Hello, I'm Christy Willocks from Ballard Health in Kingsport, Tennessee. This is Module 3 of our peripheral vascular disease learning modules, and today we'll be going over carotid, subclavian, mesenteric, and renal disease. These are my disclosures. So our learning objectives will be we will look at the signs and symptoms of a stroke as well as how stroke symptoms may relate to carotid disease. We'll evaluate the need and timing for carotid intervention. We'll understand the different approaches to carotid intervention, and then we'll go through some things, some things that you may not see every day, but renal, mesenteric, FMD, and some other things as well. Here are additional reading materials if you want to dig in. So what are the prevalence of strokes? Strokes account for one in every 21 deaths in the U.S. in 2020. There are 795,000 strokes annually in the U.S. Currently, there are 7 million people living post-stroke with varying degrees of disability. The annual burden of stroke is 53 billion dollars, with the indirect cost being 700 billion dollars and likely even higher. Worldwide stroke is the second leading cause of death, and 80% of strokes are related to either ischemic stroke or thromboembolic events. This one is the big statistic here of all these. 75% of stroke patients have no prior symptoms. When we talk to our patients in the office, we talk a lot about TIAs, and we go through a lot of those symptoms, but a lot of times patients don't have warning signs for strokes. What are the things that we can do to try to prevent strokes? This is the American Heart Association Essential 8. We want to get people to stop smoking. We want to get people to exercise, eat healthy, lose weight, of course manage their cholesterol, get seven to eight hours of sleep every night, not become diabetics or control their diabetes, and control their blood pressure. So symptoms that are related to thromboembolic events include hemiparesis, which is weakness on one side of your body or the other, hemiparestesias, which is numbness on one side of your body, ambrosis fugax, is where the patient will describe losing vision on one side or the other, even briefly. They may have difficulties with speech or aphasia. That can be expressive, and then as far as if a patient has TIAs, this increases the patient's risk 30 to 50 percent over the next five years. So a patient that has already shown warning signs has a much greater chance of something happening again. In the immediate time period, one month after that TIA, the risk of a stroke goes up by 10 to 25 percent. Now just because you have a stroke or a TIA does not mean that you have carotid disease. Only 50% of these patients will have carotid disease, but it needs to be evaluated. And you want to also look for other sources of stroke. Do they have heart issues, ASD, PFO, anything else? Do they have atrial fib? Do they have a really calcified aortic arch? Do they have intracranial disease, a hypercoagulable state? And then the unfortunate thing with a lot of strokes is we don't really ever find out exactly where they came from, and that's very frustrating as a patient and a provider not to be able to identify that. So just some terms that we use a lot with strokes. TIA, as you know, is a transient ischemic attack, and that is when the patients will have these brief episodes of neurological symptoms that typically last less than 24 hours. RIND is if the symptoms last greater than 24 hours. In order to be defined as a stroke, not only do you have to have the neurological deficits, but you need to have evidence of structural infarction, either on a CT or MRI. If the patient has a crescendo TIA, that means that they're having waxing and waning recurrent symptoms over a period of 24 to 48 hours. They are high risk for a very large event, and if a patient's had a stroke, and they continue to have the same kind of syndrome of waxing and waning symptoms, those patients again are very high risk for a much larger worsening stroke. So let's review our carotid anatomy. I won't get into every little segment of the intracranial circulation, but think of where your heart is, and then you have an arch that sits over the heart. Over that, you have both your left and right subclavian that come off of that arch. Now, the thing that complicates it for some patients is we don't all have the same arch. There's two types of arch and a bovine arch. We won't talk about that part, but off of the arch you have your subclavians. You have your common carotids that lead into your internal carotids. Off of your subclavian arteries that go to the right and the left is where you have your vertebral arteries, and that supplies the back part of your brain. You have the basilar artery that sits in the center of the brain, and you have posterior communicating arteries that go to that. And then, of course, here are all the intracranial things. But the big ones as far as carotid disease that we're monitoring for a lot of times are the subclavian disease, vertebral disease, and internal, both common and internal carotid