peripheral arterial disease guidelines: management of patients with lower extremity pad harvey m....

Peripheral Arterial Disease Peripheral Arterial Disease Guidelines: Management of Guidelines: Management of

Patients with Lower Extremity Patients with Lower Extremity PADPAD

Harvey M. Wiener, DO, FSIR, FCIRSE, Harvey M. Wiener, DO, FSIR, FCIRSE, FAHAFAHA

Phoenix, ArizonaPhoenix, Arizona

Why A PAD Guideline?Why A PAD Guideline?

To enhance the quality of patient careTo enhance the quality of patient care Increasing recognition of the importance of Increasing recognition of the importance of

atherosclerotic lower extremity PAD:atherosclerotic lower extremity PAD:• High prevalenceHigh prevalence

• High cardiovascular riskHigh cardiovascular risk

• Poor quality of lifePoor quality of life Improved ability to detect and treat renal artery Improved ability to detect and treat renal artery

diseasedisease Improved ability to detect and treat AAAImproved ability to detect and treat AAA The evidence base has become increasingly The evidence base has become increasingly

robust - a data-driven care guideline is now robust - a data-driven care guideline is now possiblepossible

Peripheral Arterial Disease Guideline:Peripheral Arterial Disease Guideline:The Target Audiences Are DiverseThe Target Audiences Are Diverse

Primary care cliniciansPrimary care clinicians•Family practiceFamily practice•Internal medicineInternal medicine•PA, NP, nurse cliniciansPA, NP, nurse clinicians

Cardiovascular/vascular medicine, vascular Cardiovascular/vascular medicine, vascular surgical, & interventional radiology trainees surgical, & interventional radiology trainees and vascular specialistsand vascular specialists

This is not intended to be a procedural guideline; it is intended to provide a guide to optimal lifelong PAD care.

Defining a Population “At Risk” Defining a Population “At Risk” for Lower Extremity PADfor Lower Extremity PAD

Age less than 50 years with diabetes, and one additional risk Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)hyperhomocysteinemia)

Age 50 to 69 years and history of smoking or diabetesAge 50 to 69 years and history of smoking or diabetes Age 70 years and olderAge 70 years and older

Leg symptoms with exertion (suggestive of claudication) or Leg symptoms with exertion (suggestive of claudication) or ischemic rest painischemic rest pain

Abnormal lower extremity pulse examinationAbnormal lower extremity pulse examination

Known atherosclerotic coronary, carotid, or renal artery diseaseKnown atherosclerotic coronary, carotid, or renal artery disease

The First Tool to Establish the PAD Diagnosis:The First Tool to Establish the PAD Diagnosis:The HPI, ROS, and Physical ExaminationThe HPI, ROS, and Physical Examination

Individuals with asymptomatic PAD should be Individuals with asymptomatic PAD should be identified in order to offer therapeutic identified in order to offer therapeutic interventions known to diminish their increased interventions known to diminish their increased risk of myocardial infarction, stroke, and death.risk of myocardial infarction, stroke, and death.

A history of walking impairment, claudication, and A history of walking impairment, claudication, and

ischemic rest pain is recommended as a required ischemic rest pain is recommended as a required component of a standard review of systems for component of a standard review of systems for adults adults >>50 years who have atherosclerosis risk 50 years who have atherosclerosis risk factors, or for adults factors, or for adults >>70 years. 70 years.

