Objectives: Peripheral Arterial Disease Overview CME.pdf · Peripheral Arterial Disease Overview Objectives: AftercompletingthisCME,thereader ... Peripheral arterial disease is a

eral arterial disease (P.A.D.) in ourpatients. The link between P.A.D.and coronary arterial disease makesrecognition of P.A.D. symptomsnot only important for potentiallyhelping to reduce amputation rates,but also for preventing catastrophicevents, such as heart attack and

Continued on page 210

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APRIL/MAY 2009 • PODIATRY MANAGEMENTwww.podiatrym.com 209

amputation.Allie reported that a three billion

dollar annual saving to the U.S.healthcare system can be realizedwith a 25% reduction in lower ex-tremity amputations.1,2

As podiatric physicians, we arepositioned to identify the early andthe advanced symptoms of periph-

By Desmond Bell, DPM

IntroductionNever as much as now has the

team approach to wound manage-ment and limb salvage presentedthe opportunity for podiatric physi-cians to serve as the gatekeepers inthe reduction of lower extremity

Here are some guidelinesfor prevention and treatmentof this disease.

PeripheralArterialDiseaseOverview

Objectives:After completing this CME, the readershould be able to:1) define peripheral arterial disease.2) comprehend the pathophysiology of

peripheral arterial disease.3) understand the risk factors for pe-

ripheral arterial disease.4) differentiate the symptoms of P.A.D.

from other conditions that share similarpresentation.5) encourage early detection of P.A.D.

to empower podiatric physicians in theprevention of critical limb ischemia andother catastrophic events, such as heartattack and stroke.6) recognize the financial impact of pe-

ripheral arterial disease, amputation, andlimb preservation7) apply knowledge of medical manage-

ment of peripheral arterial disease intopractice.8) understand the need of when to refer

patients for endovascular or surgical inter-vention to prevent amputation and to

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C L I N I C A L I S S U E SC L I N I C A L I S S U E S

but also improve wound-healingrates often lies in the amount of per-fusion available. Working closelywith interventionalists ensures betteroutcomes, reduced risk, and oppor-tunities to not only increase referrals,but to further advance the impor-tance and role of podiatry in themedical community.

P.A.D. DefinedPeripheral arterial disease is a

type of occlusive peripheral vascu-lar disease. P.A.D is the most com-mon type of peripheral vasculardisease; P.V.D., as defined, includesdisease of both the arteries andveins.P.A.D. affects the arteries outsidethe heart and brain and most com-monly affects thearteries of the pelvisand legs. It affects12-20% of Ameri-cans age 65 andolder.5 An estimated12 million peoplein the U.S. alonesuffer fromP.A.D.(6) Comparethese numbers withthose of other com-mon diseases andthe fact is thatP.A.D. is not onlymore prevalent, butis more deadly thandiseases that havebeen better publi-cized.

Consider thefact that there is a three-timegreater risk in those persons withdiabetes over the age of 50 to haveperipheral arterial disease.7

The disease prevalence of P.A.D.is approximately 12 million; this isgreater than cancer (8.9 million),stroke (5 million), congestive heartfailure (4.8 million), andAlzheimer’s disease (4 million). Thefive-year mortality rate of P.A.D. is30%, compared to colorectal cancerat 39%, stroke at 28%, CAD at 21%,and breast cancer at 14%.8

Atherosclerosis is the most com-mon form of P.A.D. and P.A.D. is asystemic marker of atherosclerosis.3

The word atherosclerosis is derivedfrom the Greek words athero(“gruel” or “paste”) and sclerosis(“hardness”). It is a process bywhich plaque builds up in the wall

of an artery leading to varying de-grees of reduced blood flowthrough the vessel, ranging frommild to complete (and often multi-segmental) occlusion. Plaque ismade up of deposits of fats, choles-terol and other substances.

P.A.D Risk FactorsThe risk factors for P.A.D. can

be classified as traditional and non-traditional. Non-traditional risk fac-tors include race/ethnicity, elevatedlevels of inflammatory markers: (C-reactive protein, fibrinogen, leuko-cytes, interleukin-6), chronic renaldisease, genetics, hypercoagulablestates (altered levels of D-dimer, ho-mocysteine, lipoprotein[a]), abnor-mal waist to hip ratio, and seden-

tary lifestyle.3

Among the tradi-tional risk factors arethose that includeadvanced aging,smoking, diabetes,hypertension and hy-perlipidemia.3

The prevalenceof P.A.D. has beenshown to increasewith age. The Fram-ingham Heart Studyfound subjects >65years old were at in-creased risk for de-velopment ofP.A.D., while theNational Health andNutrition Examina-tion Survey, 1999-

2000 (NHANES) report found pa-tients >40 years old had a preva-lence of 4.3%, while patients whowere >70 yearsold had a prevalenceof 14.5%.8,9

SmokingSmoking increases the risk of

P.A.D. four times and acceleratesthe onset of P.A.D. symptoms, par-ticularly intermittent claudication,by nearly 10 years. Additionally, adose-response relationship betweenpack year history and P.A.D. riskhas been established. Smoking isthe single most important modifi-able risk factor for prevention ofP.A.D. (Figure 1)!3

