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Health & Medicine

Published on November 21, 2008

Author: surgmax

Source: slideshare.net

Description

An update on the state of the art in vascular health. Based on current ACC/AHA guidelines.

Peripheral Arterial Disease or P.A.D. GUIDELINES

To enhance the quality of patient care Increasing recognition of the importance of atherosclerotic lower extremity PAD: High prevalence High cardiovascular risk Poor quality of life Improved ability to detect and treat renal artery disease Improved ability to detect and treat abdominal aortic aneurysm The evidence base has become increasingly robust, so that a data-driven care guideline is now possible Why a PAD Guideline?

To enhance the quality of patient care

Increasing recognition of the importance of atherosclerotic lower extremity PAD:

High prevalence

High cardiovascular risk

Poor quality of life

Improved ability to detect and treat renal artery disease

Improved ability to detect and treat abdominal aortic aneurysm

The evidence base has become increasingly robust, so that a data-driven care guideline is now possible

1. Meijer WT, et al. Arterioscler Thromb Vasc Biol . 1998;18:185-192. 2. Criqui MH, et al. Circulation . 1985;71:510-515 . Rotterdam Study San Diego Study 0 10 20 30 40 50 60 Patients With PAD (%) 55-59 60-64 65-69 70-74 75-79 80-84 85-89 Age (years) Prevalence of PAD Increases With Age ABI=ankle-brachial index

Gender Differences in the Prevalence of PAD Adapted from Diehm C. Atherosclerosis . 2004;172:95-105 with permission from Elsevier . Prevalence (%) Women Men 6880 Consecutive Patients (61% Female) in 344 Primary Care Offices <70 0 2 4 6 8 10 12 14 16 70 – 74 75–79 80–84 >85 Age (years) 18

Ethnicity and PAD: The San Diego Population Study NHW = Non-hispanic white. Reprinted with permission from Criqui, et al. Circulation. 2005:112:2703-07. NHW Black Hispanic Asian 0 1 2 3 4 5 6 7 8 9 10 Fraction of Population With PAD (%)

Diabetes Increases the Risk of PAD 22.4* 19.9* 12.5 0 5 10 15 20 25 Normal Glucose Tolerance Impaired Glucose Tolerance Diabetes Prevalence of PAD (%) Impaired glucose tolerance was defined as oral glucose tolerance test value ≥140 mg/dL but <200 mg/dL. *P  .05 vs. normal glucose tolerance. Reprinted with permission from Lee AJ, et al. Br J Haematol. 1999;105:648-654. www.blackwell-synergy.com

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192 . Relative Risk Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia C-Reactive Protein Risk Factors for PAD 1 2 3 4 5 6 0 Reduced Increased

Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) Age 50 to 69 years and history of smoking or diabetes Age 70 years and older Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal artery disease Individuals “At Risk” for Lower Extremity PAD Based on the epidemiologic evidence base, an “at risk” population for PAD can be objectively defined by:

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

Age 50 to 69 years and history of smoking or diabetes

Age 70 years and older

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

Abnormal lower extremity pulse examination

Known atherosclerotic coronary, carotid, or renal artery disease

Individuals With PAD Present in Clinical Practice With Distinct Syndromes Asymptomatic : Without obvious symptomatic complaint (but usually with a functional impairment). Classic claudication : Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest. “ Atypical” leg pain : Lower extremity discomfort that is exertional but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance.

Asymptomatic : Without obvious symptomatic complaint (but usually with a functional impairment).

Classic claudication : Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest.

“ Atypical” leg pain : Lower extremity discomfort that is exertional but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance.

Individuals With PAD Present in Clinical Practice With Distinct Syndromes Critical limb lschemia : Ischemic rest pain, nonhealing wound, or gangrene/ Acute limb ischemia: The five “P”s, defined by the clinical symptoms and signs that suggest potential limb jeopardy: Pain Pulselessness Pallor Paresthesias Paralysis (& polar, as a sixth “P”).

Critical limb lschemia : Ischemic rest pain, nonhealing wound, or gangrene/

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

Pain

Pulselessness

Pallor

Paresthesias

Paralysis (& polar, as a sixth “P”).