artery disease are the ones that we look for most frequently. If we think a patient may have carotid disease or they've presented with a stroke, the first test is a carotid duplex. It's very quick, sensitive, specific, accurate, and carries very little risk to the patient. It's overall cost effective. The only limitations to a carotid duplex are you have to think about where the sonographer can put the probe. We're not able to see under the clavicle, and we're not able to see above the clavicle. We're not able to see above the level of the jaw. So that eliminates our common carotids down here. It eliminates our intracranial disease. Sometimes it's difficult to tell if the patient has a clear occlusion on a carotid ultrasound, and it is fairly rare that you would go from carotid ultrasound to stent or surgery without a CT or MRA. The thing about an ultrasound also is that you can't always predict vessel tortuosity, and we'll look at some examples of what that means. So if you're the one ordering the carotid ultrasound, hopefully you won't have to interpret it as well, but just some things to be aware of when you look at the test results so you'll have more information to understand what it means. Now this particular chart came from the Society of Radiologists, but there are lots of different parameters out there. So this is where it's good to know the lab and the parameters that your lab uses. And the other thing that I would recommend is if you have a patient that you're following for serial carotid duplex, it's very nice to use the same lab over and over because they'll have the same set of criteria. When you're doing these measurements, it's always nice to know, well, that was done at the same lab, they use the same techs, machines, etc., etc. So if a patient has a peak systolic velocity less than 125 and an end-diastolic less than 40, that's not considered to have any disease. So put this in perspective of a blood pressure. You've got a systolic and a diastolic. Just know that in your carotid artery, I've seen these go as high as 600 and 700. So it's a little bit different than the blood pressure in your arm. If the patient develops increased peak systolic velocity between 125 and 230 and the diastolic comes up with that, then that means that they can have moderate disease between 50 and 69 percent. The other thing you can look at here is this ratio. The ratio is a calculation of the internal carotid artery to the common carotid artery. And usually if you're just going to eyeball that test really quick and you see those ratios less than two, you think, okay, I'm pretty good. Now, I would also recommend looking at the rest of it, but that's a quick way to eyeball it and say, okay, we're doing okay today. Now, when these blood pressures get higher than 230, again, depending on the scale that you use, where you work at and their diastolic gets above 100, this ratio gets above four, you're looking at some more significant disease. With critical stenosis or inclusion, you can get some really unusual reads. So these are patients for sure that you'll want to kind of follow up further with a CT or MRA. And this is just an image of a carotid duplex. If you've ever worked around a vascular lab, you know exactly what this sounds like. And this is how they measure that peak systolic velocity and the end diastolic velocity. And that's a nice, good flow in that carotid artery. So how often do we look at a patient that has carotid disease? And this is one of those things that everybody will tell you their own opinion. You can look in several different reference texts and you will have different information. If the patient has less than 49%, every one to two years is okay. But if you have established that that disease is fairly stable and they don't have a whole lot of risk factors, you could certainly move up to probably every three to five years. If it's a really high risk patient with lots of other things going on, probably every couple of years would be recommended. If the patient is in the 50 to 79% range, I would say especially greater than 70, you want to look at that patient probably every six months. If they've had a post carotid endorectomy, most places will look at that every six months for the first couple of years. If they have a contralateral carotid occlusion, meaning the other carotid artery is out and you're dependent on this one, you want to look at that patient every six months. I do that a whole lot with my patients that have had radiation-induced disease from where they've had cancers in the past. They can have really aggressive disease. And a patient that's had a carotid stent every six months, but once you know that that's stable, you can certainly move that out to every year. So additional imaging includes CTs or MRAs. These are nice because if you get a CTA head and neck, you'll also get a picture of the brain, which is nice. You can see if there's some infarcts. You can see if the patient has intercranial disease. You can get an idea of what the arch looks like and if there's a lot of calcium there. And then