DiabetesDiabetes increases the risk of de-


210 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2009

Arterial Diseases...

stroke. There is an increasedrisk of myocardial infarction

(MI), stroke, and cardiovasculardeath in patients with lower ex-tremity P.A.D., including a 20% to60% increased risk for MI and atwo- to six-fold increased risk ofdeath due to coronary heart diseaseevents. The risk of cerebral vascularaccident (CVA) is increased by 40%in this patient population.3

Medical-legally, we also find our-selves in the position where recogni-tion of P.A.D. and pro-active inter-vention will not only be expected,but also necessary for better riskmanagement. An article by Janov en-titled “Seven Keys to Preventing Mal-practice Lawsuits” included informa-tion regarding a case in Michiganwhere a jury awarded a patient $1.23million for a podiatrist’s failure torefer to a vascular specialist in atimely manner. The patient of thepodiatrist was initially treated for anulcer that deteriorated within ap-proximately a three week period andled subsequently to ischemic gan-grene and a below-the-knee amputa-tion. The jury rejected the podia-trist’s defense which included “thepatient had chronic, but stablesymptoms,” and “the patient did notneed an urgent referral”.4

The point here is that whereP.A.D. is an underlying issue, espe-cially where a wound is present, de-terioration is likely to occur. Referralto the appropriate vascular specialistis not only critical, but is a standardof care. Failure to refer a P.A.D. pa-tient to a specialist can have tragicconsequences for both patient andprovider, whether podiatrist, primarycare physician, internist, or nursepractitioner.

Team ApproachAs P.A.D. recognition and treat-

ment modalities improve with ad-vances in technology, so does theopportunity to partner with otherspecialists. “Interventionalists” is aterm used to refer to those physi-cians who can provide revasculariza-tion of arteries that are occluded dueto P.A.D. Interventionalists includenot only vascular surgeons, but alsointerventional cardiologists and in-terventional radiologists. The key tonot only reduce amputation rates,

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Figure 1: Critical Limb Ischemia innon-diabetic patient with longterm tobacco abuse


size. Advanced lesions intrude intothe lumen of vessels, resulting inflow-limiting stenoses and chronicischemia syndromes. Risk factorsare involved in the initiation andacceleration of this process.

Atherosclerosis and the evolu-tion of plaque formation may becharacterized by four distinct stagesthat include:

• lesion initiation• formation of fatty streak• fibroproliferative atheroma

development• advanced lesion development

Lesion InitiationAny mechanical or chemical

injury can damage the endothe-lial cell layer. This alters the nor-mal blood flow and provides sitesfor the adhesion and aggregationof thrombocytes, leading to theformation of blood clots orthrombi in the arterial wall. Alter-ations of the endothelial layercause white blood cel ls(macrophages) to stick and to mi-grate into this layer, where theybecome active macrophages.

Fatty StreaksThe earliest recognizable lesions

of the inner arterial layer are called“fatty streaks”, which are aggrega-

veloping P.A.D. whether asymp-tomatic or symptomatic, by 1.5 to 4times. Diabetes is also associatedwith an increased risk of cardiovas-cular events. Among diabetics,there is an early mortality amongthose with P.A.D. Diabetics are alsoat higher risk for developing is-chemic ulcerations and gangrene.Diabetics also have more risk fac-tors for developing P.A.D. than do

non-diabetics. These risk factors in-clude elevated blood pressure, in-creased triglycerides and increasedcholesterol. Diabetics also appear tohave greater vascular inflammation,increased endothelial cell dysfunc-tion, abnormalities in vascularsmooth muscle cells, increasedplatelet aggregation, and impairedfibrinolytic function when com-pared to non-diabetics.10

Pathophysiology of P.A.D.Atherosclerosis frequently oc-

curs at arterial bifurcations andbranches where endogenousatheroprotective mechanisms areimpaired as a result of disturbedflow on endothelial cells.Atherosclerosis causes the arteriesto compensate initially by remodel-ing vessels which become larger in

Arterial Diseases... tions of foam cells. Foamcells induce the further re-placement of smooth en-dothelial cells by muscle cellsfrom the medium arterial walllayer. The fatty streak affects the in-tima of the artery. The lesion con-sists largely of smooth muscle cells,monocytes, macrophages, T and Bcells.

Fibroproliferative AtheromaFibroproliferative Atheroma

originates from the fatty streak andcontains larger numbers of smoothmuscle cells filled with lipids.

Advanced LesionThis highly cellular lesion con-

tains intrinsic vascular wall cells(endothelial and smooth muscle).Advanced lesions also contain in-flammatory cells (monocytes,macrophages, T-lymphocytes).The advanced lesion also contains alipid core that is covered by a fi-brous cap. Acute arterial events canoccur if the fibrous cap is disrupted.The resulting exposure of the “pro-thrombotic” necrotic lipid core andsubendothelial tissue leads tothrombus formation and flow oc-clusion.

