the diagnosis and treatment of peripheral vascular disease

The Diagnosis and The Diagnosis and Treatment of Treatment of Peripheral Peripheral

Vascular DiseaseVascular Disease

The Diagnosis and The Diagnosis and Treatment of Peripheral Treatment of Peripheral

Vascular DiseaseVascular Disease EtiologyEtiology PrevalencePrevalence Risk FactorsRisk Factors DiagnosisDiagnosis Treatment OptionsTreatment Options

The Pathophysiology of The Pathophysiology of Atherosclerosis and Atherosclerosis and

ThrombosisThrombosis

Pathologic Progression Pathologic Progression of PADof 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

impairmentRoss R. N Engl J Med. 1999; 340:115-126.

• Ischemic strokeIschemic stroke• Transient ischemic attackTransient ischemic attack

• Myocardial infarctionMyocardial infarction• Angina pectoris (stable, unstable)Angina pectoris (stable, unstable)

•

Peripheral arterial diseasePeripheral arterial disease

• Critical limb ischemia, rest pain, Critical limb ischemia, rest pain, gangrene, necrosisgangrene, necrosis

Major Manifestations of Major Manifestations of Vascular Disease and Vascular Disease and Thrombotic EventsThrombotic Events

CoronaryArtery

Disease

CerebrovascularDisease

Peripheral Arterial Disease6%6%

16%16%40%40%

11%11% 3%3%

15%15%

9.1%9.1%

38% overlap of 2 vascular beds

Overlap of Overlap of Atherosclerotic DiseasesAtherosclerotic Diseases

Ness, Aronow. Ness, Aronow. JAGS.JAGS. 1999;47:1255-56. 1999;47:1255-56.


Vascular DiseaseVascular Disease EtiologyEtiology

PrevalencePrevalence Risk FactorsRisk Factors DiagnosisDiagnosis Treatment OptionsTreatment Options

Atherothrombotic Disease Atherothrombotic Disease in the USin the USAnnualAnnual

IncidenceIncidence(Millions)(Millions)

PrevalencePrevalence(Millions)(Millions)

Mortality/YrMortality/Yr(%)(%)

StrokeStroke 0.730.7311

4.64.622

282822

TIATIA 0.500.5033

4.94.944

6.36.355

ACSACS 2.32.366** 12.612.6

2†2†4545

2‡2‡

PADPAD ------ 8-128-1277

4488,25,25

9§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.

How Common is PAD?How Common is PAD? 1 in 4 Americans1 in 4 Americans have some form of have some form of

Cardiovascular DiseaseCardiovascular DiseaseOver 70 Million AmericansOver 70 Million Americans

Cardiovascular Disease accounts for Cardiovascular Disease accounts for more annual deaths than Cancer, more annual deaths than Cancer, Infection, and Trauma Infection, and Trauma COMBINEDCOMBINED

Responsible for:Responsible for:275,000 hospital admissions 275,000 hospital admissions

per yearper yearOver 2,750,000 office visits Over 2,750,000 office visits

per yearper yearApproximately 45,000 deaths Approximately 45,000 deaths

per yearper year

How Common is PAD?How Common is PAD?

Carotid Artery StenosisCarotid Artery Stenosis

Responsible for 35% of all strokesResponsible for 35% of all strokes The major cause of loss of independent life The major cause of loss of independent life

for patients for patients First symptom may be a catastrophic strokeFirst symptom may be a catastrophic stroke

How Common is PAD?How Common is PAD?

More than More than 700,000700,000 new STROKES new STROKES occur each yearoccur each yearApproximately 20% are RecurrentApproximately 20% are Recurrent

Aneurysms of the Abdominal Aneurysms of the Abdominal Aorta (AAA)Aorta (AAA)

A silent killerA silent killer Ninth leading cause of death in the U.S.Ninth leading cause of death in the U.S. FamilialFamilial Often causes no symptoms until ruptureOften causes no symptoms until rupture George C. Scott recently died of a George C. Scott recently died of a

ruptured abdominal aortic aneurysmruptured abdominal aortic aneurysmAlbert EinsteinAlbert Einstein

Prevalence of PAD Increases Prevalence of PAD Increases with Agewith Age

0

10

20

30

40

50

60

55-59 60-64 65-69 70-74 75-79 80-84 85-89

Age Group

Rotterdam Study (ABI <0.9) San Diego Study (PAD by noninvasive tests)

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.