you also can see the disease below the subclavians or the clavicular line there. You get a better image of those things. So two restrictions here, your CAT scan, if you have a lot of calcium in your arteries, it's a little bit difficult to see. You can't give it, of course, if the patient has renal insufficiency or elevated creatinine, an MRA should not be used, especially if your patient has had a prior carotid stent. And we'll see this a lot. Patients will go to smaller outside facilities. They've had a carotid stent. They come in with some kind of symptom. They'll get that test. And then what you see on that test is a lot of artifact from that metal. So you don't want to get an MRA on a patient that's had a stent because you're not going to get a good idea of what's going on. Typical things with your MRA that you want to avoid, which would be kidney issues, claustrophobia, and a defibrillator or pacemaker that may not be compatible for MRs. And then your last option for imaging is your carotid angiograms. That is, of course, invasive and poses some risk to the patient. So these are just some pretty pictures here. In this particular picture, you can see this is a bunch of calcium that's kind of obstructing this artery. And then when I mentioned how vessel tortuosity sometimes affected carotid duplex, this is something you can't always see in an ultrasound. You see how that kind of comes around. It does a complete 180. That will make your pressure in your neck come up even if you didn't have this problem here. This particular patient had an external carotid artery, which was occluded, which is not something you have to worry about, but it does sometimes affect how you will treat the patient with stenting and protection devices. And this is just another picture of the same thing with this little loop-de-loop going here. So if you have the patient and you know you've identified that they have carotid stenosis, the next thing you want to do is risk factor modification. This is not a whole lot different than what you do with your coronary patients. You want to monitor their blood pressure, cholesterol. If they do have coronary disease, you want to make sure that is treated with the correct medications. You want your patient to take statins. Now, occasionally you'll get a little resistance on the statin front because they'll say, well, my cholesterol is really good. Especially in these carotid patients, you want to explain that the plaque that's already in their neck, we don't want it to get worse and we don't want it to break off and go upwards. So that is the benefit of statin beyond just looking at the labs. You want these patients to be on antiplatelet therapy to prevent microemboli. And we go back to the CAPRI study where aspirin did help reduce risk of TIA stroke and death by 20%. Plavix also reduced risk by 24%. So this is a very reasonable treatment for patients that are both symptomatic and asymptomatic is to get them on their statin aspirin Plavix. And sometimes we even use dual antiplatelet therapy in these patients as well. So who do we need to treat and who do we not need to treat? The annual risk of ipsilateral stroke in patients with asymptomatic disease greater than 50% is estimated to be 0.5 to 1% annually. So that's pretty low. There's a study of 3,700 patients that had severe disease, 90 to 99, who did not have carotid revascularization. They chose medical therapy and the overall stroke risk in that group was 0.9. So very low there again. But we do know that the greater the stenosis or the blockage, the greater the risk of stroke. So if that was a little bit confusing because these patients seem to be relatively high risk, we kind of look for additional treatment guidelines. So most places look at it like this. If they have less than 50% risk factor modification, if they have 50 to 69%, you want to be more aggressive with your medical therapy. That's where your antiplatelet therapy will come into play. And you want to talk to them about risk factor modification. Again, going back to looking at your carotids every six months to a year in this group of patients. If the patient gets above 70% and their life expectancy is greater than five years and the procedure risk is less than 3%, these are the patients that you want to direct towards intervention. Now, if they have 100% occlusion in that carotid artery, there's no intervention needed at that point. And that's very difficult for patients to understand because when we talk about legs and hearts and everything else, we say, oh, we got to treat that blockage. So this is one of the situations where I like to explain the patient when that blockage goes from 95 to 100% and you're very, very hopeful when that event occurred that they didn't have a stroke, our body, our vertebral arteries and the other carotid is smart enough to kind of take over the flow of that entire brain. So the last thing we want to do is try to redirect that flow when the body is already taking care of that. And of course, we don't need to treat external carotid arteries. That's a small