P.A.D. Symptoms andDifferentiating Leg PainSymptoms

An understanding of symptomsof P.A.D. may help to isolate thelevel(s) of the disease, regions ofstenosis and, in most severe cases,the level of possible occlusions(Table 1). Since many patients whoare afflicted with diabetes also suf-fer from P.A.D and peripheral neu-ropathy (among other diseasemanifestations), it is important torecognize the similarities and over-lapping of symptoms. Rememberthat a patient does not have to bediabetic to have P.A.D., peripheralneuropathy, or both. Neuropathymay mask symptoms of P.A.D.Conversely, symptoms of P.A.D.may be mistaken for those of neu-ropathy.

Claudication is widely recog-nized as a dull cramping or pain inmuscles of hips, thighs, or calf mus-cles when walking, climbing stairs,or exercising which is relieved withcessation of activity. Claudication is


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TABLE 1

Differentiating Leg Pain Symptoms

Character Variable. Fatique to Same. May havesevere pain weakness

Location Buttock, hip, thigh,calf, feet

Exercise induced Yes Same

Distance to Same each time variableclaudication (may vary with speed)

Occurs with No Yes or nostanding

Relief Stop walking Often must sit orchange body position

Pain PAD pain Pain fromSymptomology other causes

5. minor tissue loss, e.g. non-healing ulcer, focal gangrene

6. major tissue loss, i.e. abovetransmetatarsal level

Where vascu-lar shutdown of alower extremity isoccurring as an ad-vanced symptomof critical limb is-chemia, the “6 P’sof acute limb is-chemia” may alsobe observed (Chart1).

The 6 P’s ofacute limb is-chemia will beseen in the ab-sence of compen-sating collateral

circulation. Long-standing P.A.D.typically results in the formation ofcollateralization off the primary ar-teries; in essence, the body’s creationof its own bypassing of the diseasedand occluded vessels.

The evolution to paresthesia andparalysis reflects the presence of se-vere and potentially irreversible is-chemia (Figure 2).

Recognition of P.A.D. Symp-toms by Anatomical Level

Cerebrovascular Symptoms ofP.A.D.

Patients with carotid arterystenosis present with ipsilateraltransient ischemic attacks, strokesor amaurosis fugax (transientmonocular vision loss). Symp-tomatic carotid ischemia is causedby:

• Hemodynamic factors relatingto the degree of stenosis in the inter-nal carotid artery (usually at least

70%) ipsilateral to the involvedhemisphere.

• Degree of collateral flow fromboth the Circle of Willis and the ex-ternal carotid artery.

• Degree of intracranial disease.

Embolism from an ulceratedplaque or from the stump of a com-pletely occluded internal carotidartery may also cause a neurologicaldefect.

Mesenteric IschemiaPost-prandial abdominal pain

begins 30-90 minutes after eatingand persists for two to three hours.This may cause patients to avoidfood, resulting in weight loss. Acutemesenteric ischemia is caused bythrombosis of a severely diseasedsupermesenteric artery or by an em-bolic event originating from theheart.

Aneurysmal DiseaseAbdominal aortic aneurysm

(AAA) is more commonly recog-nized thanperipheral aneurysm. It is a condi-tion marked by inherent weakeningof the arterial wall, and subsequentfocal edema. A peripheral aneurysmusually leads to acute thrombosisrather than rupture. Femoral andpopliteal athery aneurysms enlargeand compress surrounding venousstructures causing unilateral legedema, venous hypertension, ve-nous thrombosis with occlusion, orpain due to local nerve compres-sion. Ischemia is the most commonpresentation of peripheralaneurysm. It presents as mild clau-dication to severe limb threateningischemia. Urgent reperfusion orrevascularization is necessary toavoid limb loss. As in the case ofabdominal aortic aneurysm, recog-nition of the presence of peripheralaneurysm must be detected by ob-taining a thorough history and byordering the appropriate vascularstudies.

Aorto-iliac DiseaseManifested by claudication in

the buttocks, thigh and calves,isolated aorto-iliac disease is associat-ed with sexual impotence in menand is referred to as Leriche’s syn-drome. Its symptoms may be re-



Figure 2: Patient with acute limb is-chemia and the 6 P’s


the most common manifesta-tion of P.A.D.Claudication may also be charac-

terized by fatigue in the legs, whichmay require a patient to stop andrest while walking. These personsmay also exhibit a slow or antalgicgait and may have difficulty keepingup with others when ambulating.

Rest pain or night pain that oc-curs when legs elevated in bed, andrelieved when placed in dependentposition is another common symp-tom of P.A.D. Pain may typicallyoccur in the distal foot, possibly inthe vicinity of an ulcer. Questionsthat should be asked of patientswhere P.A.D. is suspected should in-clude: “Do youhave pain whenyou elevate yourlegs at night? And“Do you eversleep sitting upwith pillows be-hind your back,or with your legsdangling from theside of the bed?”

