Treatment of Arterial Occlusive Disease

Carotid/vertebral

Stroke is the 3rd leading cause of death in the United States but is the #1 cause of disability in adults. 20-30 percent of ischemic strokes are related to thromboembolic events and atherosclerosis. Atherosclerosis is responsible for 90 percent of extracranial cerebrovascular disease; other causes include fibrodysplasia, kinking, dissection and radiation-induced changes. Diagnosis is made by duplex ultrasound, CT or MRA, and sometimes by arteriography. Treatment is indicated for patients with neurologic symptoms and greater than 50 percent stenosis of the relevant carotid artery, or patients with greater than 70 percent stenosis but no symptoms. Carotid endarterectomy is the gold standard, with carotid angioplasty and stenting as a recent endovascular alternative in select anatomic or physiologic high-risk cases. Surgery or stenting can reduce the risk of a future stroke in some patients.

Mesenteric

The mesenteric vessels are the arteries that supply blood to the abdominal organs, including the stomach, liver, large and small intestines. They are interconnected in a vast, very reliable network which generally provides excellent protection against inadequate blood flow to any single organ. In up to 10 percent of the population, one or more of these arteries can become narrowed, but the majority of people will never have any symptoms. Symptoms tend to be related to an inadequate compensatory increase in intestinal blood flow after meals. Diagnosis often involves the exclusion of other more common gastrointestinal problems, followed by duplex ultrasound and CT or MRA. Treatment involves revascularization, either by endovascular or open surgery.

Renal

Renovascular occlusive disease is typically either atherosclerotic or fibrodysplastic in origin. Physiologic effects include hypertension and renal insufficiency (ischemic nephropathy). However, renovascular disease as the cause of hypertension is actually relatively rare (2-5 percent). Diagnosis can be made by duplex ultrasound and radionuclide split renal function studies. Intervention may be helpful in cases of severe drug-resistant hypertension or rapid, sudden progression of renal insufficiency. Treatment options include angioplasty, stenting and open surgical bypass.

Aortoiliac and extremity

Most patients with peripheral arterial disease of the extremities are asymptomatic or have only mild, reproducible pain in a leg muscle with walking. Less than 5 percent have upper extremity symptoms. Only about 25% of patients will have progression of symptoms over time and less than 20% will require some type of surgery or intervention within 10 years. Frequently associated diseases include hypertension, coronary artery disease, hyperlipidemia, diabetes and tobacco use. Atherosclerosis is the most common cause of peripheral arterial occlusive disease, but there are also several other conditions which may lead to similar or confounding symptoms (ie. Raynaud's syndrome and vasculitis). While there are a few medical, nonoperative therapies available, arterial occlusive disease of the aortoiliac and peripheral arteries may require direct or extra-anatomic open surgical reconstruction or the use of percutaneous, endovascular techniques to reopen partially or completely blocked arteries and restore adequate blood flow.