vessel that kind of comes up here towards our jaw and face. So what defines symptomatic disease? We want to make sure these patients have symptoms consistent with TIAs and strokes. We want to avoid kind of labeling patients that come in with dizziness, near faint or presyncope, gait issues as clear symptoms of stroke. You'll be amazed at the number of patients that will say, well, you know, I've had all kinds of TIAs and strokes and then you start talking to them about it and it sounds like a whole different thing. So you do want to kind of take some time and take a good history to figure out what their symptoms really are. If the patient has had a TIA, RIND, or an acute stroke, all need carotid evaluation and consideration of treatment. If they're symptomatic, you want to get these patients treatment. Whether they're 50, 60, 70, if they're symptomatic, they fall into a whole different category. Now, in a second set of patients, if they've already had a stroke and they have a very, very large deficit, you want that patient likely to rehabilitate a little bit and then consider bringing them back to work on that artery that caused the event. Again, you always get a little bit of kickback on that sometimes with the families and the patients, but explain it to them like this, you know, the stroke causes a weak part of the brain and the blockage caused that, but sometimes the worst thing we can do is kind of open up that water hose to that weakened part of the brain and expect that patient to get better. It doesn't always work that way. So there is sometimes a waiting period based on the size of the stroke that the patient had. Now, if they come in and they're having symptoms that come and go and come and go, those patients are very high risk. So you would probably consider intervention much earlier in that group of patients. So what are our treatment options for carotid intervention? There are three major treatment options. Kind of go through those and give you a few little studies that if you wanted to look at, to make a comparison yourself, you could do that. The first is carotid endarterectomy. That's been around the longest period of time. That's a procedure done with anesthesia. The arteries open, the plaque is removed. The patient usually stays overnight with a drain. Patients do very well with that. Several trials, the VA trial showed aspirin post carotid endarterectomy. The ACAS trial put two groups of patients, carotid endarterectomy and aspirin patients versus only aspirin. And there was some overall risk reduction in the group that had surgery and aspirin. Again, not a huge difference there. And then you have the ACST, which did carotid stenosis as soon as you identified it versus deferred when it was more severe or symptomatic. And again, the groups were fairly comparable. Transfemoral carotid stenting. This is where you use a femoral approach similar to a cardiac catheterization. Although a lot of the casts now are done radial. If this is done from a femoral approach, it uses embolic protection devices, which think of that as like a trash basket above the area of the blockage. And then a balloon is placed to dilate the blockage and then a stent is inserted after that. So that is what the purpose of a carotid stent is. Several trials, Act I, CREST and SAFIRE all proved non-inferiority to CA. So there's a little debate in the industry about what technique is best. And this is one of those things that I would recommend to you all as providers is know the people in your neighborhood, know the providers, know who's the expert and get feedback from the patients. If you refer for this type of service, see how they do, just kind of take an internal journals because you can have some really talented people that live or physicians that live in your area and you want to utilize those people. Now, there are certain times when carotid endarterectomy is preferred and then other times when we want to look towards carotid stenting and or TCAR, I'll get to that too. Carotid endarterectomy is preferred if we're not able to use embolic protection devices. So in the patient that has the artery that's very torturous and you can't put that basket up on top of that, those patients wouldn't be safe for stenting. If the patient has an arch that's very complicated or a whole lot of calcium chunks in there and you're going to take wires through that calcium, you might break some of that off and cause a stroke. If you can't get through their femoral or iliac arteries because they have really rotten vascular disease, that would kind of take them out of that option. And then also if the patient's not able to tolerate a procedure without anesthesia. So for carotid stenting, we use very, very light sedation. Some patients are just way too anxious to be able to tolerate that. So they would probably do better with the endarterectomy. Now, carotid stenting tends to be preferred if the patient has a high carotid bifurcation. That means if the blockage is way up here past the jaw line, it gets very difficult to cut into the neck that high. If