I m p o t e n c emay also be a signof P.A.D. and pa-tients may seesome relief withsildenafil citrate.

Critical Limb IschemiaCritical limb ischemia is charac-

terized by persistently recurring restpain requiring regular analgesia. Ex-ternally, CLI may reveal non-healingulceration or gangrene of the leg,ankle, foot, or toes. These ulcers aretypically exquisitely painful, even incases where patients are afflictedwith concomitant decreased sensa-tion due to neuropathy. Threatenedlimb loss or tissue loss is impending.

The Rutherford-Becker catego-rization of lower extremity P.A.D.specifies the extent of symptomsfrom asymptomatic to those seen incritical limb ischemia (Rutherford-Becker Category 4-6).(11) TheRutherford-Becker categories include:

0. asymptomatic1. mild2. moderate3. severe4. Ischemic rest pain

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The 6 P’s of Acute LimbIschemia

• Pulselessness• Pain• Pallor• Poikilothermy (cold)• Paresthesia• Paralysis

CHART 1


lieved with sildenafil ni-trate. Aorto-iliac disease ofthis nature may be seen in pa-tients <50 years of age.

Lower ExtremityDisease

Superficial femoral artery orpopliteal arteries occlusion usuallybegins at Hunter’s canal (adductorcanal of thigh). P.A.D. at thisanatomical level typically occurs inpatients over the age of 40. The pro-funda femoris functions as a bridgebetween the aortofemoral segmentand the femoropopliteal segment.The profunda femoris also providescollaterals to keep the lower leg vi-able and free of severe ischemia. It isnot uncommon for patients withisolated SFA occlusion to have onlymild to moderate, stable intermittentclaudication.

Femoropopliteal disease is mani-fested by claudication in the calvesand occasionally in the arches of thefeet. Walking for consistent distances(example-”2 blocks”) where the onsetof pain occurs and cessation of ambu-lation must result, is the hallmarksymptom of intermittent claudication.

Pseudoclaudication is a differen-tial diagnosis to intermittent claudi-cation. Pseudoclaudication is causedby lumbar canal stenosis.

Patients with pseudoclaudicationexperience leg pain with walking orprolonged standing. Calf pain ariseswhen walking variable distances, un-like in cases of intermittent claudica-tion. In cases of pseudoclaudication,relief is obtained from sitting orstooping, which decompresses thelumbar canal stenosis, usually takingat least 20 minutes for symptoms toabate. These patients often experi-ence numbness and tingling in feet.

Patients with severe chroniclower extremity ischemia manifestpallor on elevating the leg above thelevel of the heart and reveal depen-dent rubor or rubor-cyanosis. Manypatients experience ischemic restpain, especially when supine, andoften dangle their feet from the sideof the bed for relief. They may findadditional relief from symptoms bysleeping sitting up with pillows be-hind their back or in a chair to allowfor dependent position of legs. Inboth scenarios, gravity assists in theperfusion of the lower extremities.

Continuing

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Vascular Surgical Procedures forInflow Improvement

Abortobifemoral 3.3 87.5 (5 years)bypass

Aortoliac or 1 to 2 85 to 90 (5 years)aortofemoral bypass

Iliac endarterectomy 0 79 to 90 (5 years)

Fermorofemoral 6 71 (5 years)bypass

Axillofemoral bypass 6 49 to 80 (3 years)

Axxillofemoral- 4.9 63 to 67.7 (5 years)femoral bypass

Oprerative Mortality Expectied PatencyInflo Procedure (%) Rate (%)


TABLE 3

Vascular Surgical Procedures forOutflow Improvement

Fem-AK popliteal vein 1.3 to 6.3 66 (5 years)

Fem-AK popliteal 1.3 to 6.3 50 (5 years)prosthetic

Fem-BK popliteal vein 1.3 to 6.3 66 (5 years)

Fem-BK popliteal 1.3 to 6.3 33 (5 years)prosthetic

Fem-Tib vein 1.3 to 6.3 74 to 80 (5 years)

Fem-Tib prosthetic 1.3 to 6.3 25 (3 years)

Composite sequential 0 to 4 28 to 40 (5 years)bypass

Fem-Tib blind 2.7 to 3.2 64 to 67 (2 years)segmental bypass

Profundoplasty 0 to 3 49 to 50 (3 years)

Oprerative Mortality Expectied PatencyOutflow Procedure (%) Rate (%)


proach of the Interventionalist. Theapproach of the Interventionalistcan be classified in terms of tradi-tional surgical revascularization(by-pass procedures) versus en-dovascular intervention (angioplas-ty, atherectomy, stent placement,and thermal devices—i.e. cold laser,etc.).

Claudication does not usuallyprogress to limb-threatening is-chemia. Surgery is infrequentlyused to treat claudicants andshould be considered only when




Surgical ManagementTreatment Options for P.A.D.

Revascularization is indicatedwhere chronic arterial occlusive dis-ease has caused tissue loss, ischemicrest pain, or “lifestyle limiting in-termittent claudication.” Surgery isnot recommended as a prophylactictherapy in asymptomatic patientswith lower extremity P.A.D. Revas-cularization of diseased vessels canbe categorized according to the ap-

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American College of Cardiology/American Heart Association(ACC/AHA) Guidelines for the Treatment of P.A.D.