Per

cen

tag

e o

f P

atie

nts

wit

h P

AD

1 2

0.0

20.0

40.0

60.0

80.0

100.0

0.0

20.0

40.0

60.0

80.0

100.0

Mortality in Mortality in Patients With Patients With Severe PADSevere PAD

Mortality in Mortality in Patients With Patients With Severe PADSevere PAD

15151515

3838383844444444

48484848

Relative 5-Year MortalityRelative 5-Year MortalityRelative 5-Year MortalityRelative 5-Year Mortality

Belch JJF. Arch Intern Med 2003;163::884-92Belch JJF. Arch Intern Med 2003;163::884-92

²Breast ²Breast CancerCancer²Breast ²Breast CancerCancer

²Colon/Rectal ²Colon/Rectal CancerCancer

²Colon/Rectal ²Colon/Rectal CancerCancer

¹PAD¹PAD¹PAD¹PAD ²Non-Hodgkin’s ²Non-Hodgkin’s LymphomaLymphoma

²Non-Hodgkin’s ²Non-Hodgkin’s LymphomaLymphoma

Pat

ien

ts (

%)

Pat

ien

ts (

%)

Pat

ien

ts (

%)

Pat

ien

ts (

%)

0.0

2.0

4.0

6.0

8.0

10.0

All Causes CardiovascularDisease

Coronary HeartDisease

0.0

2.0

4.0

6.0

8.0

10.0

All Causes CardiovascularDisease

Coronary HeartDisease

PAD and Relative Risk of PAD and Relative Risk of DeathDeath

PAD and Relative Risk of PAD and Relative Risk of DeathDeath

Cause of Death in Patients with PADCause of Death in Patients with PADCause of Death in Patients with PADCause of Death in Patients with PAD

3.13.1(1.9-4.9)(1.9-4.9)

3.13.1(1.9-4.9)(1.9-4.9)

5.9 5.9 (3.0-11.4)(3.0-11.4)

5.9 5.9 (3.0-11.4)(3.0-11.4)

6.66.6(2.9-14.9)(2.9-14.9)

6.66.6(2.9-14.9)(2.9-14.9)

Belch JJF. Arch Intern Med 2003;163::884-92Belch JJF. Arch Intern Med 2003;163::884-92

Rel

ativ

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isk

(95%

CI)

Rel

ativ

e R

isk

(95%

CI)

Rel

ativ

e R

isk

(95%

CI)

Rel

ativ

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isk

(95%

CI)

Peripheral Arterial Peripheral Arterial DiseaseDisease

Hiatt WR. N Engl J Med. 2001;344:1608-1621.

Asymptomatic Disease

66%

Symptomatic Disease

34%


Vascular DiseaseVascular Disease EtiologyEtiology PrevalencePrevalence

Risk FactorsRisk Factors DiagnosisDiagnosis Treatment OptionsTreatment Options

What Diseases Put People What Diseases Put People at at

Risk for PAD?Risk for PAD? HypertensionHypertension Tobacco UseTobacco Use High CholesterolHigh Cholesterol Diabetes MellitusDiabetes Mellitus Family HistoryFamily History CADCAD

Risk Risk FactorsFactorsHypertensiHypertensi

onon Increases stiffness of arteriesIncreases stiffness of arteries Promotes narrowing of blood vesselsPromotes narrowing of blood vessels Increases risk of stroke, heart attack, kidney Increases risk of stroke, heart attack, kidney

failurefailure SilentSilent Must consider kidney artery blockage as culpritMust consider kidney artery blockage as culprit

Risk Risk FactorsFactors

Tobacco Tobacco UseUse

The major modifiable risk factorThe major modifiable risk factor Patients who smoke Patients who smoke >15 cigarettes>15 cigarettes daily daily

have a NINE-FOLD increase in risk of leg have a NINE-FOLD increase in risk of leg pain due to artery blockagepain due to artery blockage

Patients who smoke Patients who smoke > 5 cigarettes> 5 cigarettes daily daily close their leg artery bypass grafts more close their leg artery bypass grafts more often than those patients who do not smokeoften than those patients who do not smoke


High High CholesterolCholesterol

New medical studies suggest that lowering New medical studies suggest that lowering cholesterol levels cancholesterol levels can halt the progression halt the progression or even SHRINK plaqueor even SHRINK plaque in the leg arteriesin the leg arteries

Lowering cholesterol levelsLowering cholesterol levels DECREASESDECREASES the risk of Stroke!the risk of Stroke!


Diabetes Diabetes MellitusMellitus

Peripheral Artery Disease isPeripheral Artery Disease is FIVE TIMESFIVE TIMES more common in patients with DMmore common in patients with DM

30 % of patients with DM have PAD30 % of patients with DM have PAD Major limb amputation rate isMajor limb amputation rate is FOUR FOUR

TIMESTIMES HIGHER in patients with DM and HIGHER in patients with DM and PAD than with PAD alonePAD than with PAD alone


Family History of PADFamily History of PAD

Clear risk factor for other first degree relativesClear risk factor for other first degree relatives Must make every effort to modify risk factorsMust make every effort to modify risk factors Early diagnosis is keyEarly diagnosis is key


Vascular DiseaseVascular Disease EtiologyEtiology PrevalencePrevalence Risk FactorsRisk Factors

