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Peripheral Arterial
Disease
Mary MacDonald CD MD PhD FRCSC RPVI
Vascular Surgeon
Thunder Bay Regional Health Sciences Centre
Assistant Professor
Northern Ontario School of Medicine
Presentation
Prevention
Treatment
Cardiovascular and Stroke Summit 1 June 2018
Faculty/Presenter Disclosure
• Faculty: Dr. Mary MacDonald
• Relationships with commercial interests:
• none
Disclosure of Commercial Support
• Dr. Mary MacDonald, Vascular Surgeon, TBRHSC
• This program has received no financial or in-kind
support
• Potential for conflict(s) of interest:
• I have no conflict of interest or
affiliations that have influenced
this presentation to disclose
Objectives
1. Review presentation of peripheral
arterial disease
2. Evidence based prevention and risk
factor management
3. Treatment options: indications for
angiography and surgical bypass
Overview
Chronic Peripheral Arterial Disease
Presentation of PAD
Prevention and Management of Risk Factors
Guidelines for Treatment of Claudication
Guidelines for Treatment of Critical Limb Ischemia
Guidelines for Management of Diabetic Foot Ulcer
Treatment: Indications for intervention
What is Peripheral Arterial Disease?
Stenosis or occlusion of the aorta or limb
arteries which leads to lack of tissue
oxygenation (ischemia)
Acute PAD most often caused by
embolization
Chronic PAD most often by atherosclerosis
Either acute or chronic peripheral arterial
disease can lead to death of tissues (nerve,
muscle, bone) and loss of the limb
Peripheral Arterial Disease
The Aging Population
0
5
10
15
20
25
10 20 30 40 50 60 70 80 90
Age (years)
Pop
ula
tio
n (
mill
ion
s)
1980
1990
2000
2010
17% of the population 55-70 years of age has PAD
Fowkes FG, et al. Int J Epidemiol. 1991;20:384-392.
PAD = peripheral arterial disease
N=1592
Independent Risk Factors for PAD*
Newman AB, et al. Circulation. 1993;88:837-845
* PAD diagnosis based on ABI <0.90.
1.10 1.51
2.55
4.05
Relative Risk vs the General Population
Reduced Increased
Diabetes
Smoking
Hypertension
Total cholesterol (10 mg/dL)
Chronic Peripheral
Arterial Disease
Causes of Chronic Peripheral Arterial Ischemia
Popliteal Entrapment
Syndrome
Popliteal Adventitial
Cyst
Popliteal Aneurysm
Thromboangiitis
Obliterans (Buerger’s
disease)
Arteritis
Fibromuscular Dysplasia
Atherosclerosis
85%
5%
10%
Atherosclerosis
Atherosclerosis Risk Factors
The Ankle-Brachial Index (ABI)
Ankle systolic pressure
Brachial systolic pressure
Ankle pressure from
Posterior Tibial and
Dorsalis Pedis – use
highest
Chronic Peripheral Arterial Disease
Clinical Ankle Brachial
Index
Normal ABI is 1.0
intermittent
claudication <0.7
rest pain <0.5
tissue loss
ulcers, gangrene <0.3
Critical Limb Ischemia
Peripheral Arterial Disease w/ inadequate
tissue oxygenation even at rest
Rubor
Rest Pain
Tissue Loss
ulcers, gangrene, infection
Chronic Peripheral Arterial
Disease -- Natural History
Of patients age 50 and older with PAD,
only 1-2% will go on to develop critical
limb ischemia
but
in patients who develop critical limb
ischemia, after 1 year only 50% will be
alive with both lower limbs
Case: Belinda B
Belinda is a 70 year old who presents with
intermittent, reproducible bilateral calf pain
at 3 blocks (5-10 minutes). Symptoms have
been present for approximately 6 months.
She denies pain in her toes or feet at night
There has been no tissue loss
She has had no prior vascular interventions
Case: Belinda B
What is your next action?
