The Voyage to Peripheral
Arterial Disease
Management…Are We
Missing the Boat?
Carol Bohanon DNP, FNP-BC,
CWS, CFCN
September, 2014
Disclosure
Relevant Financial Relationships
NONE
Off-Label Investigational Uses
NONE
Objectives
• Identify signs & symptoms of lower
extremity peripheral arterial disease
(PAD)
• Significance of early recognition and
treatment options for PAD
• Discuss tests and interventions
specific to arterial disease
• Describe pharmacologic therapies for
treatment of arterial disease
• Review arterial wound care
Resources
Guideline Statements for PAD:
 Management of Patients With Peripheral Artery
Disease (Compilation of 2005 and 2011
ACCF/AHA Guideline Recommendations). J
Am Coll Cardiol. 2013;60:1555-70.
 Inter-Society Consensus for the Management
of Peripheral Arterial Disease (TASC II). J Vasc
Surg. 2007;45 Suppl S:5A–67A.
 Performance measures for adults with
peripheral artery disease. J Am Coll Cardiol.
2010;56:2147-81.
Arterial Disease of
the Lower
Extremity
Arterial Occlusive Disease
• Plaque in arterial blood vessel wall
narrows over time
Arterial Occlusive Disease
Asymptomatic:
Claudication:
reproducible pain or tightness in calf or thigh after walking a
certain predictable distance
Rest Pain:
pain that occurs with advanced atherosclerosis when limbs
are in a supine position
Tissue Damage:
not enough oxygen to support tissue growth, ulcer occurs
Clinical Presentation of PAD
Acute Lim b
Ischem ia
Chronic Lim b
Ischem ia
Stable
Claudication
Asym ptom atic
PAD
Adapted from Hirsch AT. Fam Pract Recertification. 2000;15(suppl):6-12.
Survival for PAD patients
Overall Mortality Rate: Claudicant patient 2.5 x ↑
SURVIVAL
FOR
PAD
PATIENTS
IC: intermittent claudication CLI: critical limb ischemia J Vasc Surg 2007;45,Suppl S
Risk Factors
Race: Non-Hispanic blacks (2 fold)
Gender: Male 2:1
Age: > 65 (2 fold)
Smoking (3 fold)
Diabetes mellitus (4 fold)
Hypertension
J Vasc Surg 2007; 45, Suppl S
Risk Factors
Dyslipidemia (2 fold)
Inflammatory markers
Hyperviscosity & hypercoagulable
state
Hyperhomocysteinemia
Chronic renal insufficiency
Good History &
Examination
Must specifically ask about leg
pain, claudication, and rest pain
symptoms
Many patients/family think it is a
normal part of aging.
Arterial Disease Presentation
Atrophic, shiny skin
Lack of pedal hair
Yellow, thickened nails
Decreased pulses
Ulcers
Edema of extremity – dependency
INTERMITTENT CLAUDICATION
“Exertional pain
involving the calf that
impedes walking,
resolves within 10
minutes of rest, and
neither begins at rest
nor resolves on
walking”
“Rose Criteria” Bull World Health Organ 1962;27:645-58
Intermittent Claudication
 Exertional pain:
“Fatigue”
“Cramping”
“Tightness”
 Calf > Thigh > Buttock
 Relief with standing
 Symptoms consistent
from day to day
Differentiating True from Pseudoclaudication
Variable
Character
Exertional
Symptoms
with standing
Relief
Distance
to symptoms
Intermittent
Claudication
Pseudoclaudication
Cramp, tight, fatigue
Tingling, weak, clumsy
yes
yes or no
no
yes
Stop, stand
Must sit
Consistent
Inconsistent
Arterial Pulse Exam
0 = absent pulse
1 = faint, but detectable
2 = reduced – can count pulse
3 = normal pulse
4 = bounding
Lower Extremity Arterial Pulse Exam
A: Femoral
B: Popliteal (medial)
C: Dorsalis pedis
D: Post-tibial
• Indicate presence of bruit
• Symmetrical
• Asymmetrical
Ankle Brachial Index (ABI)
Categorize Severity Using ABI Criteria
(Ankle Brachial Index)
Severity
Resting ABI ’s
Normal
1.00- 1.4
Borderline
0.91-0.99
Mild
0.80-0.90
Moderate
0.50-0.80
Severe
<0.50
Values > 1.4 “non-compressible”
JACC 2013;61:14
Ankle Brachial Index (ABI)
ABI=
Lower extremity systolic pressure
Highest brachial artery systolic pressure
Right Arm
Pressure
136 mm Hg
Highest Right
Pedal Pressure
154 mm Hg
Right ABI
154/140= 1.1
Left Arm
Pressure
140 mm Hg
Highest Left
Pedal Pressure
54 mm Hg
Left ABI
54/140 = 0.4
Scenarios where ABI lack accuracy:
• Non compressible vessels
• Elderly
• Diabetes
• Renal failure
• Iliac artery disease (isolated internal
iliac)
• If claudication symptoms and normal
ABI, exercise ABI should be done.
