Epidemiology General prevalance 3-10% (ABI < 0.9) >70 years old: 15-20% Asymptomatic 75% Symptomatic:

Intermittent claudication Critical limb ishcemia

Clinical Course

Hirsch AT et al. J Am Coll Cardiol

Asymptomatic PVD Vascular disease progression related to baseline ABI

Identical to symptomatic patients Coexisting vascular disease (atherosclerotic)

Coronary artery disease CVA

Risk: MI/CVA 5-7%/year, mortality 2%/year Also related to baseline ABI

Management: Intensive risk factor modifiation Antithrombotic therapy

Mehler PS et al. Circulation 2003

Intermittent Claudication Only about 25% deteriorate ever Disease progression related to:

ABI (<0.50 >2x more likely need intervention/amputation) Low ankle pressure (40-60mmHg 8.5% limb loss/year)

At 5 years:Stable (70-80%)

Worsening(10-20%)

Criticalischemia(5-10%)

Hirsch AT et al. J Am Coll Cardiol 2006; 47: 1239-1312

Risk Factor Modification Stop smoking Control of BP Control of DM Control of hyperlipidemia Weight reduction

Exercise Rehabilitation Supervised Program:

Treadmill or track walking to bring on claudication Followed by rest until pain subsided Then resume 30-60 minute sessions 3 times/week, for 3 months (TASC II guidelines,

Recommendation 14) Selective exercise of most ischemic muscles Doubles claudication distance in 80% of patients

Stewart K et al. N Engl J Med 2002

Drugs Antiplatelet agents

Aspirin Clopidogrel

Cilostazol (PletaalTM) Vasodilator, metabolic and antiplatelet activity Increased walking distance 50-70m Best evidence

Naftidrofuryl (PraxileneTM) Improve muscle metabolism, reduce RBC/platelet aggregation Increased walking distance by 26%

Pentoxifylline Similar to placebo

Regensteiner J et al. J Am Geriatr Soc 2002

Lehert P et al. J Cardiovasc Pharmacol 1994

Indications for Intervention Severe, lifestyle-limiting

claudication Failed drug therapy and exercise Prerequisite:

Inflow satisfactory Distal runoff patent

SFA Disease

“Stupid Femoral Artery”High failure rate after intervention

Factors affecting result of intervention Multiple lesions Long segment stenosis Complete occlusion Below knee

Choice of intervention Surgical bypass

Vein graft Prosthetic graft

Endovascular Angioplasty Primary stenting Arthrectomy

Outcome Measures Usually considered together with critical ischemia Patency rate ABI Limb salvage Mortality

Surgical Bypass vs Angioplasty

TASC classification

Angioplasty

Bypass

If high risk for surgery

Surgical Bypass – ConduitSurgical Bypass – Conduit Autogenous vs prosthetic materials:

De Vries S et al, J Vasc Surg 1997

In-situ vs reversed vein graft: No difference

Mamode N et al, Cochrane Database Syst Rev. 2000

Angioplasty vs StentingAngioplasty vs Stenting Meta-analysis: no difference

1-Year Patency Rate Postoperative ABI

Mwipatayi et al, Journal of Vascular Surgery, Feb 2008

ConclusionConclusion Clinical course/deterioration, systemic disease related to

baseline ABI When to intervene?

Lifestyle limiting claudication, failure of conservative management

Radiological confirmation of adequate inflow and runoff required

Bypass or angioplasty? Depends on disease location, extent

Angioplasty: to stent or not? No difference

Depends on expertise available, patient condition