ATHEROSCLEROTIC PERIPHERAL ARTERY DISEASE
Dr Jain T Kallarakkal MD, FRCP, DMInterventional Cardiologist
St Mary’s Hospital, Thodupuzha
Vascular diseases caused primarily by atherosclerosis and thromboembolic pathophysiologic processes of the aorta, its visceral arterial branches and the arteries of the lower extremity.
PAD
PAD is the term used to denote stenotic, occlusive and aneurysmal diseases of the aorta and its branches, exclusive of the coronaries.
PAD
Age < 50 years, with diabetes and one other risk factor (smoking, dyslipidemia, hypertension or hyperhomocysteinemia)
Age 50 to 69 with history of smoking and
diabetes
Age 70 or older
Who are at Risk?
Leg symptoms on exertion (suggestive of claudication) or ishemic rest pain
Abnormal lower extremity pulse examination
Known atherosclerotic coronary, carotid or renal artery disease
Who are at Risk?
40 – 59 Years : 3%
60 – 69 Years : 8%
> 70 Years : 19%
PREVALENCE
Exertionally associated calf pain
Pain relieved within 10 min of rest
Pain that does not come at rest
Intermittent Claudication
Leg or hip pain during walking (intermittent claudication) which stops when you rest.
Numbness, tingling or weakness in the legs.
Burning or aching pain in feet or toes when resting.
Symptoms
Sore on leg or foot that won’t heal
Cold legs or feet.
Color change in skin of legs or feet
Loss of hair on legs.
Stage I: Asymptomatic, incomplete blood vessel obstruction
Stage II: Mild claudication pain in limbIIA: Claudication at a distance of greater
than 200 metresIIB: Claudication distance of less than 200
metres Stage III: Rest pain, mostly in the feet Stage IV: Necrosis and/or gangrene of the limb
FONTAINE CLASSIFICATION
GRADE CATEGORY SYMPTOMS0 0 AsymptomatiCI 1 Mild claudication
2 Moderate claudication
3 Severe claudication II 4 Rest pain
5 Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
III 6 Major tissue loss; Severe ischemic ulcers or frank gangrene
RUTHERFORD CLASSIFICATION
Auscultation of the abdomen and flank for bruits
Palpation of the abdomen and notation of the presence of the aortic pulsation and its maximal diameter.
Physical Examination
Palpation of pulses at the femoral, popliteal, dorsalis pedis, and posterior tibial sites.
Ausculation of both femoral arteries for the presence of bruits
Pulse intensity should be assessed and should be recorded numerically as follows:
0, absent
1, diminished
2, normal
3, bounding
The feet should be inspected, the color, temperature, and integrity of the skin and intertriginous areas evaluated, and presence of ulcerations recorded.
Additional findings suggesting severe PAD◦ distal hair loss◦ trophic skin changes◦ hypertrophic nails
Ankle Brachial Index (ABI)
Treadmill Test
Ultrasound
Computed tomography angiography (CTA)
Magnetic resonance angiography (MRA)
Digital subtraction angiography (DSA)
DIAGNOSTIC TOOLS
Ankle- brachial index
Quick and cost-effective
Normal ABI is >1.0
ABI <0.90 is used to define LEAD
Sensitivity and specificity are 79% and 96%
Ankle- brachial index
A 10–12 cm sphygmomanometer cuff placed just above the ankle and a handheld Doppler instrument (5–10 MHz) to measure the pressure of the posterior and anterior tibial arteries of each foot are required. ABI is the highest ankle systolic pressure divided by the highest brachial systolic pressure
Useful to assess lower extremity PAD anatomy, severity and progression
Can provide localizing information
Limited accuracy in tortuous, overlapping, or densely calcified arterial segments and insensitive for iliac arteries
Doppler
Differentiate claudication from pseudoclaudication
Useful to diagnose when resting ABI values are normal
Useful to measure the objective functional response to claudication therapeutic interventions
Treadmill Test
Useful to select patients who are candidates for endovascular or surgical revascularization
Associated soft tissue diagnostic information (e.g., aneurysms, popliteal entrapment and cystic adventitial disease)
Patients with contraindications to MRA (e.g., pacemakers or defibrillators)
Metal clips, stents, and metallic prostheses do not cause significant CTA artifacts
Computed tomography angiography (CTA)
Useful to select patients who are candidates for endovascular or surgical revascularization
Tends to overestimate the degree of stenosis May be inaccurate in arteries treated with metal
stents Cannot be used in patients with contraindications
to the magnetic resonance technique (e.g., pacemakers, defibrillators, intracranial metallic stents, clips, coils, and other devices)
Magnetic resonance angiography (MRA)
lifestyle modification
smoking cessation
daily exercise (30 min/day)
normal body mass index (≤25 kg/m2)
Treatment
Pharmacological treatment for blood pressure control lipid-lowering treatment to achieve LDL
cholesterol100 mg/dL with an option of 70 mg/dL if feasible.