PAD Prognosis

The Natural History of PAD Individuals with PAD are at increased risk for cardiovascular ischemic events due to concomitant CAD (fatal and non-fatal MI) and cerebrovascular disease (fatal and non-fatal stroke). Cardiovascular events are more frequent than ischemic limb events in any lower extremity PAD cohort, regardless of the clinical presentation.

Individuals with PAD are at increased risk for cardiovascular ischemic events due to concomitant CAD (fatal and non-fatal MI) and cerebrovascular disease (fatal and non-fatal stroke).

Cardiovascular events are more frequent than ischemic limb events in any lower extremity PAD cohort, regardless of the clinical presentation.

Natural History of Atherosclerotic Lower Extremity PAD PAD Population (50 years and older) Initial clinical presentation Asymptomatic PAD 20%-50% Atypical leg pain 40%-50% Claudication 10%-35% Critical limb ischemia 1%-2% Progressive functional impairment 1-year outcomes Alive w/ 2 limbs 50% Amputation 25% CV mortality 25% 5-year outcomes (to next slide) Reprinted with permission from Hirsch AT, et al. Circulation. 2006;113:e463-654 .

Claudication 10%-35% 5-year outcomes Limb morbidity Stable claudication 70%-80% Worsening claudication 10%-20% Critical limb ischemia 1%-2% Amputation (see CLI data) CV morbidity & mortality Nonfatal CV event (MI or stroke) 20% Mortality 15%-30% CV causes 75% Non-CV causes 25% Reprinted with permission from Hirsch AT, et al. Circulation. 2006;113:e463-654. Asymptomatic PAD 20%-50% Atypical leg pain 40%-50% For each of these PAD clinical syndromes CLI=critical limb ischemia; CV=cardiovascular; MI=myocardial infarction

Long-Term Survival in Patients With PAD Criqui MH et al. N Engl J Med. 1992;326:381-386. Copyright © 1992 Massachusetts Medical Society. All rights reserved. Normal subjects Asymptomatic PAD Symptomatic PAD Severe symptomatic PAD Survival (%) Year 100 75 50 25 0 2 4 6 8 10 12

Association Between ABI and All‑Cause Mortality* Baseline ABI Total Mortality (%) Age range=mid- to late-50s; ABI=ankle-brachial index; *Median duration of follow-up was 11.1 (0.1–12) years. Adapted from O’Hare AM et al. Circulation . 2006;113:388-393 . N=5748 Risk increases at ABI values below 1.0 and above 1.3

Cardiovascular Risk Increases With Decreases in ABI >1.1 1.1–1.01 1.0–0.91 0.9–0.71 <0.7 ABI CHD Event Outcomes per Year (%) 0 1 2 3 4 5-year risk: 10% 5-year risk: 19% Framingham “High Risk” = 20% at 10 years Every patient with PAD is at “very high risk” *Fatal or nonfatal MI. ABI=ankle-brachial index; CHD=chronic heart failure 2% 3.8% 1.4% Leng GC, et al. Brit Med J. 1996;313:1440-44 . PAD

Critical Limb Ischemia (CLI) Fate of Patients With CLI After Initial Treatment Summary of 6-month outcomes from 19 studies Dormandy JA, Rutherford RB. J Vasc Surg . 2000;31:S1-S296. Critical limb ischemia is defined as ischemic rest pain, nonhealing wounds, or gangrene. Dead 20% Alive without amputation 45% Alive with amputation 35%

Applying Classification of Recommendations and Level of Evidence Class III Risk ≥ Benefit No additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Level B Limited (2-3) population risk strata evaluated Level A Multiple (3-5) population risk strata evaluated General consistency of direction and magnitude of effect Level C Very limited (1-2) population risk strata evaluated

The Vascular History and Physical Examination Individuals at risk for lower extremity PAD should undergo a vascular review of symptoms to assess walking impairment, claudication, ischemic rest pain, and/or the presence of nonhealing wounds. Individuals at risk for lower extremity PAD should undergo comprehensive pulse examination and inspection of the feet. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

Individuals at risk for lower extremity PAD

should undergo a vascular review of

symptoms to assess walking impairment,

claudication, ischemic rest pain, and/or the

presence of nonhealing wounds.