The First Tool to Establish the PAD Diagnosis:The First Tool to Establish the PAD Diagnosis:The HPI, ROS, and Physical ExaminationThe HPI, ROS, and Physical Examination

Pulse intensity should be assessed and should be Pulse intensity should be assessed and should be recorded numerically as follows:recorded numerically as follows:

• 0, absent0, absent• 1, diminished1, diminished• 2, normal2, normal• 3, bounding3, bounding

Use of a standardexamination should

facilitate clinicalcommunication

Individuals with PAD Present in Clinical Individuals with PAD Present in Clinical Practice with Distinct SyndromesPractice with Distinct Syndromes

AsymptomaticAsymptomatic:: Without obvious symptomatic Without obvious symptomatic complaint (but usually with a functional impairment).complaint (but usually with a functional impairment).Classic ClaudicationClassic Claudication:: Lower extremity symptoms Lower extremity symptoms confined to the muscles with a consistent confined to the muscles with a consistent (reproducible) onset with exercise and relief with (reproducible) onset with exercise and relief with rest. rest. ““Atypical” leg painAtypical” leg pain:: Lower extremity discomfort Lower extremity discomfort that is exertional, but that does not consistently that is exertional, but that does not consistently resolve with rest, consistently limit exercise at a resolve with rest, consistently limit exercise at a reproducible distance, or meet all “Rose reproducible distance, or meet all “Rose questionnaire” criteria. questionnaire” criteria.

This guideline recognizes that:

Individuals with PAD Present in Clinical Practice Individuals with PAD Present in Clinical Practice with Distinct Syndromeswith Distinct Syndromes

Critical Limb IschemiaCritical Limb Ischemia:: Ischemic rest pain, Ischemic rest pain, non-healing wound, or gangrenenon-healing wound, or gangrene

Acute limb ischemia:Acute limb ischemia: The five “P’s, defined The five “P’s, defined by the clinical symptoms and signs that by the clinical symptoms and signs that suggest potential limb jeopardy: suggest potential limb jeopardy:

PainPain PulselessnessPulselessness PallorPallor ParesthesiasParesthesias Paralysis (& polar, as a sixth “p”). Paralysis (& polar, as a sixth “p”).

This guideline recognizes that:

Hemodynamic Noninvasive TestsHemodynamic Noninvasive Tests

Resting Ankle-Brachial Index (ABI)Resting Ankle-Brachial Index (ABI)

Exercise ABIExercise ABI

Segmental pressure examinationSegmental pressure examination

Pulse volume recordingsPulse volume recordings

These traditional tests continue to provide a simple, risk-free, and cost-effective approach to establishing the PAD diagnosis

as well as to follow PAD status after procedures.

Lower extremity systolic pressureLower extremity systolic pressureBrachial artery systolic pressureBrachial artery systolic pressure ABI =

• The ankle-brachial index is 95% sensitive and 99% specific for PADThe ankle-brachial index is 95% sensitive and 99% specific for PAD

• Establishes the PAD diagnosisEstablishes the PAD diagnosis

• Identifies a population at high risk of CV ischemic eventsIdentifies a population at high risk of CV ischemic events

• ““Population at risk” can be clinically & epidemiologically defined:Population at risk” can be clinically & epidemiologically defined:

The Ankle-Brachial The Ankle-Brachial IndexIndex

Exertional leg symptoms, non-healing wounds, age > 70, age > 50 years with a history of smoking or diabetes.

• Toe-brachial index (TBI) useful in individuals Toe-brachial index (TBI) useful in individuals with non-compressible pedal pulseswith non-compressible pedal pulses

Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34; Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14

Exercise ABIExercise ABI

Confirms the PAD Confirms the PAD diagnosisdiagnosis

Assesses the Assesses the functional severity functional severity of claudicationof claudication

May “unmask” PAD May “unmask” PAD when resting the ABI when resting the ABI is normalis normal

Arterial Duplex Ultrasound TestingArterial Duplex Ultrasound Testing

• Duplex ultrasound of the extremities is Duplex ultrasound of the extremities is useful to diagnose anatomic location useful to diagnose anatomic location and degree of stenosis of peripheral and degree of stenosis of peripheral arterial disease.arterial disease.

• Duplex ultrasound is useful to provide Duplex ultrasound is useful to provide surveillance following femoral-popliteal surveillance following femoral-popliteal bypass using venous conduit (but not bypass using venous conduit (but not prosthetic grafts). prosthetic grafts).

