Peripheral InterventionalProcedures Flashcards
What procedure has shown noninferiority to traditional surgical carotid endarterectomy in high-risk populations?
Carotid artery stenting
Supported by several registries and the SAPPHIRE trial.
What was the primary endpoint of the SAPPHIRE trial?
Composite of death, stroke, and MI within 30 days
Results showed a 39% reduction in this endpoint for stenting.
What were the results regarding 1-year event-free survival in the SAPPHIRE trial?
88% for stenting vs. 79% for endarterectomy
Statistically significant with p = 0.048.
What are some criteria for high-risk candidates for carotid artery stenting?
- Age >80 years
- CHF III to IV
- EF < 30%
- Recent MI
- Unstable angina
- Severe pulmonary disease
- Contralateral laryngeal nerve palsy
These criteria were established based on clinical and anatomic considerations.
What did a recent meta-analysis conclude about stenting for symptomatic carotid stenosis in older patients?
Should be avoided in patients age ≥70 years
Stenting might be safe for younger patients.
What is the incidence of stroke post carotid artery stenting in high-risk patients?
Approaches 3%
Primary mechanism is distal embolization of atheromatous debris.
What complication can occur due to distention of the carotid sinus mechanoreceptors during stenting?
Hypotension and bradycardia
Occurs in up to 40% of procedures involving internal carotid lesions.
What was the incidence of MI within 30 days of carotid stenting in the SAPPHIRE trial?
1.9%
Significantly lower than after carotid endarterectomy.
What is the compensatory response of cerebral vessels to carotid occlusive disease?
Compensatory vasodilation
Aims to maintain adequate blood flow to the brain.
What are symptoms of hyperperfusion following carotid artery intervention?
- Throbbing headache
- Nausea
- Vomiting
- Visual changes
- Focal motor deficits
- Seizures
Symptoms can occur due to sudden increase in blood flow to dilated vasculature.
What is the initial test of choice for diagnosing PAD according to AHA Guidelines?
Resting ABI
ABI is calculated by dividing the highest dorsalis pedis or posterior tibial pressure by the highest arm pressure.
What is considered an abnormal ABI value indicating PAD?
ABI <0.9
Diagnosis is confirmed in symptomatic patients with this ABI.
What medications are FDA-approved for relief of claudication due to PAD?
- Pentoxifylline
- Cilostazol
Cilostazol is a type III phosphodiesterase inhibitor.
What was the result of cilostazol in a meta-analysis for patients with moderate to severe claudication?
Increased maximal walking distances by 50% and pain-free walking distances by 67%
Based on eight randomized trials.
What is the normal range for ABI?
1.00 to 1.40
Values above 1.40 suggest a noncompressible artery.
What is the recommendation for patients with claudication symptoms and abnormal ABI?
Undergo diagnostic testing for PAD
Patients with risk factors should also be tested.
What are the independent predictors of increased walking distances in exercise rehabilitation for PAD?
- Use of claudication endpoint
- Program length
- Mode of exercise
These factors were identified in a meta-analysis of 33 trials.
What is the significance of the Heart Protection Study regarding PAD?
Reduction in all-cause mortality by 13% and major vascular events by 24%
Study involved 20,536 patients with CAD, diabetes, or PAD.
What is the complication rate of PTA in the infrapopliteal vascular bed?
Not prohibitively high
Clear indications for PTA exist despite potential risks.
What are the lifestyle modifications recommended for patients with PAD?
- Aggressive management of diabetes
- Cessation of tobacco use
These modifications are essential alongside medical therapy.
What is the risk of limb loss for smokers with claudication symptoms?
20% risk of limb loss
Smokers have increased rates of disease progression.
What were the major adverse events reported in the studies?
No major adverse events such as death, MI, or limb loss were reported
MI stands for myocardial infarction.
What was the p-value indicating the increase in ABIs after intervention?
p = 0.0001
What is the recommended therapy for patients with PAD who smoke?
Pharmacologic therapy with varenicline, bupropion, and/or nicotine replacement
Referral to a smoking cessation program is also recommended.
What type of exercise program is recommended for patients with PAD?
Supervised exercise programs performed for 30 to 45 minutes three times per week for a minimum of 12 weeks
What is the effect of statin medications in patients with PAD?
Decrease major adverse cardiovascular and cerebrovascular events (MACCE), mortality, and major amputation or death
Which medication has been shown to improve PAD symptoms and increase walking distance?
Cilostazol
What are the mostly ineffective treatments for claudication?
Pentoxifylline, iron chelation with ethylenediaminetetraacetic acid, or B-complex vitamin supplementation
What is the primary aim of revascularization in chronic limb ischemia?
Decreasing limb pain and improving wound healing
What is favored in patients with high surgical risk for revascularization?