Individuals at risk for lower extremity PAD

should undergo comprehensive pulse

examination and inspection of the feet.

Identification of the Asymptomatic Patient With PAD A history of walking impairment, claudication, and ischemic rest pain is recommended as a required component of a standard review of systems for adults > 50 years who have atherosclerosis risk factors, or for adults > 70 years. Individuals with asymptomatic PAD should be identified in order to offer therapeutic interventions known to diminish their increased risk of myocardial infarction, stroke, and death. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

A history of walking impairment, claudication,

and ischemic rest pain is recommended as a

required component of a standard review of

systems for adults > 50 years who have

atherosclerosis risk factors, or for adults > 70 years.

Individuals with asymptomatic PAD should be

identified in order to offer therapeutic

interventions known to diminish their

increased risk of myocardial infarction, stroke,

and death.

Identification of the Symptomatic Patient With Intermittent Claudication Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the ABI. In patients with symptoms of intermittent claudication, the ABI should be measured after exercise if the resting index is normal. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

Patients with symptoms of intermittent

claudication should undergo a vascular

physical examination, including measurement

of the ABI.

In patients with symptoms of intermittent

claudication, the ABI should be measured after

exercise if the resting index is normal.

Patients with intermittent claudication should have significant functional impairment with a reasonable likelihood of symptomatic improvement and absence of other disease that would comparably limit exercise even if the claudication was improved (e.g., angina, heart failure, chronic respiratory disease, or orthopedic limitations) before undergoing an evaluation for revascularization. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

Patients with intermittent claudication should

have significant functional impairment with a

reasonable likelihood of symptomatic

improvement and absence of other disease that

would comparably limit exercise even if the

claudication was improved (e.g., angina, heart

failure, chronic respiratory disease, or

orthopedic limitations) before undergoing an

evaluation for revascularization.

Revascularization of the Patient With Intermittent Claudication Individuals with intermittent claudication who are offered the option of endovascular or surgical therapies should: be provided information regarding supervised claudication exercise therapy and pharmacotherapy; receive comprehensive risk factor modification and antiplatelet therapy; have a significant disability, either being unable to perform normal work or having serious impairment of other activities important to the patient; have lower extremity PAD lesion anatomy such that the revascularization procedure would have low risk and a high probability of initial and long-term success. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

Individuals with intermittent claudication who are offered the option of endovascular or surgical therapies should:

be provided information regarding supervised claudication exercise therapy and pharmacotherapy;

receive comprehensive risk factor modification and antiplatelet therapy;

have a significant disability, either being unable to perform normal work or having serious impairment of other activities important to the patient;

have lower extremity PAD lesion anatomy such that the revascularization procedure would have low risk and a high probability of initial and long-term success.

Evaluation of the Patient With Critical Limb Ischemia Patients with CLI should undergo expedited evaluation and treatment of factors that are known to increase the risk of amputation. Patients with CLI in whom open surgical repair is anticipated should undergo assessment of cardiovascular risk. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

Patients with CLI should undergo expedited

evaluation and treatment of factors that are

known to increase the risk of amputation.

Patients with CLI in whom open surgical repair is

anticipated should undergo assessment of

cardiovascular risk.

Patients at risk of CLI (ABI less than 0.4 in a nondiabetic individual, or any diabetic individual with known lower extremity PAD) should undergo regular inspection of the feet to detect objective signs of CLI. The feet should be examined directly, with shoes and socks removed, at regular intervals after successful treatment of CLI. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

Patients at risk of CLI (ABI less than 0.4 in a

nondiabetic individual, or any diabetic

individual with known lower extremity PAD)

should undergo regular inspection of the feet

to detect objective signs of CLI.

The feet should be examined directly, with

shoes and socks removed, at regular intervals

after successful treatment of CLI.

Patients with CLI and skin breakdown should be referred to healthcare providers with specialized expertise in wound care. Patients at risk for CLI (those with diabetes, neuropathy, chronic renal failure, or infection) who develop acute limb symptoms represent potential vascular emergencies and should be assessed immediately and treated by a specialist competent in treating vascular disease. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

Patients with CLI and skin breakdown should

be referred to healthcare providers with

specialized expertise in wound care.

