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Pranav M. Patel, MD, FACC, FAHA, FSCAIChief & Clinical Professor of Medicine
Director, Cardiac Catheterization LabUniversity of California, Irvine
Division of Cardiology
Peripheral Artery Disease:
Diagnosis and Management
Introduction
PVD/PAD effects 27 million people over 55 yrs in North America and Europe.
PAD often occurs in concert with CAD
CAD is leading cause of death in patients with PAD (75% of deaths)
Patients with PAD are at increased risk of atheroembolic events and 6 times more likely to die than patients without PAD
Cardiologists and PAD
Rationale
Coexistence of CAD & PAD
Common risk factors & modification
Expertise in clinical evaluation of the patient
Expertise in risk factor adjustment
Interest in longitudinal follow-up and global
approach to patient’s disease
Ness J, Aronow WS. J Am Geriatric Soc. 1999;47:1255-1256.
Overlap of
Atherosclerotic Disease
Patients with one manifestation often have
coexistent disease in other vascular beds
CoronaryArtery
Disease
CerebrovascularDisease
Peripheral Arterial Disease6%
16%40%
11% 3%
15%
9%
38% overlap
of 2 vascular beds
N= 1802 patients
Mean age = 80 yrs (60-102)
0% 5% 10% 15% 20% 25% 30% 35%
29%
11.7%
19.8%
19.1%
14.5%
4.3%
Prevalence of PAD
PARTNERS5
Aged >70 years, or 50–69 years with a history diabetes or smoking
San Diego2
Mean age 66 years
Diehm4
Aged 65 years
Rotterdam3
Aged >55 years
NHANES1
Aged 70 years
NHANES1
Aged >40 years
NHANES=National Health and Nutrition Examination Study;
PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program].
1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743.
2. Criqui MH, et al. Circulation. 1985;71:510-515.
3. Diehm C, et al. Atherosclerosis. 2004;172:95-105.
4. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.
5. Hirsch AT, et al. JAMA. 2001;286:1317-1324.
In a primary care
population defined by age
and common risk factors,
the prevalence of PAD
was approximately one in
three patients
29% of Patients in a Target Population Were Diagnosed With
PAD Using An Office-Based ABI
Patients diagnosed with PAD
PAD only
PAD and CVD
PARTNERS: Prevalence of PAD
and Other CVD in Primary Care Practices
29%
44%
56%
ABI=ankle-brachial index; CVD=cardiovascular disease.
Hirsch, AT et al. JAMA. 2001;286:1317-24.
1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.
2. Criqui MH, et al. Circulation. 1985;71:510-515.
Rotterdam Study (ABI <0.9)1 San Diego Study (PAD by noninvasive tests)2
0
10
20
30
40
50
60
Pati
en
ts W
ith
PA
D (
%)
55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age (years)
Prevalence of PAD Increases With Age
ABI=ankle-brachial index
Gender Differences in the
Prevalence of PAD
Adapted from Diehm C. Atherosclerosis. 2004;172:95-105 with permission from Elsevier.
Pre
va
len
ce
(%
)
Women
Men
6880 Consecutive Patients (61% Female) in 344 Primary Care Offices
<700
2
4
6
8
10
12
14
16
70–74 75–79 80–84 >85
Age (years)
18
Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
Relative Risk
Smoking
Diabetes
Hypertension
Hypercholesterolemia
Hyperhomocysteinemia
C-Reactive Protein
Reduced Increased
Risk Factors for PAD
1 2 3 4 5 60
Physical Exam Findings of Lower
Extremity PAD
Limb examination (and comparison with the opposite limb) includes:
Absent or diminished femoral or pedal pulses (especially after exercisingthe limb)
Arterial bruits
Hair loss
Poor nail growth (brittle nails)
Dry, scaly, atrophic skin
Dependent rubor
Pallor with leg elevation after 1 minute at 60 degrees (normal color should return in 10 to 15 seconds; longer than 40 seconds indicates severe ischemia)
Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene
Lesho EP, et al. Am Fam Physician. 2004;69:525-533.
