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LEARNING OBJECTIVES

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Learning Objectives

  • Obtain a working knowledge of the most common sites of peripheral vascular disease (PVD), the initial diagnostic tests, and options for treatment as well as their outcomes.

  • Understand the important role aging plays with regard to intervention in the PVD patient where the primary determination to intervene is based on risk-benefit ratio and the time to treatment equipoise.

  • Describe the key indications with regard to intervention for the most common arterial diseases including claudication, critical limb ischemia, symptomatic and asymptomatic carotid artery stenosis, and abdominal aortic aneurysms (AAAs).

  • Understand the role of minimally invasive endovascular intervention in comparison to open vascular surgery.

  • Understand the key physiologic and nonphysiologic factors that affect surgical outcomes in vascular patients especially renal failure and functional status.

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Key Clinical Points

  1. Peripheral arterial disease (PAD) is a common clinical condition in older adults with up to 20% of patients over the age of 70 having some form of PAD.

  2. PAD can be diagnosed utilizing a simple and accurate test named the ankle-brachial index (ABI), which can be falsely elevated in diabetic patients.

  3. The decision to intervene in a patient with claudication is a lifestyle choice and should be pursued only after a trial of exercise therapy has been performed as the risk of disease progression and amputation in this population is low.

  4. Intervention for patients with asymptomatic carotid artery stenosis utilizing carotid artery stenting (CAS) is not currently indicated due to the significant risk of perioperative stroke except in unusual circumstances.

  5. Carotid endarterectomy is the generally accepted intervention for older patients with both asymptomatic and symptomatic carotid artery stenosis with CAS acceptable for patients with specific indications.

  6. Intervention of patients with AAA is generally accepted between 5 and 5.5 cm.

  7. Outcomes for patients with acceptable anatomy for open or endovascular repair of infrarenal AAAs are similar based on current randomized trials, although short-term mortality appears to benefit patients undergoing endovascular repair.

  8. Long-term follow-up of patients undergoing endovascular repair of AAA using computed tomographic scanning is currently recommended based on changing morphology of the residual aneurysm.

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Peripheral vascular disease (PVD) is primarily a disease of aging and is strongly associated with impaired quality of life and increased cardiovascular mortality. The average age of patients seeking treatment is approximately 70. Various studies document a 15% to 20% prevalence rate in patients over the age of 70. With the increase in the older population, the diagnosis and treatment of PVD will become a priority. A working knowledge of the most common sites of disease, the initial diagnostic tests, and options for treatment as well as their outcomes are necessary to provide optimal guidance for these patients. This chapter is organized by the most commonly encountered arterial diseases of the geriatric patient. Although each has its unique presentation, treatment algorithms and nonoperative and operative management, it should not be forgotten that the underlying atherosclerotic process is a systemic disease and as such should ...

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