SSA Policy Conference Peripheral Arterial Disease Chronic Venous Insufficiency Jennifer A. Heller, M.D., F.A.C.S. Assistant Professor of Surgery Director, Johns Hopkins Vein Center Johns Hopkins University School of Medicine

OUTLINE Definition Diagnosis Impact of Disease on Activities of Daily Living

DEFINITION of PERIPHERAL ARTERIAL DISEASE (PAD) Hemodynamic Definition: Peripheral Arterial Disease: Resting ABI<.90

Does this definition work? In symptomatic pts, ABI is 95% sensitive in predicting “arteriogram positive” PAD Edinburgh Artery Study: 1/3 pts with asymptomatic PAD had complete occlusion of a major artery The lower the ABI, the higher the risk of cardiovascular events Abnormal ABI identifies a high risk population that needs aggressive risk factor modification and antiplatelet therapy

DIAGNOSIS Initial clinical assessment: History and Physical A Careful History includes: Evaluation of risk factors Presence of Cardiac Disease Tobacco Use Family history

PHYSICAL EXAMINATION Measurement of BP on bilateral upper extremities Assessment of cardiac murmurs, rubs gallops Changes in color, temperature of skin of feet Muscle atrophy from inability to exercise Decreased hair growth, hypertrophied slow growing nails Radial, ulnar, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedal

DO WE HAVE A CLEAR DX AFTER THE H AND P? If the symptom of classic claudication is used to identify PAD, it will lead to a significant underdiagnosis of PAD Palpable pedal pulses: negative predictive value of >90% Pulse abnormality significantly overestimates true prevalence of PAD Objective testing is therefore warranted Primary test ABI

Individuals with risks factors for PAD, limb symptoms on exertion or reduced limb function should undergo a vascular history to evaluate for symptoms of claudication or other limb symptoms that limit walking ability Patients at risk for PAD or patients with reduced limb function should also have a vascular PE to evaluate peripheral pulses Patients with a history or examination suggestive of PAD should proceed to objective testing including an ankle-brachial index

ABI SCREENING All patients with exertional leg symptoms Subjects aged 50-69 years who have cardiovascular risk factors (particularly diabetes or smoking) All patients over 70 years regardless of risk-factor status

ABI 10-12 cm sphygmomanometer cuff placed just above ankle Doppler measures systolic pressure of the posterior tibial and dorsalis pedis arteries of each leg These pressures are then normalized to the higher brachial pressures of either arm to form the ankle-brachial index

ABI Decreased ABI in symptomatic patients confirms existence of hemodynamically significant occlusive disease between heart and ankle Patients with exercise related leg pain of non vascular causes will have a normal ABI at rest and after exercise

MILD ISCHEMIA . 95-1.2 .70-.94 .50-.69 ABI DEGREE OF ISCHEMIA WAVEFORM PATTERN PHYSICAL LIMITATION . 95-1.2 None Triphasic or Biphasic No limitation or pseudoclaudication .70-.94 Mild Claudication in calves or thighs. Walking distance greater than 3-4 blocks .50-.69 Moderate Monophasic Quick systolic acceleration Claudication in calves or thighs. Walking distance less than 3 blocks

MODERATE TO SEVERE ISCHEMIA .35-.49 Moderately Severe Monophasic, Slow systolic acceleration, Tardus parvus Claudication in calves or thighs. Walkiing distance less than 1 block .26-.34 Severe Monophasic Tardus parvus Ischemic pain at rest, limited ability to walk. 0-.25 Critical Tardus parvus or no flow Ischemic pain at rest, loss of tissue, impending gangrene

Patients with PAD who do not have atypical symptoms , a reduced ABI is highly associated with reduced limb function, defined as reduced walking speed and/or a shortened walking distance during a timed 6 minute walk

VALUE OF ABI Confirms diagnosis of PAD Detects PAD in asymptomatic pts Used in Ddx to identify a vascular etiology Identifies patients with reduced limb function Provides key information on long term prognosis, with ABI<.90 associated with a 3-6 fold increased risk of cardiovascular mortality

TOE PRESSURES Small occlusion cuff is placed on the first or second toe with a flow sensor Toe pressure normally 30mmHg less than the ankle pressure Abnormal toe brachial index <.7 Rest pain if absolute toe pressure <30mmHg Non healing if toe pressure <20-30mmHg

When are toe pressures important? Diabetes Renal Insufficiency Any etiology manifesting in vascular calcification Non-compressible vessels=>250mmHg ankle pressure, or ABI >1.40

LIMITATIONS OF TOE PRESSURES Amputation of Great and/ or second toe Extensive tissue loss Ulceration Skin Perfusion Pressure Laser doppler Probe Wrapped around Forefoot

