The Cramping Leg Management of peripheral vascular disease Dr Patricia Yih Department of Surgery, Pamela Youde Nethersole Eastern Hospital Joint Hospital Surgical Grand Round 04/2009

Epidemiology General prevalance 3-10% (ABI < 0.9) >70 years old: 15-20% Asymptomatic 75% Symptomatic: Intermittent claudication Critical limb ishcemia

Clinical Course Hirsch AT et al. J Am Coll Cardiol

Asymptomatic PVD Vascular disease progression related to baseline ABI Identical to symptomatic patients Coexisting vascular disease (atherosclerotic) Coronary artery disease CVA Risk: MI/CVA 5-7%/year, mortality 2%/year Also related to baseline ABI Management: Intensive risk factor modifiation Antithrombotic therapy Mehler PS et al. Circulation 2003

Intermittent Claudication Only about 25% deteriorate ever Disease progression related to: ABI (<0.50  >2x more likely need intervention/amputation) Low ankle pressure (40-60mmHg  8.5% limb loss/year) At 5 years: Hirsch AT et al. J Am Coll Cardiol 2006; 47: 1239-1312

Risk Factor Modification Stop smoking Control of BP Control of DM Control of hyperlipidemia Weight reduction

Exercise Rehabilitation Supervised Program: Treadmill or track walking to bring on claudication Followed by rest until pain subsided Then resume 30-60 minute sessions 3 times/week, for 3 months (TASC II guidelines, Recommendation 14) Selective exercise of most ischemic muscles Doubles claudication distance in 80% of patients Stewart K et al. N Engl J Med 2002

Drugs Antiplatelet agents Cilostazol (PletaalTM) Aspirin Clopidogrel Cilostazol (PletaalTM) Vasodilator, metabolic and antiplatelet activity Increased walking distance 50-70m Best evidence Naftidrofuryl (PraxileneTM) Improve muscle metabolism, reduce RBC/platelet aggregation Increased walking distance by 26% Pentoxifylline Similar to placebo Regensteiner J et al. J Am Geriatr Soc 2002 Lehert P et al. J Cardiovasc Pharmacol 1994

Indications for Intervention Severe, lifestyle-limiting claudication Failed drug therapy and exercise Prerequisite: Inflow satisfactory Distal runoff patent

“Stupid Femoral Artery” High failure rate after intervention SFA Disease “Stupid Femoral Artery” High failure rate after intervention

Factors affecting result of intervention Multiple lesions Long segment stenosis Complete occlusion Below knee

Choice of intervention Surgical bypass Vein graft Prosthetic graft Endovascular Angioplasty Primary stenting Arthrectomy

Outcome Measures Usually considered together with critical ischemia Patency rate ABI Limb salvage Mortality

Surgical Bypass vs Angioplasty If high risk for surgery Bypass TASC classification

Surgical Bypass – Conduit Autogenous vs prosthetic materials: De Vries S et al, J Vasc Surg 1997 In-situ vs reversed vein graft: No difference Mamode N et al, Cochrane Database Syst Rev. 2000

Angioplasty vs Stenting Meta-analysis: no difference 1-Year Patency Rate Postoperative ABI Mwipatayi et al, Journal of Vascular Surgery, Feb 2008

Conclusion Clinical course/deterioration, systemic disease related to baseline ABI When to intervene? Lifestyle limiting claudication, failure of conservative management Radiological confirmation of adequate inflow and runoff required Bypass or angioplasty? Depends on disease location, extent Angioplasty: to stent or not? No difference Depends on expertise available, patient condition

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