A. Order a CT Angiogram
B. Refer for conventional angiogram +/-
angioplasty
C. Start ASA, statin, and a walking program
D. Do an ABI in the office
Clinical Presentation of PAD
Initial PAD Presentation
Symptomatic PAD
Atypical Leg Pain
40-50% Intermittent Claudication
10-35%
Critical Limb Ischemia
1-2%
Asymptomatic PAD
20-50%
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Natural History of Claudication
Natural History of PAD: 5-year
Outcomes
Stable Claudication70-80%
Worsening Claudication10-20%
Critical Limb Ischemia 1-2 %
Non-CV Causes 25% CV Causes 75%
Mortality 15-30%
Nonfatal CV Events 15-30%
Limb Morbidity Limb Morbidity Cardiovascular Morbidity and Mortality
Fate of Patients With Critical Limb
Ischemia After Initial Treatment
Dormandy JA, et al. J Vasc Surg. 2000;31:S1-S296.
Summary of 19 studies
on 6-month outcomes
5 year outcomes show
increased mortality due to
cardiovascular causes
Dead 20%
Alive Without Amputation 45%
Alive With Amputation 35%
Chronic Peripheral Arterial
Disease Management
Medical management: Risk factor modification
Antiplatelet
Statin
Revascularization
Open surgery: Endarterectomy
Bypass – anatomic
extraanatomic
Endovascular: Angioplasty – transluminal
subintimal
Stent
Other (Atherectomy, Cryoplasty)
Therapy of Intermittent Claudication:
Magnitude of Functional Improvement
Pentoxifylline
(Trental)
Cilostazol *
Supervised Exercise
Improvement Over Baseline After 90 to 180 Days (%)
Gardner AW, Poehlman ET. JAMA. 1995;274:975-980; Girolami B, et al. Arch Intern Med. 1999;159:337-345. Hiatt WR. N Engl J Med. 2001; 344;1608-1621.
0 50 100 150 200
antiplatelet not avail in Canada
Effects of Exercise Training on
Claudication
Gardner AW, Poehlman ET. JAMA. 1995;274:975-980.
Exercise Training
Control
200
0
20
40
60
80
100
120
140
160
180
Onset of Claudication Pain
Maximal Claudication Pain
Ch
ange
in T
read
mill
Wal
kin
g D
ista
nce
(%
) Meta-analysis of 21 Studies
Intermittent Claudication:
Exercise Therapy
Frequency: 3-5 supervised
sessions/week
Duration: 35 to 50 minutes of
exercise/session
Type of exercise: treadmill or track
walking to near-maximal claudication
pain
Length: 6 months or more
Results: 100%-150% improvement in
maximal walking distance
Improvement in quality of life
Stewart KJ, et al. N Eng J Med. 2002;347:1941-1951.
Goals in Treating Patients With PAD
•Improve ability to walk
–Increase walking
distance
–Improvement in
QOL
•Prevent progression to
critical limb ischemia
and amputation
Decrease mortality from
MI, stroke, and
cardiovascular death
Decrease nonfatal MI
and stroke
Limb
Outcomes
Outcomes in
Cardiovascular
Morbidity and Mortality
2015 SVS Guidelines for the
Management of Peripheral
Arterial Disease
Diagnosis
Diagnosis of PAD: The Ankle-
Brachial Index
Use ABI first to establish lower extremity PAD diagnosis
Recommend against routine screening in the absence of symptoms or risk factors
Use toe-brachial index in patients with non-compressible vessels
Anatomic imaging if revascularization is being considered
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
2015 SVS Guidelines for the
Management of Peripheral
Arterial Disease
Risk Factor Management
Risk Factor Management:
Asymptomatic Patient
1A Comprehensive Smoking Cessation
intervention(s)
1C Educate re S&S of PAD progression
1C Recommend against invasive
treatment in the absence of symptoms
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Risk Factor Management:
Symptomatic Patient
1A Comprehensive Smoking Cessation intervention(s)
1A Statin therapy
1A ASA 81 mg PO OD
1B optimal diabetes control
1B B-blocker use as indicated
1B Plavix if ASA not tolerated
Risk Factor Management:
Smoking Cessation
Patient should discontinue use of
cigarettes or other forms of tobacco
Offer comprehensive smoking cessation
interventions
Behavior modification therapy, nicotine
replacement therapy, and/or bupropion
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf.
