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Dan Varga, MD discloses that he has
nothing to disclose.
The ABCs of Vascular Disease
What is it?
Agenda
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Peripheral Vascular Disease (PVD) defined
What is PAD (Peripheral Artery Disease)?
– PAD Risk Factors
– Signs + Symptoms of Advanced PAD
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PVD Conditions
Symptomatic + Asymptomatic PAD
CLI (Critical Limb Ischemia)
Amputation Impact
Vascular Screening Recommendations
Vascular Tests – Diagnosis of PAD
– Non-invasive
– Invasive
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The MultidisciplinaryTeam
PAD Treatment Options
Vascular Center Organization Chart
Conclusion
What is Peripheral Vascular Disease?*
Peripheral Vascular Disease (PVD) refers to diseases of blood vessels
outside the heart and brain. It's often a narrowing of vessels that carry blood
to the legs, arms, stomach or kidneys. There are two types of these
circulation disorders:
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Functional peripheral vascular diseases don't have an organic cause. They
don't involve defects in blood vessels' structure. They're usually short-term
effects related to "spasm" that may come and go. Raynaud's disease is an
example. It can be triggered by cold temperatures, emotional stress,
working with vibrating machinery or smoking.
•
Organic peripheral vascular diseases are caused by structural changes in
the blood vessels, such as inflammation and tissue damage. Peripheral
artery disease is an example. It's caused by fatty buildups in arteries that
block normal blood flow.
* PVD definition is from the American Heart Association
Peripheral Artery Disease (PAD)
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PAD is most commonly caused by
atherosclerotic plaque build up in
the arteries. The plaque causes
obstruction to blood flow in the
extremities of the body, such as the
legs.
PAD affects 12-20% of Americans
age 65 and older.
Only 25% of PVD patients are in
treatment.
14-18 million have PAD (in the US)
3x greater risk for diabetics over the
age of 50
4x-5x higher risk of dying from a
cardiovascular event
Diagnostic + Therapeutic Interventional
Peripheral Vascular Disease Procedures
(actual + forcasted)
4,500,000
4,000,000
3,500,000
3,000,000
Period
Change:
28%
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
2004
Source: Meditech Insights “U.S. Markets for Interventional Peripheral Vascular Products”
2009
PAD Risk Factors
NON-MODIFIABLE RISKS:
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Age. The risk of limb loss due to PAD increases with age. People 65 or older are two to three times
more likely to have an amputation.
Gender. Men with PAD are twice as likely to undergo an amputation as women.
Race/ethnicity. Some racial and ethnic groups have a higher risk of amputation (i.e., African
Americans, Latino Americans, and Native Americans). This is because they are at increased risk for
diabetes and cardiovascular disease.
Family history of heart disease. A family history of cardiovascular disease is an indicator for risk at
developing PAD.
MODIFIABLE RISKS:
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Cigarette smoking. Smoking is a major risk factor for PAD. Smokers may have four times the risk
of PAD than nonsmokers.
Obesity. People with a Body Mass Index (BMI) of 25 or higher are more likely to develop heart
disease and stroke even if they have no other risk factors.
Diabetes mellitus. Having diabetes puts individuals at greater risk of developing PAD as well as
other cardiovascular diseases.
Physical inactivity. Physical activity increases the distance that people with PAD can walk without
pain and also helps decrease the risk of heart attack or stroke. Supervised exercise programs are
one of the treatments for PAD patients.
High blood cholesterol. High cholesterol contributes to the build-up of plaque in the arteries, which
can significantly reduce the blood's flow. This condition is known as atherosclerosis. Managing
cholesterol levels is essential to prevent or treat PAD.
High blood pressure. When blood pressure remains high, the lining of the artery walls becomes
damaged. Many PAD patients also have high blood pressure.
High levels of Homocysteine. This is an amino acid found in plasma (blood). Some recent studies
show higher levels are associated with PAD.
Signs + Symptoms of Advanced PAD
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Pain in the toes or feet. This is called rest pain and occurs because the
body is unable to deliver enough blood to the feet at rest. Rest pain usually
worsens when the legs are elevated, and may be relieved by lowering the
legs. When the legs are unable to get the nutrition needed for growth and
repair, gangrene or death of the tissue can occur.
