No Financial Disclosures
Adam M. Levine, D.O. FACC
Lourdes Cardiology Services
South Jersey Heart Group
September 13, 2014
• Who is at risk for development of PAD
• When and How to screen
• How to treat
• PAD affects 12-20% of Americans age 65 and older.1
• 12 million with PAD in the U.S. alone2
• 3x greater risk in those with diabetes over the age of
50.3
• 4x greater risk in current or past smokers. 1
1. Becker, GJ, et al. The Importance of Increasing Public and Physician Awareness of Peripheral
Arterial Disease. J Vasc interv Radiol 2002; 13[1];7-11.
2. “Peripheral Arterial Disease in People with Diabetes”, American Diabetes Association
Consensus Statement, Diabetes Care, Volume 26, Number 12, December 2003, 3333-3341.
3. “Diagnosis of PAD is Important for People with Diabetes”, American Diabetes Association
Consensus Statement, Diabetes Care, November 21, 2003, www.diabetes.org.
• Age less than 50 years with diabetes, and one
additional risk factor (e.g., smoking, dyslipidemia,
hypertension, or hyperhomocysteinemia)
• Age 50 to 69 years and history of smoking or diabetes
• Age 70 years and older
• Leg symptoms with exertion (suggestive of
claudication) or ischemic rest pain
• Abnormal lower extremity pulse examination
• Known atherosclerotic coronary, carotid, or renal
artery disease
• Asymptomatic, may have functional impairment
• Reproducible (typical) claudication
• Atypical Leg Pain
• Critical Limb Ischemia
• Rest pain, tissue loss, threatened limb loss
• Acute Limb Ischemia
• Pain, Pulseless, Pallor, Parasthesias, Paralysis
• 1.5-2 million people in the US and Europe suffer from CLI1
• Mortality rates for CLI patients2
•at one year : 25%
•two years : 31.6%
•three years : 60%
• 40-50 % amputation rate within 1st year of Dx. 3
1-2. “Conquering Critical Limb Ischemia”, Michael R. Jaff, DO and Giancarlo Biamino, MD, Endovascular Today, February
2004, Volume 3, No. 2
3.
Dormandy J.A., Heeck L., Vig S.: The fate of subjects with critical leg ischemia. Semin Vasc Surg 12. 142-147.1999;
Symptomatic and Asymptomatic PAD
Prior Diagnosis of PAD
Newly Diagnosed PAD
(n=457)
(n=366)
5.5
12.6
46.3
61.7
25.8
48.3
Claudication
No Symptoms
Hirsch AT et al. JAMA. 2001;286:1317-1324.
Non-Specific Symptoms
PARTNERS Study
Prognosis in Patients with
Intermittent Claudication
Population >55 yr
Intermittent
Claudication
Peripheral Vascular
Outcomes
Worsening
Claudication
16%
Lower Extremity
Bypass Surgery
7%
Adapted from Weitz JI et al.
Circulation. 1996;94:3026-3049.
Other Cardiovascular
Morbidity/Total Mortality
Major
Amputation
4%
Nonfatal
Cardiovascular
Event
(MI/Stroke,
5-year Rate)
20%
5-yr
Mortality
30%
Cardiovascular
Cause
75%
Does “Asymptomatic” PAD Really
Matter?
Coronary Artery Surgery Study (CASS) in patients with known CAD the
presence of PAD increased Cardiovascular mortality by 25% during a 10
yr follow-up
(J AM Coll Cardiol 1994:23:1091-5)

PAD, symptomatic or asymptomatic, is a powerful independent
predictor of CAD and CVD
(Vasc.Med.3,241,1998.)

• Claudication: Dull cramping or pain in muscles of hips, thighs
or calf muscles when walking, climbing stairs, or exercise
which is relieved with cessation of activity
• Fatigue in legs which may require patient to stop and rest while
walking
• Slow or shuffled gait & having difficulty keeping up with
others
• Neuropathy or pain in feet with exercise
• Rest pain or night pain that occurs when legs elevated in bed,
relieved when placed in dependent position. Typically in the
distal foot, possibly in vicinity of an ulcer
• Impotence may be a sign of iliac disease and may see some
relief with sildenafil citrate.
Differential Diagnosis of Exertional Leg Pain
• Vascular Causes Atherosclerosis
Thrombosis
Embolism
Vasculitis
Thromboangiitis obliterans
Takayasu arteritis
Giant cell arteritis
Aortic coarctation
Fibromuscular dysplasia
Irradiation
Endofibrosis of the external iliac artery
Extravascular compression
Arterial entrapment (e.g., popliteal artery entrapment,
thoracic outlet syndrome)
Adventitial cysts
• Cool, dry, atrophic skin on legs
• May have signs of cellulitis
•
•
•
•
•
•
Thickened or deformed nails-dystrophic
Hair loss or uneven distribution on legs
Muscle weakness or atrophy
Bruits on auscultation
Ulcers or wounds on lower extremities
Gangrene
• Pulse intensity should be assessed and should be recorded
numerically as follows:
•
•
•
•
0 - absent
1 - diminished
2 - normal
3 - bounding
 Non-invasive tests1