The high prevalence of atherosclerotic risk fac-tors places these patients at a “markedly” in-

creased risk of atherosclerotic ischemic events, in-cludingMI and stroke. All patients with lower ex-tremity P.A.D. should achieve risk reduction andspecific treatment targets comparable to those ofindividuals with established coronary artery disease.

Medical Management of P.A.D.:To reduce adverse cardiovascular events associ-

ated with lower extremity P.A.D., lifelong treat-ment should include:

• Modification or elimination of atheroscleroticrisk factors, such as cigarette smoking, diabetes,dyslipidemia, and hypertension

• Promotion of daily exercise• Non-atherogenic diet

Lipid-Lowering Drugs:Statins (Hydroxymethyl glutaryl [HMG] co-enzyme

Q reductase inhibitors) are recommended to achieve atarget LDLof <100mg /dl inALLpatientswith P.A.D.

Statins used with goal of < 70 mg/ dl in pa-tients with very high risk of ischemic events.

Among the statins recommended in theACC/AHA guidelines are the following:

• Lipitor (atorvastatin),• Lescol (fluvastatin)• Mevacor, Altoprev(lovastatin)• Pravachol (pravastatin)• Crestor (rosuvastatin)• Zocor (simvistatin)Fibric acid derivatives can be useful for patients

with P.A.D. and low HDL cholesterol, normal LDLcholesterol and elevated triglycerides. The fibricacid derivatives include:

Antara, Tricor (fenofibrate) and Lopid (genfibrozil).

Anti-hypertensive TherapyAnti-hypertensive therapy should be adminis-

tered to hypertensive patients with lower extremi-ty P.A.D. to achieve a goal of: reducing blood pres-sure to < 140 / 90 in non-diabetics and <130 / 80in diabetics to reduce the risk of MI, stroke, CHFand cardiovascular death.

Beta-adrenergic blocking drugs are effective an-tihypertensive agents and are not contraindicated.

Angiotensin-converting enzyme inhibitors arereasonable for symptomatic patients with lowerextremity P.A.D. to reduce the risk of adverse car-diovascular events.

Angiotensin-converting enzyme inhibitors maybe considered for patients with asymptomaticlower extremity P.A.D. to reduce the risk of ad-verse cardiovascular events.

ACE Inhibitors recommended for use in thetreatment of patients with P.A.D., both symp-tomatic and asymptomatic, include: Captopril,Enalapril, Fosinopril, Ramipril, Perindopril,Quinapril, Verapamil, and Trandolapril.

Anti-platelet therapy is indicated to reduce therisk of MI, stroke, or vascular death in patientswith atherosclerotic lower extremity P.A.D.

ASA (Aspirin) in daily doses of 75mg to 325mg isrecommended as a safe an effective anti-platelet thera-py to reduce the risk ofMI, stroke or vascular death inpatientswith atherosclerotic lower extremity P.A.D.

Clopidogrel (Plavix) 75 mg per day is recom-mended as an effective alternative anti-platelettherapy to ASA.

Figure 3: Annual cost of post-amputa-tion care is approximately $49,000 perpatient

no further surgicaloptions for revascular-ization. There exists a de-bate as to whether endovas-cular procedures are worth-while, as a perception existsamong some that re-occlusion ratesare high. One can argue that evenin cases where re-occlusion mayoccur, the benefit of increasedblood flow in a patient withwounds complicated by ischemiamay be enough to allow for thehealing of such wounds.



• Oral anti-coagulation therapy with Warfarinis not indicated to reduce the risk of cardiovascularischemic events in patients with atheroscleroticlower extremity P.A.D.

• Homocysteine-Lowering Drugs:

The effectiveness of the therapeutic use of folicacid and B12 supplements in patients with lowerextremity P.A.D. and homocysteine levels of > 14 µmoles/liter is not well established.

• Cilostazol (Pletal) 100mg p.o., b.i.d. is indicat-ed as an effective therapy to improve symptomsand increase walking distance in patients withlower extremity P.A.D. and intermittent claudica-tion (in the absence of heart failure).

• A therapeutic trial of cilastazol should be con-sidered in all patients with lifestyle-limiting claudi-cation (in the absence of heart failure).

• Pentoxifylline (Trental) 400mg p.o., t.i.d maybe considered as a second line alternative therapyto cilastazol to improve walking distance for pa-tients with intermittent claudication.

• The clinical effectiveness of pentoxifylline astherapy for claudication is marginal and not wellestablished.

Other Proposed Medical Therapies:The effectiveness of L-arginine for patients with

intermittent claudication is not well established.The effectiveness of propionly-L-carnitine as a

therapy to improve walking distance in patientswith intermittent claudication is not well estab-lished.

The effectiveness of ginkgo biloba to improvewalking distance is marginal and not well estab-lished.