Decreased hair growth on the legs
Paleness of the leg or foot when elevated
Blue/red discoloration of the foot when hanging down
Absence of pulses in the foot
Numbness, tingling, or pain in the foot, toes or leg
Decreased ability to spread the toes and move the foot
Cool temperature of the foot and leg
A sore on the foot that does not heal
Fatigue in legs which may require may require patient to stop and rest while
walking.
Slow or shuffled gait + having difficulty keeping up with others.
Impotence may be a sign of iliac disease and may see some relief with
sildenafil citrate.
Vascular Conditions
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Abdominal Aneurysm
Aortoiliac Disease
Upper Extremity Disease
Carotid Artery Disease
Claudication
Deep Vein Thrombosis
Diabetic Problems
Hyperlipidemia
Lymphedema
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Mesenteric Ischemia
Peripheral Aneurysm
Peripheral Arterial Disease
Pulmonary Embolism
Renovascular Conditions
Thoracic Aneurysm
Thoracic Outlet Syndrome
Varicose Veins
Venous Insufficiency
Symptomatic + Asymptomatic PAD
Hirsh AT et al. JAMA. 2001; 289: 1317-1324
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-year
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)
PAD
severity
ABI
Mortality Rate
/ CAD Death
(10 year)
None
WNL
11%
Mild to
Moderate
0.9 - 0.6
40%
Moderate
to Severe
< 0.6
60%
Critical Limb Ischemia (CLI)
• CLI affects 2 million Americans who
are at risk for amputation of the
toes, feet + legs
• 40% of amputees die within 2 years
• CLI causes persistently recurring
rest pain requiring regular analgesia
• CLI is a non-healing ulceration or
gangrene of the foot or toes.
Threatened limb loss or tissue loss
• Rutherford Becker Categories 4 – 6
– 4: Ischemic rest pain
– 5: minor tissue loss, e.g. nonhealing ulcer, focal gangrene
– 6: major tissue loss, i.e. above
transmet level
CLI: Vascular Compromise
(Impact + Mortality)
• Often due to diffuse, multi-level
arterial involvement
• Frequently involves infra-popliteal
arteries with sever diffuse disease
and/or total occlusion
– Diabetics often have entirely infrapopliteal disease
Mortality rates for CLI
patients at:
One year
25.0%
Two years
31.6%
Three years
60.0%
Amputation Impact
• International Diabetes Federation estimates that somewhere in the
world, a leg is lost to diabetes every 30 seconds
• The risk of leg amputation is 15-40 times greater for a person with
diabetes
• Each year there are 150,000 lower extremity amputations with a
$270 million price
Source: American Cancer Society, American Heart
Association, Alzheimer's Disease Education / Referral
Center, American Diabetes Association, SAGE Group.
Does “Asymptomatic” PAD Really Matter?
Vascular Screening Recommendations
• ADA Consensus Panel
recommends ABI Screening
for:
– Patients over the age of 50
years who have diabetes
– Patients with diabetes younger
than 50 years of age who
have other PAD risk factors
(i.e. smoking, hypertension,
hyperlipidemia, diabetes more
than 10 years)
• ABI should be repeated in 5
years if normal
• If ABI is abnormal, then patient
should be referred
• TASC II recommends ABI
Screening for:
– All patients who have
exertional leg symptoms
– All patients between the age
of 50-69 and who have a
cardiovascular risk factor
– All patients age greater than
70 years regardless of risk
factor status
– All patients with a
Framingham risk score of
10%-20%
Vascular Tests – Diagnosis of PAD
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Non-invasive techniques
– ABI (Ankle/Brachial Index)
– Exercise Test
– Segmental Pressures
– Segmental Volume
Plethysmography
– Duplex Ultrasonography
– CT Angiogram
– MRA (Magnetic Resonance
Arteriography)
– Carotid Doppler identifies
patients who are at risk for
stroke
– Vascular ultrasound
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Invasive techniques
– Peripheral Angiograms
– CT Angiograms
– MR Angiograms
PAD Diagnosic Test:
ABI (Ankle-Brachial Index)
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Simple, reliable means for diagnosing
PAD. Blood pressure measurements
are taken at the arms and ankles using
a Doppler.
The ABI test is simple enough to be
performed in any doctor's office.
Inexpensive equipment and
reimbursable tests.
Please note: Blood-flow waveform
analysis must be included for Medicare
reimbursement. CPT 93922 provides
coverage for a single-level lower
extremity physiologic study. Test must
be diagnosed as medically necessary
(e.g. leg pain when walking).