they've already had a surgery and they have a new stenosis, if they have neck immobility issues, or they have significant cardiac or pulmonary disease, and that goes back to if the patient can have anesthesia or not. So if the patient should not have anesthesia, that kind of pushes you more towards stinting. Carotid stinting is strongly recommended if the patient has had prior neck radiation because these patients will have a lot of scar tissue and very aggressive carotid disease. If they've had radical neck surgery, if they have a trach or a stoma, or if they have a blockage of one carotid artery, it's a safer procedure for them to have the stint versus the open surgery. So just some pictures here. This is a left carotid artery, and that would be what we would consider to be very tight. And this is just another view of that. In this particular picture, what it's showing is where the patient has filters placed above and to the side, usually in the external carotid to help protect from anything that may dislodge during the procedure itself. Again, the balloon is placed. And then the final image here is where the stint is going across that blockage. The whole thing takes somewhere about an hour to hour and a half, depending on the provider. They are awake and they do get a neurological exam while the actual procedure is going on. And then here's the final picture. So you see where we were to where we are now, hour and a half later, much better situation. So the next option is TCAR. That's a transcervical carotid revascularization. That is very trendy right now. That's getting all the talks in the meeting. And with a TCAR, the patient has a very small incision that exposes that common carotid artery. We've got a picture of that. A sheath is placed in two places. You'll have it in the common carotid as well as the common femoral vein. And then between those two access sides, you have a connected flow tubing that will catch any debris as the flow is reversed to that system. When the common carotid artery is clamped, the flow is augmented into the system from the distal carotid back to the femoral vein. The stent can be then placed using anesthesia or mild sedation. Again, the trend is try to move more away from the anesthesia to the sedation end of that. And the trial data on this is Roadster and it was sponsored by the company that makes the device. So this is your TCAR incision. And if you work in vascular world and you see that big common carotid artery, you think that's a thing of beauty. And this is just an example of what the system would look like. You know, again, access here at the common fem, access here of the common carotid, and then how the system kind of reverses flow with filters in place to minimize blood loss and any type of debris is caught into the filter. Typical procedure time, about an hour and a half, patient goes home the next day. So they're all very similar in that regard. So if the patient has had a carotid intervention, it's just like any other type of peripheral vascular disease you want to tell them that they need to continue risk factor modification. We generally almost always use some form of dolina platelet therapy depending on the type of intervention that they had done. You want to follow these patients up usually in at least six months, and you want to keep monitoring for contralateral disease because they have two carotids. So left subclavian disease is something that we usually pick up on incidentally, meaning that somebody just happens to check a blood pressure in both arms, or they get a CAT scan for another reason, and they figure out that this patient has left subclavian disease. The patients that have this particular blockage can have left arm claudication, meaning that if they work with that left arm, they can have some pain. They can also, if they have a very proximal occlusion, and I'll show you a picture of that, they can develop something called subclavian still syndrome. And the symptoms that are associated with that are dizziness, syncope, visual blurring, ataxia, and all that can occur with left arm exercises. But most of the time, what will happen is you'll have a patient that will work with their arm frequently, a hairdresser, painter, think something like that. And as they bring that arm up, what will happen is the posterior circulation, your vertebrals, the posterior part of your brain will try to help out to get that blood up there since that subclavian is blocked. And so it essentially steals that blood to help the arm. And when that happens is when you get symptoms from that. Now, there's a second type of symptom you can get in these patients, and that is if they have had a bypass. If they have a lemagraph from the chest to the anterior portion of their heart, or wherever that lemagraph goes, these patients sometimes will have angina because you'll have a competitive flow situation because of that blockage. Again, here is a kind of a proximal occlusion here, and you see the blood kind of come away from the vertebral artery trying to help that arm out, and that's when