1. 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

2. OUTLINE Definition Diagnosis
Impact of Disease on Activities of Daily Living

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

4. 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

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

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

13. MODERATE TO SEVERE ISCHEMIA
Moderately Severe
Monophasic, Slow systolic acceleration, Tardus parvus
Claudication in calves or thighs. Walkiing distance less than 1 block
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

14. 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

15. 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

16. 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

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

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

19. 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

20. 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

21. 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

23. 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): 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 Mar; 47(3): Myers SA et al

24. So…

25. VENOUS INSUFFICIENCY

26. 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

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

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

29. PREVALENCE
20+million 6 million million ,000

30. 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

31. CLASSIFICATION
CEAP
Venous Severity Score (VSS)

32. 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

33. C in CEAP Clinical 1 2 3 4 5 6 No venous disease Telangiectases1 2 3 4 5 6
No venous disease
Telangiectases
Varicose Veins
Edema
Lipodermatosclerosis
Healed ulcer
Active ulcer

34. C1: Spider veins

35. C2:Varicose Veins

36. C3: Edema

37. C4: Hyperpigmentation, atrophie blanche

38. C5: Healed ulcer

39. C6: Active ulcer

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

41. 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

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

43. 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

44. 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

45. 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

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

47. 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

48. 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

49. 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: seconds
Severe reflux: >2.0 seconds
Normal veins do not reflux with this technique

50. DIAGNOSIS

51. Thank you!