EXERCISE TESTING Patients with claudication who have an isolated iliac stenosis may have no pressure decrease across the stenosis at rest, therefore a normal ABI will be present Exercise will increase inflow velocity and make these lesions hemodynamically significant, and exercise will induce a decrease in the ABI that can be detected in the immediate recovery period and therefore establish the dx of PAD

EXERCISE TESTING II How does it work? Obtain initial ABI at rest Patient then walks (treadmill at 3.2 km/h (2mph), 10-12% grade) until claudication pain occurs (or a maximum of 5 minutes) following which ankle pressure is then again measured Decrease in ABI 15-20% is diagnostic of PAD

ALTERNATIVES TO EXERCISE/TREADMILL TESTING Climbing stairs or walking in the hallway Pts who cannot perform treadmill testing: active pedal plantar flexion Inflation of thigh cuff well above systolic pressure for 3-5 minutes to induce “reactive” hyperemia, not well tolerated, not recommednded

CAN WE QUANTIFY FUNCTION IN PATIENTS WITH PAD? Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001 Oct 3; 286(13):1599-606. McDermott MM et al. Claudication distances and the Walking Impairment Questionnaire best describe the ambulatory limiatations in patients with symptomatic peripheral arterial disease. J Vasc Surg. 2008 Mar; 47(3): 550-555. Myers SA et al

So…

VENOUS INSUFFICIENCY

VENOUS PHYSIOLOGY Venous system acts as a reservoir (60-75% of TBV in system) Venous pressures determined by gravity not by cardiac contractions Venous system largely dependent on valvular function for transport

WHAT IS CHRONIC VENOUS INSUFFICIENCY? Manifestation of valvular destruction and/or dysfunction resulting in venous hypertension of the extremity

VENOUS HYPERTENSION Caused by: Reflux through incompetent valves Venous outflow obstruction Failure of the musculovenous calf pump

PREVALENCE 20+million 6 million 1 million 500,000

SOCIOECONOMIC IMPACT 10-35% of adults in the US have some form of chronic venous insufficiency (CVI) Cost to the government for treatment amounts to 1 billion annually 2 million work days per year are lost due to venous related illnesses

CLASSIFICATION CEAP Venous Severity Score (VSS)

CEAP Created in 1994 under the auspices of the American Venous Forum Clinical-Etiologic-Anatomic-Pathophysiologic Descriptive classification Used to classify stages of venous disease Score directly correlates with CEAP clinical class

C in CEAP Clinical 1 2 3 4 5 6 No venous disease Telangiectases 1 2 3 4 5 6 No venous disease Telangiectases Varicose Veins Edema Lipodermatosclerosis Healed ulcer Active ulcer

C1: Spider veins

C2:Varicose Veins

C3: Edema

C4: Hyperpigmentation, atrophie blanche

C5: Healed ulcer

C6: Active ulcer

E in CEAP Etiologic Congenital Primary Secondary Present since birth Undetermined etiology Post-thrombotic

A in CEAP Anatomic distribution Superficial Deep Perforator Great and small saphenous veins Cava, iliac, gonadal, femoral, profunda, popliteal, tibial Thigh and leg perforating veins

P in CEAP Pathophysiological Reflux Obstruction Combination Axial and perforating veins Acute and chronic Valvular dysfunction and thrombus

Venous Severity Scoring Developed in 2000 Venous Outcomes Committee of the AVF Numeric score based on 3 components: VCSS, the anatomic segment disease score, and the VDS

Venous Severity Scoring VCSS Component Clinical Attributes Pain Varicose veins Venous edema Skin pigmentation Inflammation Induration Number of ulcers Duration of ulcers Size of ulcers Compressive therapy 4 Grades Absent Mild Moderate Severe

Venous Severity Scoring Anatomic Segmental Score Assigns a numerical value to segments that manifest reflux and/or obstruction Based on imaging Weights 11 venous segments for their relative importance when involved with reflux and/or obstruction with a maximum score of 10

DOES A PATIENT WITH CHRONIC VENOUS INSUFFICIENCY REALLY HAVE PROBLEMS FUNCTIONING?

Venous Severity Scoring Venous Disability Score Ability to perform ADLs with or without compression stockings Eliminates 8 hour work day instead replaces with normal daily activities Refinement of the CEAP disability score

NONINVASIVE PHYSIOLOGIC TESTING 2 Goals: to determine presence of obstruction, and presence of reflux in both the superficial and deep venous systems Doppler and duplex are utilized

NONINVASIVE PHYSIOLOGIC TESTING Non weight bearing calf compressed Compression with rapid release allows identification of valves and the presence of reflux Reflux will occur when calf compression is released Reflux=venous flow away from the heart (towards the feet) after release Mild reflux: .5-2.0 seconds Severe reflux: >2.0 seconds Normal veins do not reflux with this technique

DIAGNOSIS

Thank you!