Dr. Alizadegan, of Agnesian HealthCare, discusses the latest updates relating to peripheral vascular surgery.

1. Peripheral Vascular
Surgery
Shahriar Alizadegan, MD
Vascular Services

2. Professional Background
 Tabriz University of Medical Sciences (MD), 1988
to 1995
 General practitioner, 1995 to 1998
 General surgery residency, 1998 to 2003
 General surgery practice, 2003 to 2006
 General surgery residency (UIC-MGH),
2009 to 2014
 Vascular surgery fellowship (MCW) 2014-2016

3. Scope of Vascular
Surgery Practice
Arteries
Veins
Lymphatics
Vascular access
Vascular compression syndromes

4. Peripheral Arterial Disease

5. Atherosclerosis: Risk Factors
Conventional
 Smoking
 Diabetes mellitus
 Hyperlipidemia
 Hypertension
Predisposing
Advanced age
Overweight/obesity
Physical inactivity
Gender: male,
postmenopausal women
Insulin resistance
Family history/genetics
Behavioral/socioeconomic
factors

6. Atherosclerosis
Conditional
Homocysteine
C-reactive protein
(high-sensitivity CRP)
Fibrinogen
Lipoprotein (a)
Hypertriglyceridemia
Emerging
Inflammatory markers
Infectious agents
Vascular calcification
markers
Hemostatic factors
MMP

7. Arterial Disease: Atherosclerosis

9. Cerebrovascular Disease
Carotid stenosis
Fibromuscular dysplasia (FMD)
Aneurysms
Dissections

10. Carotid Stenosis
Asymptomatic
Symptomatic
- TIA
- Stroke

11. Carotid Endarterectomy

13. Carotid Stenting

15. Inability to tolerate general anesthesia for
CEA
History of damage to the contralateral vocal
cord (previous CEA or neck surgery)
Previous neck surgery on the ipsilateral side
Neck irradiation
Restenosis after CEA
Indications for
Carotid Artery Stenting

16.  Among patients with symptomatic or
asymptomatic carotid stenosis, the risk of the
composite primary outcome of stroke, myocardial
infarction or death did not differ significantly in the
group undergoing carotid-artery stenting and the
group undergoing carotid endarterectomy.
 During the periprocedural period, there was a
higher risk of stroke with stenting and a higher risk
of myocardial infarction with endarterectomy.
Carotid Artery Endarterectomy
Versus Stenting

17. Fibromuscular Dysplasia (FMD)

18. Carotid Artery Aneurysm

19. Pulsating Neck Mass
Most common cause of pulsating neck
mass

20. Carotid Dissection

21. Carotid Dissection, cont.
The carotid artery is compressed by blood
dissecting upward from a tear with aortic
dissection. Blood may also dissect to coronary
arteries. Thus patients with aortic dissection
may have symptoms of severe chest pain (for
distal dissection) or may present with findings
that suggest a stroke (with carotid dissection)
or myocardial ischemia (with coronary
dissection).

22. Brachiocephalic and
Subclavian Artery

25. Severe Multivessel Disease
of Aortic Arch Branches

26. Subclavian Steal Syndrome

27. Carotid Subclavian Bypass

28. Subclavian Carotid Transposition

29. Hybrid Repair of Distal Arch and
Descending Thoracic Aortic Aneurysm

31. Endovascular Treatment
With Brachial Access

37. Intermittent Claudication
 Most common reason for referral to vascular
surgeon
 Calf, thigh or buttock pain after certain distance of
walking
 Symptoms of intermittent claudication are
alleviated by a brief period of rest
 Abnormal ankle brachial indexes
 No constant pain, no tissue loss
 Inflow disease
Outflow disease

38. Inflow Disease Outflow Disease

39. Critical Limb Ischemia
 Common major manifestations of CLI are rest pain
and ischemic ulceration or gangrene of the
forefoot or toes, representing a reduction in distal
tissue perfusion below resting metabolic
requirements.
 Ankle pressure less than 50 mm Hg
 Toe pressure to less than 30 mm Hg
or
 ABI to less than 0.40

40. Natural History of IC versus
Critical Limb Ischemia
 The risk of major amputation is small; over a five-year
period, the rate of amputation was less than five
percent (IC)
 Only insulin-requiring diabetes, low initial ABI, and high
pack-years of smoking predicted progression to
ischemic rest pain and ischemic ulceration
 Natural history of CLI is grim, remarkable for the high
risk of major amputation and death

42. Aneurysms
 Aneurysms can be categorized according to
their anatomic, pathologic or etiologic
characteristics.
 Ectasia: Intermediate stage of enlargement
when an artery is less than 50 percent enlarged,
whereas
 Arteriomegaly: Diffuse, continuous enlargement
of multiple arterial segments dilated to greater
than 50 percent of normal.

43. Aneurysms, cont.

44. Aneurysms, cont.
Degenerative
Inflammatory
Post dissection
Traumatic
Developmental
Infectious

47. Endovascular Repair
TAA
AAA
Iliac aneurysm
Visceral aneurysms

50. Endovascular Repair of
Abdominal Aortic Aneurysm
(EVAR)

53. Open Versus Endovascular Repair
 CRT has shown no significant survival benefit at any
time-point for an endovascular strategy (using a
standard EVAR device whenever anatomically and
operationally possible, with open repair as a default
option) versus open repair.
 In contrast, there were gains for the endovascular
strategy versus the open repair group with respect to
patient-preferred outcomes: faster discharge, more
often to home, and QoL and overall the endovascular
strategy was cost-effective.

54. Open vs. Endovascular Repair, cont.
Follow-up:
One imaging after five years for open repair
EVAR requires imaging on a yearly basis
Risk of endo leak after EVAR
Risk of limb occlusion, slippage of the graft,
limb separation

55. Endoleak

56. Harvard Report on Cancer Prevention, Cancer Causes and Control 1999;10:167.
Visceral Interventions

57. Venous Diseases
 Deep vein thrombosis
 Venous insufficiency and stasis ulcer
 Superficial thrombophlebitis
 Differentiation of venous stasis ulcer versus
arterial insufficiency

58. Venous Stasis Ulcer
Knowing the underlying pathophysiology
Compression therapy
Reflux studies (venous duplex)
Arterial flow
Ablation of incompetent veins if indicated
Local wound care and hygiene

60. Treatment Options for
Venous Disease
Laser or RFA ablation( for larger veins GSV)
Sclerosing agent
 Polidecanol
 Hypertonic NACL
 Varithena(injectable foam)
Microphlebectomy
Ligation and division
Stripping

61. Thank You
Questions?