Peter P. Monteleone, MD

Peripheral Arterial Disease Diagnosis and Treatment of the Ischemic Limb

To that end…

•  Claudication

•  Criticallimbischemia(CLI)

•  Acutelimbischemia(ALI)

Before we get there… Scope and the “incidence of PAD”

•  Whodoweevenneedtosort?

•  Howdowedefinethepopulationofpatientswithperipheralarterialdisease?

• Weknowitwhenweseeit…•  Buthowwouldwelookforit?•  Andshouldwelookforit?

•  Anklebrachialindexasatestablesurrogate?

ABI/PVR

Segmental ABI

Segmental ABI

>1.4-non-compressible

0.91-1.4-“normal”

0.71-0.9-mildPAD

0.41-0.7-moderatePAD

0-0.4-severePAD

What a straightforward… easy to perform… inexpensive test! Should we screen everyone with an ABI?

If the question is…

•  ShouldwescreeneveryonewithanABIsothateveryonewithasevereblockagecangetastentorabypass?

•  theanswerisastrongNO

•  ShouldwescreeneveryonewithanABIsothateveryonewithPADcanbemedicallytreatedtopreventanincreasedriskofcardiovascularmorbidity/mortality?

•  TheanswerisastrongMAYBE

USPTF 2014

USPTF 2014

Like we said…

•  “Astrongmaybe”

If you look at ABIs… you will find PAD…

And if you find it… it will mean something…

AnABI<=0.90wasassociatedwithapproximatelytwicetheage-adjusted10-yeartotalmortality,cardiovascularmortality,andmajorcoronaryevent

ratecomparedwiththeoverallrateineachFRScategoryAnklebrachialindexcombinedwithFraminghamriskscoretopredictcardiovasculareventsandmortality:ameta-analysis.JAMA.2008;300:197–208.

ACC/AHA 2017 Guideline

ACCAHAGuidelines

Not back to symptomatic LE PAD…

Categorizing lower extremity ischemia

•  Claudication

•  Criticallimbischemia(CLI)

•  Acutelimbischemia(ALI)

Categorizing lower extremity ischemia

•  Claudication

•  Criticallimbischemia(CLI)

•  Acutelimbischemia(ALI)

The claudication to CLI “spectrum”

The claudication to CLI “spectrum”

The claudication to CLI “spectrum”

CRITICALLIMBISCHEMIA

Claudication

•  Supply&demandmismatch

•  99.9%historytaking•  Naturalhistory•  Treatmentoptions

Claudication

•  Supply&demandmismatch

•  99.9%historytaking•  Naturalhistory•  Treatmentoptions

Natural history key points

•  Lowerextremityamputationrate2-5%at5years

•  But5yearmortalityrateupto30%(primarilycardiac)

Follow those 2 points forward

•  Amputationrateaslowas2%dictateshowaggressivewearewiththelimbprocedurally

•  5yearmortalityrateashighas30%dictateshowaggressiveyouMUSTbewithpreventativemedicaltherapies

Treatment for patients with PAD (not just “treatment of PAD”)

•  Diet/exercise•  Tobaccocessation•  Supervisedphysicaltherapy

•  3monthsandsignificantQOL&walkingdistances

•  GDMTforBPcontrol•  Highdosestatintherapy•  ASAforMACEreduction•  OR(notand)clopidogrel(seeCAPRIE/CHARISMA)•  Cilostazoltoincreaseambulation(PDEIIIinhibitorcontraindicatedinCHF)

What about anticoagulation & the COMPASS trial?

Compass (peripheral)

NNT=50 NNT=100

NNH=50

NNT=50 NNT=100

NNH=50

•  Notyetinguidelines

•  Bayersponsoredtrial

•  “Verylowdose”availability?

So which claudicants should you refer for revascularization?

