the diagnosis and treatment of peripheral vascular disease

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  • Slide 1
  • The Diagnosis and Treatment of Peripheral Vascular Disease
  • Slide 2
  • Etiology Prevalence Risk Factors Diagnosis Treatment Options
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  • The Diagnosis and Treatment of Peripheral Vascular Disease Etiology Prevalence Risk Factors Diagnosis Treatment Options
  • Slide 4
  • The Pathophysiology of Atherosclerosis and Thrombosis
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  • Pathologic Progression of PAD Atherosclerosis > Thrombus Formation > Ischemia > Limb Pain > Impairment Atherosclerosis and platelet activation lead to the formation of a thrombus in arteries Narrowed arteries and formation of a thrombus impedes blood flow to the periphery and results in ischemia Ischemia leads to painful symptoms, cell death, and results in physical impairment Ross R. N Engl J Med. 1999; 340:115-126.
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  • Ischemic stroke Ischemic stroke Transient ischemic attack Transient ischemic attack Myocardial infarction Myocardial infarction Angina pectoris (stable, unstable) Angina pectoris (stable, unstable) Peripheral arterial disease Peripheral arterial disease Critical limb ischemia, rest pain, gangrene, necrosis Critical limb ischemia, rest pain, gangrene, necrosis Major Manifestations of Vascular Disease and Thrombotic Events
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  • Coronary Artery Disease Cerebrovascular Disease Peripheral Arterial Disease 6% 16%40% 11%3% 15% 9.1% 38% overlap of 2 vascular beds Overlap of Atherosclerotic Diseases Ness, Aronow. JAGS. 1999;47:1255-56.
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  • The Diagnosis and Treatment of Peripheral Vascular Disease Etiology Prevalence Risk Factors Diagnosis Treatment Options
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  • Atherothrombotic Disease in the US Annual Incidence (Millions) Prevalence (Millions) Mortality/Yr (%) Stroke 0.73 1 4.6 2 28 2 TIA 0.50 3 4.9 4 6.3 5 ACS 2.3 6 * 12.6 2 45 2 PAD--- 8-12 7 4 8,25 9 TIA = transient ischemic attack; ACS = acute coronary syndrome; PAD = peripheral arterial disease. *Includes unspecified angina pectoris; includes history of MI or stable/unstable angina pectoris or both; CHD defined as MI or fatal CHD; patients with critical limb ischemia, who have lowest ABI values, have an annual mortality rate of 25%. 1. Broderick J, et al. Stroke. 1998;29:415-421; 2. American Heart Association. 2002 Heart and Stroke Statistical Update; 3. Brown et al. Amer. Stroke Assoc. 25th Int. Stroke Conference. 2000; 4. National Stroke Association Press Release. April 25, 2000; 5. Dennis M, et al. Stroke. 1990;21: 848-853; 6. National Hospital Discharge Survey 1999. National Center for Health Statistics/Centers for Disease Control and Prevention. Series 13, No.151. September 2001; 7. Hirsch AT, et al. JAMA. 2001;286:1317-1324; 8. Dormandy JA, et al. Eur J Vasc Surg. 1991;5:132-133; 9. Hiatt WR. N Engl J Med. 2001;344:1608-1621.
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  • How Common is PAD? 1 in 4 Americans have some form of Cardiovascular Disease Over 70 Million Americans Cardiovascular Disease accounts for more annual deaths than Cancer, Infection, and Trauma COMBINED
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  • Responsible for: 275,000 hospital admissions per year Over 2,750,000 office visits per year Approximately 45,000 deaths per year How Common is PAD?