• Duplex ultrasound of the extremities can Duplex ultrasound of the extremities can be used to select candidates for:be used to select candidates for:(a)(a) endovascular intervention; endovascular intervention; (b)(b) surgical bypass, andsurgical bypass, and(c)(c) to select the sites of surgical to select the sites of surgical

anastomosis. anastomosis.

However, the data that might support use of duplex ultrasound to assess long-term patency of PTA is not robust.

Noninvasive Imaging TestsNoninvasive Imaging Tests

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


Duplex Ultrasound

Duplex ultrasound of the extremities is useful Duplex ultrasound of the extremities is useful to diagnose the anatomic location and degree to diagnose the anatomic location and degree of stenosis of PAD. of stenosis of PAD.

Duplex ultrasound is recommended for routineDuplex ultrasound is recommended for routinesurveillance after femoral-popliteal or femoral-surveillance after femoral-popliteal or femoral-tibial-pedal bypass with a venous conduit. tibial-pedal bypass with a venous conduit. minimum surveillance intervals are minimum surveillance intervals are approximately 3,6, and 12 months, and then approximately 3,6, and 12 months, and then yearly after graft placement.yearly after graft placement.




MRA of the extremities is useful to diagnoseMRA of the extremities is useful to diagnoseanatomic location and degree of stenosis of anatomic location and degree of stenosis of PAD.PAD.

MRA of the extremities should be performedMRA of the extremities should be performedwith a gadolinium enhancement. with a gadolinium enhancement.

MRA of the extremities is useful in selectingMRA of the extremities is useful in selectingpatients with lower extremity PAD as candidates patients with lower extremity PAD as candidates

for endovascular intervention.for endovascular intervention.

Magnetic Resonance Angiography (MRA)





CTA of the extremities may be consideredCTA of the extremities may be consideredto diagnose anatomic location and to diagnose anatomic location and presence of significant stenosis in presence of significant stenosis in patients with lower extremity PAD. patients with lower extremity PAD.

CTA of the extremities may be considered CTA of the extremities may be considered as a substitute for MRA for those patientsas a substitute for MRA for those patientswith contraindications to MRA. with contraindications to MRA.

Computed Tomographic Angiography (CTA)

Natural History of PADAge > 50 years

Limb

Morbidity

Cardiovascular Morbidity / Mortality

Worsening Claudication

10-20%

Critical Limb

Ischemia

1-2%

Nonfatal CV Events

20%

Mortality 15-30%

Stable Claudication

70-80%

CV Causes75%

Non CV Causes25%

Lipid Lowering and Antihypertensive Therapy

Treatment with an HMG coenzyme-A reductase inhibitor Treatment with an HMG coenzyme-A reductase inhibitor

(statin) medication is indicated for all patients with peripheral (statin) medication is indicated for all patients with peripheral

arterial disease to achieve a target LDL cholesterol of less arterial disease to achieve a target LDL cholesterol of less

than 100 mg/dl. than 100 mg/dl.

Antihypertensive therapy should be administered to Antihypertensive therapy should be administered to

hypertensive patients with lower extremity PAD to a goal of hypertensive patients with lower extremity PAD to a goal of

less than 140/90 mmHg (non-diabetics) or less than 130/80 less than 140/90 mmHg (non-diabetics) or less than 130/80

mm/Hg (diabetics and individuals with chronic renal disease) mm/Hg (diabetics and individuals with chronic renal disease)

to reduce the risk of myocardial infarction, stroke, congestive to reduce the risk of myocardial infarction, stroke, congestive

heart failure, and cardiovascular death. heart failure, and cardiovascular death.



Antiplatelet Therapy

Antiplatelet therapy is indicated to reduce the risk of Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.with atherosclerotic lower extremity PAD.

Aspirin, in daily doses of 75 to 325 mg, is recommended as Aspirin, in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of safe and effective antiplatelet therapy to reduce the risk of myocardial infarction, stroke, or vascular death in individuals myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD. with atherosclerotic lower extremity PAD.



