Peripheral Arterial Disease Mary MacDonald CD MD PhD FRCSC RPVI Vascular Surgeon Thunder Bay Regional Health Sciences Centre Assistant Professor Northern Ontario School of Medicine Presentation Prevention Treatment Cardiovascular and Stroke Summit 1 June 2018
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Peripheral Arterial Insufficiency - NOSM · 2019-03-19 · Chronic Peripheral Arterial Disease Presentation of PAD Prevention and Management of Risk Factors Guidelines for Treatment
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Peripheral Arterial
Disease
Mary MacDonald CD MD PhD FRCSC RPVI
Vascular Surgeon
Thunder Bay Regional Health Sciences Centre
Assistant Professor
Northern Ontario School of Medicine
Presentation
Prevention
Treatment
Cardiovascular and Stroke Summit 1 June 2018
Faculty/Presenter Disclosure
• Faculty: Dr. Mary MacDonald
• Relationships with commercial interests:
• none
Disclosure of Commercial Support
• Dr. Mary MacDonald, Vascular Surgeon, TBRHSC
• This program has received no financial or in-kind
support
• Potential for conflict(s) of interest:
• I have no conflict of interest or
affiliations that have influenced
this presentation to disclose
Objectives
1. Review presentation of peripheral
arterial disease
2. Evidence based prevention and risk
factor management
3. Treatment options: indications for
angiography and surgical bypass
Overview
Chronic Peripheral Arterial Disease
Presentation of PAD
Prevention and Management of Risk Factors
Guidelines for Treatment of Claudication
Guidelines for Treatment of Critical Limb Ischemia
Guidelines for Management of Diabetic Foot Ulcer
Treatment: Indications for intervention
What is Peripheral Arterial Disease?
Stenosis or occlusion of the aorta or limb
arteries which leads to lack of tissue
oxygenation (ischemia)
Acute PAD most often caused by
embolization
Chronic PAD most often by atherosclerosis
Either acute or chronic peripheral arterial
disease can lead to death of tissues (nerve,
muscle, bone) and loss of the limb
Peripheral Arterial Disease
The Aging Population
0
5
10
15
20
25
10 20 30 40 50 60 70 80 90
Age (years)
Pop
ula
tio
n (
mill
ion
s)
1980
1990
2000
2010
17% of the population 55-70 years of age has PAD
Fowkes FG, et al. Int J Epidemiol. 1991;20:384-392.
PAD = peripheral arterial disease
N=1592
Independent Risk Factors for PAD*
Newman AB, et al. Circulation. 1993;88:837-845
* PAD diagnosis based on ABI <0.90.
1.10 1.51
2.55
4.05
Relative Risk vs the General Population
Reduced Increased
Diabetes
Smoking
Hypertension
Total cholesterol (10 mg/dL)
Chronic Peripheral
Arterial Disease
Causes of Chronic Peripheral Arterial Ischemia
Popliteal Entrapment
Syndrome
Popliteal Adventitial
Cyst
Popliteal Aneurysm
Thromboangiitis
Obliterans (Buerger’s
disease)
Arteritis
Fibromuscular Dysplasia
Atherosclerosis
85%
5%
10%
Atherosclerosis
Atherosclerosis Risk Factors
The Ankle-Brachial Index (ABI)
Ankle systolic pressure
Brachial systolic pressure
Ankle pressure from
Posterior Tibial and
Dorsalis Pedis – use
highest
Chronic Peripheral Arterial Disease
Clinical Ankle Brachial
Index
Normal ABI is 1.0
intermittent
claudication <0.7
rest pain <0.5
tissue loss
ulcers, gangrene <0.3
Critical Limb Ischemia
Peripheral Arterial Disease w/ inadequate
tissue oxygenation even at rest
Rubor
Rest Pain
Tissue Loss
ulcers, gangrene, infection
Chronic Peripheral Arterial
Disease -- Natural History
Of patients age 50 and older with PAD,
only 1-2% will go on to develop critical
limb ischemia
but
in patients who develop critical limb
ischemia, after 1 year only 50% will be
alive with both lower limbs
Case: Belinda B
Belinda is a 70 year old who presents with
intermittent, reproducible bilateral calf pain
at 3 blocks (5-10 minutes). Symptoms have
been present for approximately 6 months.
