The Diagnosis and Treatment of Peripheral Vascular Disease

1
The Diagnosis and Treatment of Peripheral
Vascular Disease
2
The Diagnosis and Treatment of Peripheral
Vascular Disease

• Etiology
• Prevalence
• Risk Factors
• Diagnosis
• Treatment Options

3
The Diagnosis and Treatment of Peripheral
Vascular Disease

• Etiology
• Prevalence
• Risk Factors
• Diagnosis
• Treatment Options

4
The Pathophysiology of Atherosclerosis and
Thrombosis
5
Pathologic Progression of PAD
Atherosclerosis gt Thrombus Formation gt Ischemia
gt Limb Pain gt Impairment
Atherosclerosis and platelet activation lead to
the formation of a thrombus in arteries
Narrowed arteries and formation of a thrombus
impedes blood flow to the periphery and results
in ischemia
Ischemia leads to painful symptoms, cell death,
and results in physical impairment
Ross R. N Engl J Med. 1999 340115-126.
6
Major Manifestations of Vascular Disease and
Thrombotic Events

• Ischemic stroke
• Transient ischemic attack
• Myocardial infarction
• Angina pectoris (stable, unstable)
• Peripheral arterial disease
• Critical limb ischemia, rest pain, gangrene,
  necrosis

7
Overlap of Atherosclerotic Diseases
Ness, Aronow. JAGS. 1999471255-56.
8
The Diagnosis and Treatment of Peripheral
Vascular Disease

• Etiology
• Prevalence
• Risk Factors
• Diagnosis
• Treatment Options

9
Atherothrombotic Disease in the US
AnnualIncidence(Millions) Prevalence(Millions) Mortality/Yr()
Stroke 0.731 4.62 282
TIA 0.503 4.94 6.35
ACS 2.36 12.62 452
PAD --- 8-127 48,259
TIA transient ischemic attack ACS acute
coronary syndrome PAD peripheral arterial
disease. Includes unspecified angina pectoris
includes history of MI or stable/unstable angina
pectoris or both CHD defined as MI or fatal
CHD patients with critical limb ischemia, who
have lowest ABI values, have an annual mortality
rate of 25.
1. Broderick J, et al. Stroke. 199829415-421
2. American Heart Association. 2002 Heart and
Stroke Statistical Update 3. Brown et al. Amer.
Stroke Assoc. 25th Int. Stroke Conference. 2000
4. National Stroke Association Press Release.
April 25, 2000 5. Dennis M, et al. Stroke.
199021 848-853 6. National Hospital Discharge
Survey 1999. National Center for Health
Statistics/Centers for Disease Control and
Prevention. Series 13, No.151. September 2001 7.
Hirsch AT, et al. JAMA. 20012861317-1324 8.
Dormandy JA, et al. Eur J Vasc Surg.
19915132-133 9. Hiatt WR. N Engl J Med.
20013441608-1621.
10
How Common is PAD?

• 1 in 4 Americans have some form of Cardiovascular
  Disease
• Over 70 Million Americans
• Cardiovascular Disease accounts for more annual
  deaths than Cancer, Infection, and Trauma COMBINED

11
How Common is PAD?

• Responsible for
• 275,000 hospital admissions per year
• Over 2,750,000 office visits per year
• Approximately 45,000 deaths per year

12
Carotid Artery Stenosis

• Responsible for 35 of all strokes
• The major cause of loss of independent life
  for patients
• First symptom may be a catastrophic stroke

13
How Common is PAD?

• More than 700,000 new STROKES occur each year
• Approximately 20 are Recurrent

14
Aneurysms of the Abdominal Aorta (AAA)

• A silent killer
• Ninth leading cause of death in the U.S.
• Familial
• Often causes no symptoms until rupture
• George C. Scott recently died of a ruptured
  abdominal aortic aneurysm
• Albert Einstein

15
Prevalence of PAD Increases with Age
1
2
Percentage of Patients with PAD

• Figure adapted from Creager M. Management of
  Peripheral Arterial Disease. Medical, Surgical,
  and Interventional Aspects. 2000.
• 1 Criqui MH, Arnost F, Barret-Connor E, et al.
  Circulation. 198571510-515.
• 2 Meijer WT, Hoes A, Rutgers D, et al.
  Arterioscler Thromb Vasc Biol. 199818185-92.