Sample vendors that meet
reimbursement criteria:
– LifeDop ABI ($2,000)
– PADnet ($22,000 – auto transmission)
Medicare
Reimbursement of
CPT Code 93922
= $97 - $165
(depending on
location)
Normal ABI Exceptions
• Normal resting ABI does not exclude PAD in patients
with symptoms of PAD
– Exercise induced claudication
• Patients with diabetes with arterial claudication
– Toe pressures
PAD Diagnostic Test:
Segmental Pressures
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Similar to the ABI plus 2 or 3 additional
blood pressure cuffs. These additional
cuffs are placed just below the knee and
one large cuff or two narrow cuffs are
placed above the knee and at the upper
thigh. These cuffs are then inflated above
your normal systolic blood pressure, and
then slowly deflated.
Using the Doppler instrument, a significant
drop in pressure between two adjacent
cuffs indicates a narrowing of the artery or
blockage along the arteries in this portion
of your leg. This allows the physician to
identify more precisely the location of such
blockages in the arteries of your leg.
PAD Diagnostic Test:
Duplex Scanning
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Duplex Scanning = a combination of real-time
and Doppler ultrasonography
Purpose: to evaluate arterial and venous
disorders noninvasively.
The most common application for the
examination is to determine the presence of deep
vein thrombosis (DVT) in the extremity, usually
because of leg swelling.
The deep veins are examined every 1-2 cm and
gentle pressure is applied with the scan head to
demonstrate that the walls of the vein can be
easily collapsed. When thrombus is present
there is little if any compressibility. The flow
patterns are also assessed with Doppler
recording. The presence or absence of venous
valve insufficiency is assessed with compression
maneuvers of the extremity.
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TYPES OF
DUPLEX SCANS:
Extracranial
Cerebrovascular
Abdominal
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Renal
Aortoiliac
Mesenteric
Arterial
Venous Duplex
Scan Upper and
Lower Extremities
The Team
The Team
• Podiatry
– Care directly for patients with CLI
• Wound Care: Medication, Debridement, HBO, Skin
Grafting, Limited Amputation
• Identify Patients who may benefit from
revascularization…for claudication as well as for CLI
• Serve as “Gate Keeper/PCP” as 70% of patients with
PAD also have CAD , Carotid Disease, other vascular
disease (AAA, RAS)
The Multidisciplinary Team
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Interventional Cardiology
Committed to Endovascular Revascularization
– Management of Dyslipidemia
– Screening for CAD: nuclear stress testing
– Evaluation of carotid disease: stenting vs. CEA
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Interventional Radiology
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Committed to Endovascular Revascularization
Experts in Vascular Imaging
Screening for Vascular Disease in other areas
Experts in Endovascular Therapy for other Vascular areas
Surgery
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Committed to Endovascular Revascularization
Experts in Vascular Disease
Screening for Vascular Disease in other areas
Can offer both Open and Endovascular Revascularization
Experts in Vascular Imaging
MOST PATIENTS WITH PAD DIE FROM MI OR STROKE
PAD Treatment Options
• Medical
– Risk Factor Modification
– Exercise Therapy
– Drug Therapy
• Endovascular Therapy
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Peripheral Transluminal Therapy
Peripheral Stenting
Angioplasty
Laser
Cryoplasty
Atherectomy
Thrombolic Therapy (adjunctive)
• Surgery
– Bypass Grafts
– Amputation
– Endarterectomy
AAA Screening
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Medicare now pays for this!
Class 1 Indication: Current or prior
Smoking history, male, age 65-75
Ultrasound, CT or MRA all acceptable, but
cost argues for ultra sound
Medical Care of the PAD Patient
• Remember: You are treating a systemic disease
Medical Care of the PAD Patient
• Most PAD patients will die of cardiovascular disease
distant from the affected limb.
• Five year MI risk of mild claudicants exceeds that of a MI
survivor!
• CLI patients have an exceptionally poor prognosis—
average survival less than one year in some series.
Medical Care of the PAD Patient
• Antiplatelet agents
--ASA or Clopidogrel; both in high risk patients only
• Lipid lowering agents
--PAD is a CAD risk equivalent; LDL target is ,100
--Statins are the preferred agent
• Blood Pressure targets are also secondary prevention
targets
Vascular Center Organizational Chart
Thank you.