She denies pain in her toes or feet at night
There has been no tissue loss
She has had no prior vascular interventions
Case: Belinda B
What is your next action?
A. Order a CT Angiogram
B. Refer for conventional angiogram +/-
angioplasty
C. Start ASA, statin, and a walking program
D. Do an ABI in the office
Clinical Presentation of PAD
Initial PAD Presentation
Symptomatic PAD
Atypical Leg Pain
40-50% Intermittent Claudication
10-35%
Critical Limb Ischemia
1-2%
Asymptomatic PAD
20-50%
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Natural History of Claudication
Natural History of PAD: 5-year
Outcomes
Stable Claudication70-80%
Worsening Claudication10-20%
Critical Limb Ischemia 1-2 %
Non-CV Causes 25% CV Causes 75%
Mortality 15-30%
Nonfatal CV Events 15-30%
Limb Morbidity Limb Morbidity Cardiovascular Morbidity and Mortality
Fate of Patients With Critical Limb
Ischemia After Initial Treatment
Dormandy JA, et al. J Vasc Surg. 2000;31:S1-S296.
Summary of 19 studies
on 6-month outcomes
5 year outcomes show
increased mortality due to
cardiovascular causes
Dead 20%
Alive Without Amputation 45%
Alive With Amputation 35%
Chronic Peripheral Arterial
Disease Management
Medical management: Risk factor modification
Antiplatelet
Statin
Revascularization
Open surgery: Endarterectomy
Bypass – anatomic
extraanatomic
Endovascular: Angioplasty – transluminal
subintimal
Stent
Other (Atherectomy, Cryoplasty)
Therapy of Intermittent Claudication:
Magnitude of Functional Improvement
Pentoxifylline
(Trental)
Cilostazol *
Supervised Exercise
Improvement Over Baseline After 90 to 180 Days (%)
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf.
2015 SVS Guidelines for the
Management of Peripheral
Arterial Disease
Treatment for Claudication
Claudication Treatment: Exercise
Supervised exercise training should be
the initial treatment
30-45 minute sessions
3 or more times per week
At least 12 weeks
Value of unsupervised exercise programs
is not well established
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Claudication Treatment:
Endovascular or Surgical Therapies
Indicated only for patients with
Vocational or lifestyle-limiting disability;
Reasonable likelihood of symptomatic improvement;
Prior failure of exercise therapy or pharmacological therapy; and
Favorable risk-benefit ratio
Not indicated as a prophylactic treatment for asymptomatic patients
1A Optimal Medical Management postintervention (Smoking cessation, ASA, Statin, glycemic and HTN control)
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
PAD Indications for Intervention
Persistent, lifestyle limiting claudication
despite maximal medical therapy
Rest pain
Nonhealing ulcer
Gangrene
Case: Belinda B
Belinda is a 70 year old who presents with
intermittent, reproducible bilateral calf pain
at 3 blocks (5-10 minutes). Symptoms have
been present for approximately 6 months.
She denies pain in her toes or feet at night
There has been no tissue loss
She has had no prior vascular interventions
Case: Belinda B
What is your next action?
A. Order a CT Angiogram
B. Refer for conventional angiogram +/-
angioplasty
C. Start ASA, statin, and a walking program
D. Do an ABI in the office
Case: Clive C
78 year old man brought to clinic by his daughters, who describe progressive loss of mobility. At camp last summer, Clive could walk for at least 30 min, but now complains of severe pain in his left calf when walking to the mailbox (100m) and left foot pain that wakes him at night.
PMHx: CAD with stents 10 yrs ago, HTN, ex-smoker. Not taking any medication. No prior leg-related complaints.
On examination of the left leg he has dependent rubor without tissue loss in the left foot and no palpable pulses in either groin or the distal left leg.