Circulation 2006;113;e463
Arterial Vascular Study
Doppler Waveform
Normal Doppler Arterial Signal
Triphasic
Biphasic
Abnormal Doppler Arterial Signal
Reduced Bi.
Monophasic
Absent
Transcutaneous Oximetry (TcP02)
Supine (15 minutes)
Elevation (3 minutes)
Dependent (10 minutes)
Healing range
Grey zone
Unlikely to heal
>40
20 to 40
<20
Survival is directly related with
ABI severity
J Vasc Surg 2007;45 Suppl S:5A
Coexisting Vascular Disease
• Coronary artery disease
(44.6 %)
25% symptomatic
• Cerebral artery disease
(16.6 %)
• Renal artery disease
(23-42%)
> 50 % stenosis
J Vasc Surg 2007;45,Suppl S
60 year-old man is evaluated for a 1 year history
of progressive right leg pain. Vascular
examination reveals diminished pedal pulses.
Which of the following features will be most
useful to distinguish between intermittent
claudication and pseudoclaudication?
1. History of nicotine addiction
2. Symptoms brought on by exertion
3. Soft bruit over the right common femoral artery.
4. ABI of 0.8 on the right and 0.85 on the left.
5. Symptom relief with sitting only
60 year-old man is evaluated for a 1 year history
of progressive right leg pain. Vascular
examination reveals diminished pedal pulses.
Which of the following features will be most
useful to distinguish between intermittent
claudication and pseudoclaudication?
1. History of nicotine addiction
2. Symptoms brought on by exertion
3. Soft bruit over the right common femoral artery.
4. ABI of 0.8 on the right and 0.85 on the left.
5. Symptom relief with sitting only
Arterial Disease Initial Treatment
Risk Factor Modification:
Reduce high cholesterol
Tobacco cessation
Tight glucose control
Reduce hypertension
Avoid sedentary lifestyle
Claudication Treatment
TASC II Guidelines:
• Cilostazol (Pletal) 100 mg PO daily
• First-line pharmacotherapy (3 – 6 months)
for the relief of claudication symptoms
(Inter-Society Consensus for the
Management of. Peripheral Arterial
Disease (TASC II)
• Drug class: Antiplatelet agent
• Contraindicated in patients with heart
failure
TASC II J Vasc Surg 2007;45 Suppl S:5A
J Am Coll Cardiol 2011;58 (19)
Claudication Treatment
TASC II Guidelines:
• Pentoxifylline (Trental) 400 mg ORALLY
three times a day with meals
• Considered second-line alternative
• Class: Hemorheologic
• Reduces blood viscosity and improves
erythrocyte flexibility, microcirculatory
flow, and tissue oxygen concentrations
TASC II J Vasc Surg 2007;45 Suppl S:5A
J Am Coll Cardiol 2011;58 (19)
Morbidity Reduction
GOAL: reduce risk of MI, stroke, & vascular
death in individuals with symptomatic (IC, CLI,
IR or surgical revasc, amputation related to
ischemia) & NONSYMPTOMATIC lower
extremity PAD with ABI ≤ 0.90
Aspirin 325 mg daily and/or
Clopidogrel 75 mg daily
Assess bleeding risk
NO benefit of anticoagulation therapy (warfarin)
TASC II / JACC 2011;58(19)
Non-diabetic 76 year-old male with remote
tobacco use presents with claudication at 3
block, reduced biphasic Doppler signals,
and ABI of .89. No hx of CHF or ulcers. Initial
treatment should include:
1. Encourage activity
2. Cilostazol 100 mg BID
3. Monitor & treat risk factors for PAD
4. Appropriate antiplatelet therapy
5. All of the above
Non-diabetic 76 year-old male with remote
tobacco use presents with claudication at 3
block, reduced biphasic Doppler signals,
and ABI of .89. No hx of CHF or ulcers. Initial
treatment should include:
1. Encourage activity
2. Cilostazol 100 mg BID
3. Monitor & treat risk factors for PAD
4. Appropriate antiplatelet therapy
5. All of the above
CLEVER Study
Supervised Exercise vs Stenting for Intermittent
Claudication
Patients: Intermittent claudication due to aorto-iliac PAD
Supervised exercise
111 patients
Primary Stenting
Optimal medical management (cilostazol)
Primary efficacy outcome assessed @ 6 months
Circulation. 2012;125:130-9.