Clopidogrel (75 mg per day) is recommended as an Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce effective alternative antiplatelet therapy to aspirin to reduce the risk of myocardial infarction, stroke, or vascular death the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.in individuals with atherosclerotic lower extremity PAD.


Supervised Exercise Rehabilitation

A program of supervised exercise training is A program of supervised exercise training is

recommended as an initial treatment modality recommended as an initial treatment modality

for patients with intermittent claudication. for patients with intermittent claudication.

Supervised exercise training should be Supervised exercise training should be

performed for a minimum of 30 to 45 minutes, in performed for a minimum of 30 to 45 minutes, in

sessions performed at least three times per sessions performed at least three times per

week for a minimum of 12 weeksweek for a minimum of 12 weeks..



Pharmacotherapy of Claudication

Cilostazol (100 mg orally two times per day) Cilostazol (100 mg orally two times per day) is indicated as an effective therapy to is indicated as an effective therapy to improve symptoms and increase walking improve symptoms and increase walking distance in patients with lower extremity distance in patients with lower extremity PAD and intermittent claudication (in the PAD and intermittent claudication (in the absence of heart failure).absence of heart failure).


Endovascular procedures are indicated for Endovascular procedures are indicated for individuals with a vocational or lifestyle-individuals with a vocational or lifestyle-limiting disability due to intermittent limiting disability due to intermittent claudication when clinical features suggest a claudication when clinical features suggest a reasonable likelihood of symptomatic reasonable likelihood of symptomatic improvement with endovascular intervention improvement with endovascular intervention andand… …

a.a. Response to exercise or pharmacologic Response to exercise or pharmacologic therapy is inadequate, therapy is inadequate, and/orand/or

b. there is a very favorable risk-benefit ratio b. there is a very favorable risk-benefit ratio (e.g. focal aortoiliac occlusive disease)(e.g. focal aortoiliac occlusive disease)


Endovascular Treatment for Claudication

Endovascular intervention is recommended as the preferred revascularization technique for TASC type A iliac and femoropopliteal lesions.

TASC A:(PTA recommended)

Iliac Femoropopliteal

TASC B: (insufficient data to recommend)



Provisional stent placement is indicated for use Provisional stent placement is indicated for use in iliac arteries as salvage therapy for in iliac arteries as salvage therapy for suboptimal or failed result from balloon dilation suboptimal or failed result from balloon dilation (e.g. persistent gradient, residual diameter (e.g. persistent gradient, residual diameter stenosis >50%, or flow-limiting dissection).stenosis >50%, or flow-limiting dissection).

Stenting is effective as primary therapy for Stenting is effective as primary therapy for common iliac artery stenosis and occlusions.common iliac artery stenosis and occlusions.

Stenting is effective as primary therapy in Stenting is effective as primary therapy in external iliac artery stenosis and occlusions.external iliac artery stenosis and occlusions.

Endovascular Treatment for Claudication: Iliac Arteries




Endovascular intervention is not indicated if Endovascular intervention is not indicated if there is no significant pressure gradient across there is no significant pressure gradient across a stenosis despite flow augmentation with a stenosis despite flow augmentation with vasodilators.vasodilators.

Primary stent placement is not recommended Primary stent placement is not recommended in the femoral, popliteal, or tibial arteries.in the femoral, popliteal, or tibial arteries.

Endovascular intervention is not indicated as Endovascular intervention is not indicated as prophylactic therapy in an asymptomatic patient prophylactic therapy in an asymptomatic patient with lower extremity PAD.with lower extremity PAD.





Surgery for Critical Limb IschemiaSurgery for Critical Limb Ischemia

Patients who have significant necrosis of the weight-bearing portions of the foot, an uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or a very limited life expectancy due to co-morbid conditions should be evaluated for primary amputation.

Surgery is not indicated in patients with severe decrements in limb perfusion in the absence of clinical symptoms of critical limb ischemia.