Endovascular revascularization
What percentage of patients experience restenosis after balloon angioplasty within one year?
Approximately 60%
What was the primary endpoint of the LEVANT 2 trial?
Freedom from restenosis or repeat revascularization of the target lesion at 12 months
What are the two main causes of renal artery stenosis?
Atherosclerotic disease and fibromuscular dysplasia (FMD)
What is the characteristic appearance of FMD on angiography?
String of beads
What is recommended for patients with unilateral renal artery stenosis who have hypertension?
Treatment of renal artery stenosis may benefit patients
What factors guide the management strategy for asymptomatic aneurysms?
Risk of rupture, size of aneurysm, and rate of aneurysm expansion
What is the recommended treatment for aneurysms larger than 5.5 cm?
Surgical repair
What does renal denervation target to address resistant hypertension?
The autonomic nervous system, particularly the sympathetic nervous system
What was the outcome of the SIMPLICITY HTN-3 trial regarding renal denervation?
Renal denervation did not provide better blood pressure control than medical therapy alone
What are the common complications associated with renal arteriography?
Atheroembolism, renal artery ostial trauma, dissection, and contrast nephrotoxicity
What is the technical success rate of percutaneous revascularization in patients with FMD?
88.2%
What is the combined complication rate for surgical revascularization in FMD?
16.9%
What is the combined complication rate for patients who underwent surgical revascularization?
16.9%
The majority of complications were defined as major (15.4%) with a perioperative mortality of 1.2%
What is the hypertension cure rate with surgery?
57.5%
This indicates the effectiveness of surgical intervention in treating hypertension.
What is the most critical component of a technically successful endovascular AA repair?
Preprocedural planning
CT provides the backbone for evaluating patient candidacy.
What anatomic criteria must patients fulfill for EVAR?
Patients must have:
* Iliofemoral access vessels that allow safe insertion and deployment of the device
* An infrarenal aortic neck of adequate length, limited angulation, and appropriate diameter
What was the significant finding of the EVAR-1 trial regarding 30-day mortality?
Endovascular repair group had 1.6% mortality compared to 4.7% in surgical group
p = 0.007 indicates statistical significance.
What were the long-term follow-up results of the EVAR-1 trial regarding all-cause mortality?
Similar all-cause mortality between endovascular and surgical repair groups
Endovascular repair group had higher overall rates of complication.
What was the complication rate in the endovascular group of the EVAR-1 trial?
17.6/100 person years
Compared to 3.3/100 person years in the surgical group.
What do the results of the DREAM trial indicate about endovascular vs. open surgical repair?
Similar long-term cumulative survival rates
A significant reduction in aneurysm-related mortality was noted in the endovascular group.
What is the five-year and nine-year rupture-free survival rate observed after EVAR?
> 97% for 5-year and >94% for 9-year
Indicates the long-term effectiveness of EVAR.
What are independent risk factors for AA rupture?
- COPD
- Hypertension
- Female gender
- Smoking
- Symptoms like abdominal tenderness or back pain
- Expansion >0.6 cm in 1 year
What is the most common serious perioperative complication of EVAR?
Cardiac complications
These complications are also the most common cause of late death.
What is subclavian steal syndrome?
A group of symptoms due to vertebrobasilar insufficiency from proximal subclavian stenosis
Symptoms can include upper extremity claudication, paresthesia, and visual symptoms.
What are the indications for revascularization of the subclavian artery?
- Symptomatic steal syndrome
- Disabling upper extremity weakness
- Vertebrobasilar insufficiency
- Preservation of flow to in situ internal mammary grafts
- Evidence of embolic phenomenon
What is the most efficient and precise strategy to diagnose and treat subclavian steal syndrome?
Angiography
While ultrasound and MRA can help, angiography is preferred.
What is the most commonly seen variation of right-sided aortic arch?
Left carotid as the first branch and left subclavian as the last branch
Understanding this requires familiarity with embryology.
What characterizes Takayasu’s arteritis?
Inflammation of the aorta and its main branches
It primarily affects females, is more common in Asians, and has a mean age presentation of 25 years.
What were the most common presenting symptoms in patients with Takayasu’s arteritis?
- Arm claudication
- Light-headedness
- Visual changes
- Constitutional complaints (weight loss, fever)
What is the treatment for Takayasu’s arteritis?
Oral steroids at 1 mg/kg for up to 3 months; cytotoxic agents if steroids can’t be weaned
Surgical treatment is indicated for refractory hypertension or severe stenosis.
What branches does the celiac artery divide into?
- Left gastric artery
- Hepatic artery
- Splenic artery
What is the function of the left gastric artery?
Provides blood flow to portions of the esophagus and the cardiac portion of the stomach
It anastomoses with the right gastric artery.