Conventional Angiography
Advantages
• Most sensitive
(calcified vessels)
• Angioplasty/stenting
Disadvantages
• Invasive
• Iodinated contrast
• Bad outcome
1:1000
CLEVER STUDY
SUPERVISED EXERCISE VS STENTING FOR
INTERMITTENT CLAUDICATION
Patients: Intermittent claudication due to aorto-iliac PAD
Change in peak walking time @ 6 months
P-value
Supervised exercise:
5.8 ± 4.6 minutes
0.04
Stenting:
3.7 ± 4.9 minutes
0.001
0.02
Opt med therapy (cilostazol):
1.2 ± 2.6 minutes
Circulation. 2012;125:130-9.
Treatment Guidelines:
Canadian Walking Program
• Supervised exercise should be part of the
initial treatment for all PAD patients
• Treadmill or track walking to reproduce
symptoms
 30 – 60 minutes/session,
 3 sessions per week
 for 3 months
TASC II J Vasc Surg 2007;45 Suppl S:5A
J Am Coll Cardiol 2010;56;2147
Indications for Revascularization
Absolute:
Rest Pain
Non-healing ulceration
Relative:
Life-style limiting symptoms
Diagnose PAD
Risk Factor Modification
No limitation
Life-style limiting
claudication
Exercise
program
Critical limb ischemia*
Define anatomy: Angiogram, CTA, MRA
Revascularize: Endovascular, Surgical
*rest pain, non-healing ulcers, gangrene
CT Angiography
Advantages
• Non-Invasive
• Accuracy
• Multi-assessment
Disadvantages
• No angioplasty/stenting
• Iodinated contrast
MR Angiography
Advantages
• Non-invasive
• No iodinated contrast
Disadvantages
• Less Specific
(overcalls stenoses)
• No angioplasty/stenting
• Nephrogenic systemic fibrosis
Creatinine clearance cutoff: 30 ml/min
5 Year Primary Patency Rates
Angioplasty±Stenting
Bypass Grafting
80%
80%
Iliac
70%
Vein
60%
50%
20%
Synthetic
Femoral
Popliteal
Tibial
70%
60%
65%
40%
50%
10%
BYPASS VERSUS ANGIOPLASTY IN
SEVERE ISCHAEMIA OF THE LEG (BASIL)
TRIAL:
Severe lower limb ischemia (rest pain, ulceration, gangrene)
Bypass surgery
452 patients
Balloon angioplasty
J Vasc Surg 2010;51:5S-17S
BYPASS VERSUS ANGIOPLASTY IN SEVERE
ISCHAEMIA OF THE LEG (BASIL) TRIAL:
Amputation-free survival
Overall survival
J Vasc Surg 2010;51:5S-17S
Treatment Guidelines:
Critical limb ischemia
• Estimated life expectancy ≤ 2 years or
autogenous vein is not available, balloon
angioplasty is reasonable (II B)
• Estimated life expectancy > 2 years and
autogenous vein is available, bypass
surgery is reasonable (II B)
JACC 2011;58:2020
Consultation with Vascular
Surgeon or Interventional
Radiologist
Angioplasty
Revascularize when possible
 Endovascular angioplasty
and/or stenting
(proximal/smokers)
 Surgical arterial bypass
(distal/diabetes)
Bypass surgery
Poor Invasive or Surgical
Candidate
Medical comorbidity
Lack of suitable outflow
vessel
Patient preference
Therapies to augment
arterial blood flow
Cardiac gaited pump
Circulator Boot ®
Non-cardiac Gaited Pumps
ArtAssist™
Plexi- Pulse ®
Aircast Arterial Flow ®
Arterial Ulcers Therapy
Hyperbaric Oxygen Therapy
(HBOT)
Indicated and insurance payment for:
Osteomyelitis
Diabetic ulcers not moving
toward closure after 30
days
Acute traumatic ischemia
Enhancement of healing in
selected problem wounds,
infection
78 year-old nondiabetic man with thigh/calf
claudication, smoker, renal cancer, Cr 0.9 who
presents with a traumatic plantar surface foot
ulcer. Doppler signals are abnormal at the
superficial femoral level with TCPO2s of 30/10/40,
pulse exam: fem 3, pop 1. Most expedient
treatment to improve arterial blood flow:
1. Medical management with supervised Canadian
walking program
2. Arterial pumping of the lower extremity
3. Angiogram +/- angioplasty/stenting
4. Vascular surgical consult for distal pedal
arterial bypass
78 year-old nondiabetic man with thigh/calf
claudication, smoker, renal cancer, Cr 0.9 who