ABI (Ankle/Brachial Index)
Exercise Test
Segmental Pressures
Segmental Volume Plethysmography
Duplex Ultrasonography
MRA (Magnetic Resonance Arteriography),or CTA
 Invasive tests1
 Peripheral Angiography
1. Krajewski and Olin Chapter 11 Peripheral Vascular Disease. 2nd ed.
1996
I IIa IIb III
MODIFIED
The resting ABI should be used to establish the lower
extremity PAD diagnosis in patients with suspected
lower extremity PAD, defined as individuals with 1 or
more of the following: exertional leg symptoms,
nonhealing wounds, age ≥65 years, or ≥50 years with
a history of smoking or diabetes.
2011 ACC/AHA Guideline for Management of PAD
The Ankle-Brachial Index
ABI =
Lower extremity systolic pressure
Brachial artery systolic pressure
Normal
PAD
Rest pain/ulceration


0.95-1.2
<0.90
<0.40
The Ankle-Brachial Index is 95% sensitive and
99% specific for PAD
Both ankle and brachial systolic pressures are
obtained using a hand-held Doppler
instrument
Source: Peripheral Arterial Disease in People with Diabetes, ADA, Consensus
Statement, Diabetes Care, Volume 26, Number 12, December 2003.
Performing a resting ankle-brachial index measurement
ABI >1.30
(abnormal)
PVR, Toe-brachial index
Duplex ultrasonography
ABI 0.91 to1.30
(borderline &normal
Measure ABI
After exercise test
MRA, or CTA
Peripheral Angiography
ABI <= to 0.90
(abnormal)
Confirmation of PAD
diagnosis
Decreased post-exercise
ABI
Duplex ultrasonography
MRA,or CTA
Peripheral Angiography
Duplex ultrasonography
MRA,or CTA
Peripheral Angiography
Exercise ABI

Confirms the PAD
diagnosis

Assesses the
functional severity of
claudication

May “unmask” PAD
when the resting ABI
is normal
I IIa IIb III
• Duplex ultrasound of the extremities is useful to
diagnose anatomic location and degree of stenosis
of peripheral arterial disease.
• Duplex ultrasound is useful to provide surveillance
following femoral-popliteal bypass using venous
conduit (but not prosthetic grafts).
2011 ACC/AHA Guideline for Management of PAD
Arterial Duplex Ultrasound Testing
Duplex ultrasound of the extremities can
be used to select candidates for:
• endovascular intervention;
• surgical bypass, and
• to select the sites of surgical
anastomosis.
However, the data that might support use
of duplex ultrasound to assess long-term
patency of PTA is not robust.
• Duplex Ultrasound 3, 6, 12 months post and at yearly intervals
• Early Failure Rates 9-47% after PTA
• If recognized secondary patency rates > 90%
• Indications for restudy
• Worsening ABI ( 0.15) is an indication for restudy
• Decreased flow less then 40 cm/sec
• PSV >180 cm/sec, Vr > 2
I IIa IIb III
• MRA of the extremities is useful to diagnose
anatomic location and degree of stenosis of PAD.
• MRA of the extremities should be performed
with gadolinium enhancement. (Level of
Evidence: B)
• MRA of the extremities is useful in selecting
patients with lower extremity PAD as candidates
for endovascular intervention.
I IIa IIb III
• Computed tomographic angiography (CTA) of
the extremities may be considered to diagnose
anatomic location and presence of significant
stenosis in patients with lower extremity PAD.
• CTA of the extremities may be considered as a
substitute for magnetic resonance angiography
(MRA) for those patients with contraindications
to MRA.
Contrast angiography provides detailed information about arterial
anatomy and is recommended for evaluation of patients with lower
extremity PAD when revascularization is contemplated. (Class I, LOE B)
• Suspected PAD
• exertional leg symptoms
or non-healing wounds
• Age ≥65 years
• Age ≥50 years with a
history of smoking or
diabetes.
• ABI/PVR
• If normal and symptomatic
then Exercise ABI
•
•
•
•
Duplex ultrasound
MRA
CTA
Angiogram
• Risk Factor Modification
• Hypertension - BP < 140/90
• Diabetes – HgA1c ≤ 7%
• Hyperlipidemia – LDL ≤ 100
• Smoking Cessation
• Supervised Exercise Program (30-45 min/day, 3
days/week)
• Class I, LOE A
• Antiplatlet to reduce risk of MI, stroke, vascular death in PAD
• Symptomatic
• Aspirin (Class I, LOE B)
• Clopidogrel (Class I, LOE B)
• Asymptomatic
• If ABI ≤ 0.90 (Class IIa, LOE C)
• Cilostazol (Class I, LOE A)
• Indicated to improved symptoms and increase walking distance in PAD
• Contraindicated in CHF
• 100mg BID
• Endovascular
• Advantage
•
•
•
•
Local anesthesia
No vein grafts needed
Fast recovery
Potential for Hybrid
approach
• Disadvantage
• Lower Patency rates
• Need for repeat procedures
• Surgical
• Advantage
• Less interventions
• Better patency
• Disadvantage
•
•
•
•
General anesthesia
Need vein grafts
Longer recovery
Higher systemic
complications
1 year
primary
patency
2 year
primary
patency
58%
51%
Stents
65-85%
55-68%
Bypass
77-81%
66-77%
Percutaneous
Transluminal
Angioplasty (PTA)
Source: J Endovas There 2004;11(suppl II):II-107-II-127 “Lower Extremity Endovascular Interventions” Bates and AbuRahma
• Who is at risk for development of PAD
• Diabetes, known vascular disease, Smokers, Older age
• When and How to screen
• Exertional leg symptoms or nonhealing wounds
• Anyone age ≥65 years or ≥50 years with a history of smoking or
diabetes.
• ABI and doppler ultrasound is first line
• How to treat
• Aspirin, exercise, risk factor modification, cilostazol, revascularization
• Prevention is KEY!!!!!
• When in doubt, refer to your local vascular
specialist.