Palliative Care for Peripheral Arterial Disease

1
Palliative Care for Peripheral Arterial Disease

• Dr Marion Lieth
• November 2006

2
Palliative Care for PAD

• How do people cope with this chronic illness?
• What are the palliative care needs?
• Is there a sub-group that would particularly
  benefit from Palliative Care?
• When do or should we get involved?

3
What is known about Palliative Care for PAD?

• Various Palliative Medicine textbooks
• Pain, nothing else
• Medline search
• PVD palliative medicine 1 article
• PVD palliative 18
• PAD palliative - gene therapy the potential
  of vascular endothelial growth factor
• 1 qualitative study patients perspective after
  bypass surgery
• Feeling of powerlessness

4

• What now?

5
Needed Better Understanding of Disease

• Prevalence Co-morbidities
• Course of disease
• Medical treatment
• Prognosis
• Group discussion
• Palliative Care needs
• Time of involvement

6
Peripheral Arterial Disease

• Significant narrowing of arteries distal to arch
  of aorta
• Atherosclerosis most common cause
• athero greek, gruel or porridge
• sclerosis greek, scaring
• Inflammatory fibroproliferative response to
  injurious process within arterial wall leading to
  occlusion of lumen
• Lipids key-role in plaque formation

7
Atherosclerosis

• Damage to endothelium
• Mononuclear cells in subendothelial space take up
  lipids
• Cell death of foam cells releases lipids
• Stimulate smooth muscle cells in media to produce
  extracellular matrix
• Plaques narrow lumen
• If plaque disrupted expose highly thrombogenic
  core

8
Risk factors for PAD

• Age
• Prevalence 60-69 years 16
• 70-82 years 33
• Current cigarette smoking
• Arterial hypertension
• Diabetes mellitus
• Hypercholesterinaemia

9
PAD Co-morbidities

• Powerful predictor of CAD, stroke, cardiovascular
  death
• Coronary artery disease 58-68
• Previous stroke 34-42
• All-cause mortality 3x higher than age and sex
  matched control
• Coronary artery mortality 6.6x
• Overall mortality
• 30 after 5 years
• Mainly major cardiovascular events

10
Symptoms

• Fontaine classification
• 1 Unlimited walking distance
• 2 - Intermittent claudication
• 3 Ischaemic rest pain
• 4 Tissue necrosis, gangrene
• Critical limb ischaemia
• Endangers viability of limb
• 5-10 of all patient with PAD
• Annual incidence 0.25-0.45/1000

Critical limb ischaemia
11
Progression of PAD

• Often not in orderly fashion
• Only 50 with CLI had claudication in previous
  6/12
• Up to 15 with intermittent claudication develop
  critical ischaemia later on

12
Treatment Aim

• Reduce
• Exertional symptoms
• Local complication of arterial leg ulcers,
  critical limb ischaemia
• General cardiovascular morbidity and mortality
• Maintain ambulation, independence, QOL
• Medical
• Surgical re-vascularisation, amputation
• Symptom control

13
Standard Medical Treatment

• Modify risk factors
• Exercise programmes
• Improve pain free walking distance
• Good foot care
• Antiplatlets drugs
• Reduce major cardiovascular events
• Reduce risk of arterial occlusion
• Statins
• Reduce all cardiovascular events by 52
• Improve exercise duration by 42
• ACE-Inhibitors, ß-blocker

14
Symptomatic Medical Treatment for Intermittent
Claudication

• Cilostazol
• Mechanism of action unclear
• Inhibits Phosphodiesterase type 3
• Suppresses platelet aggregation
• Improves endothelial function
• Vasodilator
• Shown to improve pain free walking distance
• Side-effects headache, diarrhoea, palpitation
• Contraindication severe heart failure

15
Symptomatic Medical Treatment for Intermittent
Claudication

• Pentoxifylline
• Reduces viscosity -gt improves blood flow
• Insufficient data from RCT
• No difference to placebo found

16
Medical Treatment Options for Critical Limb
Ischaemia

• Iloprost
• Prostacycline derivate
• Reduces endothelial cell and coagulation cascade
  activation
• Improves microcirculation
• If surgery not possible in stage 3 or 4
• IV infusion, 6-16 hours/day, 7-28 days
• Responder rate
• 69 initially, 38 after 6/12
• Alive without amputation after 6/12
• 96 of responder vs 37 of non-responder