DiagnosisDiagnosis Treatment OptionsTreatment Options

What Symptoms do What Symptoms do Patients Have With Patients Have With

PAD?PAD? Leg ArteriesLeg Arteries

Pain, Ache, Tightness, Tiredness, Pain, Ache, Tightness, Tiredness, Weakness, Numbness in legs brought on by Weakness, Numbness in legs brought on by walking and relieved by rest (walking and relieved by rest (claudicationclaudication))

Pain in feet at rest due to poor circulation Pain in feet at rest due to poor circulation ((rest painrest pain))

Poorly healing woundPoorly healing wound GangreneGangrene

What Symptoms do What Symptoms do Patients Have With Patients Have With

PAD?PAD? ClaudicationClaudication

Symptoms manifests a level below the Symptoms manifests a level below the vascular lesionvascular lesion

Lesion LocationLesion Location Claudicating MuscleClaudicating Muscle distal aortadistal aorta buttocksbuttocks common iliaccommon iliac thighthigh SFASFA calfcalf tibialstibials NONE!!NONE!!

How Do We Diagnose PAD?How Do We Diagnose PAD?

Listen to the storyListen to the story What kind of problems are you having?What kind of problems are you having? How long have you been having these How long have you been having these

problems?problems? What makes the symptoms better/worse?What makes the symptoms better/worse? Have you had any prior treatment for these Have you had any prior treatment for these

problems?problems? Are things getting worse?Are things getting worse?


Perform an examinationPerform an examination Feel pulsesFeel pulses Feel for aneurysmsFeel for aneurysms Listen for noises over arteries that can Listen for noises over arteries that can

signify blockagesignify blockage Look at feetLook at feet

Elevation Pallor/Dependent Elevation Pallor/Dependent RuborRubor

Don’t Wait For This To Don’t Wait For This To Happen...Happen...


Non-Invasive TestingNon-Invasive Testing Blood Pressure CuffsBlood Pressure Cuffs Duplex UltrasoundDuplex Ultrasound Magnetic Resonance ArteriographyMagnetic Resonance Arteriography Computed Tomographic AngiographyComputed Tomographic Angiography

The Ankle-Brachial The Ankle-Brachial IndexIndex

Office Measurement ofOffice Measurement of the Ankle–Brachial the Ankle–Brachial

Index (ABI)Index (ABI)

Highest arm pressure

Pressure: PT DP

Pressure:PTDP

The ratio of:

(over)

Ankle – Brachial Ankle – Brachial IndexIndex

>> 0.9 0.9 NormalNormal

0.9 to 0.750.9 to 0.75 Mild PVDMild PVD

0.75 to 0.40.75 to 0.4 Moderate PVD Moderate PVD

(IC)(IC)

<< 0.4 0.4 Severe DiseaseSevere Disease

Ankle–Brachial Index and Ankle–Brachial Index and MortalityMortality

70

75

80

85

90

95

100

105

1 2 3 4

Number of Years of Follow-up

Patient Survival,% >1

1.0->0.90.9->0.8<0.8

Vogt MT et al. JAMA 1993;270:465-469.

~1500 Women Over Age 65 in Osteoporosis Study

Peripheral Arterial Peripheral Arterial DiseaseDiseaseDuplex Ultrasound of Common Femoral Artery Bifurcation

From lateral to medial the anatomic order is: Nerve, Artery, Vein, Empty space, Lymphatics (NAVEL)

Magnetic Resonance Magnetic Resonance ArteriographyArteriography

Saccular AAA

AngiogramAngiogram

Severe Right Common Iliac

Artery Stenosis

External Iliac Artery

Inferior Epigastic Artery

Internal Iliac Artery

Common femoral artery

Angiogram of an AAAAngiogram of an AAA


Vascular DiseaseVascular Disease EtiologyEtiology PrevalencePrevalence Risk FactorsRisk Factors DiagnosisDiagnosis

Treatment OptionsTreatment Options

What Are the Indications What Are the Indications for Therapy?for Therapy?

Critical Limb IschemiaCritical Limb Ischemia Ischemic UlcerationIschemic Ulceration Disabling ClaudicationDisabling Claudication

Medical Therapy for Medical Therapy for Intermittent Intermittent ClaudicationClaudication

Symptom/LimbSymptom/Limb Tobacco CessationTobacco Cessation Foot CareFoot Care Control of DMControl of DM StatinsStatins Antiplatelet AgentsAntiplatelet Agents ExerciseExercise CilostazolCilostazol

LifeLife Tobacco CessationTobacco Cessation Control of DMControl of DM Reduction in CholesterolReduction in Cholesterol Reduction in BPReduction in BP Antiplatelet AgentsAntiplatelet Agents ExerciseExercise

Angioplasty and Stenting Angioplasty and Stenting of the Iliac Arteriesof the Iliac Arteries

Balloon Angioplasty of the Balloon Angioplasty of the SFASFA

If plaque burden is too great for angioplasty , Femoral to Popliteal artery bypass with vein (preferabl) or PTFE is indicated.

the diagnosis and treatment of peripheral vascular disease

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