Volume 100, Issue s10

Education and instruction in the care of the patient with peripheral vascular diseases is, at best, fragmented during the first years of medical training. Attention to the issues of peripheral arterial, venous, and lymphatic disorders deserves a more formal approach with respect to physician education, patient evaluation and treatment, knowledge and application of various diagnostic modalities, and involvement of our physician colleagues in complementary disciplines. The vascular medicine internist is an invaluable resource in these areas. The aging of our general population will lead to an increase in manifest peripheral vascular disease within our patient population. Having received additional comprehensive training in the management of the complex patient with peripheral vascular disease, the vascular medicine internist may serve as a complete resource for their care.

Hypertension remains the most common reason for patients to visit physicians in the United States. Although awareness of hypertension among patients continues to increase, adequate control of hypertension remains poor. In addition, as the population of patients with hypertension ages, atherosclerosis becomes increasingly prevalent. Atherosclerotic renal artery stenosis is the most common secondary cause of hypertension and can cause hypertension to be difficult to control. Atherosclerotic renal artery stenosis may also result in chronic renal insufficiency. The physician must be aware of the clinical scenarios in which renal artery stenosis may occur, methods of diagnosis, and indications for intervention.

Intermittent claudication is a symptom complex associated with atherosclerosis of the aorta and lower extremities. It is a clinical marker of systemic atherosclerosis, and therefore, management cannot be considered isolated from treatment of underlying risk factors of atherosclerosis. The focus of the management is twofold. The first is to reduce morbidity and mortality from cardiovascular events, including myocardial infarction and stroke. The second focus is to improve the functional status of patients who have impairment of daily activities secondary to symptoms of claudication through pharmacologic and rehabilitative means, that is, exercise. Exercise is the cornerstone of therapy. A conservative approach is favored in patients who have mild and moderate symptoms of claudication. Intervention with percutaneous techniques or surgery is generally reserved for patients who have severe impairment of lifestyle or threatened tissue.

Atherosclerosis is a systemic disease affecting quality and length of life. Endovascular revascularization can be used to improve quality of life. The benefit is greatest in patients with subclavian, renal, or iliac artery symptomatic disease. The advent of stents improves the initial technical success rates of angioplasty to more than 90% in most locations. The development of stent: grafts has altered the treatment of abdominal aortic aneurysms and should be strongly considered as an alternative to open surgery.