The Diagnosis and
Treatment of Peripheral
Vascular Disease
The Diagnosis and Treatment of
Peripheral Vascular Disease
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



Etiology
Prevalence
Risk Factors
Diagnosis
Treatment Options
The Diagnosis and Treatment of
Peripheral Vascular Disease

Etiology

Prevalence
Risk Factors
Diagnosis
Treatment Options
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The Pathophysiology of
Atherosclerosis and Thrombosis
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
Ross R. N Engl J Med. 1999; 340:115-126.
Ischemia leads to
painful symptoms,
cell death, and
results in physical
impairment
Major Manifestations of Vascular
Disease and Thrombotic Events
•
Ischemic stroke
•
Transient ischemic attack
•
Myocardial infarction
Angina pectoris (stable, unstable)
•
•
•
Peripheral arterial disease
Critical limb ischemia, rest pain,
gangrene, necrosis
Overlap of Atherosclerotic Diseases
Coronary
Artery
Disease
Cerebrovascular
Disease
40%
15%
16%
9.1%
11%
3%
6%
38% overlap
of 2 vascular beds
Ness, Aronow. JAGS. 1999;47:1255-56.
Peripheral Arterial Disease
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)
Stroke
TIA
ACS
PAD
0.73
1
3
0.50
6
Prevalence
(Millions)
Mortality/Yr
(%)
2
2
4.6
4
4.9
2†
2.3 *
12.6
---
8-12
7
28
5
6.3
45
8
2‡
9§
4 ,25
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?
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
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
How Common is PAD?

Responsible for:
 275,000 hospital admissions
per year
 Over 2,750,000 office visits
per year
 Approximately 45,000 deaths
per year
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
How Common is PAD?
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More than 700,000 new STROKES
occur each year
 Approximately
20% are Recurrent
Aneurysms of the Abdominal Aorta
(AAA)
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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
Prevalence of PAD Increases with Age
Rotterdam Study (ABI
1 <0.9)
San Diego Study
(PAD by noninvasive tests)
2
Percentage of
Patients with PAD
60
50
40
30
20
10
0
55-59
60-64
65-69
70-74
75-79
80-84
85-89
Age Group
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.
Mortality in Patients
With Severe PAD
Relative 5-Year Mortality
100.0
Patients (%)
80.0
60.0
44
38
40.0
48
15
20.0
0.0
²Breast
Cancer
²Colon/Rectal
Cancer
Belch JJF. Arch Intern Med 2003;163::884-92
¹PAD
²Non-Hodgkin’s
Lymphoma
PAD and Relative Risk of Death
Relative Risk (95% CI)
10.0
5.9
(3.0-11.4)
8.0
6.0
6.6
(2.9-14.9)
3.1
(1.9-4.9)
4.0
2.0
0.0
All Causes
Cardiovascular
Disease
Coronary Heart
Disease
Cause of Death in Patients with PAD
Belch JJF. Arch Intern Med 2003;163::884-92
Peripheral Arterial Disease
Symptomatic Disease
34%
Asymptomatic Disease
66%
Hiatt WR. N Engl J Med. 2001;344:1608-1621.
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?
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Hypertension
Tobacco Use
High Cholesterol
Diabetes Mellitus
Family History
CAD
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

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
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!
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
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

The Diagnosis and Treatment of
Peripheral Vascular Disease

Etiology
Prevalence
Risk Factors

Diagnosis

Treatment Options


What Symptoms do Patients
Have With PAD?
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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
What Symptoms do Patients
Have With PAD?

Claudication
 Symptoms
manifests a level below the
vascular lesion
 Lesion Location
Claudicating Muscle
 distal aorta
buttocks
 common iliac
thigh
 SFA
calf
 tibials
NONE!!
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?
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
Elevation Pallor/Dependent Rubor
Don’t Wait For This To
Happen...
How Do We Diagnose PAD?

Non-Invasive Testing
 Blood Pressure Cuffs
 Duplex Ultrasound
 Magnetic Resonance Arteriography
 Computed Tomographic Angiography
The Ankle-Brachial Index
Office Measurement of
the Ankle–Brachial Index (ABI)
The ratio of:
Highest
arm
pressure
(over)
Pressure:
PT
DP
Pressure:
PT
DP
Ankle – Brachial Index
> 0.9
Normal
0.9 to 0.75
Mild PVD
0.75 to 0.4
Moderate PVD (IC)
< 0.4
Severe Disease
Ankle–Brachial Index and Mortality
~1500 Women Over Age 65 in Osteoporosis Study
105
100
95
Patient 90
Survival,% 85
>1
1.0->0.9
0.9->0.8
<0.8
80
75
70
1
2
3
Number of Years of Follow-up
Vogt MT et al. JAMA 1993;270:465-469.
4
Peripheral Arterial Disease
Duplex Ultrasound of Common Femoral Artery Bifurcation
From lateral to medial the anatomic order is:
Nerve, Artery, Vein, Empty space, Lymphatics
(NAVEL)
Magnetic Resonance Arteriography
Saccular AAA
Angiogram
Severe Right
Common Iliac
Artery Stenosis
Inferior Epigastic Artery
External Iliac
Artery
Internal Iliac Artery
Common femoral artery
Angiogram of an AAA
The Diagnosis and Treatment of
Peripheral Vascular Disease

Etiology
Prevalence
Risk Factors
Diagnosis

Treatment Options

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
What Are the Indications for
Therapy?
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Critical Limb Ischemia
Ischemic Ulceration
Disabling Claudication
Medical Therapy for
Intermittent Claudication

Symptom/Limb
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Tobacco Cessation
Foot Care
Control of DM
Statins
Antiplatelet Agents
Exercise
Cilostazol
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Life

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Tobacco Cessation
Control of DM
Reduction in Cholesterol
Reduction in BP
Antiplatelet Agents
Exercise
Angioplasty and Stenting of the
Iliac Arteries
Balloon Angioplasty of the SFA
If plaque burden is too great for angioplasty , Femoral
to Popliteal artery bypass with vein (preferabl) or PTFE
is indicated.