Patients at risk for CLI (those with diabetes,

neuropathy, chronic renal failure, or infection)

who develop acute limb symptoms represent

potential vascular emergencies and should be

assessed immediately and treated by a

specialist competent in treating vascular

disease.

The Clinical Approach to the Patient With, or at Risk for, PAD A vascular review of symptoms A vascular-focused physical examination Use of the noninvasive vascular diagnostic laboratory (ABI and toe-brachial index [TBI], exercise ABI, Duplex ultrasound, magnetic resonance angiography [MRA], and computed tomographic angiography [CTA]) When required, use of diagnostic catheter-based angiography Clinicians who care for individuals with PAD should be able to provide :

A vascular review of symptoms

A vascular-focused physical examination

Use of the noninvasive vascular diagnostic laboratory (ABI and toe-brachial index [TBI], exercise ABI, Duplex ultrasound, magnetic resonance angiography [MRA], and computed tomographic angiography [CTA])

When required, use of diagnostic catheter-based angiography

The Vascular Review of Symptoms: An Essential Component of the Vascular History Key components of the vascular review of systems (not usually included in the review of systems of the extremities) and family history include the following: Any exertional limitation of the lower extremity muscles or any history of walking impairment. The characteristics of this limitation may be described as fatigue, aching, numbness, or pain. The primary site(s) of discomfort in the buttock, thigh, calf, or foot should be recorded, along with the relation of such discomfort to rest or exertion. Any poorly healing or nonhealing wounds of the legs or feet. Any pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions. Post-prandial abdominal pain that reproducibly is provoked by eating and is associated with weight loss. Family history of a first-degree relative with an abdominal aortic aneurysm.

Key components of the vascular review of systems (not usually included in the review of systems of the extremities) and family history include the following:

Any exertional limitation of the lower extremity muscles or any history of walking impairment. The characteristics of this limitation may be described as fatigue, aching, numbness, or pain. The primary site(s) of discomfort in the buttock, thigh, calf, or foot should be recorded, along with the relation of such discomfort to rest or exertion.

Any poorly healing or nonhealing wounds of the legs or feet.

Any pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions.

Post-prandial abdominal pain that reproducibly is provoked by eating and is associated with weight loss.

Family history of a first-degree relative with an abdominal aortic aneurysm.

Comprehensive Vascular Examination Pulse Examination Carotid Radial/ulnar Femoral Popliteal Dorsalis pedis Posterior tibial Scale: 0=Absent 1=Diminished 2=Normal 3=Bounding (aneurysm) Bilateral arm blood pressure (BP) Cardiac examination Palpation of the abdomen for aneurysmal disease Auscultation for bruits Examination of legs and feet Key components of the vascular physical examination include:

Pulse Examination

Carotid

Radial/ulnar

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

Scale:

0=Absent

1=Diminished

2=Normal

3=Bounding (aneurysm)

Bilateral arm blood pressure (BP)

Cardiac examination

Palpation of the abdomen for aneurysmal disease

Auscultation for bruits

Examination of legs and feet

ACC/AHA Guideline for the Management of PAD: Steps Toward the Diagnosis of PAD Perform a resting ankle-brachial index measurement Recognizing the “at risk” groups leads to recognition of the five main PAD clinical syndromes: No leg pain Classic claudication Chronic critical limb ischemia (CLI) Acute limb ischemia (ALI) “ Atypical” leg pain Obtain history of walking impairment and/or limb ischemic symptoms: Obtain a vascular review of symptoms: Leg discomfort with exertion Leg pain at rest; non-healing wound; gangrene

Obtain history of walking impairment and/or limb ischemic symptoms:

Obtain a vascular review of symptoms:

Leg discomfort with exertion

Leg pain at rest; non-healing wound; gangrene

Performed with the patient resting in the supine position All pressures are measured with an arterial Doppler and appropriately sized blood pressure cuff (edge 1-2 inches above the pulse; cuff width should be 40% of limb circumference). Systolic pressures will be measured in the right and left brachial arteries followed by the right and left ankle arteries. How to Perform an ABI Exam

Performed with the patient resting in the supine position

All pressures are measured with an arterial Doppler and appropriately sized blood pressure cuff (edge 1-2 inches above the pulse; cuff width should be 40% of limb circumference).

