BRACHIOCEPHALIC INTERVENTION

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Peripheral Arterial Disease (PAD) Diagnosis and
Management
Peter J Mackrell, MD Chief Division Vascular
Surgery Co-Director Vascular Lab Sinai Hospital
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WHY?

• Affects approximately 8-12 million Americans
• If positive risk factors prevalence of 29
• Patients with PAD and no known CAD have 30 risk
  of MI, stroke, vascular death over 5 years

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Why?

• Often asymptomatic
• Early identification can save lives and limbs
• Poorly taught in all specialties
• Crosses many specialties

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Who

• Elderly
• CAD
• Smokers
• Diabetics
• ESRD

• High Cholesterol
• Family history
• HTN
• Male

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Anatomy
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Leg Pain Differential

• Vascular
• -Arterial
• -Venous
• Musculoskeletal
• -arthritis
• Neurogenic
• -spinal stenosis
• -DJD

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Symptoms
None
Claudication -pain calf,buttock -ambulation
-consistent
Limb Threatening Ischemia -rest
pain -ulcer -gangrene
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Claudication
Pain -with walking-hills versus
flat -calves/thighs/buttocks -consistent -reproduc
ible -resolved with standing vs sitting -no pain
when recumbent
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Rest Pain
Pain -Often at night/lying flat -More distal
pain/feet -Relieved by gravity/walking
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Evaluation

• Inspection
• -hair
• -capillary refill
• -cyanosis/rubor
• -edema
• -nails
• -foot architecture/callouses
• -cellulitis
• -ulcers
• -gangrene

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Palpation

• Sitting
• Supine

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PE Findings Suggestive of PVD

• Decreased Pulses
• -Femoral
• -Popliteal
• -Dorsalis Pedis
• -Posterior Tibial
• Muscle atrophy/hair loss/nail changes
• Dependent Rubor
• Ulcers/Gangrene

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Indirect Physiologic Tests consists of

• Pressure assessment
• ABI and/or segmental pressures
• ( or) Doppler waveform analysis

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Segmental pressure principle

• In a normal individual in a supine position,
  ankle systolic pressure is brachial pressure.

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The Ankle/Brachial Index (ABI)

• bilateral ankle pressures divided by the higher
  brachial pressure

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Doppler Pressure Sites for ABI

• Dorsalis Pedis
• easily compressed
• harder to locate

• Posterior Tibial
• harder to compress
• easier to locate

Essential not to drift off vessel !
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Brachial pressure
ABI
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Resting ABI values

• gt 1.0 normal (usually)
• lt 0.92 abnormal,
• exercise patient if borderline
• lt 0.8 probable claudication
• lt 0.5 multi-level disease or long
  segment occlusion
• lt 0.3 ischemic rest pain

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The bane of pressure measuremements

• Calcific medial sclerosis
• diabetics
• chronic steroid therapy
• renal dialysis patients
• elderly patients
• Segmental pressures unobtainable or excessively
  high
• In these patients use toe pressures
• gt40 mmHg for tissue healing in diabetics
• gt20 mmHg for tissue healing in non-diabetics

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Doppler waveform analysisNormal lower arterial
waveforms are triphasic
Analog, low-cost zero-crossing detector
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Doppler Waveform analysis Interpretation

• Abnormal
• loss of triphasic waveform
• dampening of amplitude
• slow upstroke

CFA
SFA
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ABI Interpretation

• ABI
• 0.92 normal
• 0.50-0.91 claudication
• 0.3-0.5 rest pain
• lt0.3 ulcer/gangrene
• Non-compressible

Toe Pressure gt20 mmHg non-diabetic gt40 mmHg
diabetic
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PE Findings Suggestive of PVD

• Decreased Pulses
• -Femoral
• -Popliteal
• -Dorsalis Pedis
• -Posterior Tibial
• Muscle atrophy/hair loss/nail changes
• Dependent Rubor
• Ulcers/Gangrene

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Diagnosis of PVD

• Duplex US
• Angiography
• MRA

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Treatment of PVD

• Medical Therapy

• Antiplatelet Tx\
• Statins
• Risk factor Mgt
• Foot Care
• -moisturizers
• -footware

• STOP SMOKING!!!!
• Walking Program
• Pharmacologic Tx
• -Pletal

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Treatment of PVD

• Medical Therapy
• Open Surgery
• Endovascular Repair

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Surgical RevascularizationAorto-iliac ASO

• Excellent patency
• Operative mortality 3.3
• Peri-op morbidity 8.3

Meta-analysis - DeVries JVS 199726558-69
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PTA of Iliac Arteries

• AUTHOR TECHNICAL SUCCESS
• Colapinto (1986) 78
• Gupta (1993) 78
• Johnston (1987) 82
• Vorwerk (1995) 81
• Blum (1993) 98
• 71 in 1st 50 patients
• 93 in 2nd 50 patients

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Stenting of Iliac Arteries
Author Date Patency

• Palmaz 1992 92 (1 yr)
• Sullivan 1997 84 (2 yrs)

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PTA Versus Stents

• Limited data
• 4 yr patency stents 94
• 4 yr patency PTA 69

Richter et al Radiology 1991 181 Supplement
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AORTO-ILIAC ASOSUMMARY

• Focal disease endovascular therapy
• More complex disease
• Good risk surgical revascularization
• Poor risk endovascular

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OUTCOME OF THERAPY FOR FEM-POP ASO -
CLAUDICATION

• Method/indication 5-yr patency
• PTA-stenosis 68
• PTA-occlusion 35
• Fem-pop bypass vein 80
• Fem-pop bypass AK PTFE 75
• Fem-pop bypass BK PTFE 65

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Fem-pop and tibialSUMMARY

• Focal disease endovascular therapy
• More complex disease
• Good risk surgical revascularization
• Poor risk endovascular
• Claudication - open surgery
• Tissue Loss - endovascular therapy