• Oral vasodilator prostaglandins such as be-raprost and iloprost are not effective medicationsto improve the walking distance for patients withintermittent claudication.

• Vitamin E is not recommended as a treat-ment for patients with intermittent claudication.

• Chelation (e.g. Disodium ethylenediaminete-traacetic acid [EDTA]) is not indicated for treatmentof intermittent claudication andmay have harmfuladverse effects, including hypocalcemia, renal insuffi-ciency, proteinuria, and gastro-intestinal distress.

Additional ACC/AHA Non-surgical Recommen-dations for the Management of P.A.D.

Patients with lower extremity P.A.D. whosmoke or use other forms of tobacco should be ad-vised by each of their clinicians to stop smokingand should be offered comprehensive interven-tions, including behavior modification therapy,nicotine replacement therapy, or buproprion(Wellbutrin, Zyban).

Proper foot care including use of appropriatefootwear, referral to podiatric medicine, daily footinspection, skin cleansing and use of topical mois-turizing creams should be encouraged.

Skin lesions and ulcerations should be ad-dressed urgently in all diabetic patients with lowerextremity P.A.D. (e.g. all diabetic patients shouldbe assumed to have lower extremity P.A.D.).

Treatment of diabetes in individuals with lowerextremity P.A.D. by administration of glucose con-trol therapies to reduce HbA1C to < 7% can be ef-fective to reduce microvascular complications andpotentially improve cardiovascular outcomes.

A program of supervised exercise training isrecommended as an initial treatment modality forpatients with intermittent claudication.

Supervised exercise training should be per-formed for a minimum of 30-45 minutes, in ses-sions performed at least three times per week for aminimum of 12 weeks. The usefulness of unsuper-vised exercise is not well established as an effectiveinitial treatment modality for patients with inter-mittent claudication. �

Continuing

Medical Educationatherosclerotic risk factors havebeen treated and appropriate trialsof exercise and pharmacotherapyhave been utilized.

Endovascular procedures maybe useful where patients suffer fromsymptomatic focal aorto-iliac dis-ease, iliac and femoropopliteal le-sions.

Stenting may be useful where il-iacs have had suboptimal or failedballoon dilation, in cases of com-mon and or external iliac stenosis

or occlusion.Stents, lasers, cutting balloons,

atherectomy devices, and thermaldevices can be useful in femoral,popliteal and tibial artery revascu-larization as salvage treatments orwhen failed results are found afterballoon dilation.

It should be noted that the im-provements in endovascular tech-nology have been dramatic overthe past five years and have playeda major role in re-perfusion of oc-cluded lower extremity vessels inpatients previously presented with Continued on page 216

The P.A.D. network also refer-ences the American Diabetes Asso-ciation’s recommendation that peo-ple with diabetes who are over 50years old be regularly screened forP.A.D. as well as recommend thatthey have an annual foot exam.

In conclusion, the problems as-sociated with peripheral arterial dis-ease are extensive, and the impactof P.A.D. affects millions of patientsand their families and costs billionsof dollars to our healthcare system.Baby-boomers are aging and thenumber of diabetics continues toincrease. Fortunately, technology isimproving to address complicationsof P.A.D., yet prevention remainsthe best way to address the overallproblem. Greater understanding ofP.A.D. by all healthcare providersthrough greater awareness, earlyrecognition, and knowledge oftreatment options can have anenormous benefit to individual pa-tients and society as a whole. �

References:1 Allie, David E, MD. New Advances

in Critical Limb Ischemia. “The Stagger-ing Clinical and Economic Cost of CLI”Lecture. New Cardio Vascular Horizons.CLI Summit. Miami, FL. 2006.

2 Allie, David E, MD. PodiatryToday. Vol. 20. July 2007. “EmergingVascular Approaches for Healing Diabet-ic Foot Ulcers”. 44-54.

3 Hirsch, Alan T., MD; Haskal, Ziv J.MD; Hertzer, Norman R., MD, et al.:ACC/AHA Guidelines for the Manage-ment of Patients with Peripheral ArterialDisease (Lower extremity, renal, Mesen-teric, and Abdominal Aortic). Journal ofthe American College of Cardiology. ©2006 by the American College of Cardi-ology Foundation and the AmericanHeart Association, Inc.American Dia-betes Association: Diabetes 1996 VitalStatistics.

4 Janov, J. Podiatry Today. SevenKeys to Preventing Malpractice Law-suits. August 2007. 96-106.

5 Becker, GJ, et al. The Importanceof Increasing Public and PhysicianAwareness of Peripheral Arterial Disease.J Vasc interv Radiol 2002; 13[1];7-11.

6 “Peripheral Arterial Disease in Peo-ple with Diabetes”, American DiabetesAssociation Consensus Statement, Dia-betes Care, Volume 26, Number 12, De-cember 2003, 3333-3341.

7 “Diagnosis of P.A.D. is Importantfor People with Diabetes”, American Di-abetes Association Consensus State-ment, Diabetes Care, November 21,2003, www.diabetes.org.