you get symptoms. Testing for subclavian stenosis, again, blood pressure's both arms would be the first check. You can get a carotid ultrasound. We'll sometimes give you a clue, but remember this is a little bit further down in the chest and not always able to be fully visualized. So you may want to consider a CTA or MRA. Now, if these patients come to you with no symptoms and it's just been caught, the best thing you can do is reassure them they're not at risk for heart attack or stroke, and you're just gonna kind of monitor their risk factors. You see this more commonly in females. Tends to be left greater than right, although in hervascular patients, they can have left and right, and you can check stress tests, lower extremity ABIs, et cetera, but sometimes it's an isolated phenomenon in younger females. If the patient is symptomatic, it certainly can be treated with either bypass or stenting, and then after they have the procedure done, a simple blood pressure in both arms is a very easy way to tell if the patient has good flow in the artery. So vertebral basilar insufficiency comes along to kind of confuse us all when we're talking about what symptoms are and aren't strokes. If a patient has disease in their vertebral artery or basilar artery, they can have vertigo, double vision, sudden falls, numbness, gait imbalance issues, which guess what? Are all symptoms that patients that are older tend to have anyway. So very difficult sometimes to distinguish what's coming from the vertebral artery and what is actually coming from age or other issues. You certainly can get a duplex CTA, MRA on these patients. Now, vertebral artery anatomy is much like coronary anatomy in that we have a pattern of dominance. So you'll either have a right or left vertebral artery that is dominant. If the patient is felt to be fairly symptomatic from that blockage in a dominant vessel, then that patient can get intervention. There are surgical bypass options and endovascular treatment options for this. A lot of patients prefer the endovascular means just because it is a stinting procedure. Carotid FMD is not something that you'll see a whole lot, but if you ever see it on an overread, it's good to be aware of what it is. FMD stands for fibromuscular dysplasia. It's a condition where you have a lot of cells that grow on the inner wall of your arteries. And as that sclerosis, it kind of makes a beaded appearance. Occasionally, this can just be very superficial, but sometimes it can cause occlusion or obstruction of the arteries. It generally affects medium-sized arteries, the renals, carotids, and mesenterics. If a patient has FMD, they do not need to be treated with stinting. They are usually treated with angioplasty alone. But most of the time when you see this, probably more renals than anything, you'll just see that beaded appearance there. And then you'll kind of try to figure out if the patient's symptomatic enough to need intervention. So talking about renal arteries, there are several groups of renal artery disease that you think about in the vascular world. One is aneurysms, which is fairly infrequent. The other one is FMD that we mentioned before. And the other is atherosclerotic renovascular disease. And that would be your renal artery stenosis. And that's what a lot of people think about when they're looking at patients with high blood pressure. In these particular patients, we're worried about blood pressure control and do they have a decline in renal function? So when do you screen and when do you not screen for renal artery stenosis? So you've got to think about one third of the American population has high blood pressure. People with renal artery stenosis, only about 5% of those one third. So it's not something that you're going to come upon every day. So routine screening is not indicated for all patients with blood pressure issues. We want to reserve screening for those with multidrug hypertension. That means two to three medications if their renal function is getting worse or they're young. So those are the patients that you look at more clearly. If you have a patient with high blood pressure, you want to begin with risk factor modification, weight loss, dietary changes. We always recommend the DASH diet again for our patients that have poorly controlled blood pressure. You want to see if you can get them exercising, have them stop smoking, and then you want to start one to two meds. After you've done those first steps, it's always good to follow up in about three to six months to see if you're seeing any improvement at all. If not, then you can move on to renal duplex, a CT or MRA. You do have to be cautious in these patients because they may present with renal dysfunction and a CT and MRA may be out of the question. Again, you can see in this picture, this patient has very tight renal artery stenosis in both kidney arteries. So what patients benefit from renal intervention? It works better in patients that are younger with FMD, again, angioplasty only, that have a focal lesion and good renal function. If patient has bilateral