2015 SVS Guidelines for the
Management of Peripheral
Arterial Disease
Treatment for Claudication
Claudication Treatment: Exercise
Supervised exercise training should be
the initial treatment
30-45 minute sessions
3 or more times per week
At least 12 weeks
Value of unsupervised exercise programs
is not well established
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Claudication Treatment:
Endovascular or Surgical Therapies
Indicated only for patients with
Vocational or lifestyle-limiting disability;
Reasonable likelihood of symptomatic improvement;
Prior failure of exercise therapy or pharmacological therapy; and
Favorable risk-benefit ratio
Not indicated as a prophylactic treatment for asymptomatic patients
1A Optimal Medical Management postintervention (Smoking cessation, ASA, Statin, glycemic and HTN control)
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
PAD Indications for Intervention
Persistent, lifestyle limiting claudication
despite maximal medical therapy
Rest pain
Nonhealing ulcer
Gangrene
Case: Belinda B
Belinda is a 70 year old who presents with
intermittent, reproducible bilateral calf pain
at 3 blocks (5-10 minutes). Symptoms have
been present for approximately 6 months.
She denies pain in her toes or feet at night
There has been no tissue loss
She has had no prior vascular interventions
Case: Belinda B
What is your next action?
A. Order a CT Angiogram
B. Refer for conventional angiogram +/-
angioplasty
C. Start ASA, statin, and a walking program
D. Do an ABI in the office
Case: Clive C
78 year old man brought to clinic by his daughters, who describe progressive loss of mobility. At camp last summer, Clive could walk for at least 30 min, but now complains of severe pain in his left calf when walking to the mailbox (100m) and left foot pain that wakes him at night.
PMHx: CAD with stents 10 yrs ago, HTN, ex-smoker. Not taking any medication. No prior leg-related complaints.
On examination of the left leg he has dependent rubor without tissue loss in the left foot and no palpable pulses in either groin or the distal left leg.
Case 3: Clive C
Case: Clive C
Initial management options:
A. Give him a prescription for aspirin and tell
him to walk it out -- reassess in a few
months
B. Start aspirin, a statin and an ACE Inhibitor
and arrange an outpatient CT angiogram
C. Admit him to hospital and continue the
workup as an inpatient
D. Start a heparin infusion and take him to
the OR
Chronic Peripheral Arterial
Insufficiency
Clinical Ankle Brachial
Index
Normal ABI is 1.0
intermittent
claudication <0.7
rest pain <0.5
tissue loss
ulcers, gangrene <0.3
Rubor
Tissue
Loss
Major Tissue Loss
Selection of Treatment
Acute or Chronic?
Critical/Limb-threatening?
Level, extent and severity of
lesion(s)
Surgical Revascularization for
Peripheral Arterial Disease
Endarterectomy
Bypass
anatomic
extra-anatomic
autogenous (vein) or non-
autogenous graft (Dacron, PTFE)
Peripheral Arterial Disease
Endovascular Treatment
Endovascular:
Angioplasty –
transluminal
subintimal
Stent
Other
(Atherectomy, Cryoplasty)
Superficial Femoral Artery Occlusion
Superficial
Femoral
Artery
Angioplasty
Stent Deployment
://www.youtube.com/watch?v=xRwI
R7XUnvs
Surgical Bypass
Open
Anatomic
Bypass with
Saphenous
Vein Graft
Popliteal-popliteal
bypass with
saphenous vein graft
Femoral Endarterectomy
Postintervention Surveillance
2C Clinical surveillance program to
include interval history, ABI, Duplex
scanning (for vein grafts), and
1C prophylactic reintervention for graft
stenosis to promote long-term bypass
patency
Case: Clive C
78 year old man with dependent rubor, left foot
pain at night and no pulses in the groins or left
leg.
