PERIPHERAL ARTERIAL DISEASE (PAD) Dr. Riko Prima Putra, Sp.JP.

PERIPHERAL PERIPHERAL ARTERIAL DISEASE ARTERIAL DISEASE

(PAD)(PAD)

Dr. Riko Prima Putra, Sp.JP Dr. Riko Prima Putra, Sp.JP

Peripheral Arterial Disease Peripheral Arterial Disease

= Peripheral Vascular Disease= Peripheral Vascular Disease

Vascular disease caused primarily by Vascular disease caused primarily by atherosclerosis & thromboembolic atherosclerosis & thromboembolic pathophysiological processes that alter the pathophysiological processes that alter the normal structure and function of the aorta, normal structure and function of the aorta, its visceral arterial branches, and the its visceral arterial branches, and the arteries of the lower extremitiesarteries of the lower extremities

Peripheral Arterial Disease Peripheral Arterial Disease

Stenotic Stenotic

Occlusive Occlusive

AneurysmaAneurysma

Prevalence of PAD Prevalence of PAD

Extremely commonExtremely common

Increasingly common with ageIncreasingly common with age

20% of people over age 70 have PAD20% of people over age 70 have PAD

5% of people over age 40 have PAD5% of people over age 40 have PAD

Prevalence of PAD: 11 Million, compared Prevalence of PAD: 11 Million, compared to stroke: 4.4 Million, and MI: 7 Million to stroke: 4.4 Million, and MI: 7 Million

PAD and mortality PAD and mortality

Morbidity & mortality Morbidity & mortality

Only 5% of PAD patients will need Only 5% of PAD patients will need treatment for limb related sequelae.treatment for limb related sequelae.

23% will die within 5 years from cardiac, 23% will die within 5 years from cardiac, cerebral, or other vascular events cerebral, or other vascular events (Aronow, 1994).(Aronow, 1994).

Risk factorsRisk factors

Older age (> 40 years)Older age (> 40 years)

Male genderMale gender

SmokingSmoking

Diabetes mellitusDiabetes mellitus

HyperlipidemiaHyperlipidemia

HypertensionHypertension

HyperhomocysteinemiaHyperhomocysteinemiaWhen risk factors coexist, the risk increases several-foldWhen risk factors coexist, the risk increases several-fold

Clinical presentation Clinical presentation

AsymptomaticAsymptomatic

Claudication Claudication

Critical limb ischemiaCritical limb ischemia

Acute limb ischemiaAcute limb ischemia

Prior limb arterial revascularizationPrior limb arterial revascularization

21/04/2321/04/23

PRIMARY SITES OF PRIMARY SITES OF INVOLVEMENTINVOLVEMENT

Femoral & Popliteal arteries: Femoral & Popliteal arteries: 80-90%80-90%

Tibial & Peroneal arteries: Tibial & Peroneal arteries: 40-50%40-50%

Aorta & Iliac arteries: 30%Aorta & Iliac arteries: 30%

Harrison’s Principles of Int Med

Differential diagnosisDifferential diagnosisCALFCALF

Venous occlusionVenous occlusion

– Tight bursting pain / dull ache Tight bursting pain / dull ache that worsens on standing and that worsens on standing and resolves with leg elevationresolves with leg elevation

– Positional pain reliefPositional pain relief

Chronic compartment Chronic compartment syndromesyndrome

– Tight bursting painTight bursting pain


Nerve root compressionNerve root compression


Baker’s cystBaker’s cyst


HIP/THIGH/BUTTOCKHIP/THIGH/BUTTOCKArthritisArthritis

– Persistent pain, brought on by Persistent pain, brought on by variable amounts of exercisevariable amounts of exercise

– Associated symptoms in Associated symptoms in other jointsother joints

Spinal cord compressionSpinal cord compression

– History of back painHistory of back pain

– Symptoms while standingSymptoms while standing


FOOTFOOTArthritisArthritis

Buerger diseaseBuerger disease (thromboangitis obliterans)(thromboangitis obliterans)

