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