A. Give him a prescription for aspirin and tell him
to walk it out -- reassess in a few months
B. Start aspirin, a statin and an ACE Inhibitor and
arrange an outpatient CT angiogram
C. Admit him to hospital and continue the workup
D. Start a heparin infusion and take him to the OR
Management of Peripheral Arterial
Disease -- Summary
Asymptomatic: CV Risk Factor Management
Claudication:
CV RF Mgt + Walking Program
Consider Revascularization if disabling
Critical Limb Ischemia:
CV Risk Factor Management +
Revascularization
Wound Healing after
Revascularization
Ischemia and Diabetes
Risk Factor Management:
Diabetes Therapies
Encourage proper foot care
Appropriate footwear, chiropody/podiatric medicine, daily foot inspection, skin cleansing, and topical moisturizing creams
Urgently address skin lesions and ulcerations
Target HbA1C<7% to reduce microvascular complications and potentially improve cardiovascular outcomes
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Diabetic Foot Ulcer/Infection
NEUROPATHY + ISCHEMIA = INFECTION
20-40% of healthcare resources spent on diabetes are related to diabetic feet
7-10% annual incidence ulcer formation if NO confounders
25-30% annual incidence if PAD, Charcot foot, prior ulcers or amputation
Diabetic Foot Ulcer/Infection
5-8% of patients with new ulcers require major amputation within a year
Ischemia should be considered as a cause of DFU unless proven absent
Neuroischemic and ischemic lesions should be considered together as both may require revascularization
Diabetic Foot Ulcer/Infection
As intermittent claudication and rest pain are reported far less commonly in diabetics with ischemia compared to non-diabetics;
early non-invasive vascular evaluation (ABI) recommended for patients with poor ulcer healing and a high risk for amputation;
IWG for the Diabetic Foot recommends vascular studies if the DFU has not healed in 6 weeks even if initial diagnostics suggest only mild disease
Diabetic Foot Ulcer/Infection
2B Surgical intervention for moderate or severe infections is likely to decrease the risk of major amputation
2B open, endovascular or hybrid methods should be chosen depending on patient comorbidities, anatomy of the arterial lesion(s) and expertise of the centre
1A Negative-pressure wound therapy appears to be as, or more, effective than other local wound treatments in patients without significant infection
Summary: Peripheral Arterial
Disease
Chronic Limb Ischemia: clinical presentation,
risk factors, medical, surgical and endovascular
management
Guidelines for care of Diabetic Foot Ulcers
Acute Limb Ischemia: clinical presentation and
treatment
Barriers to Practice Change
Discussion
What is the most prevalent barrier
to change that you see in your
practice?
What can vascular surgery do to
mitigate this barrier?
Rapid Access to Vascular Evaluation
RAVE clinic weekly at TBRHSC
we intend to expand clinic frequency,
resources
Rapid referral and assessment for patients
with tissue loss and suspected vascular
disease
No imaging required – we will arrange
Fax referrals to 1-888-504-1696 (office)
References
Cronenwett and Johnston (2012). Rutherford’s Vascular Surgery 7th ed, Elsevier, Philadelphia PA
Dormandy JA, et al. J Vasc Surg. 2000;31:S1-S296.
Fowkes FG, et al. Int J Epidemiol. 1991;20:384-392.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf.
Newman AB, et al. Circulation. 1993;88:837-845
Norgren et al., (2007). Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC
II). JVS 45:1(S) 1A-65A.
Pomposelli et al Society for Vascular Surgery Clinical Guidelines for Management of Peripheral Arterial
Insufficiency JVS 66:3(S) Dec 2015
Schneider, PA (2009). Endovascular Skills: Guidewire and catheter skills for endovascular surgery 3rd ed
Informa, New York NY.