Am J Cardiol 2001; 87 (suppl): 3D-13D

DiagnosisDiagnosis

SymptomsSymptoms

Diagnostic studiesDiagnostic studies

Laboratory Laboratory

SymptomsSymptoms

Leg pain, particularly when walking or Leg pain, particularly when walking or exercising, which disappears after a few exercising, which disappears after a few minutes of restminutes of rest

Numbness, tingling, or coldness in the Numbness, tingling, or coldness in the lower leg or feetlower leg or feet

Sores or infection on feet or legs that heal Sores or infection on feet or legs that heal slowlyslowly

Fontaine ,Ⅰ ⅡFontaine ,Ⅰ Ⅱ ⅢⅢ ,Ⅳ,Ⅳ

Fontaine Classification

Claudication Critical limb ischemia

Pentecost MJ, Circulation 89:51, 1994

StageStage Clinical

0 Asymptomatic

1 Mild claudication

2 Moderate claudication

4 Ischemic rest pain

6 Major tissue loss

3 Severe claudication

5 Minor tissue loss

Rutherford Classification

Rutherford RB, et al, J Vasc Surg 1986;4:80-94Rutherford RB, et al, J Vasc Surg 1986;4:80-94

Claudication

Critical limb ischemia

Rutherford 4

Ischemic rest pain

Rutherford 4

Ischemic rest pain

Rutherford 5

Minor tissue loss

Rutherford 5

Minor tissue loss

Rutherford 6

Major tissue loss

Rutherford 6

Major tissue loss

Critical Limb IschemiaCritical Limb Ischemia

Resting ischemic painResting ischemic pain

PAD with skin breakdownPAD with skin breakdown– Nonhealing ulcersNonhealing ulcers– Gangrene Gangrene

Spectrum of Spectrum of Peripheral Arterial DiseasePeripheral Arterial Disease

Worsening flow limitation

Claudication Limb-Threatening Ischemia

"Normal”Fatigue,

Heaviness Mild Moderate- Severe Rest pain

Poorwoundhealing

Impendingor overt

gangrene

Vascular Vascular diagnostic techniquediagnostic technique

Ankle-brachial index (ABI)Ankle-brachial index (ABI)

Toe-brachial indexToe-brachial index

Segmental pressure measurementSegmental pressure measurement

Pulse volume recordingPulse volume recording


Continuous-wave doppler ultrasoundContinuous-wave doppler ultrasound

Duplex ultasoundDuplex ultasound

Treadmill exercise testing with & Treadmill exercise testing with & without ABI assessments, 6-minute without ABI assessments, 6-minute walk testwalk test

Vascular Echo and ABI for PADVascular Echo and ABI for PAD

Ankle-brachial index (ABI)Ankle-brachial index (ABI)

Ankle-Brachial Index Values Ankle-Brachial Index Values and Clinical Classificationand Clinical Classification

Clinical PresentationClinical Presentation Ankle-Brachial IndexAnkle-Brachial Index

NormalNormal > 0.90> 0.90

ClaudicationClaudication 0.50-0.900.50-0.90

Rest painRest pain 0.21-0.490.21-0.49

Tissue lossTissue loss < 0.20< 0.20

Am J Cardiol 2001; 87 (suppl): 3D-13DNEJM 2001; 344: 1608-1621

Values >1.25 falsely elevated; commonly seen in diabetics

Duplex in SFA Disease

Triphasic Biphasic Systolic flow Systolic + Diaslic flow

Doppler at Popliteal Artery

CFA

POP

AT

Multi-level of Stenosis Findings by Doppler

POP AT

PT

PT

Echo Assessment of Infrapopliteal artery

Po

AT

PTPePe

TP

TP

How many tests do we need to evaluate PVD ?