For individuals with combined inflow and For individuals with combined inflow and outflow disease with critical limb ischemia, outflow disease with critical limb ischemia, inflow lesions should be addressed first.inflow lesions should be addressed first.

When surgery is to be undertaken, an When surgery is to be undertaken, an

aorto-bifemoral bypass isaorto-bifemoral bypass is

recommended for patients with recommended for patients with

symptomatic, hemodynamically symptomatic, hemodynamically

significant, aorto-bi-iliac disease significant, aorto-bi-iliac disease

requiring intervention.requiring intervention.




Bypasses to the above-knee popliteal Bypasses to the above-knee popliteal artery should be constructed with autogenousartery should be constructed with autogenoussaphenous vein when possible.saphenous vein when possible.

Bypasses to the below-knee popliteal artery Bypasses to the below-knee popliteal artery should be constructed with autogenous vein should be constructed with autogenous vein when possible.when possible.

Prosthetic material can be used effectively Prosthetic material can be used effectively for bypasses to the below knee popliteal for bypasses to the below knee popliteal artery when no autogenous vein from artery when no autogenous vein from ipsilateral or contralateral leg or arm is ipsilateral or contralateral leg or arm is available.available.





Femoral-tibial artery bypasses should beFemoral-tibial artery bypasses should beconstructed with autogenous vein, constructed with autogenous vein, including ipsilateral greater saphenous including ipsilateral greater saphenous vein, or if unavailable, other sources of vein vein, or if unavailable, other sources of vein from the leg or arm.from the leg or arm.

Composite sequential femoropopliteal-tibial Composite sequential femoropopliteal-tibial bypass, or bypass to an isolated popliteal bypass, or bypass to an isolated popliteal arterial segment that has collateral outflow arterial segment that has collateral outflow to the foot, are acceptable methods of to the foot, are acceptable methods of revascularization and should be considered revascularization and should be considered when no other form of bypass with when no other form of bypass with adequate autogenous conduit is possible.adequate autogenous conduit is possible.



Acute Limb Ischemia (ALI)Acute Limb Ischemia (ALI)

Patients with ALI and a salvageable Patients with ALI and a salvageable extremity should undergo an emergent extremity should undergo an emergent evaluation that defines the anatomic level evaluation that defines the anatomic level of occlusion, and that leads to prompt of occlusion, and that leads to prompt endovascular or surgical intervention.endovascular or surgical intervention.

Patients with ALI and a non-viable Patients with ALI and a non-viable extremity should not undergo an extremity should not undergo an evaluation to define vascular anatomy or evaluation to define vascular anatomy or efforts to attempt revascularization.efforts to attempt revascularization.



Population at risk is now defined Population at risk is now defined by epidemiologic criteria by epidemiologic criteria applied to practice.applied to practice.

ACC/AHA Guidelines for the Management of PAD:ACC/AHA Guidelines for the Management of PAD:Major Contributions to Improved Care StandardsMajor Contributions to Improved Care Standards

Presentation-specific algorithms will expedite care (e.g., asx, atypical leg pain, classic claudication, critical limb ischemia, & acute arterial occlusion).

Use of exercise, pharmacologic, Use of exercise, pharmacologic, endovascular, and surgical endovascular, and surgical interventions are emplaced in interventions are emplaced in care as defined by evidence.care as defined by evidence.

The PAD Guidelines & the “PAD Coalition”:The PAD Guidelines & the “PAD Coalition”:An Ideal Health Partnership To Foster An Ideal Health Partnership To Foster

Clinician and Public PAD EducationClinician and Public PAD Education

The PAD CoalitionThe PAD CoalitionA public, interdisciplinary Coalition devoted to

creating a national PAD public awareness campaign and to coordinating

PAD public & physician education.

www.padcoalition.orgwww.padcoalition.org

peripheral arterial disease guidelines: management of patients with lower extremity pad harvey m....

Documents

pad guideline

lower extremity pad

lower extremity pad

asymptomatic pad

diabetes age

pad diagnosis

renal artery disease

optimal lifelong pad