for4% Hispanic,and 10%not haveidentifying ethnicOpen surgicalpatientswere primarilymaleand(63%)comparisonswith a mean age wereof 66. Medianof staywasthe years 2005 to 2006. edure,79%werewhite,10%black,different ethnic groups. Results: There were 1568 patients identified in the NSQIP database as having undergone a major2%Hispanic, 1% Asian, and 8% did not have identifying ethnic data. The endovascular group was also primarily male (61%) with a meanlower extremity amputation inage20052006.Ofof thesewerewhite,black, 8% ThereHispanic,and0.7% Asian.Eightof 68.andMedianlengthstay waspatients,5 days, and54%30-daymortalitywas 29%4%. Conclusion:remainsa significantethnic disparityApercent of patients did not haveidentifyingrevascularization.ethnic data. Theundergoingamputationprimarilymale (61%)withbuta onlymeanin limb-salvageBlacksgroupcomprise29% of patientsundergoing awasmajorlower extremityamputation,12%of thosean opensurgicalprocedurewasand 10%those undergoingan endovascularfor timelimb salvage.Theage of 65. Median length of staywas undergoing11 days, and30-daymortality9% offollowingamputation.Duringprocedurethis sameperiod,blawidespread adoption of endovascular revascularization techniques appears not to have had much impact on this disparity.4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes oflimb salvage. Of those patients undergoing an open procedure, 74% were white, 12% black, 4% Hispanic, 0.4% Asian, and 10% did theKeywordsnot have identifying ethnic data.limbOpensurgicalpatientswere primarilymale (63%)with a mean age of 66. Median length of stay hnicdisparities

Technique28

96 years old with right foot ulcers

96 years old with right foot ulcers

Devices36

Mrs. Ey/o female with PAD, churg-strauss syndrome, prior 59LLE BKA. She was doing well until recently. Shedeveloped an ulcer on the right 2nd and right great toesince September 2017.with podiatrist who referred for evaluation prior to Followsintervention on the right 2ed and great toes.37

RLE Angiogram 1/24/201838

RLE Angiogram 1/24/2018Right PT angioplasty.Unsuccessful revascularization of the pedal arteries.39

1/18/20182/15/20181/18/20182/15/2018TBI 0.28to have pain Continuesand non healing ischemic ulcers of the right foot thatwere worsening.Patient is taking vicodinfor pain.40

LimFlow Procedure for limb salvage 4/11/2018

Pre LimFlowPost LimFlow

Pre LimFlowPost LimFlow2/15/20184/13/2018TBI 0.1811/27/2018TBI 0.5443

Commitment and Passion44

Limb Salvage Advisory CouncilMultidisciplinary Team: Vascular Medicine,Vascular Surgery, Podiatry, Wound Care,Interventional CardiologyPatient withplanned majoramputationAmputation preventionresearch coordinatorName: Tonia RhoneExt: 45170Pager: 30075Email:Tonia.Rhone@UHhospitals.orgFellow inTraining(alternatingbetween VS/IC)Boardmeeting(Webx/conference)ActionPlan

Thank you!shishem@gmail.com440-725-647346

Atherosclerotic Disease is a Pan Vascular Process Coronary Artery Disease (CAD) Non-coronary Atherosclerosis -Peripheral Artery Disease (PAD) -Lower extremity -Upper extremity (subclavian stenosis) -Carotid artery disease -Renal artery disease -Mesenteric artery disease -Aortic aneurysm -Vasculogenic Erectile Dysfunction Vascular disease is

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