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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 disease presentations 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.
Understand the presentation of chronic venous insufficiency including diagnosis and new treatment modalities.
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Key Clinical Points
Peripheral arterial disease (PAD) is a common clinical condition in older adults with up to 20% of people older than 70 years having some form of PAD.
PAD can be diagnosed utilizing a simple and accurate test named the ankle-brachial index (ABI).
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.
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.
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.
Intervention of patients with AAA is generally accepted when aneurysmal diameter exceeds 5 to 5.5 cm.
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.
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.
Chronic venous disorders of the lower extremities are present in over 30% of the population and are generally treated first with graduated compression stockings.
Recent data support ablation of the saphenous vein as initial treatment in appropriate patients with venous stasis ulceration.
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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 years. Various studies document a 15% to 20% prevalence rate over the age of 70 years. With the increasing age of the 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, options for treatment, and treatment outcomes in the geriatric population are necessary to provide optimal guidance for these patients. This chapter is organized by ...