Pranav M. Patel, MD, FACC, FAHA, FSCAIChief & Clinical Professor of Medicine

Director, Cardiac Catheterization LabUniversity of California, Irvine

Division of Cardiology

Peripheral Artery Disease:

Diagnosis and Management

Introduction

PVD/PAD effects 27 million people over 55 yrs in North America and Europe.

PAD often occurs in concert with CAD

CAD is leading cause of death in patients with PAD (75% of deaths)

Patients with PAD are at increased risk of atheroembolic events and 6 times more likely to die than patients without PAD

Cardiologists and PAD

Rationale

Coexistence of CAD & PAD

Common risk factors & modification

Expertise in clinical evaluation of the patient

Expertise in risk factor adjustment

Interest in longitudinal follow-up and global

approach to patient’s disease

Ness J, Aronow WS. J Am Geriatric Soc. 1999;47:1255-1256.

Overlap of

Atherosclerotic Disease

Patients with one manifestation often have

coexistent disease in other vascular beds

CoronaryArtery

Disease

CerebrovascularDisease

Peripheral Arterial Disease6%

16%40%

11% 3%

15%

9%

38% overlap

of 2 vascular beds

N= 1802 patients

Mean age = 80 yrs (60-102)

0% 5% 10% 15% 20% 25% 30% 35%

29%

11.7%

19.8%

19.1%

14.5%

4.3%

Prevalence of PAD

PARTNERS5

Aged >70 years, or 50–69 years with a history diabetes or smoking

San Diego2

Mean age 66 years

Diehm4

Aged 65 years

Rotterdam3

Aged >55 years

NHANES1

Aged 70 years

NHANES1

Aged >40 years

NHANES=National Health and Nutrition Examination Study;

PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program].

1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743.

2. Criqui MH, et al. Circulation. 1985;71:510-515.

3. Diehm C, et al. Atherosclerosis. 2004;172:95-105.

4. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.

5. Hirsch AT, et al. JAMA. 2001;286:1317-1324.

In a primary care

population defined by age

and common risk factors,

the prevalence of PAD

was approximately one in

three patients

29% of Patients in a Target Population Were Diagnosed With

PAD Using An Office-Based ABI

Patients diagnosed with PAD

PAD only

PAD and CVD

PARTNERS: Prevalence of PAD

and Other CVD in Primary Care Practices

29%

44%

56%

ABI=ankle-brachial index; CVD=cardiovascular disease.

Hirsch, AT et al. JAMA. 2001;286:1317-24.

1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.

2. Criqui MH, et al. Circulation. 1985;71:510-515.

Rotterdam Study (ABI <0.9)1 San Diego Study (PAD by noninvasive tests)2

0

10

20

30

40

50

60

Pati

en

ts W

ith

PA

D (

%)

55-59 60-64 65-69 70-74 75-79 80-84 85-89

Age (years)

Prevalence of PAD Increases With Age

ABI=ankle-brachial index

Gender Differences in the

Prevalence of PAD

Adapted from Diehm C. Atherosclerosis. 2004;172:95-105 with permission from Elsevier.

Pre

va

len

ce

(%

)

Women

Men

6880 Consecutive Patients (61% Female) in 344 Primary Care Offices

<700

2

4

6

8

10

12

14

16

70–74 75–79 80–84 >85

Age (years)

18

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Relative Risk

Smoking

Diabetes

Hypertension

Hypercholesterolemia

Hyperhomocysteinemia

C-Reactive Protein

Reduced Increased

Risk Factors for PAD

1 2 3 4 5 60

Physical Exam Findings of Lower

Extremity PAD

Limb examination (and comparison with the opposite limb) includes:

Absent or diminished femoral or pedal pulses (especially after exercisingthe limb)

Arterial bruits

Hair loss

Poor nail growth (brittle nails)

Dry, scaly, atrophic skin

Dependent rubor

Pallor with leg elevation after 1 minute at 60 degrees (normal color should return in 10 to 15 seconds; longer than 40 seconds indicates severe ischemia)

Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene

Lesho EP, et al. Am Fam Physician. 2004;69:525-533.

