The Detection and Management of Peripheral Arterial Disease
Family Medicine Spring ReviewMay 1, 2019
Mohammed M. Moursi, MDProfessor, Vascular Surgery
Division Chief, UAMS Vascular and Endovascular Surgery
Chief, Vascular Surgery, Little Rock VA
Nothing to Disclose
ObjectivesPeripheral Arterial Disease (PAD)•Understand the clinical characteristics of PAD•Understand the principles of management of PAD by severity
Definitions
• Peripheral arterial disease (PAD) –atherosclerotic disease of the lower limbs that limits blood flow
Arterial Anatomy
• Three layers to an artery• Innermost: Intima• Media• Adventitia
Atherosclerotic Artery
ObstructedLumenPlaque
NormalArtery
Beginningof Plaque
Formation
Progression Of Stenosis
Bernoulli’s (1700–1782) principle?
Poiseuille’s (1797–1869) law
Poiseuille’s (1797–1869) law• Turbulence eats up energy after a stenosis• Changes in the radius affect energy to the
4th power• When a stenosis is >50% you lose
pressure and flow
Spectrum of Arterial Ischemia
Claudication Rest Pain Tissue Loss
Critical Limb Ischemia
Claudication• Exertional aching pain, cramping, tightness,
fatigue• Occur in muscle groups, not joints (buttocks,
hips, legs, calves)• Are reproducible from one day to the next on
similar terrain• Mismatch between supply and demand in the
leg• Resolve completely with 2-5 min of rest
Rest Pain
• Occurs at night with foot elevation• Relieved by hanging foot over bed• Impending tissue loss• Intervention required
Tissue Necrosis
• Small areas of trauma lead to large areas of tissue loss
• Clipping toe nails in diabetic patients• Intervention required
Prevalence
Age (yr)Total Pop (millions)
PAD (millions)
IC (millions)
40-59 68.9 2.1 0.9
60-69 19.8 1.6 0.8
>70 24.8 4.7 2.5
113.5 8.4 4.2
Risk Factors for Developing PAD
-2 -1 0 1 2 3 4
Male sex (vs female)
Age (per 10 y)
Diabetes
Smoking
Hypertension
Hypercholesterolemia
Fibrinogen
Protective Harmful
Prevalence of PVD in Persons with Diabetes
• 2 – 4 times more common among persons with diabetes
Prevalence of PAD in Smokers
• Severity of PAD increases with number of cigarettes smoked
• Diagnosis is made a decade earlier• Intermittent claudication is 4 times more
common in smokers• Smoking is the most powerful modifiable
risk factor for PAD
Relative 5-Year Mortality Rates
818 23
3239
86
0
20
40
60
80
100
ProstateCancer*
Hodgkin'sDisease
BreastCancer*
PAD ColorectalCancer*
LungCancer*
Pat
ient
s(%
)
*†
8%
13% 33%
5% 14%
12%
15%
Coronary
Cerebral
PAD
Prevalence of Atherosclerotic Co-morbidities
Causes of Death in Pts with PAD
CAD
Non-Vascular
Cerebrovascular
Other vascular
12%
10%
60%18%
Population >55 y
Intermittent claudication
40%
PAD outcomes
Cardiovascularmorbidity/mortality
Worsening claudication
16%
Leg bypass surgery
7%
Major amputation
4%
Nonfatal events (MI/stroke)
20%
Mortality 30%
Critical leg ischemia 10%
Asymptomatic 50%
Stableclaudication
73%
(5-year outcomes)
Clinical Outcomes in Patients With PAD
Aortoiliac Disease
• Younger, female patients• Heavy smoking history• Claudication involves the hips, thighs and
buttocks• Impotence• Absent fem pulses, bruit
Occluded common iliac
Femoropopliteal Disease
• Older population• Diabetes, hypertension• Superficial fem artery disease• Calf claudication
Occluded SFA
Occluded SFA
Common Sites of ClaudicationObstruction in:
Aorta or Iliac artery
Superficial femoral
Popliteal
Ischemia/pain in:
Buttocks, hips
Calf
Ankle, foot
Diagnosis of PAD
