Peripheral Arterial Disease (PAD):

Diagnosis and Management

Peter J Mackrell, MD

Chief: Division Vascular Surgery

Co-Director: Vascular Lab

Sinai Hospital

WHY?

• Affects approximately 8-12 million Americans

• If positive risk factors prevalence of 29%

• Patients with PAD and no known CAD have 30%

risk of MI, stroke, vascular death over 5 years

Why?

• Often asymptomatic

• Early identification can save lives and limbs

• Poorly taught in all specialties

• Crosses many specialties

Who

• Elderly

• CAD

• Smokers

• Diabetics

• ESRD

• High Cholesterol

• Family history

• HTN

• Male

Anatomy

Leg Pain Differential

• Vascular

-Arterial

-Venous

• Musculoskeletal

-arthritis

• Neurogenic

-spinal stenosis

-DJD

Symptoms

None Claudication

-pain calf,buttock

-ambulation

-consistent

Limb Threatening Ischemia

-rest pain

-ulcer

-gangrene

Claudication

Pain

-with walking-hills versus flat

-calves/thighs/buttocks

-consistent

-reproducible

-resolved with standing vs sitting

-no pain when recumbent

Rest Pain

Pain

-Often at night/lying flat

-More distal pain/feet

-Relieved by gravity/walking

Evaluation

• Inspection-hair

-capillary refill

-cyanosis/rubor

-edema

-nails

-foot architecture/callouses

-cellulitis

-ulcers

-gangrene

Palpation

Sitting

Supine

PE Findings Suggestive of PVD

• Decreased Pulses

-Femoral

-Popliteal

-Dorsalis Pedis

-Posterior Tibial

• Muscle atrophy/hair loss/nail changes

• Dependent Rubor

• Ulcers/Gangrene

Indirect Physiologic Tests consists of:

• Pressure assessment– ABI and/or segmental pressures

• ( or) Doppler waveform analysis

Segmental pressure principle

• In a normal individual in a supine position, ankle systolic pressure is ≥ brachial pressure.

The Ankle/Brachial Index

(ABI)

• bilateral ankle pressures divided by the higher brachial pressure

• Dorsalis Pedis– easily compressed

– harder to locate

Doppler Pressure Sites for ABI

• Posterior Tibial• harder to compressharder to compress

• easier to locate

• Posterior Tibial• harder to compressharder to compress

• easier to locate

Essential not to drift off vessel !

Brachial pressure

ABI

Resting ABI values

• > 1.0 = normal (usually)

• < 0.92 = abnormal, – exercise patient if borderline

• < 0.8 = probable claudication

• < 0.5 = multi-level disease or long segment occlusion

• < 0.3 = ischemic rest pain

The bane of pressure measuremements:

• Calcific medial sclerosis

– diabetics – chronic steroid therapy – renal dialysis patients – elderly patients

• Segmental pressures unobtainable or excessively high

• In these patients use toe pressures– >40 mmHg for tissue healing in diabetics– >20 mmHg for tissue healing in non-diabetics

Doppler waveform analysis:Normal lower arterial waveforms

are “triphasic”

Analog, low-cost zero-crossing detector

Doppler Waveform analysis: Interpretation

• Abnormal: • loss of triphasic waveform• dampening of amplitude• slow upstroke

CFA

SFA

ABI Interpretation

ABI

0.92 normal

0.50-0.91 claudication

0.3-0.5 rest pain

<0.3 ulcer/gangrene

Non-compressible

Toe Pressure

>20 mmHg non-diabetic

>40 mmHg diabetic

PE Findings Suggestive of PVD

• Decreased Pulses

-Femoral

-Popliteal

-Dorsalis Pedis

-Posterior Tibial

• Muscle atrophy/hair loss/nail changes

• Dependent Rubor

• Ulcers/Gangrene

Diagnosis of PVD

• Duplex US

• Angiography

• MRA

Treatment of PVD

• Medical Therapy

•Antiplatelet Tx\

• Statins

• Risk factor Mgt

• Foot Care

-moisturizers

-footware

• STOP SMOKING!!!!

• Walking Program

• Pharmacologic Tx-Pletal

Treatment of PVD

• Medical Therapy

• Open Surgery

• Endovascular Repair

Surgical RevascularizationAorto-iliac ASO

Excellent patency

Operative mortality 3.3%

Peri-op morbidity 8.3%

Meta-analysis - Meta-analysis - DeVriesDeVriesJVS 1997;26:558-69JVS 1997;26:558-69

PTA of Iliac Arteries

AUTHOR TECHNICAL SUCCESS

Colapinto (1986) 78%

Gupta (1993) 78%

Johnston (1987) 82%

Vorwerk (1995) 81% *

Blum (1993) 98% * — 71% in 1st 50 patients

— 93% in 2nd 50 patients

Stenting of Iliac Arteries

• Palmaz 1992 92% (1 yr)

• Sullivan 1997 84% (2 yrs)

AuthorAuthor Date Date Patency Patency

PTA Versus Stents

Limited data

4 yr patency stents = 94%

4 yr patency PTA = 69%

Richter et al Radiology Richter et al Radiology 19911991181 Supplement181 Supplement

AORTO-ILIAC ASOSUMMARY

Focal disease – endovascular therapy

More complex disease

Good risk – surgical revascularization

Poor risk – endovascular

OUTCOME OF THERAPY FOR FEM-POP ASO - CLAUDICATION

Method/indication 5-yr patency

PTA-stenosis 68%

PTA-occlusion 35%

Fem-pop bypass – vein 80%

Fem-pop bypass – AK PTFE 75%

Fem-pop bypass – BK PTFE 65%

Fem-pop and tibialSUMMARY

Focal disease – endovascular therapy

More complex disease

Good risk – surgical revascularization

Poor risk – endovascular

Claudication - open surgery

Tissue Loss - endovascular therapy