Systolic pressures will be measured in the right and left brachial arteries followed by the right and left ankle arteries.

ABI Procedure Step 1 : Apply the appropriately sized blood pressure cuff on the arm above the elbow (either arm). Step 2 : Apply Doppler gel to skin surface. Step 3 : Turn on the Doppler and place the probe in the area of the pulse at a 45-60° angle to the surface of the skin, pointing to the shoulder. Step 4 : Move the probe around until the clearest arterial signal is heard.

Step 1 : Apply the appropriately sized blood pressure cuff on the arm above the elbow (either arm).

Step 2 : Apply Doppler gel to skin surface.

Step 3 : Turn on the Doppler and place the probe in the area of the pulse at a 45-60° angle to the surface of the skin, pointing to the shoulder.

Step 4 : Move the probe around until the clearest arterial signal is heard.

ABI Procedure http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_diagnosis.html

Step 5 : Inflate the blood pressure cuff to approximately 20 mmHg above the point where systolic sounds are no longer heard. Step 6 : Gradually deflate until the arterial signal returns. Record the pressure reading. Step 7 : Repeat the procedure for the right and left posterior tibial and dorsalis pedis arteries. Place the probe on the pulse and angle the probe at 45 o toward the knee. Step 8 : Record the systolic blood pressure of the contralateral arm. ABI Procedure

Step 5 : Inflate the blood pressure cuff to approximately 20 mmHg above the point where systolic sounds are no longer heard.

Step 6 : Gradually deflate until the arterial signal returns. Record the pressure reading.

Step 7 : Repeat the procedure for the right and left posterior tibial and dorsalis pedis arteries. Place the probe on the pulse and angle the probe at 45 o toward the knee.

Step 8 : Record the systolic blood pressure of the contralateral arm.

Understanding the ABI The ratio of the higher brachial systolic pressure and the higher ankle systolic pressure for each leg: ABI = Ankle systolic pressure Higher brachial artery systolic pressure

The ratio of the higher brachial systolic pressure and the higher ankle systolic pressure for each leg:

Using the ABI: An Example ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure. Right ABI 80/160=0.50 Brachial SBP 160 mm Hg PT SBP 120 mm Hg DP SBP 80 mm Hg Brachial SBP 150 mm Hg PT SBP 40 mm Hg DP SBP 80 mm Hg Left ABI 120/160=0.75 Highest brachial SBP Highest of PT or DP SBP ABI (Normal >0.90)

ABI Limitations Incompressible arteries (elderly patients, patients with diabetes, renal failure, etc.) Resting ABI may be insensitive for detecting mild aorto-iliac occlusive disease Not designed to define degree of functional limitation Normal resting values in symptomatic patients may become abnormal after exercise Note : “Non-compressible” pedal arteries is a physiologic term and such arteries need not be “calcified”

Incompressible arteries (elderly patients, patients with diabetes, renal failure, etc.)

Resting ABI may be insensitive for detecting mild aorto-iliac occlusive disease

Not designed to define degree of functional limitation

Normal resting values in symptomatic patients may become abnormal after exercise

Note : “Non-compressible” pedal arteries is a physiologic term and such arteries need not be “calcified”

Toe-Brachial Index Measurement The toe-brachial index (TBI) is calculated by dividing the toe pressure by the higher of the two brachial pressures. TBI values remain accurate when ABI values are not possible due to non-compressible pedal pulses. TBI values ≤ 0.7 are usually considered diagnostic for lower extremity PAD.

The toe-brachial index (TBI) is calculated by dividing the toe pressure by the higher of the two brachial pressures.

TBI values remain accurate when ABI values are not possible due to non-compressible pedal pulses.

TBI values ≤ 0.7 are usually considered diagnostic for lower extremity PAD.

Arterial Duplex Ultrasound Testing Duplex ultrasound of the extremities is useful to diagnose anatomic location and degree of stenosis of peripheral arterial disease. Duplex ultrasound is useful to provide surveillance following femoral-popliteal bypass using venous conduit (but not prosthetic grafts). Duplex ultrasound of the extremities can be used to select candidates for: endovascular intervention surgical bypass, and to select the sites of surgical anastomosis. However, the data that might support use of duplex ultrasound to assess long-term patency of PTA is not robust. PTA=percutaneous transluminal angioplasty.

