SSA Policy Conference Peripheral Arterial Disease Chronic Venous Insufficiency

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SSA Policy Conference Peripheral Arterial
Disease Chronic Venous Insufficiency

• Jennifer A. Heller, M.D., F.A.C.S.
• Assistant Professor of Surgery
• Director, Johns Hopkins Vein Center
• Johns Hopkins University School of Medicine

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OUTLINE

• Definition
• Diagnosis
• Impact of Disease on Activities of Daily Living

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DEFINITION of PERIPHERAL ARTERIAL DISEASE (PAD)

• Hemodynamic Definition Peripheral Arterial
  Disease Resting ABIlt.90

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Does this definition work?

• In symptomatic pts, ABI is 95 sensitive in
  predicting arteriogram positive PAD
• Edinburgh Artery Study 1/3 pts with asymptomatic
  PAD had complete occlusion of a major artery
• The lower the ABI, the higher the risk of
  cardiovascular events
• Abnormal ABI identifies a high risk population
  that needs aggressive risk factor modification
  and antiplatelet therapy

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DIAGNOSIS

• Initial clinical assessment History and Physical
• A Careful History includes
• Evaluation of risk factors
• Presence of Cardiac Disease
• Tobacco Use
• Family history

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PHYSICAL EXAMINATION

• Measurement of BP on bilateral upper extremities
• Assessment of cardiac murmurs, rubs gallops
• Changes in color, temperature of skin of feet
• Muscle atrophy from inability to exercise
• Decreased hair growth, hypertrophied slow growing
  nails
• Radial, ulnar, brachial, carotid, femoral,
  popliteal, posterior tibial, dorsalis pedal

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DO WE HAVE A CLEAR DX AFTER THE H AND P?

• If the symptom of classic claudication is used to
  identify PAD, it will lead to a significant
  underdiagnosis of PAD
• Palpable pedal pulses negative predictive value
  of gt90
• Pulse abnormality significantly overestimates
  true prevalence of PAD
• Objective testing is therefore warranted
• Primary test ABI

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• Individuals with risks factors for PAD, limb
  symptoms on exertion or reduced limb function
  should undergo a vascular history to evaluate for
  symptoms of claudication or other limb symptoms
  that limit walking ability
• Patients at risk for PAD or patients with reduced
  limb function should also have a vascular PE to
  evaluate peripheral pulses
• Patients with a history or examination suggestive
  of PAD should proceed to objective testing
  including an ankle-brachial index

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ABI SCREENING

• All patients with exertional leg symptoms
• Subjects aged 50-69 years who have cardiovascular
  risk factors (particularly diabetes or smoking)
• All patients over 70 years regardless of
  risk-factor status

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ABI

• 10-12 cm sphygmomanometer cuff placed just above
  ankle
• Doppler measures systolic pressure of the
  posterior tibial and dorsalis pedis arteries of
  each leg
• These pressures are then normalized to the higher
  brachial pressures of either arm to form the
  ankle-brachial index

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ABI

• Decreased ABI in symptomatic patients confirms
  existence of hemodynamically significant
  occlusive disease between heart and ankle
• Patients with exercise related leg pain of non
  vascular causes will have a normal ABI at rest
  and after exercise

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MILD ISCHEMIA
ABI DEGREE OF ISCHEMIA WAVEFORM PATTERN PHYSICAL LIMITATION
. 95-1.2 None Triphasic or Biphasic No limitation or pseudoclaudication
.70-.94 Mild Triphasic or Biphasic Claudication in calves or thighs. Walking distance greater than 3-4 blocks
.50-.69 Moderate Monophasic Quick systolic acceleration Claudication in calves or thighs. Walking distance less than 3 blocks



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MODERATE TO SEVERE ISCHEMIA
.35-.49 Moderately Severe Monophasic, Slow systolic acceleration, Tardus parvus Claudication in calves or thighs. Walkiing distance less than 1 block
.26-.34 Severe Monophasic Tardus parvus Ischemic pain at rest, limited ability to walk.
0-.25 Critical Tardus parvus or no flow Ischemic pain at rest, loss of tissue, impending gangrene




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• Patients with PAD who do not have atypical
  symptoms , a reduced ABI is highly associated
  with reduced limb function, defined as reduced
  walking speed and/or a shortened walking distance
  during a timed 6 minute walk

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VALUE OF ABI

• Confirms diagnosis of PAD
• Detects PAD in asymptomatic pts
• Used in Ddx to identify a vascular etiology
• Identifies patients with reduced limb function
• Provides key information on long term prognosis,
  with ABIlt.90 associated with a 3-6 fold increased
  risk of cardiovascular mortality

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TOE PRESSURES

• Small occlusion cuff is placed on the first or
  second toe with a flow sensor
• Toe pressure normally 30mmHg less than the ankle
  pressure
• Abnormal toe brachial index lt.7
• Rest pain if absolute toe pressure lt30mmHg
• Non healing if toe pressure lt20-30mmHg

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When are toe pressures important?

• Diabetes
• Renal Insufficiency
• Any etiology manifesting in vascular
  calcification
• Non-compressible vesselsgt250mmHg ankle pressure,
  or ABI gt1.40

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LIMITATIONS OF TOE PRESSURES

• Amputation of Great and/ or second toe
• Extensive tissue loss
• Ulceration

• Skin Perfusion Pressure
• Laser doppler Probe
• Wrapped around Forefoot

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EXERCISE TESTING

• Patients with claudication who have an isolated
  iliac stenosis may have no pressure decrease
  across the stenosis at rest, therefore a normal
  ABI will be present
• Exercise will increase inflow velocity and make
  these lesions hemodynamically significant, and
  exercise will induce a decrease in the ABI that
  can be detected in the immediate recovery period
  and therefore establish the dx of PAD

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EXERCISE TESTING IIHow does it work?

