Peripheral Vascular Disease
Review For The General Surgeon
Elizabeth Pensler, DO
Vascular Surgery
Kansas City Review April 3-5th 2014
Peripheral Vascular Disease
• A disorder that compromise
blood flow to the limbs
• The prevalence of PVD
increases with age
– 3% in persons younger than 60
years
– More than 20% in person 75
years or older
• Long term survival is reduced in pts with PVD
– Risk of death 2 – 4 fold (due to MI, CVA)
– Pts with claudication have a 10 year survival of 50%
– Pts with critical limb ischemic have 10 years survival of
25%
Risk Factors
• The risk factors are
similar to those that
cause CAD
• These include :
– Cigarette smoking
– Diabetes
– Dyslipidemia
– HTN
– Hyperhomocytinemia
– Family History
Risk Factors
Cigarette Smoking:
– Developing intermittent claudication 2 – 5
fold higher in smokers than non-smokers
– Continued smoking : increases the risk
of progression from stable claudication
to severe limb ischemia and
amputation.
– (2 – 4% of pts with claudication develop
critical ischemia vs. 4 – 6 % in smokers)
Risk Factors
Diabetes
– Diabetes is associated with 3 – 4 fold increase
developing PVD
– Infrapopliteal
– Prognosis is poor for diabetics who with claudication;
30 – 40 % will develop critical limb ischemia in 6 years
(vs 10 –20 years of non-diabetics)
Risk Factors
Dyslipidemia
– Hypercholesterolemia in 40% of pts
with PVD
– Hypertriglyceridemia
– HTN: increases risk of claudication 2
folds in man and 4 folds in women.
– Hyperhomocystinemia: increases risk
of PVD by 2 fold.
Claudication
• Latin claudicare “to limp”
• Ischemic pain lower legs when walking
• Inadequate blood flow leg muscles from
atherosclerotic narrowing of the arteries
• Annual incidence is 20 per 1,000 in persons
older than 65 years.
Claudication - Evaluation
History
• Acuteness of symptom onset
• Ambulating distance before onset of pain
• Whether pain is relieved by standing
Physical Exam
• quality of femoral, popliteal, dorslis pedis pulses
• signs of arterial insufficiency - coolness, scaling,
paleness (especially with leg elevation), or ulcer
• ankle-brachial index (ABI)
Clevland Clinic J of Med, 1997; 64:429-436
Clinical Presentation
• Intermittent Claudication:
• Discomfort, pain, fatigue or heaviness
that is felt in the affected extremity
during walking and resolved at resting.
• The location of the symptoms depend on
the site of stenosis
– Thigh, hip or buttock claudication (and
impotence) develops with proximal
occlusions – aorta or iliac arteries
– Calf claudication develops with femoral
and popliteal arteries occlusions.
– Pedal Claudication – tibial and peroneal
stenoses
• Rest Pain :
– Pain typically in the toes and foot
– initially worse at night with persistent
severe ischemia
– Skin breakdown occurs, leading to
ulcerations, necrosis and gangrene
Ischemia in Right Foot
Intermittent Claudication
Clinical Features
• Symptoms always exertional
• Muscular discomfort: Fatigue, aching,
cramping
• Reproducible distance
• Relief by standing still (minutes)
• Location of discomfort aids in localizing
disease
• Diagnosis – pre / post – exercise ABI
Intermittent Claudication Differential
Diagnosis
Onset
Claudication
Walking
Pseudoclaudication
Standing & Walking
Character
Cramp, Pain
“Parasthetic”
Bilateral
+/-
+
Walking Distance
Minor Variable
Cause
Fairly
Constant
PVO
Relief
Standing still
Sit down, lean forward
Spinal stenosis
PVD-Tests
• ABI
• Segmental B.P. measurement to assess the
presence and severity of PVD
• Pulse volume recording (Plethysmography)
• Duplex ultrasonography
• MRI
• Angiography
Ankle: Brachial Index (ABI)
Supine systolic BP: Ankle / Brachial
– Normal ABI  1.0
– Medial calcinosis (incompressability)
falsely elevate ankle pressure
– Low ABI (<0.9) associated increased risk for
• Stroke
• Cardiovascular death
• All cause mortality
Ankle: Brachial Index (ABI)
Disease Severity
ABI (rest)
None
> 1.0
Minimal
0.9 – 1.0
Mild (claudication)
< 0.9
Moderate (claudication)
0.5 – 0.8
Severe (ischemia at rest)
< 0.5
Intermittent Claudication
5 Years Outcome
• Mortality
29%
• Claudication improves or stable 55%
• Amputation
4%
Anm Vasc. Surg evt 3: 273, 1989.
Claudication - Natural History
• Symptoms remain stable or improve with time 65% 70% due to development of collateral vessels.
• < 25% ever need surgery or angioplasty.