8 American Cancer Society, Ameri-can Heart Association, Alzheimer’s Dis-ease Education/Referral Center, Ameri-can Diabetes Association, SAGE Group

9 Framingham Heart Studyhttp://www.framinghamheartstudy.orghttp://www.americanheart.org/downloadable/heart/1136822690283P.A.D.06%20REVdoc.pdf

10 American Diabetes Association:National Diabetes Fact Sheet, 2005.Bartholomew, John MD and Olin, Jef-fery DO. Cleveland Clinic Journal ofMedicine. Vol. 73 Supplement 4. Octo-ber 2006. “Pathophysiology of peripher-al arterial disease and risk factors for itsdevelopment”.

11 www.tasc-P.A.D..org, TASC Con-sensus Paper, Outcome AssessmentMethodology in Peripheral Arterial Dis-ease—Impetus for Outcomes Research,Page 39, Table IX; Classifications ofP.A.D.

Additional References:Strategic Health Resources commis-

sioned by the Spectranetics Corp.Falanga, Vincent, MD. Editor. Cuta-

neous Wound Healing. Copyright 2001,Martin Dunitz, Ltd. United Kingdom.

Navarro, Felipe MD. Cleveland ClinicMedicine Index. May 29, 2002. “PeripheralArterial Disease” www.clevelandclin-icmeded.com/medicalpubs/diseasemanagement/cardiology/P.A.D./P.A.D..htm



Evidence to support the useof endovascular procedures is

limited to date and can only be es-tablished after significant numbersof cases are performed along withfollow-up data accumulation. Anec-dotal and clinical evidence appearsto strongly support the use of en-dovascular procedures for limbpreservation and it is anticipatedthat further evidence will be forth-coming in the near future.

Surgical bypass data is presentedin Tables 2 and 3, for a comparativeperspective.

Conclusion:• <50% of all amputees regain

the ability to ambulate.• <50% post BKA <25% post

AKA.• <50% of amputees survive

past 2-3 years.• 25% of all diabetics will face

critical limb ischemia.• Associated costs of amputa-

tion are between $10-20 BILLIONannually in the U.S. alone.

• Lower extremity amputationsare still the most common treat-ment for critical limb ischemia.

• In 2000-01, 67% of CLI pa-tients had amputation as their ini-tial treatment.

• Most shockingly, 50% of am-putations are performed withoutprior angiography or even ABI!

• Annual cost of post-amputa-tion care is approximately $49,000,per patient.

• Annual cost of care and fol-low-up, post-limb salvage: $600.

• Nursing home care after am-putation is approximately $100,000per patient (Figure 3).

• Steps are highlighted to im-prove P.A.D. treatment and out-comes per the Prevention ofAtherothrombotic Disease network(P.A.D. Network).

1. Increase awareness of P.A.D.and its consequences;

2. Identify people with symp-tomatic P.A.D.;

3. Screen for patients at highrisk;

4. Improve treatment for symp-tomatic P.A.D. cases;

5. Increase early detection ofasymptomatic cases.

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Dr. Bell is aBoard CertifiedWound Special-ist (CWS)-(Amer-ican Academy ofWound Manage-ment), a Fellowof the AmericanCollege of Certi-fied Wound Spe-cialists (FAC-CWS) and a Fellow of the American Pro-fessional Wound Care Association (FAP-WCA). Dr. Bell also serves as the Vice-President of the Southeastern compo-nent of APWCA. He is the co-founder ofWound Care on Wheels, LLC, and theFirst Coast Diabetic Foot and WoundManagement Center.He is the co-founder and Director of

the Southeastern Interactive WoundSummit (SIWS), a multidisciplinary con-ference on advanced wound manage-ment, and is the co-founder and Presi-dent of the “Save A Leg, Save A Life”Foundation. Dr. Bell is the CEO ofWound Summit Outreach, Inc., a non-profit organization. He is in privatepractice in Jacksonville, FL and is onstaff at Memorial Hospital of Jack-sonville, St. Luke’s Hospital, and Spe-cialty Hospital of Jacksonville.


6)Which of the following is not con-sidered a non-traditional risk factorfor the development of P.A.D.?

A) advanced ageB) race/ethnicityC) abnormal waist to hip ratioD) elevated levels of inflammatory

markers: (C-reactive protein, fibrino-gen, leukocytes, interleukin-6)

7) The single-most important modifi-able risk factor in the prevention ofP.A.D. is:

A) dietB) sedentary lifestyleC) smokingD) abnormal hip-to waist ratio

8) Atherosclerosis and the evolutionof plaque formationmay becharacterized by four distinct stages,which include the following, EXCEPT:

A) lesion initiationB) formation of fatty streakC) fibroproliferative atheroma de-

velopmentD) foam cell induction

9) Diabetics have more risk factors fordeveloping P.A.D. than do non-dia-betics. Which of the following is notconsidered among those risk factors?