• Obtain initial ABI at rest
• Patient then walks (treadmill at 3.2 km/h
  (2mph), 10-12 grade) until claudication pain
  occurs (or a maximum of 5 minutes) following
  which ankle pressure is then again measured
• Decrease in ABI 15-20 is diagnostic of PAD

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ALTERNATIVES TO EXERCISE/TREADMILL TESTING

• Climbing stairs or walking in the hallway
• Pts who cannot perform treadmill testing active
  pedal plantar flexion
• Inflation of thigh cuff well above systolic
  pressure for 3-5 minutes to induce reactive
  hyperemia, not well tolerated, not recommednded

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CAN WE QUANTIFY FUNCTION IN PATIENTS WITH PAD?

• Leg symptoms in peripheral arterial disease
  associated clinical characteristics and
  functional impairment. JAMA 2001 Oct 3
  286(13)1599-606. McDermott MM et al.
• Claudication distances and the Walking Impairment
  Questionnaire best describe the ambulatory
  limiatations in patients with symptomatic
  peripheral arterial disease. J Vasc Surg. 2008
  Mar 47(3) 550-555. Myers SA et al

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So
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VENOUS INSUFFICIENCY
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VENOUS PHYSIOLOGY

• Venous system acts as a reservoir (60-75 of TBV
  in system)
• Venous pressures determined by gravity not by
  cardiac contractions
• Venous system largely dependent on valvular
  function for transport

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WHAT IS CHRONIC VENOUS INSUFFICIENCY?

• Manifestation of valvular destruction and/or
  dysfunction resulting in venous hypertension of
  the extremity

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VENOUS HYPERTENSION

• Caused by
• Reflux through incompetent valves
• Venous outflow obstruction
• Failure of the musculovenous calf pump

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PREVALENCE

• 20million 6 million 1 million
  500,000

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SOCIOECONOMIC IMPACT

• 10-35 of adults in the US have some form of
  chronic venous insufficiency (CVI)
• Cost to the government for treatment amounts to
  1 billion annually
• 2 million work days per year are lost due to
  venous related illnesses

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CLASSIFICATION

• CEAP
• Venous Severity Score (VSS)

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CEAP

• Created in 1994 under the auspices of the
  American Venous Forum
• Clinical-Etiologic-Anatomic-Pathophysiologic
• Descriptive classification
• Used to classify stages of venous disease
• Score directly correlates with CEAP clinical class

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C in CEAP Clinical

• 0
• 1
• 2
• 3
• 4
• 5
• 6

• No venous disease
• Telangiectases
• Varicose Veins
• Edema
• Lipodermatosclerosis
• Healed ulcer
• Active ulcer

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C1 Spider veins
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C2Varicose Veins
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C3 Edema
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C4 Hyperpigmentation, atrophie blanche
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C5 Healed ulcer
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C6 Active ulcer
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E in CEAP Etiologic

• Congenital
• Primary
• Secondary

• Present since birth
• Undetermined etiology
• Post-thrombotic

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A in CEAP Anatomic
distribution

• Superficial
• Deep
• Perforator

• Great and small saphenous veins
• Cava, iliac, gonadal, femoral, profunda,
  popliteal, tibial
• Thigh and leg perforating veins

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P in CEAP Pathophysiological

• Reflux
• Obstruction
• Combination

• Axial and perforating veins
• Acute and chronic
• Valvular dysfunction and thrombus

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Venous Severity Scoring

• Developed in 2000 Venous Outcomes Committee of
  the AVF
• Numeric score based on 3 components VCSS, the
  anatomic segment disease score, and the VDS

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Venous Severity ScoringVCSS Component

• Clinical Attributes
• Pain
• Varicose veins
• Venous edema
• Skin pigmentation
• Inflammation
• Induration
• Number of ulcers
• Duration of ulcers
• Size of ulcers
• Compressive therapy

• 4 Grades
• Absent
• Mild
• Moderate
• Severe

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Venous Severity ScoringAnatomic Segmental Score

• Assigns a numerical value to segments that
  manifest reflux and/or obstruction
• Based on imaging
• Weights 11 venous segments for their relative
  importance when involved with reflux and/or
  obstruction with a maximum score of 10

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DOES A PATIENT WITH CHRONIC VENOUS INSUFFICIENCY
REALLY HAVE PROBLEMS FUNCTIONING?
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Venous Severity ScoringVenous Disability Score

• Ability to perform ADLs with or without
  compression stockings
• Eliminates 8 hour work day instead replaces with
  normal daily activities
• Refinement of the CEAP disability score

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NONINVASIVE PHYSIOLOGIC TESTING

• 2 Goals to determine presence of obstruction,
  and presence of reflux in both the superficial
  and deep venous systems
• Doppler and duplex are utilized

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NONINVASIVE PHYSIOLOGIC TESTING

• Non weight bearing calf compressed
• Compression with rapid release allows
  identification of valves and the presence of
  reflux
• Reflux will occur when calf compression is
  released
• Refluxvenous flow away from the heart (towards
  the feet) after release
• Mild reflux .5-2.0 seconds
• Severe reflux gt2.0 seconds
• Normal veins do not reflux with this technique

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DIAGNOSIS
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Thank you!