• Vascular history• Physical examination• ABI• Noninvasive vascular lab• Arteriography
Questions for Patients
• Cramping or fatigue in leg muscles with walking
• Occurs only with walking• Resolve when stop walking• Pain at night• Nonhealing foot wounds
Claudication is Not:
• Cramping at night• Shooting pain down leg• Edema• Tingling• Numbness• Cold feet at night• Cramping pain unrelieved by rest• “weak pulses”
Differential Diagnosis
• Nervous system• Sciatica• Spinal stenosis, back trauma• Diabetic neuropathy
• Musculoskeletal• Arthritis• trauma
• Venous• Venous hypertension
Arterial Physical Exam for PAD
• Auscultate abdomen for bruits• Palpate for abdominal aortic aneurysm• Palpate femoral, popliteal, posterior
tibial and dorsalis pedis pulses• Inspect feet for ulcers or wounds
Terms and definitions
• Pulse• Signal• ABI
Vascular Lab
• ABI, toe pressures• Segmental pressures• Exercise ABI
Defining ABI
ABIAnkle systolic pressure
Brachial artery systolic pressure=
Interpreting the ABI
ABI Interpretation
0.90-1.30 Normal
0.70-0.89 Mild
0.40-0.69 Moderate
<0.40 Severe
>1.30 Noncompressible vesselsCalcified tibial vessels
as seen in diabetes
150
98
90
0.6
150
145
90
0.6
Treadmill Testing
• Objective and reproducible end points• Initial claudication distance (ICD or PFWD)• Absolute claudication distance (ACD or
MWD)
Arteriography
• Only when intervention is determined• Provides an anatomic roadmap not a
physiological assessment
Presentation
• 71 y/o male with hx HTN, s/p CABG presents with 3 block claudication on right, non disabling
• History positive for smoking• LDL 135, HDL 35, TG 240• No rest pain or tissue loss
Vascular lab
• ABI 0.69 on right, 1.0 on left• Duplex shows an isolated right superficial
femoral artery occlusion
Angiography
• Not needed – for talk purpose only
Recommendation• Smoking cessation• Exercise
• Structured, supervised • Diet modification/wt reduction• Lipid lowering agent• Blood pressure control• Blood sugar control• Pletal• Anti platelet agent• Reassurance
Do not recommend
• Anticoagulation• Invasive intervention
Invasive Options• Balloon angioplasty• Stent angioplasty
• Balloon expandable stents• Self expanding stents• Covered stents• Drug eluding stents
• Cryoballoon angioplasty• Laser angioplasty• Subintimal angioplasty• Remote atherectomy
Invasive Options
• Remote endarterectomy• Open endarterectomy• Fem pop bypass
• Greater saphenous vein (ipsilateral vs contralateral)• Lesser saphenous vein• Arm vein• Deep fem vein• Synthetic material
Claudication – summary
• Strong indicator of central cardiovascular atherosclerotic disease
• No clear evidence that early intervention improves outcome
• Endovascular therapy is complicated by a large failure rate and restenosis
• Stenting of sfa can lead to a worsening of the primary condition
P.S.
• 63 y/o male with non healing ulcer left foot
• Toe pressures on the left 15
Occluded SFA
Target vessel - post tib
Origin of graft
Distal anastomosis
P.S.
• Post operative toe pressures left 82• Healed toe ulcer
Aortofemoral Bypass Graft
Aortofemoral Bypass Graft
Aortic Endarterectomy
Endovascular therapy for PVD
R com iliacoccluded
Acute lower limb ischemia
• Presents with 5 “p”
• Pulseless• Pain• Pallor• Parasthesia• poikiothermia
Acute lower limb ischemia
• Embolus• Thrombosis of existing stenosis
Extra anatomical bypass grafts
Clinical Presentation
Claudication
Thank you
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