1. Peripheral Interventions in the VA Healthcare System
Ehrin J. Armstrong MD MSc
Director, Interventional Cardiology
Denver VA Medical Center

2. Disclosures
None relevant

3. Manifestations of Peripheral Artery Disease
Lower Extremity Claudication
Critical Limb Ischemia
Acute Limb Ischemia
Carotid Artery Stenosis
Subclavian Artery Stenosis
Renal Artery Stenosis
Mesenteric Stenosis
Abdominal Aortic Aneurysm
Popliteal Artery Aneurysm

4. Estimates of PAD Prevalence
Every patient in the VA!
In a primary care population defined by age and common risk factors, the prevalence of PAD was approximately one in three patients
NHANES1
Aged >40 years
4.3%
San Diego2
Mean age 66 years
11.7%
NHANES1
Aged 70 years
14.5%
Rotterdam3
Aged >55 years
19.1%
Diehm4
Aged 65 years
19.8%
PARTNERS5
Aged >70 years, or 50–69 years with a history diabetes or smoking
29%
PARTNERS trial showed us that many patients were not aware of the sx’s of PAD, and that routine screening, especially with ABIs can detect and treat these patients sooner.
Prevalence of PAD Increases with Age 0% 5%
10%
15%
20%
25%
30%
35%
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: Criqui MH, et al. Circulation. 1985;71: Diehm C, et al. Atherosclerosis. 2004;172: Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18: Hirsch AT, et al. JAMA. 2001;286:
Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the national health and nutrition survey, Circulation. 2004;110:
Criqui MH, et al. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71:
Meijer WT, et al. Peripheral arterial disease in the elderly: the Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998;18:
Diehm C, et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis. 2004;172:95–105.
Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286: 4

5. PAD in Veterans
403 patients in Houston area over 50 years of age were screened with ABI.
Prevalence was
13% among whites
22% among African Americans
14% among Hispanics
Collins, Arch Int Med 2003

6. PAD and Survival Survival (%) Years Normal subjects Asymptomatic PAD
100 75 50 25
Normal subjects
Survival (%)
Asymptomatic PAD
Symptomatic PAD
Previous investigators have observed a doubling of the mortality rate among patients with intermittent claudication, and we have reported a fourfold increase in the overall mortality rate among subjects with large-vessel peripheral arterial disease, as diagnosed by noninvasive testing. In this study, we investigated the association of large-vessel peripheral arterial disease with rates of mortality from all cardiovascular diseases and from coronary heart disease. METHODS. We examined 565 men and women (average age, 66 years) for the presence of large-vessel peripheral arterial disease by means of two noninvasive techniques--measurement of segmental blood pressure and determination of flow velocity by Doppler ultrasound. We identified 67 subjects with the disease (11.9 percent), whom we followed prospectively for 10 years. RESULTS. Twenty-one of the 34 men (61.8 percent) and 11 of the 33 women (33.3 percent) with large-vessel peripheral arterial disease died during follow-up, as compared with 31 of the 183 men (16.9 percent) and 26 of the 225 women (11.6 percent) without evidence of peripheral arterial disease. After multivariate adjustment for age, sex, and other risk factors for cardiovascular disease, the relative risk of dying among subjects with large-vessel peripheral arterial disease as compared with those with no evidence of such disease was 3.1 (95 percent confidence interval, 1.9 to 4.9) for deaths from all causes, 5.9 (95 percent confidence interval, 3.0 to 11.4) for all deaths from cardiovascular disease, and 6.6 (95 percent confidence interval, 2.9 to 14.9) for deaths from coronary heart disease. The relative risk of death from causes other than cardiovascular disease was not significantly increased among the subjects with large-vessel peripheral arterial disease. After the exclusion of subjects who had a history of cardiovascular disease at base line, the relative risks among those with large-vessel peripheral arterial disease remained significantly elevated. Additional analyses revealed a 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease that was both severe and symptomatic. CONCLUSIONS. Patients with large-vessel peripheral arterial disease have a high risk of death from cardiovascular causes
PAD is an equivalent to ischemic heart disease risk.
The association between peripheral arterial disease and coronary artery disease has been known for many years
Prevalence of CHD if history/physical exam is used
20%-40%
Prevalence of CHD if noninvasive testing is used
50%-60%
Prevalence of CHD if coronary arteriography is used
~90%
Dormandy JA, and Murray GD. Eur J Vasc Surg. 1991;5(2):
Severe symptomatic
PAD 2 4 6 8 10 12
Years
Criqui MH et al. N Engl J Med. 1992;326: 6

7. Vascular Medicine at Denver VA
Claudication
Critical Limb Ischemia
Acute Limb Ischemia
Carotid Artery Stenosis
Subclavian Artery Stenosis
Renal Artery Stenosis
Mesenteric Ischemia
Abdominal Aortic Aneurysm
Popliteal Artery Aneurysm
DVT/PE e.g., IVC filters
Vasculitis
Fibromuscular Dysplasia

8. What We Do Inpatient Consultation Outpatient Consultation
About 2-3/week
Outpatient Consultation
Three clinics a week: see patients weekly
Dedicate vascular NP
Vascular Noninvasive Studies
One vascular tech
1600 studies/year
Endovascular Procedures
Mix of LE, carotid, and AAA interventions
cases/year

9. Placing an Outpatient Vascular Medicine Consult

10. Placing an Outpatient Vascular Medicine Consult

11. Ordering Vascular Lab Studies

12. Vascular Imaging Options

13. Arterial Imaging Examples

14. Case: Claudication
64M with PMH of prior smoking, hypercholesterolemia p/w calf pain on ambulation.
Pain is bilateral, but left worse than right.
Claudication begins at 100 yards, has to stop walking at 200 years.
Tried a walking program x 6 months, but remains severely impaired in daily activities.

22. Follow-Up Patient went home later that day. No more claudication
Have been following last 3.5 years – patent vessels, no symptoms.

23. Case: Critical Limb Ischemia
61 woman with ischemic rest pain and worsening necrotic ulcers on the medial and lateral aspect of the left lower leg
CAD with h/o 2 vessel CABG in 2003 and recent stenting
On hemodialysis
No usable saphenous or arm vein

24. Arterial Ulcer

32. Follow Up No further rest pain. Ulcers healed.
Duplex ultrasound: wide patency of popliteal artery stent, TP trunk, and peroneal artery.

33. Case: AAA
67M with 6.0 cm infrarenal AAA and severe R>L claudication.
Concomitant R CIA aneurysm (30 mm).
Occluded R EIA artery.

39. Credentialing Every VA hospital has a different credentialing system.
All politics are local.
Work with administration to ensure you are covered.

43. Opportunities for Advancing the Care of Veterans with PAD
More research on prevalence and outcomes of Veterans with PAD
Optimal medical therapy
Smoking cessation programs
Integrated CART-peripheral
Defined data elements
Amputation prevention programs
Centers of excellence?
Multidisciplinary coordination