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

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

Duplex ultrasound of the extremities can be used to select candidates for:

endovascular intervention

surgical bypass, and

to select the sites of surgical anastomosis.

Computed Tomographic Angiography (CTA) Requires iodinated contrast Requires ionizing radiation Produces an excellent arterial picture

Requires iodinated contrast

Requires ionizing radiation

Produces an excellent arterial picture

Computed Tomographic Angiography (CTA) Requires iodinated contrast Requires ionizing radiation Produces an excellent arterial picture

Requires iodinated contrast

Requires ionizing radiation

Produces an excellent arterial picture

ACC/AHA Guideline for the Management of PAD: Steps Toward the Diagnosis of PAD Obtain history of walking impairment and/or limb ischemic symptoms: Obtain a vascular review of symptoms: Leg discomfort with exertion Leg pain at rest; nonhealing wound; gangrene No leg pain Classic claudication Chronic critical limb ischemia (CLI) “ Atypical” leg pain Diagnosis and Treatment of Asymptomatic PAD and Atypical Leg Pain Diagnosis and Treatment of Claudication Diagnosis and Treatment of Critical Limb Ischemia Diagnosis and Treatment of Acute Limb Ischemia Diagnosis and Treatment of Asymptomatic PAD and Atypical Leg Pain Individuals “ at risk” for PAD Age 50 to 69 years and history of smoking or diabetes Age ≥ 70 years Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal arterial disease Acute limb ischemia (ALI) Perform a resting ankle-brachial index measurement Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Obtain history of walking impairment and/or limb ischemic symptoms: Obtain a vascular review of symptoms:

Leg discomfort with exertion

Leg pain at rest; nonhealing wound; gangrene

Individual at PAD risk: No leg symptoms or atypical leg symptoms Perform a resting ankle-brachial index measurement Confirmation of PAD diagnosis ABI ≥ 1.30 (abnormal) ABI ≤ 0.90 (abnormal) Pulse volume recording Toe-brachial index (Duplex ultrasonography) Abnormal results Evaluate other causes of leg symptoms Decreased post-exercise ABI Normal post-exercise ABI: No PAD Measure ABI after exercise test ABI 0.91 to 1.30 (borderline & normal) Normal results: No PAD Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Risk factor normalization : Immediate smoking cessation Treat hypertension Treat lipids Treat diabetes mellitus: HbA 1c less than 7% Pharmacological Risk Reduction : Antiplatelet therapy (ACE inhibition) Confirmation of PAD diagnosis Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. ACE=angiotensin-converting enzyme; JNC-7=Joint National Committee on Prevention ; NCEP=National Cholesterol Education Program – Adult Treatment Panel III .

Antihypertensive Therapy Antihypertensive therapy should be administered to hypertensive patients with lower extremity PAD to a goal of less than 140/90 mm Hg (non-diabetics) or less than 130/80 mm Hg (diabetics and individuals with chronic renal disease) to reduce the risk of myocardial infarction, stroke, congestive heart failure, and cardiovascular death. Beta-adrenergic blocking drugs are effective antihypertensive agents and are not contraindicated in patients with PAD.

Lipid Lowering Therapy Treatment with a HMG coenzyme-A reductase inhibitor (statin) medication is indicated for all patients with peripheral arterial disease to achieve a target LDL cholesterol of less than 100 mg/dL. Treatment with a HMG coenzyme-A reductase inhibitor (statin) medication to achieve a target LDL cholesterol level of less than 70 mg per dl is reasonable for patients with lower extremity PAD at very high risk of ischemic events † . † Factors that define “very high risk” in individuals with established PAD are: (a) multiple major risk factors (especially diabetes), (b) severe and poorly controlled risk factors (especially continued cigarette smoking), (c) multiple risk factors of the metabolic syndrome and (d) individuals with acute coronary syndromes. HMG coenzyme=3-hydroxy-3-methylglutaryl coenzyme I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B

