1. Carotid intervention as a preventive strategy should
be performed in patients with 50% or greater symptomatic
internal carotid artery stenosis, and those with 80% or
greater asymptomatic internal carotid artery stenosis. Carotid intervention
for asymptomatic stenosis between 60% and 79% remains
controversial, and is a function of an operator’s stroke
rate. The choice of intervention—carotid endarterectomy
vs. carotid stenting—remains controversial; currently,
carotid endarterectomy appears to be associated with lower stroke
rate, whereas carotid stenting is more suitable under certain anatomic
or physiologic conditions.
2. Abdominal aortic aneurysms should be repaired when the risk of
rupture, determined mainly by aneurysm size, exceeds the risk of
death due to perioperative complications or concurrent illness. Endovascular
repair is associated with less perioperative morbidity and mortality
compared to open reconstruction, and is preferred for high-risk patients
who meet specific anatomic criteria.
3. Symptomatic mesenteric ischemia should be treated to improve
quality of life and prevent bowel infarction. Operative treatment—bypass—is
superior to endovascular intervention, although changes in wire
and stent technology have improved the results of mesenteric stenting
in recent series.
4. Aortoiliac occlusive disease can be treated with either endovascular
means or open reconstruction, depending on patient risk stratification,
occlusion characteristics, and symptomatology.
5. Claudication is a marker of extensive atherosclerosis, and is
mainly managed with risk factor modification and pharmacotherapy.
Only 5% of claudicants will need intervention because of
disabling extremity pain. The five-year mortality of a patient with
claudication approaches 30%. Patients with rest pain or
tissue loss need expeditious evaluation and vascular reconstruction
to ameliorate the severe extremity pain and prevent limb loss.
6. For infrainguinal occlusive disease, open revascularization is
more durable than endovascular treatment. The latter, however, is
associated with significantly less morbidity, may represent the procedure
of choice in high-risk patients, and can provide adequate inflow
to treat limited areas of tissue loss.
Because the vascular system involves every organ system in our body,
the symptoms of vascular disease are as varied as those encountered
in any medical specialty. Lack of adequate blood supply to target
organs typically presents with pain; for example, calf pain with
lower extremity (LE) claudication, postprandial abdominal pain from
mesenteric ischemia, and arm pain with axillosubclavian arterial
occlusion. In contrast, stroke and transient ischemic attack (TIA)
are the presenting symptoms from middle cerebral embolization as
a consequence of a stenosed internal carotid artery (ICA). The pain
syndrome of arterial disease usually is divided clinically into
acute and chronic types, with all shades of severity between the
two extremes. Sudden onset of pain can indicate complete occlusion
of a critical vessel, leading to more severe pain and critical ischemia
in the target organ, resulting in lower limb gangrene or intestinal
infarction. Chronic pain results from a slower, more progressive
atherosclerotic occlusion, which can be totally or partially compensated
by developing collateral vessels. Acute on chronic is another pain
pattern in which a ...