The Physical Exam Should Be

Performed With Patient’s Pants/Shoes Off

Elevation Pallor/Dependent Rubor

1/14/2009 Template copyright 2005 www.brainybetty.com 1

Gangrene

http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_diagnosis.html

ABI Procedure

Using the ABI

ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.

Right ABI

80/160=0.50

Brachial SBP160 mm Hg

PT SBP 120 mm Hg

DP SBP 80 mm Hg

Brachial SBP150 mm Hg

PT SBP 40 mm Hg

DP SBP 80 mm Hg

Left ABI

120/160=0.75

Highest

brachial SBP

Highest of PT

or DP SBP

ABI

(Normal >0.90)

Interpreting the Ankle-Brachial Index

Adapted from Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Figure 6.

ABI Interpretation

1.00–1.29 Normal

0.91–0.99 Borderline

0.41–0.90 Mild-to-moderate disease

≤0.40 Severe disease

≥1.30 Noncompressible

Normal values: Ankle pressure > Brachial; ABI after Exercise: Fall < 20%; Proximal thigh pressure 30 mmHg higher

than brachial; Segmental Pressure < 20mm Hg drop between levels

Cardiovascular Risk Increases With

Decreases in Ankle-Brachial Index

>1.1 1.1–1.01 1.0–0.91 0.9–0.71 <0.7

ABI

CH

D E

ven

t O

utc

om

es

pe

r Ye

ar

(%)

0

1

2

3

4

5-year risk:

10%

5-year risk:

19%

Framingham “High Risk” = 20% at 10 yearsEvery patient with PAD is at “very high risk”

PAD

*Fatal or nonfatal MI. ABI=ankle-brachial index; CHD=chronic heart failure

2%

3.8%

1.4%

Leng GC, et al. Brit Med J. 1996;313:1440-44.

Exercise ABI Testing

Confirms the PAD diagnosis

Assesses the functional severity of claudication

May “unmask” PAD when resting the ABI is normal

Aids differentiation of intermittent claudication vs. pseudoclaudication diagnoses

Normal values: Ankle pressure > Brachial; ABI after Exercise: Fall < 20%; Proximal thigh pressure 30 mmHg higher

than brachial; Segmental Pressure < 20mm Hg drop between levels

Segmental Pressures (mm Hg)

150

110

108

62

0.54

150

146

100

84

0.44ABI

150 150Brachial

Decrease in pressure

between 2 levels > 30mm

Hg = stenosis proximal to

cuff

Greater than 20-30mm Hg

= significant disease

Pulse Volume Recordings

Normal waveform is rapid systolic upstroke and rapid downstroke with prominent dicrotic notch. With

increasing PAD severity the waveform is attenuate and widened with ultimate flat or non-pulsatile waveform

Arterial Duplex Ultrasound Testing

• Diagnose anatomic location and

degree of stenosis of peripheral

arterial disease.

• Duplex ultrasound of the

extremities can be used to select

candidates for:

(a) endovascular intervention

(b) surgical bypass, and

(c) to select the sites of surgical

anastomosis.

Magnetic Resonance Angiography (MRA)

MRA has virtually replaced contrast arteriography for PAD diagnosis

No ionizing radiation

Non-iodine–based intravenous contrast medium

~10% of patients cannot utilize MRA because of:

Claustrophobia

Pacemaker/implantable cardioverter-defibrillator

Obesity

• Gadolinium use in individuals with an eGFR <60 mL/min has been associated with nephrogenic systemic fibrosis (NSF)/nephrogenic fibrosing dermopathy

MRA in PAD

Computed Tomographic Angiography (CTA)

Requires

iodinated

contrast

Requires

ionizing

radiation

Produces an

excellent

arterial

picture

Right

Fem-Pop

BPG

CTA DSA(Pre-PTA)

