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Peripheral Arterial DiseaseDiagnosis and Management

Sam Mehta MDDirector of Cardiology- St. Anthony’s Hospital

Interventional CardiologistColorado Heart and Vascular PC

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DisclosuresSpeakers Bureau: Bard Vascular

Cardiovascular Systems Inc

Dermasciences

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Disclosures cont

I like legs

3Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Relative Risk

Smoking

Diabetes

Hypertension

Hypercholesterolemia

Hyperhomocysteinemia

C-Reactive Protein

Reduced Increased

Risk Factors for PAD

1 2 3 4 5 60

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60% Upper 2/3 Calf Claudication

Lower 1/3 Calf Claudication

Foot Claudication

30% Buttock & Hip Claudication±Impotence – Leriche’s Syndrome

Thigh Claudication

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Chronic PVD History

1. INTERMITTENT CLAUDICATION• Derived from the Latin word ‘to limp’• “Reproducible pain on exercise which is relieved by rest”• Pain can also be reproduced by elevating the leg• “my legs get sore at night and feel better when I hang them over the edge of the bed”

2. OTHER SYMPTOM/SIGNS:• A burning or aching pain in the feet (especially at night)• Cold skin/feet• Increased occurrence of infection• Non-healing Ulcers• Asymptomatic

3. CRITICAL STENOSIS = >60%, IMPENDING ACUTE ISCHEMIC LIMB:• - rest pain• - ischemic ulceration• - gangrene

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Examination: What To Do:

InspectionExpose the skin and

lookfor:

• Thick, Shiny Skin• Hair Loss• Brittle Nails• Color Changes (pallor)• Ulcers• Muscle Wasting

Palpation • Temperature (cool,bilateral/unilateral)• Pulses:? Regular,? AAA• Capillary Refill• Sensation/Movement

Auscultation • Femoral Bruits

Ankle Brachial Index (ABI)

= Systolic BP in ankle Systolic BP in brachial artery

Buerger’s Test • Elevate the leg to 45°- and look for pallor• Place the leg in a dependent position 90° & look for a red

flushed foot before returning to normal•Pallor at <20° = severe PAD.

Physical Examination:

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CAUTION:Patient’s with Diabetes + Renal Failure:

They have calcified arterial walls which can falsely elevate their ABI.

What does the ABI mean?

Figure 1. PAQ summary scores.

David M. Safley et al. Circulation. 2007;115:569-575

Copyright © American Heart Association, Inc. All rights reserved.

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Wounds will not heal without blood supply!

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Avoid at all Cost!

• BKA patient has 50% mortality at 5 years• Estimated > 50% increase in energy expenditure in order

to• Ambulate after BKA

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Treatment goals

• Pain relief

• Heal wounds

• Avoid amputation

• Limit level of amputation

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I found a pedal pulse, so patient should heal…

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Avoid at all Cost!

• BKA patient has 50% mortality at 5 years• Estimated > 50% increase in energy expenditure in order to• Ambulate after BKA

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Goals of vascular therapy in foot ulcers

•Provide straight line flow to the wound (angiosome directed therapy)

•Often requires multilevel revascularization

•It is suboptimal to get larger arteries revascularized and hope wound will heal

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Noninvasive Testing

• ABIs

• Pulse Volume recordings

• Arterial ultrasound

• CT Angiogram

• MR Angiogram

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• No noninvasive test is perfect

• Frankly, they are all fraught with imperfections, physical exam and wound location trumps all noninvasive testing

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• If suspected vascular wound, refer to vascular specialist early, rather than ordering further testing.

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Who Should I Refer to???

• Vascular Surgeon?

• Interventional Cardiologist?

• Interventional Radiologist?• Cardiothoracic Surgeon???

Case 1• 55 yo diabetic female, experienced

sudden cardiac death after a myocardial infarction.

• atherosclerotic risk factors include diabetes, family history, dyslipidemia and tobacco abuse.

• Prolonged hospital stay, requiring vasopressor agents.

Case 1 cont

• Referred from cardiologist (my partner) to podiatrist for gangrenous 2nd toe (dry but painful)

• Referred back to me from podiatrist as he was unable to palpate pedal pulses

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Case 1

• Though images look suboptimal for flow, wound completely healed.

Case 2

• 58 yo male, hx DM and tobacco abuse.

• nonhealing great toe, ulcer. patient ignored, now gangrene.

Anterior Tibial lesion in CLI

Before and After

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Take Home Message

• For patients who present with CLI, it is imperative to move quickly and consult an endovascular specialist

• Positive outcomes require the cohesive team of endovascular specialists, podiatry, wound care, infectious disease specialists, and primary care physicians.

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