The Physical Exam Should Be
Performed With Patient’s Pants/Shoes Off
Elevation Pallor/Dependent Rubor
1/14/2009 Template copyright 2005 www.brainybetty.com 1
Gangrene
http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_diagnosis.html
ABI Procedure
Using the ABI
ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.
Right ABI
80/160=0.50
Brachial SBP160 mm Hg
PT SBP 120 mm Hg
DP SBP 80 mm Hg
Brachial SBP150 mm Hg
PT SBP 40 mm Hg
DP SBP 80 mm Hg
Left ABI
120/160=0.75
Highest
brachial SBP
Highest of PT
or DP SBP
ABI
(Normal >0.90)
Interpreting the Ankle-Brachial Index
Adapted from Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Figure 6.
ABI Interpretation
1.00–1.29 Normal
0.91–0.99 Borderline
0.41–0.90 Mild-to-moderate disease
≤0.40 Severe disease
≥1.30 Noncompressible
Normal values: Ankle pressure > Brachial; ABI after Exercise: Fall < 20%; Proximal thigh pressure 30 mmHg higher
than brachial; Segmental Pressure < 20mm Hg drop between levels
Cardiovascular Risk Increases With
Decreases in Ankle-Brachial Index
>1.1 1.1–1.01 1.0–0.91 0.9–0.71 <0.7
ABI
CH
D E
ven
t O
utc
om
es
pe
r Ye
ar
(%)
0
1
2
3
4
5-year risk:
10%
5-year risk:
19%
Framingham “High Risk” = 20% at 10 yearsEvery patient with PAD is at “very high risk”
PAD
*Fatal or nonfatal MI. ABI=ankle-brachial index; CHD=chronic heart failure
2%
3.8%
1.4%
Leng GC, et al. Brit Med J. 1996;313:1440-44.
Exercise ABI Testing
Confirms the PAD diagnosis
Assesses the functional severity of claudication
May “unmask” PAD when resting the ABI is normal
Aids differentiation of intermittent claudication vs. pseudoclaudication diagnoses
Normal values: Ankle pressure > Brachial; ABI after Exercise: Fall < 20%; Proximal thigh pressure 30 mmHg higher
than brachial; Segmental Pressure < 20mm Hg drop between levels
Segmental Pressures (mm Hg)
150
110
108
62
0.54
150
146
100
84
0.44ABI
150 150Brachial
Decrease in pressure
between 2 levels > 30mm
Hg = stenosis proximal to
cuff
Greater than 20-30mm Hg
= significant disease
Pulse Volume Recordings
Normal waveform is rapid systolic upstroke and rapid downstroke with prominent dicrotic notch. With
increasing PAD severity the waveform is attenuate and widened with ultimate flat or non-pulsatile waveform
Arterial Duplex Ultrasound Testing
• Diagnose anatomic location and
degree of stenosis of peripheral
arterial disease.
• Duplex ultrasound of the
extremities can be used to select
candidates for:
(a) endovascular intervention
(b) surgical bypass, and
(c) to select the sites of surgical
anastomosis.
Magnetic Resonance Angiography (MRA)
MRA has virtually replaced contrast arteriography for PAD diagnosis
No ionizing radiation
Non-iodine–based intravenous contrast medium
~10% of patients cannot utilize MRA because of:
Claustrophobia
Pacemaker/implantable cardioverter-defibrillator
Obesity
• Gadolinium use in individuals with an eGFR <60 mL/min has been associated with nephrogenic systemic fibrosis (NSF)/nephrogenic fibrosing dermopathy
MRA in PAD
Computed Tomographic Angiography (CTA)
Requires
iodinated
contrast
Requires
ionizing
radiation
Produces an
excellent
arterial
picture
Right
Fem-Pop
BPG
CTA DSA(Pre-PTA)
Left
SFA
Stenosis
Two Major Goals in Treating Patients With PAD
Improved ability to walk
Increase in peak walking
distance
Improvement in quality-of-
life
Prevention of progression to
CLI and amputation
• Decrease in morbidity from
non-fatal MI and stroke
• Decrease in cardiovascular
mortality from fatal MI and
stroke
Limb outcomes
Cardiovascular
morbidity and mortality
outcomes
Benefit on PAD Cohort
Intervention Treadmill/QoL Limitations Indicated
Exercise 100% / Improved Availability 50%-85%
Motivation
Cilostazol 50% / Improved CHF 50%-85%
Medication
Angioplasty Improvement Proximal 10%-15%
arteries best
Surgery 150% / Improved Graft failure < 5%
Morbidity, mortality
Treatment of Claudication: Therapeutic Choice & Evidence
Effects of Exercise Training
on Claudication
Gardner AW, Poehlman ET. JAMA. 1995;274:975-980.