Target HbA1C<7% to reduce microvascular complications and potentially improve cardiovascular outcomes
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Diabetic Foot Ulcer/Infection
NEUROPATHY + ISCHEMIA = INFECTION
20-40% of healthcare resources spent on diabetes are related to diabetic feet
7-10% annual incidence ulcer formation if NO confounders
25-30% annual incidence if PAD, Charcot foot, prior ulcers or amputation
Diabetic Foot Ulcer/Infection
5-8% of patients with new ulcers require major amputation within a year
Ischemia should be considered as a cause of DFU unless proven absent
Neuroischemic and ischemic lesions should be considered together as both may require revascularization
Diabetic Foot Ulcer/Infection
As intermittent claudication and rest pain are reported far less commonly in diabetics with ischemia compared to non-diabetics;
early non-invasive vascular evaluation (ABI) recommended for patients with poor ulcer healing and a high risk for amputation;
IWG for the Diabetic Foot recommends vascular studies if the DFU has not healed in 6 weeks even if initial diagnostics suggest only mild disease
Diabetic Foot Ulcer/Infection
2B Surgical intervention for moderate or severe infections is likely to decrease the risk of major amputation
2B open, endovascular or hybrid methods should be chosen depending on patient comorbidities, anatomy of the arterial lesion(s) and expertise of the centre
1A Negative-pressure wound therapy appears to be as, or more, effective than other local wound treatments in patients without significant infection
Summary: Peripheral Arterial
Disease
Chronic Limb Ischemia: clinical presentation,
risk factors, medical, surgical and endovascular
management
Guidelines for care of Diabetic Foot Ulcers
Acute Limb Ischemia: clinical presentation and
treatment
Barriers to Practice Change
Discussion
What is the most prevalent barrier
to change that you see in your
practice?
What can vascular surgery do to
mitigate this barrier?
Rapid Access to Vascular Evaluation
RAVE clinic weekly at TBRHSC
we intend to expand clinic frequency,
resources
Rapid referral and assessment for patients
with tissue loss and suspected vascular
disease
No imaging required – we will arrange
Fax referrals to 1-888-504-1696 (office)
References
Cronenwett and Johnston (2012). Rutherford’s Vascular Surgery 7th ed, Elsevier, Philadelphia PA
Dormandy JA, et al. J Vasc Surg. 2000;31:S1-S296.
Fowkes FG, et al. Int J Epidemiol. 1991;20:384-392.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf.
Newman AB, et al. Circulation. 1993;88:837-845
Norgren et al., (2007). Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC
II). JVS 45:1(S) 1A-65A.
Pomposelli et al Society for Vascular Surgery Clinical Guidelines for Management of Peripheral Arterial
Insufficiency JVS 66:3(S) Dec 2015
Schneider, PA (2009). Endovascular Skills: Guidewire and catheter skills for endovascular surgery 3rd ed
Informa, New York NY.
Zarins and Gewertz (2005). Atlas of Vascular Surgery 2nd ed, Elsevier, Philadelphia PA
58 year old man presents acutely to ED with a pale,
pulseless right foot, with progressive sensory and
motor changes
A. Give the patient aspirin and get him to walk it out -
- reassess in an hour
B. Start a heparin infusion and obtain a CT scan
C. Start a heparin infusion and obtain an angiogram
D. Start a heparin infusion and take the patient to the
Operating Room
Classification of Recommendations
Class I: Evidence and/or general agreement that
procedure or treatment is beneficial, useful, and
effective
Class II: Conflicting evidence and/or divergence
of opinion about usefulness or efficacy of a
procedure or treatment
Class IIa: Weight of evidence or opinion favors
usefulness or efficacy
Class IIb: Usefulness or efficacy is less well
established by evidence or opinion
Class III: Evidence and/or general agreement that
procedure is not useful or effective and in some
cases may be harmful Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Classification of Recommendations
Class I: Evidence and/or general agreement that
procedure or treatment is beneficial, useful, and
effective
Class II: Conflicting evidence and/or divergence
of opinion about usefulness or efficacy of a
procedure or treatment
Class IIa: Weight of evidence or opinion favors
usefulness or efficacy
Class IIb: Usefulness or efficacy is less well
established by evidence or opinion
Class III: Evidence and/or general agreement that
procedure is not useful or effective and in some
cases may be harmful Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.