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  • Carotid Artery Stenosis Responsible for 35% of all strokes The major cause of loss of independent life for patients First symptom may be a catastrophic stroke
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  • How Common is PAD? More than 700,000 new STROKES occur each year Approximately 20% are Recurrent
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  • Aneurysms of the Abdominal Aorta (AAA) A silent killer Ninth leading cause of death in the U.S. Familial Often causes no symptoms until rupture George C. Scott recently died of a ruptured abdominal aortic aneurysm Albert Einstein
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  • Prevalence of PAD Increases with Age Figure adapted from Creager M. Management of Peripheral Arterial Disease. Medical, Surgical, and Interventional Aspects. 2000. 1 Criqui MH, Arnost F, Barret-Connor E, et al. Circulation. 1985;71:510-515. 2 Meijer WT, Hoes A, Rutgers D, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-92. Percentage of Patients with PAD 12
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  • Mortality in Patients With Severe PAD 1515 3838 4444 4848 Relative 5-Year Mortality Belch JJF. Arch Intern Med 2003;163::884-92 Breast Cancer Colon/Rectal Cancer PADPAD Non-Hodgkins Lymphoma Patients (%)
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  • PAD and Relative Risk of Death Cause of Death in Patients with PAD 3.1(1.9-4.9)3.1(1.9-4.9) 5.9(3.0-11.4)5.9(3.0-11.4) 6.6(2.9-14.9)6.6(2.9-14.9) Belch JJF. Arch Intern Med 2003;163::884-92 Relative Risk (95% CI)
  • Slide 18
  • Peripheral Arterial Disease Hiatt WR. N Engl J Med. 2001;344:1608-1621. Asymptomatic Disease 66% Symptomatic Disease 34%
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  • The Diagnosis and Treatment of Peripheral Vascular Disease Etiology Prevalence Risk Factors Diagnosis Treatment Options
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  • What Diseases Put People at Risk for PAD? Hypertension Tobacco Use High Cholesterol Diabetes Mellitus Family History CAD
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  • Risk Factors Hypertension Increases stiffness of arteries Promotes narrowing of blood vessels Increases risk of stroke, heart attack, kidney failure Silent Must consider kidney artery blockage as culprit
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  • Risk Factors Tobacco Use The major modifiable risk factor Patients who smoke >15 cigarettes daily have a NINE-FOLD increase in risk of leg pain due to artery blockage Patients who smoke > 5 cigarettes daily close their leg artery bypass grafts more often than those patients who do not smoke
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  • Risk Factors High Cholesterol New medical studies suggest that lowering cholesterol levels can halt the progression or even SHRINK plaque in the leg arteries Lowering cholesterol levels DECREASES the risk of Stroke!
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  • Risk Factors Diabetes Mellitus Peripheral Artery Disease is FIVE TIMES more common in patients with DM 30 % of patients with DM have PAD Major limb amputation rate is FOUR TIMES HIGHER in patients with DM and PAD than with PAD alone
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  • Risk Factors Family History of PAD Clear risk factor for other first degree relatives Must make every effort to modify risk factors Early diagnosis is key
  • Slide 26
  • The Diagnosis and Treatment of Peripheral Vascular Disease Etiology Prevalence Risk Factors Diagnosis Treatment Options
  • Slide 27
  • What Symptoms do Patients Have With PAD? Leg Arteries Pain, Ache, Tightness, Tiredness, Weakness, Numbness in legs brought on by walking and relieved by rest (claudication) Pain in feet at rest due to poor circulation (rest pain) Poorly healing wound Gangrene
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  • What Symptoms do Patients Have With PAD? Claudication Symptoms manifests a level below the vascular lesion Lesion LocationClaudicating Muscle distal aortabuttocks common iliacthigh SFAcalf tibialsNONE!!
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  • How Do We Diagnose PAD? Listen to the story What kind of problems are you having? How long have you been having these problems? What makes the symptoms better/worse? Have you had any prior treatment for these problems? Are things getting worse?
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  • How Do We Diagnose PAD? Perform an examination Feel pulses Feel for aneurysms Listen for noises over arteries that can signify blockage Look at feet
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  • Elevation Pallor/Dependent Rubor
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  • Dont Wait For This To Happen...
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  • How Do We Diagnose PAD? Non-Invasive Testing Blood Pressure Cuffs Duplex Ultrasound Magnetic Resonance Arteriography Computed Tomographic Angiography
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  • The Ankle-Brachial Index
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  • Office Measurement of the AnkleBrachial Index (ABI) Highest arm pressure Pressure: PT DP Pressure: PT DP The ratio of: (over)
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  • Ankle Brachial Index > 0.9Normal 0.9 to 0.75Mild PVD 0.75 to 0.4 Moderate PVD (IC) < 0.4Severe Disease
  • Slide 37
  • AnkleBrachial Index and Mortality 70 75 80 85 90 95 100 105 1234 Number of Years of Follow-up Patient Survival,% >1 1.0->0.9 0.9->0.8


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