Exercise Training
Control
200
0
20
40
60
80
100
120
140
160
180
Onset of Claudication Pain
Maximal Claudication Pain
Ch
an
ge
in
Tre
ad
mil
l W
alk
ing
Dis
tan
ce
(%
)
Meta-analysis of 21 Studies
*
*
* P < 0.05
0
10
20
30
40
50
0 4 8 12 16 20 24
Treatment (weeks)
Pe
rce
nta
ge
Ch
an
ge
Fro
m
Ba
se
lin
e M
WD
(m
ea
n)
Cilostazol vs. Pentoxifylline: Relative Efficacy to Improve Walking Distance in Claudication
Cilostazol 100 mg 2 times/day (n=227)
Pentoxifylline 400 mg 3 times/day (n=232)
Placebo (n=239)
MWD=maximal walking distance.
*P<0.001 vs pentoxifylline.
Reprinted from Dawson DL, et al. Am J Med. 2000;109:523-530 with permission from Elsevier.
*
Effect of Cilostazol on Quality of Life
0
5
10
15
20
25
30
Wk 4 Wk 8 Wk 16 Wk 20 Wk 24
Ph
ysic
al S
um
ma
ry S
co
re
Placebo
Cilostazol 100 mg bid
Medical Outcome Scale SF-36
*
***
*
Tools of the trade for Infrainguinal
Endovascular Intervention
Hydrophilic & “coronary” guidewires
Nitinol S-E Stents (flexible, strong)
Atherectomy (remove plaque)
Thrombolytic Therapy
Laser
Cryoplasty
60 y.o woman has chest pain, HTNsive
crisis. Also complains of LE claudication
Abnormal adenosine
myocardial perfusion scan
Coronary Angiogram:
sequential LCX stenosis and
occluded mid LAD that fills via
collateral vessels
Patient refusing CABG
60 y.o woman with CAD, HTN and dyslipidemia presents with HTNsive crisis,
ACS, claudication (LE) and renal insufficiency. Cr ~ 1.5 2.5 7.6.
Angiogram of innominate and left subclavian artery
Pressure difference of 60mmHg between aorta & right brachial artery
Pressure difference of 40 mmHg between aorta and left brachial artery
Angiogram of innominate and left subclavian artery
Pressure difference of 60mmHg between aorta & right brachial artery
Pressure difference of 40 mmHg between aorta and left brachial artery
Final angiogram of left renal artery
Final angiogram of right renal arteryCreatinine back to baseline at 6 month follow up
SFA Intervention
Mid SFA
lesionAfter
angioplasty
Pre Post
Distal aorta
Left Common
Iliac Artery
Left Internal
iliac artery
Left ext. iliac art.
66 y.o man with CAD, DM, PAD and severe claudication. Three
years after intervention-no further claudication
Tibio-Peroneal Trunk Atherectomy
56 y.o male patient with PAD, CAD and tobacco use. Presents
with recurrent disabling RLE claudication.
Noted to have hemodynamically significant in-stent
restenoses within the previously-stented Right SFA
Proximal
SFA
Mid SFA
Distal SFA
Popliteal artery
Popliteal artery
Distal SFA
Proximal
SFA
Mid SFA
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