Zarins and Gewertz (2005). Atlas of Vascular Surgery 2nd ed, Elsevier, Philadelphia PA
Questions?
Acute limb ischemia
Case: Eric E
58 year old man presents to ED with 4
hours of right foot pain which woke him
from sleep. The foot is pale, with no
palpable pulses or Doppler signal.
He now also has motor weakness at the
ankle and toes, and numbness from the
mid-shin down to the toes.
He is a 1 PPD smoker with hypertension.
He is otherwise healthy and has had no
previous problems with either leg.
Case: Eric E
Initial management options:
A. Give the patient aspirin and get him to
walk it out -- reassess in an hour
B. Start a heparin infusion and obtain a CT
scan
C. Start a heparin infusion and obtain an
urgent conventional angiogram
(diagnostic, possibly therapeutic)
D. Start a heparin infusion and take the
patient to the Operating Room
Causes of
Acute Limb Ischemia
Acute limb ischemia is usually embolic -- a
blood clot forms elsewhere in the body
and travels to the limb
Most (85%) emboli come from the heart;
the remainder originate in proximal
arteries (especially if these arteries are
aneurysmal)
Non embolic causes: thrombosis,
dissection, trauma (including iatrogenic)
Cardiac Embolization
Acute limb ischemia – like a stroke, but for your leg
Clinical Presentation of Acute
Limb Ischemia
Acute limb ischemia:
pain, progressive loss of motor and
sensory function, diminished or absent
pulses
Clinical examination +/- imaging localize
the level of occlusion
Acute occlusion of a major artery is not
well tolerated as there is little collateral
flow, and the tissues will not typically
survive longer than 4-6 hours
Clinical Presentation of
Acute Limb Ischemia
Rutherford Classification
Sensory Motor Doppler
Arterial Venous
I Normal Normal Normal Audible
IIa Toes only/ Normal Diminished Audible
No change
IIb Pain/ Weak Poor/no Audible
sens loss
III Pain/ No/Rigor None None
insensate
Acute Limb Ischemia --
Treatment
1. Embolectomy
2. Thrombolysis
IF the limb is viable, heparin infusion and catheter-directed TPA
may be appropriate
Femoral Embolectomy for Acute
Limb Ischemia
Incision and exposure
Proximal and distal control
Transverse arteriotomy
Embolectomy with
Fogarty catheter of
1-3 vessels
On-table angio if poor result
Closure
http://youtu.be/QBSGFf4YSFk
Acute Ischemia: Embolus
Pre and Post Embolectomy
Case: Eric E
58 year old man presents acutely to ED with a pale,
pulseless right foot, with progressive sensory and
motor changes
A. Give the patient aspirin and get him to walk it out -
- reassess in an hour
B. Start a heparin infusion and obtain a CT scan
C. Start a heparin infusion and obtain an angiogram
D. Start a heparin infusion and take the patient to the
Operating Room
Classification of Recommendations
Class I: Evidence and/or general agreement that
procedure or treatment is beneficial, useful, and
effective
Class II: Conflicting evidence and/or divergence
of opinion about usefulness or efficacy of a
procedure or treatment
Class IIa: Weight of evidence or opinion favors
usefulness or efficacy
Class IIb: Usefulness or efficacy is less well
established by evidence or opinion
Class III: Evidence and/or general agreement that
procedure is not useful or effective and in some
cases may be harmful Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Classification of Recommendations
Class I: Evidence and/or general agreement that
procedure or treatment is beneficial, useful, and
effective
Class II: Conflicting evidence and/or divergence
of opinion about usefulness or efficacy of a
procedure or treatment
Class IIa: Weight of evidence or opinion favors
usefulness or efficacy
Class IIb: Usefulness or efficacy is less well
established by evidence or opinion
Class III: Evidence and/or general agreement that
procedure is not useful or effective and in some
cases may be harmful Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Peripheral Arterial Disease
