PERIPHERAL ARTERIAL DISEASE (PAD) Dr. Riko Prima Putra, Sp.JP

Peripheral Arterial Disease = Peripheral Vascular Disease Vascular disease caused primarily by atherosclerosis & thromboembolic pathophysiological processes that alter the normal structure and function of the aorta, its visceral arterial branches, and the arteries of the lower extremities

Peripheral Arterial Disease Stenotic Occlusive Aneurysma

Prevalence of PAD Extremely common Increasingly common with age 20% of people over age 70 have PAD 5% of people over age 40 have PAD Prevalence of PAD: 11 Million, compared to stroke: 4.4 Million, and MI: 7 Million

PAD and mortality

Morbidity & mortality Only 5% of PAD patients will need treatment for limb related sequelae. 23% will die within 5 years from cardiac, cerebral, or other vascular events (Aronow, 1994).

Risk factors Older age (> 40 years) Male gender Smoking Diabetes mellitus Hyperlipidemia Hypertension Hyperhomocysteinemia When risk factors coexist, the risk increases several-fold

Clinical presentation Asymptomatic Claudication Critical limb ischemia Acute limb ischemia Prior limb arterial revascularization

A recent review in The New England Journal of Medicine noted that more than 50% of patients with peripheral arterial disease (PAD) do not have “typical” claudication or leg ischemia at rest, but instead have leg pain on exertion associated with reduced ambulatory activity and quality of life.[1] Less than 5% to 10% of patients with PAD have critical leg ischemia (defined as ischemic pain in the distal foot, ischemic ulceration, or gangrene), and approximately one-third present with typical claudication. Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med. 2001;344:1608-1621.

21/04/2017

Note: Plavix® (clopidogrel bisulfate) is not indicated for all the conditions listed on this slide. Vascular disease is the common underlying disease process for MI, ischemia and vascular death. Acute coronary syndrome (ACS) is a classic example of the progression of vascular disease to an ischemic event. ACS (in common with ischemic stroke and critical leg ischemia) is typically caused by rupture or erosion of an atherosclerotic plaque followed by formation of a platelet-rich thrombus. Atherosclerosis is an ongoing process affecting mainly large and medium-sized arteries, which can begin in childhood and progress throughout a person’s lifetime. Stable atherosclerotic plaques may encroach on the lumen of the artery and cause chronic ischemia, resulting in (stable) angina pectoris or intermittent claudication, depending on the vascular bed affected. Unstable atherosclerotic plaques may rupture, leading to the formation of a platelet-rich thrombus that partially or completely occludes the artery and causes acute ischemic symptoms.

Atherosclerosis results from an extensive inflammatory and fibroproliferative response to insults within the vasculature leading to disruption of normal homeostasis of the endothelium. The dysfunctional endothelium leads to an increase in adhesiveness and procoagulant properties of platelets. Atherosclerotic lesions form and through progression of the disease eventually become atherosclerotic plaques. Activated platelets can amplify the inflammatory response and are an important component leading to vasoconstriction. Rupture of the atherosclerotic plaque occurs in advanced stages of the disease and results in the formation of a thrombus and arterial occlusion. Atherosclerotic plaque, thrombosis, and vasoconstriction of the arteries all lead to decreased blood flow in the periphery. Ischemia may lead to painful symptoms that can be worsened as the demand of oxygen increases in response to activity such as walking. Painful symptoms at rest are signs of progressive disease. Ischemia may lead to cell death and tissue destruction. Progression of limb pain and destruction of tissue eventually leads to physical impairment. Ross R. Atherosclerosis—an inflammatory disease. N Engl J Med. 1999;340:115-126.

PRIMARY SITES OF INVOLVEMENT Femoral & Popliteal arteries: 80-90% Tibial & Peroneal arteries: 40-50% Aorta & Iliac arteries: 30% Harrison’s Principles of Int Med

Differential diagnosis CALF Venous occlusion Tight bursting pain / dull ache that worsens on standing and resolves with leg elevation Positional pain relief Chronic compartment syndrome Tight bursting pain Nerve root compression Baker’s cyst HIP/THIGH/BUTTOCK Arthritis Persistent pain, brought on by variable amounts of exercise Associated symptoms in other joints Spinal cord compression History of back pain Symptoms while standing Positional pain relief FOOT Arthritis Buerger disease (thromboangitis obliterans) Am J Cardiol 2001; 87 (suppl): 3D-13D

Diagnosis Symptoms Diagnostic studies Laboratory

Symptoms Leg pain, particularly when walking or exercising, which disappears after a few minutes of rest Numbness, tingling, or coldness in the lower leg or feet Sores or infection on feet or legs that heal slowly

Fontaine Classification Claudication Critical limb ischemia Fontaine Ⅰ,Ⅱ　　　　　 Ⅲ,Ⅳ Pentecost MJ, Circulation 89:51, 1994

Rutherford Classification Stage Stage Clinical Claudication Critical limb ischemia 0 Asymptomatic 1 Mild claudication 2 Moderate claudication 3 Severe claudication 4 Ischemic rest pain 5 Minor tissue loss 6 Major tissue loss Rutherford RB, et al, J Vasc Surg 1986;4:80-94

Rutherford 4 Ischemic rest pain Rutherford 5 Minor tissue loss Rutherford 6 Major tissue loss