disease, they tend to have better long-term improvement. If they have a severe stenosis and one functioning kidney, you certainly don't want to let that one functioning kidney with a 90% stenosis kind of fly by your radar. It only causes a cure though in about 10% of patients. So you also want to be very realistic that this is not always a cure for hypertension, but 70% will have some transient improvement with fewer blood pressure medications. So you may tell them that they may be able to stop a medicine occasionally more. Who does not benefit from renal artery intervention? That would be your older patients, the patients that have had high blood pressure for a lot of years and your diabetic patients. And the reason that they don't benefit if you identify the blockage is that they already have renal pericardial disease, meaning that their kidneys are already fairly diseased and opening up that flow to that kidney really does a whole lot to make the kidney better. If you get an ultrasound or when you're getting your duplex, if you see that the patient already has renal atrophy or small kidneys, that patient's not likely gonna benefit from intervention. Renal angioplasty again is most likely indicated for FMD. You don't want to do stinting in those patients. Stinting is preferred versus open surgical if the patient does have renal artery stenosis. There are several studies there. Astral study was one that they decided that they would put the patients that had less than desirable stenosis in instead of those with high stenosis. And it came out with a horrible complication rate, about 9%. So that wasn't very helpful. CORAL came around, we did CORAL here, and what that did is it randomized either to medical therapy or stinting in patients with greater than 80% stenosis. There wasn't a whole lot of difference between the two groups, but we did notice that they did have more benefit. The higher the blockage, the better the outcome and the complication rates were much better than earlier trials. And then STAR was another med management versus meds versus stinting that looked at creatinine and end points with minimal difference between the two groups. So Medicare in general and sometimes other insurances don't want you to jump to treatment first. They want to make sure that you've looked at, are they on the right medications? Have you done some risk factor modification before you jump into intervention on these patients? So switching gears again to mesenteric anatomy, we have three major arteries in our belly. One is the celiac artery, and that supplies our distal esophagus through the second part of the duodenum. Then there's the SMA. It gets the majority of our midgut, a lot of our small intestine, a lot of our colon, and the IMA is the smallest of those vessels, and it supplies the hindgut, the semicolon, and rectum. So the point of this particular picture here is just so you see the stomach in general is highly vascular, and there's lots of opportunities here for collateral flow. So that does affect how we fix this particular type of disease. The first test that we generally get for mesenteric disease or screening test is a mesenteric duplex, similar to a carotid ultrasound. The only issue with a mesenteric duplex is it depends a lot on the patient's body habitus. A large patient is very hard to get to be able to see their mesenteric vessels, and if they have any gas in their stomach at all, it makes it very hard to visualize. If you have staff or sonographers that are very good at mesenteric, it really helps. It's not uncommon to get some mesenteric duplex, so some really high flow readings into those arteries, and you end up getting a CT or MRI. So something to consider when you're looking at your mesenteric duplex. This particular picture, this patient had a little bit up here, or they had a chunk of their celiac, and then they had some SMA when we actually did angios too. But sometimes it is good before you go to angiography to have kind of an idea of what's going on there and have information about the collateral flow so you can identify if the patient needs intervention or not. Two different pathways here for patients. The patient that you're gonna see in the office is gonna be the chronic mesenteric patient. The patient you're gonna see in the hospital is gonna be your acute patient. The chronic patients can present with some abdominal pain that can be vague and nonspecific. Most of these patients will have a very clear pain pattern though. They'll have pain when they eat a meal. After they eat, they'll have bloating or diarrhea. They may have weight loss, or almost all the time they'll have weight loss. And then when they eat a meal, they'll have food fear because they know that pain's gonna happen. You may be able to hear abdominal bruise. They tend to be vascular paths, meaning they may have lower extreme disease, carotid disease, coronary disease. It's kind of a package deal. And this patient may come to you after having lots of negative workups and desperation of, you know, why am I having this pain? The