presents with a traumatic plantar surface foot
ulcer. Doppler signals are abnormal at the
superficial femoral level with TCPO2s of 30/10/40,
pulse exam: fem 3, pop 1. Most expedient
treatment to improve arterial blood flow:
1. Medical management with supervised Canadian
walking program
2. Arterial pumping of the lower extremity
3. Angiogram +/- angioplasty/stenting
4. Vascular surgical consult for distal pedal
arterial bypass
Treatment of
Arterial Ulcers
Arterial Ulcers
•Discrete edge
•Pale base / eschar
• Atrophic skin
• Lack of pedal hair
• Severe pain – rest pain
• Located on heel, toe, foot, trauma
Arterial ulcers
• Optimize blood flow
•
•
•
•
•
Proactive care
Natural warmth
Control edema
Consider debridement
Pain Management
Indications for Amputation
Absolute:
Severe rest pain with no revascularization
option
Limb gangrene
Life threatening infection
Relative:
Life-style limiting symptoms
Amputation for Critical Limb
Ischemia
Below knee:
• 10% perioperative mortality
mortality rate @ 1 year = 25%
• 60% primary healing rate
• 15% will need future AKA
TASC II J Vasc Surg 2007;45 Suppl S:5A
Wound Dressing Decision Tree
Dry Wound
Hydrogel:
Curasol
Wound’ Dres,
Silvasorb,
Biafine
Minimal Wound
Drainage
Hydrogels:
Curasol, Woun’Dres,
Silvasorb, Biafine
Gauze:
Xeroform, Excilon,
Nu Gauze, Adaptic
Alginates:
Sorbsan, Restore,
Kaltostat , Algicell
Hydrofibers
Aquacel, Aquacel AG,
Maxorb AG
Iodosorb:
Mixed with Curasol
Collagen:
Fibracol, Promogran,
Prisma, Medifil
Moderate Wound
Drainage
Hydrogels:
Curasol, Woun’Dres,
Silvasorb, Biafine
Gauze:
Xeroform, Excilon,
Nu Gauze, Adaptic,
Curasalt, Gauze
Alginates:
Sorbsan, Restore,
Kaltostat , Algicell
Hydrofibers
Aquacel, Aquacel AG,
Maxorb AG
Iodosorb:
Mixed with Curasol
Collagen:
Fibracol, Promogran
Prisma, Medifil
Heavy Wound
Drainage
Infected Wound
Iodosorb
Alginates:
Sorbsan, Restore,
Kaltostat , Algicell
Hydrofibers
Aquacel, Aquacel AG,
Maxorb AG
Foam:
Allevyn, Mepilex,
Mepilex Lite
Collagen:
Fibracol, Promogran
Prisma, Medifil
Iodosorb
Gauze with:
NS, DABS,
Acetic Acid, Dakin’s
Change 3-4x/ day
Silver Dressings:
Aquacel AG, Prisma,
Silverlon, Acticoat 7,
Maxorb AG
WOUND FILLERS
 Absorbent
 Moist healing environment
 Facilitates debridement
 Eliminates dead space
 Softens eschar and liquefies slough
 Easy to apply
WOUND FILLERS
Difficult to remove
Not for dry eschar or light
exudate
(unless goal is to desiccate
the ulcer bed)
Can dehydrate wound bed
Requires secondary dressing
Not for deep or sinus tracting
wounds
Take home points
Early identification of peripheral
arterial disease
Early intervention of peripheral
arterial disease
Proactively protect from injury
Do not hydrate/macerate eschar
(dead tissue)
Do not debride if moderate to severe
ischemia
Treatment Options
Identify etiology of wound and treat
appropriately
Create proper wound environment
for healing
Current therapies available
Goals of the patient
Insurance rules
Atypical Arterial Disease
 Thromboangiitis Obliterans/Buerger’s
disease
 Nonatherosclerotic, segmental,
inflammatory (vasculitis), occlusive
disease that affects the small & medium
arteries and veins and is strongly
associated with tobacco exposure
(cigarettes, cannabis, tobacco chewing)
Demographics:
 Young smokers
 15 - 45 years old
 Male (9:1)
Presentation:
 Foot claudication
 Rest pain / Digital ulcers
 Superficial phlebitis
Upper extremity involvement
Variable
Buerger’s
Disease
Premature
Atherosclerosis
Upper Extremity
Yes
No
Foot Claudication
Yes
No
Phlebitis
Yes
No
Tobacco
Yes
Yes
Age
< 40
> 40
Treatment
 Smoking cessation
 Digit protection
 Arterial pumping
 Non-surgical candidate
 Wound care
 Auto amputation