Left

SFA

Stenosis

Two Major Goals in Treating Patients With PAD

Improved ability to walk

Increase in peak walking

distance

Improvement in quality-of-

life

Prevention of progression to

CLI and amputation

• Decrease in morbidity from

non-fatal MI and stroke

• Decrease in cardiovascular

mortality from fatal MI and

stroke

Limb outcomes

Cardiovascular

morbidity and mortality

outcomes

Benefit on PAD Cohort

Intervention Treadmill/QoL Limitations Indicated

Exercise 100% / Improved Availability 50%-85%

Motivation

Cilostazol 50% / Improved CHF 50%-85%

Medication

Angioplasty Improvement Proximal 10%-15%

arteries best

Surgery 150% / Improved Graft failure < 5%

Morbidity, mortality

Treatment of Claudication: Therapeutic Choice & Evidence

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

an

ge

in

Tre

ad

mil

l W

alk

ing

Dis

tan

ce

(%

)

Meta-analysis of 21 Studies

*

*

* P < 0.05

0

10

20

30

40

50

0 4 8 12 16 20 24

Treatment (weeks)

Pe

rce

nta

ge

Ch

an

ge

Fro

m

Ba

se

lin

e M

WD

(m

ea

n)

Cilostazol vs. Pentoxifylline: Relative Efficacy to Improve Walking Distance in Claudication

Cilostazol 100 mg 2 times/day (n=227)

Pentoxifylline 400 mg 3 times/day (n=232)

Placebo (n=239)

MWD=maximal walking distance.

*P<0.001 vs pentoxifylline.

Reprinted from Dawson DL, et al. Am J Med. 2000;109:523-530 with permission from Elsevier.

*

Effect of Cilostazol on Quality of Life

0

5

10

15

20

25

30

Wk 4 Wk 8 Wk 16 Wk 20 Wk 24

Ph

ysic

al S

um

ma

ry S

co

re

Placebo

Cilostazol 100 mg bid

Medical Outcome Scale SF-36

*

***

*

Tools of the trade for Infrainguinal

Endovascular Intervention

Hydrophilic & “coronary” guidewires

Nitinol S-E Stents (flexible, strong)

Atherectomy (remove plaque)

Thrombolytic Therapy

Laser

Cryoplasty

60 y.o woman has chest pain, HTNsive

crisis. Also complains of LE claudication

Abnormal adenosine

myocardial perfusion scan

Coronary Angiogram:

sequential LCX stenosis and

occluded mid LAD that fills via

collateral vessels

Patient refusing CABG

60 y.o woman with CAD, HTN and dyslipidemia presents with HTNsive crisis,

ACS, claudication (LE) and renal insufficiency. Cr ~ 1.5 2.5 7.6.

Angiogram of innominate and left subclavian artery

Pressure difference of 60mmHg between aorta & right brachial artery

Pressure difference of 40 mmHg between aorta and left brachial artery

Angiogram of innominate and left subclavian artery

Pressure difference of 60mmHg between aorta & right brachial artery

Pressure difference of 40 mmHg between aorta and left brachial artery

Final angiogram of left renal artery

Final angiogram of right renal arteryCreatinine back to baseline at 6 month follow up

SFA Intervention

Mid SFA

lesionAfter

angioplasty

Pre Post

Distal aorta

Left Common

Iliac Artery

Left Internal

iliac artery

Left ext. iliac art.

66 y.o man with CAD, DM, PAD and severe claudication. Three

years after intervention-no further claudication

Tibio-Peroneal Trunk Atherectomy

56 y.o male patient with PAD, CAD and tobacco use. Presents

with recurrent disabling RLE claudication.

Noted to have hemodynamically significant in-stent

restenoses within the previously-stented Right SFA

Proximal

SFA

Mid SFA

Distal SFA

Popliteal artery

Popliteal artery

Distal SFA

Proximal

SFA

Mid SFA