patient that would benefit here would be a patient that for sure has clear cut postprandial symptoms and weight loss. That's the most definitive. If you get that perfect patient that presents like that, if the patient tends to be fairly overweight, really hasn't lost any weight at all, and they have some really vague symptoms, it makes it a whole lot more confusing about if intervention will help that particular type of patient. Now, your acute patients probably had chronic disease, but now they've thrombosed that artery. If they have atrial fib, they can certainly have an embolism, and that will usually obstruct the SMAs, the most common thing that'll obstruct. There's a different branch here of patients that have non-occlusive small vessel disease. And those are your patients that have had a recent MRI or heart failure. They just have poor gut flow overall. These patients that have had these thrombosis or these small vessel disease, they'll have severe pain out of proportion to their abdominal exam. They'll present very ill, high Y count, acidotic, shock. So they need fairly immediate intervention. So patients that have chronic disease, if you do a CAT scan and you just do a drive-by and you see that they have some mesenteric disease, but they have no symptoms whatsoever, we do not usually recommend treatment for those patients. Because these arteries have such an extensive collateral flow, we rarely consider disease unless they have blockage in two of the three arteries. The only artery in oscillation that you would treat would be the SMA, and that's just because it supplies so much of the gut. So if you get a CAT scan and you say IMA disease only, again, you're probably not gonna think about intervention or celiac disease only, but if they have two of the three blood vessels, you would consider intervention only in your symptomatic patients. Intervention's the only way to restore blood flow. There's not a magic pill here, and there are surgical and endovascular options. I think angioplasty and stenting would be more common at most facilities just because it's not an open-top procedure. Your acute patients, rapid imaging is a must. Most of these patients will have a CD abdomen pelvis when they hit the door. If they have a thrombosis, it's usually likely to hit that superior mesenteric artery. They'll need heparin and antibiotics. Most likely, they'll need emergency intervention not only to revascularize the bowel, but to revascularize the bowel and remove the gangrenous or perforation that's occurred. Usually it's best to do the revascularization before the rest of it, but a lot of times this can be done altogether. If the patient has had an embolic event, you can use devices such as aspiration thrombectomy, thrombolysis, angioplasty and stenting, as well as surgical embolectomy. So there's several things you can do there if the patient has acute clot to go in and remove that clot and hopefully restore blood flow to the gut. Your patients with non-occlusive mesenteric disease or NOMI, these are the patients that are the sickest. They usually have very low cardiac output. So the heart's not adequately supplying enough pump to supply the gut. They're not well enough for intervention. The best option here is try to help them with some inotropes, some drips. You can consider papravine as a vasodilator. These patients usually don't do very well. So here is another oddball diagnosis in case you ever see it. Median arcuate ligament. That's a ligament that we all have that can compress the celiac axis and cause functional stenosis. So you see here in the diagram, normally the ligament kind of passes over the aorta with no problems, but on occasion it can kind of pinch off that celiac and kind of pull tight there. Now, usually patients won't have ischemic bowel symptoms or chronic mesenteric symptoms because the other arteries will collateralize and they won't have symptoms related to that. But on occasionally they can have nerve irritation that will require release of this particular ligament. And on a rare occasion, you will see somebody that will kind of present like a typical mesenteric patient. And it's not able to be treated with stenting. So it is a surgical procedure. In conclusion, TIAs and stroke patients should always undergo carotid evaluation. Not every patient with a TIA or stroke will have carotid disease, but you certainly want to look for it. Get your testing and evaluate what treatment option would be best for your patient based on the providers you have available to you. Patients with peripheral artery disease tend to be vascular paths and they can have lots of other things. So think about renal arteries, think about mesenterics. If the patient comes to you with acute symptoms, you want to react early in order to preserve quality of life. Here are some references. And if you have any questions, please contact us at academy at medaxiom.com. Thank you for your attention.

peripheral vascular disease

PVD

carotid disease

subclavian disease

mesenteric disease

renal disease

strokes

risk factor modification