Critical Limb Ischemia Resting ischemic pain PAD with skin breakdown Nonhealing ulcers Gangrene

Spectrum of Peripheral Arterial Disease As the topic title would suggest, this represents a very wide spectrum of potential disease presentations, the use of a wide of variety of diagnostic tools, and a diversity of both endovascular and surgical modalities. An adequate discussion of this important topic is clearly of the realm of a 20 min talk, and therefore I have decided that rather than discuss superficially many topics, I would like to discuss in-depth two ot three core issues regarding treating patients with PVD. Worsening flow limitation

Vascular diagnostic technique Ankle-brachial index (ABI) Toe-brachial index Segmental pressure measurement Pulse volume recording

Vascular diagnostic technique Continuous-wave doppler ultrasound Duplex ultasound Treadmill exercise testing with & without ABI assessments, 6-minute walk test

Vascular Echo and ABI for PAD

Ankle-brachial index (ABI)

Ankle-Brachial Index Values and Clinical Classification Clinical Presentation Ankle-Brachial Index Normal > 0.90 Claudication 0.50-0.90 Rest pain 0.21-0.49 Tissue loss < 0.20 Values >1.25 falsely elevated; commonly seen in diabetics Am J Cardiol 2001; 87 (suppl): 3D-13D NEJM 2001; 344: 1608-1621

McDermott and colleagues evaluated the relationship between the ankle brachial index (ABI) and leg function in 740 patients (460 with peripheral arterial disease [PAD]).[1] They demonstrated that ABI is more closely related with leg function than intermittent claudication or other leg symptoms. Lower ABI scores were consistently associated with shorter distance walked in 6 minutes, lower accelerometer-measured activity over 7 days, poorer standing balance, slower walking velocity at usual and fast pace, and lower overall summary performance scores. McDermott MM, Greenland P, Liu K, et al. The ankle brachial index is associated with leg function and physical activity: the walking and leg circulation study. Ann Intern Med. 2002;136:873-883.

Duplex in SFA Disease

Doppler at Popliteal Artery Systolic +　Diaslic flow Triphasic Systolic flow Biphasic

Multi-level of Stenosis Findings by Doppler CFA POP AT

Echo Assessment of Infrapopliteal artery AT PT AT TP PT TP Pe Pe PT

How many tests do we need to evaluate PVD ? TCD Duplex Duplex MRA CTA ABI DSA Segmental pressure Treadmill ABI ABI Pulse volume Toe pressure tPO2

Vascular diagnostic technique Magneting resonance angiography (MRA) Computed tomographic angiography (CTA) Contrast angiography

In the past, invasive vascular testing was considered the gold standard for vascular imaging and planning of revascularization procedures.[1] Images obtained using this procedure provide information about the level and severity of vascular disease. However, the utility of invasive imaging in all patients has been challenged, as duplex ultrasonography may provide adequate information for planning revascularization procedures in some patients. Collins KA, Sumpio BE. Vascular assessment. Clin Podiatr Med Surg. 2000;17:171-191.

The history and physical examination (pulse evaluation and careful examination of the leg) are usually sufficient to establish the diagnosis

Laboratory Hemoglobin Serum creatinine Lipid profile Hypercoagulability screen Homocysteine level Lp(a) lipoprotein

Goals of treatment To relieve exertional symptoms and improve walking capacity To improve quality of life To reduce total mortality as well as cardiac and cerebrovascular morbidity and mortality

Management Risk factor modification Exercise therapy Antiplatelet therapy Medical therapy targeted at symptoms Revascularisation procedures

Cardiovascular risk reduction Lipid lowering drugs Antihypertensive drugs Diabetes therapies Smoking cessation Homocysteine lowering drugs Antiplatelet and antihtrombotic drugs

Cardiovascular risk reduction Diabetes control (FBG 80-120 mg/dl, PPG < 180 mg/dl, HbA1c < 7%) Dyslipidemia management (LDL < 100 mg/dl, TG < 150 mg/dl): Statins (RR 38%; 4S) Hypertension control (BP < 130/85 mmHg)

Claudication Exercise and lower extremity PAD rehabilitation Exercise program : Improves walking ability Requires motivation & personalised supervision Benefits lost if not maintained on regular basis Overall effectiveness limited

Claudication Medical and pharmacological treatment Cilostazol Pentoxifylline Other proposed medical therapies (?) L-arginine Propionil-L-carnitine Ginkgo biloba

Claudication Endovascular treatment Surgery

Revascularisation procedures Incapacitating claudication Limb-threatening ischemia (pain at rest, non-healing ulcers and/or infections or gangrene) If symptoms persist despite medical therapy AHA guidelines 1996

Revascularisation procedures Angioplasty (balloon angioplasty) PTA (percutaneous transluminal angioplasty) Artery bypass graft

PTA & stenting

Screening for PAD

Low-tech, low cost and few people involved Angioplasty for PAD Low-tech, low cost and few people involved

Iliac Artery Intervention

TASC D lesions of the Pelvic Artery: Is there still a role for Aorta-Femoral bypass ?

SFA Intervention

71 y/o Male CAD, HTN, DM Rutherford 5

71 y/o Male CAD, HTN, DM Rutherford 5

Pre 71 y/o Male CAD, HTN, DM Rutherford 5 2 weeks 2 mo

Infrapopliteal Intervention for CLI

Pre 3mo

Thank you for your attention