•  True“lifestyle-limitingclaudication”• Differentfordifferentpeople

•  Donot“procedurallyconvertthebenignnaturalhistoryofthediseasetosomethingmoremalignant”

• Rememberthat5yearamputationrateofaslowas2-5%

Claudication

•  Therighttreatmentfortherightpatient

•  PreventativemedicaltherapytodecreaseriskofMACE

•  Targetedrevascularizationfor“life-limitingclaudication”

Categorizing lower extremity ischemia

•  Claudication

•  Criticallimbischemia(CLI)

•  Acutelimbischemia(ALI)

Back to CLI

•  Thoughona“spectrum”withclaudication,amuchmoreseverenaturalhistory

•  PatientswithCLI(restpainortissueloss)with%amputationrateat6-12months

• Versus2-5%amputationrateat5yearswithclaudication

•  s/pBKAforCLIwith48%mortalityat2years

•  s/pBKAonly4%ambulatingat2years

Diagnosis

•  Historyandphysical•  NormalABIdoesnotruleoutanischemicwoundetiology

•  “30%ofCLIpatientsw/restABIbetween0.7and1.4”inINPACT-DEEPDEBCLIstudy

•  Thinkaboutanatomyandthe“angiosome”

43

Urgent treatment

•  Considerthedifferentialdiagnosisofwounds•  Urgentvascularreferral(w/woundcare)•  Delineationofanatomy

• RestABI/PVR(thoughimperfect)

• Vascularultrasound•  ?maybeCTA(considerrenalfunction)

• Angiography

•  Evaluationforunderlyinginfection/osteomyelitis

Revascularize

•  Urgentrevascularization

Revascularization options

•  Endovascularversussurgical• BEST-CLIongoing•  ?avoidcreatingasurgicalbypasswoundtotreatanon-healingwound

•  Noveltechniques• Atherectomy,DEB,below-kneerevasc,retrogradeaccess

•  Doanythingyoucantosavethelimborconverttoalesseramputation

The battle of the cath lab ends but the war has just begun…

•  Closefollowup•  Anti-platelettherapies•  EXCELLENTwoundcareaboveallelse•  Avoidanceoffurtherinjury(offloadingshoes)•  Medicaloptimization(tobaccocessation!)

Categorizing lower extremity PAD

•  Claudication

•  Criticallimbischemia(CLI)

•  Acutelimbischemia(ALI)

ALI is different…

I will deny the existence of the following slide…

Categorizing lower extremity PAD

•  Claudication……………………………….Angina

•  Criticallimbischemia(CLI)…………ACS(UA/NSTEMI)

•  Acutelimbischemia(ALI)………….STEMI

Finally the 6 P’s

When you suspect ALI

•  Thinksomethinghashappenedrapidly

•  Alimbisdying

•  Itneedstobetreatedequallyrapidly

Consider certain circumstances

•  Mostcommonlyarevascularizationthathasfailed•  Surgicalgraftgoesdown•  Stentthromboses

•  Rememberthromboembolicdisease• AtrialfibrillationorpostanteriorMIandcardiacthrombusembolization

• DVTandintracardiacshunt• Hypercoagulablestates(HITT,lupusanticoag,?hyperhomocysteine

Concurrent diagnosis/treatment

•  Allimportantphysicalexam/Dopplerpulses

•  Anticoagulatewithheparin•  Arterialultrasound,oftenCTAespeciallywhenembolicphenomenonisaconcern

•  Oftenthefirsttestistheangiogram

•  Revascularizeemergently

ALI Evaluation

Evaluation

Evaluation

GOES1ST

GOES2N

D

Take home points…

ABI

•  PADasdiagnosedevenbyscreeningABIisassociatedwithincreasedcardiovascularrisk

•  Debatere:useoftrue“screeningABI”•  “Atherosomewhereisatheroeverywhere”

Claudication

•  Claudicationcarriesarelativelylowriskofamputation(“benignnaturalhistory”)butisassociatedwithaveryrealriskofcardiovasculareventsincludingmortality

•  Thereforeaggressivelymedicallymanageyourclaudicants

•  Patientswith“lifestyle-limitingclaudication”benefitfromrevascularization+exercisewithimprovedwalkingdistanceandrealQOLimprovement

CLI

•  Ischemicrestpainand/ortissuelossmeanCLI

•  CLIamputationratesupto50%at6-12months

•  s/pBKAforCLIwith50%mortalityat2yearsandonly4%ambulating

•  BeaggressivewithrevascularizationforCLIwhenappropriate

•  Exceptionalfollowupandwoundcarerequired

ALI

•  ALIisanacutelydyinglimb

•  Rememberpost-procedureandthromboembolicetiologies

•  Anticoagulate,diagnoseandtreat

Questions?

Peter Monteleone, MD Interventional Cardiology Vascular Medicine & Intervention Pedro Teixeira, MD Vascular Surgery