CURRICULUM VITAE
Nama : dr. Hariadi Hariawan SpPD SpJP (K)
Tempat, tanggal lahir : Lumajang, 18 Juni 1953
Current Education :
Internist : Universitas Gadjah Mada (1993)
Cardiologist : Universitas Indonesia (2006)
Cardiologist Consultant : Universitas Indonesia (2008)
Current Position:
Staf Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah Mada/RSUP
dr. Sardjito Yogyakarta
Kepala Program Studi Bagian Kardiologi dan Kedokteran Vaskular Universitas
Gadjah Mada/RSUP dr. Sardjito Yogyakarta
MEDICAL MANAGEMENT
AND REVASCULARIZATION
OF PERIPHERAL ARTERY
DISEASE
Hariadi HariawanDepartment of Cardiology and Vascular Medicine - Medical School
Universitas Gadjah Mada / RSUP Dr Sardjito
Yogyakarta
Peripheral Arterial Disease (PAD)
• PAD: is a manifestation of systemic atherosclerosis that is common
• Associated with an increased risk of death and ischemic events
• May be underdiagnosed in primary care practice.
PAD
• PAD : stenosis / occlusion of upper or lower-extremity arteries due to atherosclerotic or thromboembolic disease.1)
• In practice, the term PAD generally refers to chronic narrowing or blockage (also referred to as atherosclerotic disease) of the lower extremities
PAD
• PAD : 12-14% population
• >20% of patients >65 yo4)
• Male >
• Increasing with DM, Hipertension, DyslipidemiaSmoking .5)
PAD: PREVALENCE vs AGE
Criqui MH, et al, Circulation, 1985
Fontaine classification
• Stage I : No symptoms
• Stage IIa : Intermittent claudication >200 m of walking distance (mild)
• Stage IIb : Intermittent claudication <200 m of walking distance (moderate to severe)
• Stage 3 : Rest pain
• Stage 4 : Necrosis/gangrene
Rutherfort Classification
• Stage 0 : Asymptomatic
• Stage 1 : Mild claudication
• Stage 2 : Moderate claudication
• Stage 3 : Severe claudication
• Stage 4 : Rest pain
• Stage 5 : Ischemic ulceration not exceeding ulcer of the digits of the foot
• Stage 6 : Severe ischemic ulcers or frank gangrene
Individuals with PAD Present in Clinical Practice with Distinct Syndromes
Asymptomatic: Without obvious symptomatic complaint (but usually with a functional impairment).
Classic Claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest.
“Atypical” leg pain: Lower extremity discomfort that is exertional, but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance
Individuals with PAD Present in Clinical Practice with Distinct Syndromes
Critical Limb Ischemia: Ischemic rest pain, non-healing wound, or gangrene
Acute limb ischemia: The five “P’s, defined by the clinical symptoms and signs that suggest potential limb jeopardy:
Pain
Pulselessness
Pallor
Paresthesias
Paralysis
Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudication±Impotence – Leriche’s Syndrome
What does the ABI mean?
ABI Clinical Correlation
>0.9 Normal Limb
0.5-0.9 Intermittent Claudication
<0.4 Rest Pain
<0.15 Gangrene
CAUTION: Patient’s with Diabetes + Renal Failure:
They have calcified arterial walls which can falsely elevate their ABI.
Ankle Brachial Index
• Cornerstone of lower extremity vascular evaluation
– Blood pressure cuffs, Doppler
– Ankle (DP or PT) to brachial artery pressure
Normal 0.96
Claudication 0.41 -0.95
Rest Pain 0.21-0.41
Tissue loss 0.20
Significant change 0.15 or more
ANGIOGRAPHY:
Non-invasive:• CT Angiogram• MR Angiogram
Invasive:• Digital Subtraction Angiography
Gold Standard Intervention at the same time
CTA of PVD
MRI
CT Angiography Digital Subtraction Angiography
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot silhouette
Treatment of PADTherapies Based Upon Symptoms
Intermittent Claudication
• Exercise Therapy
• Drugs• Pentoxifylline
• Cilostazol
• Revascularization• Severe disability
Goal to provide relief of symptoms
Critical limb ischemia
• Wound care
• Antibiotics
• Revascularization• Endovascular
• Surgery
Goal to promote limb survival
Supervised Exercise Rehabilitation
• A program of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication.
