Going out on a Limb: Peripheral Arterial Disease in Primary Care

Adam M. Levine, D.O. FACC

Lourdes Cardiology Services

South Jersey Heart Group

September 13, 2014

No Financial Disclosures

Goals

• Who is at risk for development of PAD

• When and How to screen

• How to treat

Peripheral Artery Disease (PAD)• 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.

Defining a Population “At Risk” for Lower Extremity PAD

• 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

Presentations in Clinical Practice

• 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

CLI Impact and Mortality

• 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;

61.7

12.6

25.8

Symptomatic and Asymptomatic PAD

PARTNERS StudyHirsch AT et al. JAMA. 2001;286:1317-1324.

Prior Diagnosis of PAD

(n=366)

46.3

5.5

48.3

Claudication No Symptoms Non-Specific Symptoms

Newly Diagnosed PAD

(n=457)

Prognosis in Patients with Intermittent Claudication

Peripheral VascularOutcomes

Other CardiovascularMorbidity/Total Mortality

Lower ExtremityBypass Surgery

7%

MajorAmputation

4%

WorseningClaudication

16%

Population >55 yr

IntermittentClaudication

NonfatalCardiovascular

Event(MI/Stroke, 5-year Rate)

20%

5-yrMortality

30%

CardiovascularCause75%

Adapted from Weitz JI et al.

Circulation. 1996;94:3026-3049.

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.)

Symptoms of PAD

• 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

Symptoms of PAD

• 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

ThrombosisEmbolismVasculitisThromboangiitis obliteransTakayasu arteritisGiant cell arteritisAortic coarctationFibromuscular dysplasiaIrradiationEndofibrosis of the external iliac arteryExtravascular compressionArterial entrapment (e.g., popliteal artery entrapment,

thoracic outlet syndrome)Adventitial cysts

Visual Cues to PAD and Arterial Insufficiency• 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

The First Tool to Establish the PAD Diagnosis:The HPI, ROS, and Physical Examination

• Pulse intensity should be assessed and should be recorded numerically as follows:• 0 - absent• 1 - diminished• 2 - normal• 3 - bounding

PAD Diagnostic TestsNon-invasive tests1

ABI (Ankle/Brachial Index) Exercise TestSegmental PressuresSegmental Volume PlethysmographyDuplex UltrasonographyMRA (Magnetic Resonance Arteriography),or CTA

Invasive tests1

Peripheral Angiography

1. Krajewski and Olin Chapter 11 Peripheral Vascular Disease. 2nd ed. 1996

Recommendations for ABI, Toe-Brachial Index, and Segmental Pressure Examination

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.

MODIFIED

I IIa IIb III

2011 ACC/AHA Guideline for Management of PAD

The Ankle-Brachial Index

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

Normal 0.95-1.2PAD <0.90

Rest pain/ulceration <0.40

ABI = Lower extremity systolic pressure Brachial artery systolic pressure

Source: Peripheral Arterial Disease in People with Diabetes, ADA, ConsensusStatement, Diabetes Care, Volume 26, Number 12, December 2003.

The Ankle-Brachial Index

Performing a resting ankle-brachial index measurement

ABI >1.30(abnormal)

ABI 0.91 to1.30(borderline &normal

ABI <= to 0.90(abnormal)

Confirmation of PAD diagnosis

Measure ABIAfter exercise test

PVR, Toe-brachial indexDuplex ultrasonography

Decreased post-exerciseABI

Duplex ultrasonographyMRA,or CTA

Peripheral Angiography

Duplex ultrasonographyMRA,or CTA

Peripheral Angiography

MRA, or CTAPeripheral Angiography

Exercise ABI

Confirms the PAD diagnosis

Assesses the functional severity of claudication

May “unmask” PAD when the resting ABI is normal

Arterial Duplex Ultrasound Recommendations

• 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).

I IIa IIb III

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.

Surveillance post Bypass or Endovascular Procedure• 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

Magnetic Resonance Angiography

• 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

• 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.

I IIa IIb III

Lower Extremity AngiographyContrast 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)

Summary of Diagnostic tests

• 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

Treatment

• 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

Pharmacotherapy

• 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

Revascularization Options

• 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

Comparative Intervention Treatment Options

1 year primary patency

2 year primary patency

Percutaneous Transluminal Angioplasty (PTA)

58% 51%

Stents 65-85% 55-68%

Bypass 77-81% 66-77%

Source: J Endovas There 2004;11(suppl II):II-107-II-127 “Lower Extremity Endovascular Interventions” Bates and AbuRahma

Summary

• 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

Conclusion

• Prevention is KEY!!!!!

• When in doubt, refer to your local vascular specialist.