Internal Medicine

P1: SBT

0521779407-04a CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:48

184 Atherosclerotic Occlusive Disease

➣Anti-platelet therapy for patients with expected survival < 2 years

due to co-morbid conditions

➣Angioplasty+stenting in patients with surgically inaccessible

lesions or hazardous comorbidity (irradiated neck, etc.)

■Visceral occlusive disease

➣Surgical revascularization (bypass or endarterectomy) in all

symptomatic patients or patients with 2 or more involved mesen-

teric vessels

➣Percutaneous angioplasty in very high risk patients, recurrent

disease or as a bridge to surgery in patients with severe weight

loss

■Renal artery occlusive disease

➣Angioplasty+stenting for focal stenosis of main renal artery

➣Renal artery bypass (better long-term results than angioplasty)

Younger patients (age <65)

Failed stenting or in-stent restenosis

Diffuse disease

Disease of branch vessels

In conjuction with other vascular procedure (aneurysm repair,

etc.)

■Lower Extremity Occlusive Disease

➣Smoking cessation and graduated walking program for claudi-

cation

➣Revascularization for disabling claudication unresponsive to

above measures or limb threat

Angioplasty+stenting or aortofemoral bypass for iliac disease

Bypass for femoral, popliteal and tibial artery disease

Side Effects & Contraindications

■Carotid Endarterectomy

➣Contraindications

➣Absolute

➣Occlusion of internal carotid artery

must be confirmed by either MRA or angiogram

Duplex has 8% false-positive rate for occlusion

➣Relative

➣Irradiated or surgically reconstructed neck (muscle flap)

➣Symptomatic coronary artery disease requiring revasculariza-

tion first

■Mesenteric and Visceral Revascularization

➣Contraindications