• Low risk of losing a limb - only 1.4% per year
progress to critical life-threatening ischemia
• Diabetes increased overall amputation risk of 20%
Intermittent Claudication
Increased Risk of Limb Loss
•
•
•
•
•
Tobacco use
Diabetes mellitus
Ischemic rest pain
Ischemic ulceration
Gangrene
Intermittent Claudication
Initial Management
• Aggressive modification of risk factors
– Tobacco, diabetes, HTN, lipids
• Diagnosis and treatment of associated
– CAD (prevalence > 50%)
– Carotid artery disease
• Foot care and protection
• Weight reduction (if obese)
• Walking program
TASC II Recommendations for Lipid Control
in Patients with Peripheral Arterial Disease
Patient Characteristics
Recommendation
Symptomatic PAD
PAD and CAD
Asymptomatic PAD and no other
clinical evidence of cardiovascular
diseaseLower
All symptomatic PAD
LDL <100 mg/dL
LDL<70 mg/dL
<100 mg/dL
PAD and abnormal lipid fractions
Consider fibrates, niacin, or both to
raise HDL levels and lower
triglyceride levels
Dietary modification
Statins—primary agents to lower
Hypertension
• Associated with a 2-3X risk of PAD
• RF for stroke, CAD, CHF and CRF
• < 140/90 mm Hg in high-risk groups (PAD)
• < 130/80 mm Hg diabetes or renainsufficiency
• Normotensive state
• Multiple agents for control
Effect of Diabetes Mellitus
• Amputation value (cumulative risk 25 years)
– IDDM
11.2%
– NIDDM 11.0%
• 12 – fold increase risk: BKA
• 400 – fold increase risk: transphalangeal
amputation
• Account for 60% of amputations in a
community
Intermittent Claudication
Outcome After 5 Years (Quitting Smoking)
Continued (%)
Stopped (%)
Mortality
27
12
Major
Amputation
11
0
Claudication
Stable
40
56
Ann Vasc Surgery 3:273, 1989
Intermittent Claudication
Pharmacologic Therapy
• Antiplatelet therapy
– Aspirin
• Reduces risk of amputation
• Reduces ischemic events
• Reduces risk for revascularizaton
– Clopidogrel
• 8.71% relative risk reduction compared to aspirin.
Pharmacotherapy for Claudication
FDA Approved Drugs:
• Pentoxifylline
• Cilostazol
There is inadequate evidence of clinical efficacy or a therapeutic role for:
L-arginine, propionyl-L-carnitine, gingko biloba, oral prostaglandins,
vitamin E, or chelation therapy.
Effect of Cilostazol on Walking Distance
in Patients With Claudication
*
260
*
240
*
220
*
Meters (mean)
200
*
*
180
160
*
*
*
*
140
*
120
*
100
*
80
*
*
*
*
*
*
*
Maximal
Walking Distance
Cilostazol 100 mg bid
(n=140)
Cilostazol 50 mg bid
(n=139)
Placebo (n=140)
Pain-Free
Walking Distance
* P < 0.05 vs. placebo
60
0
4
8
12
16
20
Weeks of Treatment
24
Beebe, et al. Arch Internal Medicine. 1999;159:2041-50.
Cilostazol vs. Pentoxifylline:
Relative Efficacy to Improve Walking Distance in Claudication
Cilostazol 100 mg 2 times/day (n=227)
Pentoxifylline 400 mg 3 times/day (n=232)
Placebo (n=239)
Percentage Change From
Baseline MWD (mean)
50
40
*
30
20
10
0
0
4
8
12
16
Treatment (weeks)
20
24
MWD=maximal walking distance.
*P<0.001 vs pentoxifylline.
Reprinted from Dawson DL, et al. Am J Med. 2000;109:523-530 with permission from Elsevier.
Pharmacotherapy of Claudication
I IIa IIb III
Cilostazol (100 mg orally two times per
day) is indicated as an effective
therapy to improve symptoms and
increase walking distance in patients
with lower extremity PAD and
intermittent claudication (in the
absence of heart failure).
Intermittent Claudication:
Exercise Therapy (Supervised)
• Frequency: 3–5 supervised sessions/week
• Duration: 35–50 minutes of exercise/session
• Type of exercise: treadmill or track walking
to near-maximal claudication pain
• Length: 6 months
• Results: 100%–150% improvement in maximal
walking distance and associated improvement
in quality-of-life
Stewart KJ et al. N Eng J Med. 2002;347:1941-1951.
SURGICAL AND INTERVENTIONAL
TREATMENT OPTIONS
Arterial reconstructions
Endarterectomy
Patch angioplasty
Bypass (autologous vein graft, prosthetic graft)
Endovascular techniques
Thrombectomy
Atherectomy
Balloon angioplasty
Stent placement
Endograft (covered stent)
Indications for Revascularization
• Elective
– Disabling (life style limiting) symptoms
• Indication to the physician
– Diabetes with significant disease
– Ischemic foot pain
– Ischemic ulceration
– Gangrene
Percutaneous Transluminal Angioplasty
• Peripheral arteries
–
–
–
–
Mortality 0.5%
Mobility 1 – 3 days
initial good results > 80% (iliac)
2 – 3 years good results > 70%
• Best results in
– Short, partial occlusions
– Proximal disease
– Good distal run – off
Clinical Variables Favoring
Vascular Surgery
•
•
•
•
•
Long, diffusely stenotic, eccentric lesions
Long occlusions
Stenoses adjacent to aneurysms
Tibial occlusive lesions
Lesions causing atheromatous embolism
• Vein is best