Aneurysms
Rupture, thrombosis, embolization or mass
effect
Risk of rupture increases with size of
aneurysm
Treatment involves exclusion of the entire
aneurysm sac with preservation of vascular
supply to branch vessels and end organs
Aneurysm thrombus may embolize distally,
causing acute or chronic limb ischemia
Endovascular Complications Dissection: intimal tear +/- propagation, arterial occlusion
Perforation: 1-3%, tx usually conservative
Embolization: 3-5% distal embolization of which approx half is clinically significant. Anticoagulate early and minimize traversal of lesion(s)
Access Site:
Groin Hematoma
Retroperitoneal Hematoma
Pseudoaneurysm
AV Fistula
Axillary/Brachial Nerve Injury
Axillary/Brachial Thrombosis
Closure Device Complications
Ischemic
Infectious (EVAR 02-1.2% with 18-50% mortality)
Evidence Based Guidelines for
Management of PAD
ACC/AHA/TASC Guidelines for Treatment -- Class I
Evaluate and treat conditions known to increase risk for
primary amputation
Onset of acute limb symptoms in an at-risk patient should
be evaluated by a specialist in vascular disease
Specialized wound care for skin breakdown
Patients with CLI should be evaluated at least twice yearly
by a specialist in vascular disease
Evaluate patients with evidence of embolization for
aneurysmal disease
Hirsch et al 2005 Consensus Guidelines
Critical Limb Ischemia -- Evidence
Based Guidelines ACC/AHA/TASC Guidelines for Treatment -- Class I
Preop cardiac risk stratification prior to open repair
Prompt antibiotics in patients with skin ulceration or evidence of limb infection
Catheter-based thrombolysis for acute limb ischemia (class I or IIa) of less than 14 days duration
Address inflow lesion(s) first in combined disease, then revascularize outflow for persistent symptoms or infection
If there is uncertainty regarding inflow disease, measure intraarterial pressures before and after vasodilator administration
Hirsch et al 2005 Consensus Guidelines
Thrombolysis
Contraindications
Absolute – existing,very recent or high risk
hemorrhage
true allergy
ie. active internal bleeding,
recent (2 months) stroke, trauma or neurosurgery
known intracranial neoplasm
uncontrollable coagulopathy or hypertension,
known allergic reaction
Relative -- moderate risk for bleeding (recent biopsy, obstetric,
GI surgery or bleeding, trauma, endocarditis, pancreatitis);
severe renal or hepatic failure
Peripheral artery thrombolysis led to significant hemorrhage in 5.7%
(STILE) to 13% (TOPAS) of patients
Thrombolysis
Complications
Hemorrhagic -- local up to 25%, intracerebral 1-2%
Antigenic -less than 0.01% with TPA
Catheter-related -- up to 3%
Embolic -- distal limb 9 to 13%, of which most (75%+)
may be treated by advancing the catheter and
continuing the infusion
post DVT PE up to 10%, not all clinically significant
Thrombolytic Treatment of Critical
Limb Ischemia
Catheter-based thrombolysis is effective and beneficial for patients with Rutherford category I-IIa acute limb ischemia of less than 14 days’ duration
Mechanical thrombectomy can be used as an adjunctive therapy for acute limb ischemia
Catheter-based thrombolysis or thrombectomy may be considered for Rutherford category IIb acute limb ischemia of more than 14 days’ duration
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.
Thrombolytic Treatment of Critical
Limb Ischemia
Catheter-based thrombolysis is effective and beneficial for patients with Rutherford category I-IIa acute limb ischemia of less than 14 days’ duration
Mechanical thrombectomy can be used as an adjunctive therapy for acute limb ischemia
Catheter-based thrombolysis or thrombectomy may be considered for Rutherford category IIb acute limb ischemia of more than 14 days’ duration
Hirsch AT, Haskal ZJ, Hertzer NR, et al. Available at http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed December 13, 2005.