MRA

ABI Segmental pressure

Toe pressure

DSA

Pulse volume

CTA

Duplex

Duplex

ABI

Treadmill ABI

TCD

tPO2


Magneting resonance Magneting resonance angiography (MRA)angiography (MRA)

Computed tomographic Computed tomographic angiography (CTA)angiography (CTA)

Contrast angiographyContrast angiography

The history and physical examination (pulse The history and physical examination (pulse evaluation and careful examination of the evaluation and careful examination of the leg) are usually sufficient to establish the leg) are usually sufficient to establish the diagnosisdiagnosis

LaboratoryLaboratory

HemoglobinHemoglobin

Serum creatinineSerum creatinine

Lipid profileLipid profile

Hypercoagulability screenHypercoagulability screen

Homocysteine levelHomocysteine level

Lp(a) lipoproteinLp(a) lipoprotein

Goals of treatmentGoals of treatment

To relieve exertional symptoms and To relieve exertional symptoms and improve walking capacityimprove walking capacity

To improve quality of lifeTo improve quality of life

To reduce total mortality as well as To reduce total mortality as well as cardiac and cerebrovascular cardiac and cerebrovascular morbidity and mortalitymorbidity and mortality

ManagementManagement

Risk factor modificationRisk factor modification

Exercise therapyExercise therapy

Antiplatelet therapyAntiplatelet therapy

Medical therapy targeted at Medical therapy targeted at symptomssymptoms

Revascularisation proceduresRevascularisation procedures

Cardiovascular risk reductionCardiovascular risk reduction

Lipid lowering drugsLipid lowering drugs

Antihypertensive drugsAntihypertensive drugs

Diabetes therapiesDiabetes therapies

Smoking cessationSmoking cessation

Homocysteine lowering drugsHomocysteine lowering drugs

Antiplatelet and antihtrombotic drugsAntiplatelet and antihtrombotic drugs

Cardiovascular risk reductionCardiovascular risk reduction

Diabetes control (FBG 80-120 mg/dl, Diabetes control (FBG 80-120 mg/dl, PPG PPG << 180 mg/dl, HbA 180 mg/dl, HbA1c1c < 7%) < 7%)

Dyslipidemia management (LDL < 100 Dyslipidemia management (LDL < 100 mg/dl, TG < 150 mg/dl): Statins (RR mg/dl, TG < 150 mg/dl): Statins (RR 38%; 4S)38%; 4S)

Hypertension control (BP < 130/85 Hypertension control (BP < 130/85 mmHg)mmHg)

ClaudicationClaudication

Exercise and lower extremity PAD Exercise and lower extremity PAD rehabilitation rehabilitation Exercise program :Exercise program :

Improves walking abilityImproves walking abilityRequires motivation & personalised Requires motivation & personalised supervisionsupervisionBenefits lost if not maintained on regular Benefits lost if not maintained on regular basisbasisOverall effectiveness limitedOverall effectiveness limited


Medical and pharmacological Medical and pharmacological treatmenttreatmentCilostazolCilostazolPentoxifyllinePentoxifyllineOther proposed medical therapies (?)Other proposed medical therapies (?)

L-arginineL-argininePropionil-L-carnitinePropionil-L-carnitineGinkgo bilobaGinkgo biloba


Endovascular treatmentEndovascular treatment

SurgerySurgery


Incapacitating claudicationIncapacitating claudication

Limb-threatening ischemia (pain at rest, Limb-threatening ischemia (pain at rest, non-healing ulcers and/or infections or non-healing ulcers and/or infections or gangrene)gangrene)

If symptoms persist despite medical If symptoms persist despite medical therapytherapy

AHA guidelines 1996


Angioplasty (balloon angioplasty)Angioplasty (balloon angioplasty)

PTA (percutaneous transluminal angioplasty) PTA (percutaneous transluminal angioplasty)

Artery bypass graftArtery bypass graft

PTA & stentingPTA & stenting

Screening for PADScreening for PAD

Low-tech, low cost and few people involved

Angioplasty for PAD

Iliac Artery Intervention

TASC D lesions of the Pelvic Artery:Is there still a role for Aorta-Femoral

bypass ?

SFA Intervention

71 y/o Male

CAD, HTN, DM

Rutherford 5

Pre

2 weeks

2 mo

71 y/o Male

CAD, HTN, DM

Rutherford 5

Infrapopliteal Intervention for CLI

Pre

3mo

Thank you for your attention

PERIPHERAL ARTERIAL DISEASE (PAD) Dr. Riko Prima Putra, Sp.JP.

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