• Supervised exercise training should be performed for a minimum of 30 to 45 minutes, in sessions performed at least three times per week for a minimum of 12 weeks.
Bhatt, D. L. et al. J Am Coll Cardiol 2007;49:1982-1988
Effect of Dual Antiplatelet Therapy with Established Atherosclerotic Disease
PCI/Surgery:Indications/Considerations:•Poor response to exercise rehabilitation + pharmacologic therapy.•Significantly disabled by claudication, poor QOL•The patient is able to benefit from an improvement in claudication•The individual’s anticipated natural hx and prognosis•Morphology of the lesion (low risk + high probabilty of operation success)
PCI:•Angioplasty and Stenting•Should be offered first to patients with significant comorbidities who are not expected to live more than 1-2 years
Bypass Surgery:•Reverse the saphenous vein for femoro-popliteal bypass•Synthetic prosthesis for aorto-iliac or ilio-femoral bypass•Others = iliac endarterectomy & thrombolysis•Current Cochrane review = not enough evidence for Bypass>PCI
Amputation: Last Resort
Some Bypass Options:
Antiplatelet Therapy
Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
Aspirin, in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
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Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
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Pharmacotherapy of Claudication
Cilostazol (100 mg orally two times per day) is
indicated as an effective therapy to improve
symptoms and increase walking distance in
patients with lower extremity PAD and
intermittent claudication (in the absence of
heart failure).
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Endovascular procedures are indicated for individuals with a vocational or lifestyle-limiting disability due to intermittent claudication when clinical features suggest a reasonable likelihood of symptomatic improvement with endovascular intervention and…
a. Response to exercise or pharmacologic therapy is inadequate, and/or
b. there is a very favorable risk-benefit ratio (e.g. focal aortoiliac occlusive disease)
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Endovascular Treatment for Claudication
Endovascular intervention is not indicated if there is no significant pressure gradient across a stenosisdespite flow augmentation with vasodilators.
Primary stent placement is not recommended in the femoral, popliteal, or tibial arteries.
Endovascular intervention is not indicated as prophylactic therapy in an asymptomatic patient with lower extremity PAD.
Endovascular Treatment for Claudication
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Surgery for Critical Limb Ischemia
Patients who have significant necrosis of the weight-bearing portions of the foot, an uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or a very limited life expectancy due to co-morbid conditions should be evaluated for primary amputation.
Surgery is not indicated in patients with severe decrements in limb perfusion in the absence of clinical symptoms of critical limb ischemia.
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Surgery for Critical Limb Ischemia
For individuals with combined inflow and outflow disease with critical limb ischemia, inflow lesions should be addressed first.
When surgery is to be undertaken, an aorto-
bifemoral bypass is recommended for patients
with symptomatic, hemodynamically
significant, aorto-bi-iliac disease requiring
intervention.
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Surgery for Critical Limb Ischemia
Bypasses to the above-knee popliteal artery should be constructed with autogenoussaphenous vein when possible.
Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible.
Prosthetic material can be used effectively for bypasses to the below knee popliteal artery when no autogenous vein from ipsilateral or contralateral leg or arm is available.
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Acute Limb Ischemia (ALI)
Patients with ALI and a salvageable
extremity should undergo an emergent
evaluation that defines the anatomic level of
occlusion, and that leads to prompt
endovascular or surgical intervention.
Patients with ALI and a non-viable extremity
should not undergo an evaluation to define
vascular anatomy or efforts to attempt
revascularization.
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Summary of PAD and Its Management
• PAD is common and has a significant impact upon cardiovascular outcomes
• Treatment of PAD, even asymptomatic, should focus on risk factor modification/risk reduction
• Treatment of intermittent claudication should include exercise therapy, drug therapy and selective use of revascularization. Endovascular revascularization more preferable (baloon, stents)
• Treatment for critical limb ischemia warrants aggressive efforts at revascularization, including surgery, to reduce the risk of amputation
Terima Kasih