PAD Care Standards for Patients With Diabetes Proper foot care, including use of appropriate footwear, chiropody/podiatric medicine, daily foot inspection, skin cleansing, and use of topical moisturizing creams, should be encouraged and skin lesions and ulcerations should be addressed urgently in all diabetic patients with lower extremity PAD. Treatment of diabetes in individuals with lower extremity PAD by administration of glucose control therapies to reduce the hemoglobin HbA1C to less than 7% can be effective to reduce microvascular complications and potentially improve cardiovascular outcomes. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

Risk Reduction of Clopidogrel vs. Aspirin in Patients With Atherosclerotic Vascular Disease Reprinted with permission from CAPRIE Steering Committee. Lancet . 1996;348:1329-1339. Stroke 0 10 20 -10 -20 MI PAD All patients Aspirin favored -30 30 40 Clopidogrel favored N=19,185

Classic Claudication Symptoms : Muscle fatigue, cramping, or pain that reproducibly begins during exercise and that promptly resolves with rest Document pulse examination ABI Exercise ABI (TBI, segmental pressure, or Duplex ultrasound examination) Chart document the history of walking impairment (pain-free and total walking distance) and specific lifestyle limitations Confirmed PAD diagnosis ABI greater than 0.90 ABI less than or equal to 0.90 No PAD or consider arterial entrapment syndromes Normal results Abnormal results Cont’d Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. ABI=ankle-brachial index; TBI=toe-brachial index .

Risk factor normalization : Immediate smoking cessation Treat hypertension Treat lipids Treat diabetes mellitus: HbA1c less than 7% Pharmacological risk reduction : Antiplatelet therapy (ACE inhibition) Confirmed PAD diagnosis Treatment of Claudication Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. ACE=angiotensin-converting enzyme; JNC-7=Joint National Committee on Prevention ; NCEP=National Cholesterol Education Program – Adult Treatment Panel III .

Significant disability despite medical therapy and/or inflow endovascular therapy, with documentation of outflow PAD, with favorable procedural anatomy and procedural risk-benefit ratio No significant functional disability Lifestyle-limiting symptoms Supervised exercise program Three-month trial Preprogram and postprogram exercise testing for efficacy Lifestyle-limiting symptoms with evidence of inflow disease Further anatomic definition by more extensive noninvasive or angiographic diagnostic techniques Clinical improvement: Follow-up visits at least annually Endovascular therapy or surgical bypass per anatomy Pharmacological therapy: Cilostazol (Pentoxifylline) Three-month trial Evaluation for additional endovascular or surgical revascularization Confirmed PAD Diagnosis No claudication treatment required. Follow-up visits at least annually to monitor for development of leg, coronary, or cerebrovascular ischemic symptoms. Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192 .

No claudication treatment required.

Follow-up visits at least annually to monitor for development of leg, coronary, or cerebrovascular ischemic symptoms.

Endovascular Treatment for Claudication Endovascular procedures are indicated for individuals with a vocational or lifestyle-limiting disability due to intermittent claudication when clinical features suggest a reasonable likelihood of symptomatic improvement with endovascular intervention and … response to exercise or pharmacologic therapy is inadequate, and/or there is a very favorable risk-benefit ratio (e.g., focal aortoiliac occlusive disease) I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III

response to exercise or pharmacologic therapy is inadequate, and/or

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

Endovascular Treatment for Claudication Endovascular intervention is not indicated if there is no significant pressure gradient across a stenosis despite flow augmentation with vasodilators. Primary stent placement is not recommended in the femoral, popliteal, or tibial arteries. Endovascular intervention is not indicated as prophylactic therapy in an asymptomatic patient with lower extremity PAD. I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

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

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

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

Chronic CLI symptoms : Ischemic rest pain, gangrene, nonhealing wound Ischemic etiology must be established promptly by examination and objective vascular studies Implication : Impending limb loss History and physical examination : Document lower extremity pulses; Document presence of ulcers or infection ABI, TBI, or Duplex US Evaluation of source (ECG or Holter monitor; TEE; and/or abdominal US, MRA, or CTA); or venous Duplex Consider atheroembolism, thromboembolism, or phlegmasia cerulea dolens No or minimal atherosclerotic arterial occlusive disease Assess factors that may contribute to limb risk: diabetes, neuropathy, chronic renal failure, infection Severe lower extremity PAD documented: ABI less than 0.4; flat PVR waveform; absent pedal flow Cont’d Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. ABI=ankle-brachial index; CLI=critical limb ischemia; CTA=computed tomographic angiography; ECG=electrocardiogram; MRA=magnetic resonance angiography; PVR=pulse volume recording; TEE=transesophageal echocardiogram; TBI=toe-brachial index; US= ultrasound.