16
Mortality in Patients With Severe PAD
Relative 5-Year Mortality
48
44
38
Patients ()
15
²Breast Cancer
²Colon/Rectal Cancer
¹PAD
²Non-Hodgkins Lymphoma
Belch JJF. Arch Intern Med 2003163884-92
17
PAD and Relative Risk of Death
6.6 (2.9-14.9)
5.9 (3.0-11.4)
3.1 (1.9-4.9)
Relative Risk (95 CI)
Cause of Death in Patients with PAD
Belch JJF. Arch Intern Med 2003163884-92
18
Peripheral Arterial Disease
Symptomatic Disease 34
Asymptomatic Disease 66
Hiatt WR. N Engl J Med. 20013441608-1621.
19
The Diagnosis and Treatment of Peripheral
Vascular Disease

• Etiology
• Prevalence
• Risk Factors
• Diagnosis
• Treatment Options

20
What Diseases Put People at Risk for PAD?

• Hypertension
• Tobacco Use
• High Cholesterol
• Diabetes Mellitus
• Family History
• CAD

21
Risk Factors
Hypertension

• Increases stiffness of arteries
• Promotes narrowing of blood vessels
• Increases risk of stroke, heart attack, kidney
  failure
• Silent
• Must consider kidney artery blockage as culprit

22
Risk Factors
Tobacco Use

• The major modifiable risk factor
• Patients who smoke gt15 cigarettes daily have a
  NINE-FOLD increase in risk of leg pain due to
  artery blockage
• Patients who smoke gt 5 cigarettes daily close
  their leg artery bypass grafts more often than
  those patients who do not smoke

23
Risk Factors
High Cholesterol

• New medical studies suggest that lowering
  cholesterol levels can halt the progression or
  even SHRINK plaque in the leg arteries
• Lowering cholesterol levels DECREASES the risk of
  Stroke!

24
Risk Factors
Diabetes Mellitus

• Peripheral Artery Disease is FIVE TIMES more
  common in patients with DM
• 30 of patients with DM have PAD
• Major limb amputation rate is FOUR TIMES HIGHER
  in patients with DM and PAD than with PAD alone

25
Risk Factors
Family History of PAD

• Clear risk factor for other first degree
  relatives
• Must make every effort to modify risk factors
• Early diagnosis is key

26
The Diagnosis and Treatment of Peripheral
Vascular Disease

• Etiology
• Prevalence
• Risk Factors
• Diagnosis
• Treatment Options

27
What Symptoms do Patients Have With PAD?

• Leg Arteries
• Pain, Ache, Tightness, Tiredness, Weakness,
  Numbness in legs brought on by walking and
  relieved by rest (claudication)
• Pain in feet at rest due to poor circulation
  (rest pain)
• Poorly healing wound
• Gangrene

28
What Symptoms do Patients Have With PAD?

• Claudication
• Symptoms manifests a level below the vascular
  lesion
• Lesion Location Claudicating Muscle
• distal aorta buttocks
• common iliac thigh
• SFA calf
• tibials NONE!!

29
How Do We Diagnose PAD?

• Listen to the story
• What kind of problems are you having?
• How long have you been having these problems?
• What makes the symptoms better/worse?
• Have you had any prior treatment for these
  problems?
• Are things getting worse?

30
How Do We Diagnose PAD?

• Perform an examination
• Feel pulses
• Feel for aneurysms
• Listen for noises over arteries that can signify
  blockage
• Look at feet

31
Elevation Pallor/Dependent Rubor
32
Dont Wait For This To Happen...
33
How Do We Diagnose PAD?

• Non-Invasive Testing
• Blood Pressure Cuffs
• Duplex Ultrasound
• Magnetic Resonance Arteriography
• Computed Tomographic Angiography

34
The Ankle-Brachial Index
35
Office Measurement of the AnkleBrachial Index
(ABI)
The ratio of
Highest arm pressure
(over)
Pressure PT DP
Pressure PT DP
36
Ankle Brachial Index

• gt 0.9 Normal
• 0.9 to 0.75 Mild PVD
• 0.75 to 0.4 Moderate PVD (IC)
• lt 0.4 Severe Disease

37
AnkleBrachial Index and Mortality
1500 Women Over Age 65 in Osteoporosis Study
Vogt MT et al. JAMA 1993270465-469.
38
Peripheral Arterial Disease
Duplex Ultrasound of Common Femoral Artery
Bifurcation
From lateral to medial the anatomic order is
Nerve, Artery, Vein, Empty space, Lymphatics
(NAVEL)
39
Magnetic Resonance Arteriography
Saccular AAA
40
Angiogram
Severe Right Common Iliac Artery Stenosis
Inferior Epigastic Artery
External Iliac Artery
Internal Iliac Artery
Common femoral artery
41
Angiogram of an AAA
42
Stenosis of the Carotid Artery
Duplex US of Severe ICA Stenosis Post CEA
43
The Diagnosis and Treatment of Peripheral
Vascular Disease

• Etiology
• Prevalence
• Risk Factors
• Diagnosis
• Treatment Options

44
What Are the Indications for Therapy?

• Critical Limb Ischemia
• Ischemic Ulceration
• Disabling Claudication

45
Medical Therapy for Intermittent Claudication

• Symptom/Limb
• Tobacco Cessation
• Foot Care
• Control of DM
• Statins
• Antiplatelet Agents
• Exercise
• Cilostazol

• Life
• Tobacco Cessation
• Control of DM
• Reduction in Cholesterol
• Reduction in BP
• Antiplatelet Agents
• Exercise

46
Angioplasty and Stenting of the Iliac Arteries
47
Balloon Angioplasty of the SFA
If plaque burden is too great for angioplasty ,
Femoral to Popliteal artery bypass with vein
(preferabl) or PTFE is indicated.