A) elevated blood pressureB) increased triglyceridesC) increased cholesterolD) peripheral neuropathy

10) Themost commonmanifestationof P.A.D. is:

A) Arch pain in feetB) ClaudicationC) Abdominal pain after eatingD) Amaurosis fugax

11) Pseudoclaudication is a differen-tial diagnosis for claudication. Whichstatement is false regarding pseudo-claudication?

A) Calf pain arises after walking

1) Allie reported that a 25% reductionin lower extremity amputations couldresult in multi-billion dollar annualsavings to the U.S. healthcare system.This amount is:

A) $ 3 billionB) $5 billionC) $30 billionD) $50 billion

2) There is an increased risk of my-ocardial infarction (MI), stroke andcardiovascular death for patients withlower extremity P.A.D. The risk ofthese patients suffering a heart attackor stroke, respectively, is:

A) 20-30% and 50%B) 40-60% and 30%C) 20-60% and 40%D) 40-60% and 20%

3) An interventionalist is a term usedto refer to those physicians who canprovide revascularization of arteriesthat are occluded due to P.A.D.Among those considered interven-tionalists are:

A) cardiologists, podiatrists, radi-ologists

B) cardiologists, podiatrists, vascu-lar surgeons

C) cardiologists, radiologists, vas-cular surgeons

D) podiatrists, radiologists, vascu-lar surgeons

4) Themost common type of periph-eral vascular disease is:

A) atherosclerosisB) peripheral arterial diseaseC) amaurosis fugaxD) hyperlipidemia

5)Which of the following is not con-sidered a traditional risk factor for thedevelopment of P.A.D.?

A) DiabetesB) SmokingC) HypertensionD) Hypercoagulable state

consistent distances.B) Leg pain is experienced with

walking or standing for prolonged pe-riods.

C) Numbness and tingling in feetare common symptoms.

D) Relief is obtained from sittingor stooping, typically for at least 20minutes.

12) The Rutherford-Becker is a classifi-cation system used to identify the de-gree of symptoms of P.A.D. At whatlevels of Rutherford-Becker can criticallimb ischemia be found?

A) 0,1,2B) 1,2,3C) 3,4,5D) 4,5,6

13) Acute limb ischemia is an ad-vanced form of critical limb ischemia.The 6 P.’s of acute limb ischemia in-clude: pulselessness, pain, pallor, poik-ilothermy, paresthesia and paralysis.Which two symptoms represent thepresence of severe and potentially ir-reversible ischemia?

A) pain and paresthesiaB) poikilothermy and paralysisC) paresthesia and paralysisD) pulselessness and pain

14.Which of the following is manifest-ed by claudication in the calves andoccasionally in the arches of the feet?

A) Leriche’s syndromeB) mesenteric ischemiaC) peripheral aneurysmD) femorpopliteal disease

15)Which is not indicated to reducethe risk of cardiovascular ischemicevents in patients with atheroscleroticlower extremity P.A.D.?

A) ACE InhibitorsB) StatinsC) CoumadinD) Clopidogrel (Plavix)

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E X A M I N A T I O N

See answer sheet on page 219.


218 PODIATRY MANAGEMENT

16) The following are recommended to reduce the riskof myocardial infarction, stroke, or vascular death in pa-tients with atherosclerotic lower extremity P.A.D.:

A) CoumadinB) AspirinC) Clopidogrel (Plavix)D) B and C

17) Treatment of diabetes in individualswith lower extrem-ity P.A.D. by administrationof glucose control therapies canbe effective to reducemicrovascular complications andpo-tentially improve cardiovascular outcomes.What is the rec-ommendedHbA1C level for this patient population?

A) < 8.5%B) <8.0%C) <7.5%D) <7.0%

18) Endovascular intervention to open occluded arteriesincludes all of the followingmodalities, except:

A) atherectomyB) angioplastyC) chelationD) stent placement

19)Which of the following statements regarding pen-toxifylline (Trental) is false?

A) Pentoxifylline may be considered as a second linealternative therapy to cilastazol (Pletal) to improve walk-ing distance for patients with intermittent claudication.

B) Pentoxifylline may be considered as a first linetherapy over cilastazol (Pletal) to improve walking dis-tance for patients with intermittent claudication.

C) The clinical effectiveness of pentoxifylline as ther-apy for claudication is marginal and not well established.

D) The typical dosing schedule of pentoxifylline is400mg three times daily.

20)Which of the following statements is false?A) Less than 50% of all amputees will regain the

ability to ambulate (<50% of below knee and <25% ofabove knee amputees).

B) Amputation is still the most common form oftreatment for critical limb ischemia.

C) Less than 50% of lower extremity amputees sur-vive past 2-3 years.

D) Amputation should be recommended versus en-dovascular procedures in cases where patients havebeen classified as having no further surgical options atrevascularization.

E X A M I N A T I O N

(cont’d)

See answer sheet on page 219.

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LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #4/09Peripheral ArterialDisease Overview

(D. Bell)

Objectives: Peripheral Arterial Disease Overview CME.pdf · Peripheral Arterial Disease Overview Objectives: AftercompletingthisCME,thereader ... Peripheral arterial disease is a

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