Obtain prompt vascular specialist consultation : Diagnostic testing strategy Creation of therapeutic intervention plan Ongoing vascular surveillance Written instructions for self-surveillance Patient is not a candidate for revascularization Medical therapy or amputation (when necessary) Severe lower extremity PAD documented: ABI less than 0.4; flat PVR waveform; absent pedal flow Systemic antibiotics if skin ulceration and limb infection are present ABI=ankle-brachial index; PVR=pulse volume recording. Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Cont’d Patient is a candidate for revascularization

Obtain prompt vascular specialist consultation :

Diagnostic testing strategy

Creation of therapeutic intervention plan

Define limb arterial anatomy Assess clinical and objective severity of ischemia Revascularization possible (see treatment text, with application of thrombolytic, endovascular, and surgical therapies) Revascularization not possible: medical therapy; amputation (when necessary) Ongoing vascular surveillance Written instructions for self-surveillance Patient is a candidate for revascularization Imaging of relevant arterial circulation (noninvasive and angiographic) Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Define limb arterial anatomy

Assess clinical and objective severity of ischemia

For individuals with combined inflow and outflow disease with CLI, inflow lesions should be addressed first. For individuals with combined inflow and outflow disease in whom symptoms of CLI or infection persist after inflow revascularization, an outflow revascularization procedure should be performed. Endovascular Treatment for Critical Limb Ischemia I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III c

For individuals with combined inflow and outflow

disease with CLI, inflow lesions should be

addressed first.

For individuals with combined inflow and outflow

disease in whom symptoms of CLI or infection

persist after inflow revascularization, an outflow

revascularization procedure should be performed.

Achieve pulsatile flow to the foot. Restore straight-line flow to the pedal arch in order to achieve clinical success. Endovascular Treatment for Critical Limb Ischemia Effective endovascular treatment will usually: Dilation of a proximal (inflow) lesion alone in the setting of a distal arterial occlusion may not be adequate to achieve wound healing. Balloon angioplasty with bail-out (provisional) stent placement is the treatment of choice. Note:

Achieve pulsatile flow to the foot.

Restore straight-line flow to the pedal arch in order to achieve clinical success.

Dilation of a proximal (inflow) lesion alone in the setting of a distal arterial occlusion may not be adequate to achieve wound healing.

Balloon angioplasty with bail-out (provisional) stent placement is the treatment of choice.

Appropriate patient and lesion selection is critical to success. Focal stenoses do best.  6 cm occlusions  5 stenotic lesions Success is measured by: Relief of rest pain Healing of ulcers Avoidance of amputation Endovascular Treatment for Critical Limb Ischemia

Appropriate patient and lesion selection is critical to success.

Focal stenoses do best.

 6 cm occlusions

 5 stenotic lesions

Success is measured by:

Relief of rest pain

Healing of ulcers

Avoidance of amputation

The PAD Guideline is Intended to Guide Lifelong Primary to Specialty PAD Care Population at risk : (Age and risk factors) Establish the PAD diagnosis Population with symptoms : Improve limb outcomes Prevent CV ischemic events Medical Therapy Endovascular Therapy Surgical Therapy ABI TBI Duplex US MRA CTA Angiography Population remains at risk: Primary care management of legs and life, in collaboration with vascular specialists Integrated care requires a partnership of vascular specialists (vascular surgery, nursing, podiatry, and others)

ABI

TBI

Duplex US

MRA

CTA

Angiography

Individual “at risk” or with PAD seeks care (primary care) Individual “at risk” or with PAD receives vascular care The Ideal Clinical Synergy: When an Informed Patient Seeks an Informed Clinician Public Awareness of Peripheral Arterial Disease Clinician Awareness of Peripheral Arterial Disease The PAD Coalition & PAD Guideline

NMHI Vascular: 843-2525

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