In diabetic patients, glucose control should be obtained, with the target glycated haemoglobin (HbA1c) 7%
Phosphodiesterase inhibitor (PDE-3)
Promotes vasodilatation and inhibit platelet aggregation
More effective than pentoxifylline
Caution in patients with CHF
Cilostazol
Indicated in patients with lifestyle-limiting claudication and an inadequate response to conservative therapy
Obstructive distal aortic and iliac artery lesions are treated with endovascular techniques and an endovascular-first strategy can be recommended for all (TASC) A–C lesions
Low morbidity and mortality and a >90% technical success is seen
Endovascular therapy
Type A:1. Single stenosis <3 cm of the CIA or EIA (unilateral/bilateral)
Type B:2. Single stenosis 3 to 10 cm in length, not extending into the CFA
3. Total of 2 stenoses <5 cm long in the CIA and/or EIA and not extending into the CFA
4. Unilateral CIA occlusion
Trans Atlantic Inter Society Consensus (Ileac lesions)
Type C: 5. Bilateral 5 to 10 cm long stenosis of the CIA and/or EIA, not extending into the CFA
6. Unilateral EIA occlusion not extending into the CFA
7. Unilateral EIA stenosis extending into the CFA
8. Bilateral CIA occlusion
Type D: 9. Diffuse, multiple unilateral stenoses involving the CIA, EIA, and CFA (usually >10 cm long)
10. Unilateral occlusion involving both the CIA and EIA
11. Bilateral EIA occlusions12. Diffuse disease involving the aorta
and both iliac arteries13. Iliac stenoses in a patient with an
abdominal aortic aneurysm or other lesion requiring aortic or iliac surgery
Endovascular therapy is the preferred choice in patients with long and complex femoropopliteal lesions
Self expandable nitinol stents may be recommended as the first-line treatment
Femoropopliteal Disease
Type A: 1. Single stenosis <3 cm of the superficialfemoral artery or popliteal artery
Type B:2. Single stenosis 3 to 10 cm in length, not involving the distal popliteal artery
3. Heavily calcified stenoses up to 3 cm in length
4. Multiple lesions, each <3 cm (stenoses or occlusions)
5. Single or multiple lesions in the absence of continuous tibial runoff to improve inflow for distal surgical bypass
Trans Atlantic Inter Society Consensus (Femoropopliteal lesions)
Type C: 6. Single stenosis or occlusion longer than 5 cm
7. Multiple stenoses or occlusions, each 3 to 5 cm in length, with or without heavy calcification
Type D: 8. Complete common femoral artery or superficial femoral artery occlusions or complete popliteal and proximal trifurcation occlusions
Limb salvage is the primary indication for endovascular treatment of infrapopliteal lesions
Angioplasty of these arteries is usually not indicated in patients with intermittent claudication
Infrapopliteal disease
Diffuse aortoiliac disease is usually managed with aorto-biiliac or -bifemoral bypass
The surgical strategy depends on the lesion location and technical possibilities
Compared with the aortofemoral bypass, extra-anatomical bypasses present poorer patency rates and higher risk of complications.
Surgery
Therapeutic angiogenesis based on the use of angiogenic factors or stem cells to promote revascularization and remodelling of collaterals are being investigated, but too early to give recommendations
Future
Atherosclerosis is the most common cause (90%)
Typically ostial in location
FMD is the second common cause
Typically produce a beaded appearance
Renal Artery Disease
Hypertension before age 35 and after 55
Hypertension that abruptly becomes more difficult to control
Resistant hypertension
Patients with marked elevation in both systolic and diastolic pressures
Discrepancy in renal size > 1.5 cm
Patients who develop azotemia upon initiation of ACEI or ARB
Who all should be considered?
Duplex ultrasonography
◦Peak systolic velocity > 180 cm / sec 95% sensitivity and 90% specificity
◦Ratio of peak systolic velocity in stenosed renal artery to the peak systolic velocity in the aorta > 3.5, predicted 60% RAS with 92% sensitivity
Diagnostic tests
Metal may cause artifacts
Not a useful test for patients who have undergone renal artery stenting
Claustrophobia, Implanted metal devices
MRA
Gold standard
Catheter commonly used: Internal mammary, JR.
Pressure gradient PG > 20 mm hg or a MG > 0 mm hg is significant
Invasive angiography
Percutaneous revascularisation is reasonable for patients with hemodynamically significant RAS and accelerated hypertension, resistant hypertension, malignant hypertension, hypertension with an unexplained unilateral small kidney or hypertension with intolerance to medications.
Revascularisation
It is also reasonable for patients with RAS and progressive CKD with bilateral RAS or RAS of a solitary functioning kidney.
Reasonable for patients with significant RAS and flash pulmonary edema.
Reasonable for patients with significant RAS and ACS
Benefits are less well established when considering endovascular therapy for asymptomatic disease or for preservation of renal function
Surgical revascularisation is considered in those patients whose anatomy makes endovascular therapy less attractive and/or who require concomitant operative treatment of aortic disease.
Krum et al
Renal sympathetic denervation
Blood pressure reduction was significant
Large trials are required
Renal Artery Denervation
PAD is highly prevalent, particularly with advancing age
Despite the high prevalence it is still underdiagnosed and undertreated.
Diagnosis of PAD confers a 25-30% 5 year risk of cardiovascular death and additional 20% risk of non fatal major adverse cardiovascular events
Conclusions
Main focus of therapy for PAD is secondary prevention of stroke and MI, including:
◦ Smoking cessation
◦ Reduce LDL < 100
◦ HbA1c < 7%
◦ BP < 140/90 and < 130/80 with DM or RI
◦ Antiplatelet therapy
◦ Preventive foot care
Conclusions
For severe limb ischemia endovascular options may rival gold standard surgical approach
RAS is a common finding in patients with atherosclerosis
Atherosclerotic disease affects the ostium and proximal part of the renal artery, from direct extension of aortic disease
Conclusions
The diagnosis of RAS should be considered in patients with early or late onset hypertension or in patients with previously well controlled hypertension that was escaped
Invasive angiography remains gold standard for diagnosis
Conclusions
Revascularisation is reasonable for patients with significant RAS and recurrent HF, pulmonary edema and unstable angina.
The strategy is also reasonable for patients with uncontrolled hypertension and deteriorating renal function in the setting of significant RAS.
Conclusions
Thank You
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