17
Possible Future Medical Treatment

• Therapeutic angiogenesis
• Vascular endothelial growth factor
• Animal model and clinical trials
• Promotes development of collateral vessels
• Shown to reduce rest pain
• Further studies needed

18
Prognosis in Critical Limb Ischaemia

• Overall 2 year mortality 30
• Predictor of mortality
• Age over 70
• History of stroke
• Major amputation
• 3-fold risk of MI, stroke, vascular death
  compared to patients with stage 2 PAD
• Peri-operative 30 day mortality
• Fem-distal bypass 2.1, BKA 6.3, AKA 13.3

19
Severely Ischaemic Limb

• If not treated usually fatal
• Options
• Revascularisation
• Amputation
• Symptomatic treatment only
• Decision influenced by
• Peri-operative risk
• Co-morbidities
• QOL
• What is the evidence?

20
Outcome Studies

• Historically end-point mainly procedure related
• Peri-operative mortality
• Graft patency
• Limb salvage
• More recently functional outcome
• Ambulation
• Functional independence
• Patient reported QOL
• Mainly compare different surgical techniques

21
Outcome Studies

• Selection bias
• Rarely mentions sub-group, who do not receive
  re-vascularisation
• Poor outcome in patients aged over 80 with
  limb-threatening ischaemia Cardiovasc Surg 1999
  Jan 7 (1) 56-7
• Retrospective case-note review of all patients
• 56 suitable for active treatment
• Amputation 4 vs 50
• Death 21 vs 31

22
Outcome studies

• Subgroup of patients recognized, who undergo
  surgery but die prior to healing of incisions or
  pedal wounds
• But no clear evidence so far in how to identify

23
Non-operative treatment of Advanced Limb
Ischaemia the Decision for Palliative CareEur
J Vasc Endovasc Surg 19, 246-249 (2000)

• Retrospective 1993-1998
• All patients with critical limb ischaemia, but
  not for surgical or radiological intervention
• Identified 30 patients with documented decision
  for terminal care
• About 700 surgical re-vascularisation procedures,
  300 major amputations for PAD

24
Non-operative treatment of Advanced Limb
Ischaemia

• Aged 55-95, median 87
• 17 lived independently at home
• 66 immobile
• 66 cardiac disease, 50 stroke
• All had at least 1 co-morbidity, 50 had 3 or
  more
• Decision discussed with
• Patient in 43
• Relatives 90

25
Non-operative treatment of Advanced Limb
Ischaemia

• Time to death less the 24 hours to 42 days
• median 3.5 days
• Place of death 70 acute hospital, 20
  community hospital, 10 at home
• Most difficult patients are those for whom the
  balance of medical and humanitarian
  considerations sway against intervention, but for
  whom amputation might save life, albeit of very
  poor quality

26
Questions

• What are the palliative care needs of patients
  with PAD?
• When should palliative care services get
  involved?
• Are there unmet needs?

27
Palliative Care for PAD

• Diverse group of patients
• Sub-group
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  with poor prognosis
• Further understanding of predictor for poor
  outcome post-surgery required
• More evidence needed about
• Patients perspective on illness
• Palliative care needs
• How to best provide care

28

• Is revascularisation and limb salvage always the
  treatment for critical limb ischaemia?, J of
  Cardiovasc Surg, Jun 2004 45(3), 177-184
• Non-operative treatment of advanced limb
  ischaemia the decision for palliative care, Eur
  J Vasc Endovasc Surg 19, 246-249 (2000)
• Long-term mortality and its predictors in
  patients with critical leg ischaemia, Eur J Vasc
  Endovasc Surg 1997 Aug 14 (2)91-5
• Management of peripheral arterial disease of the
  lower extremities in elderly patients, J
  Gerontology, Feb 2004 59A(2), 172-177
• Pain and powerlessness the experience of living
  with peripheral vascular disease, J Adv Nurs
  1998 Apr 27(4) 737-45
• Non-intervention and palliative care in vascular
  patients, Brit J Surg, 87, 1601-1602