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Peripheral Vascular Disease Review For The General Surgeon. Elizabeth Pensler, DO Vascular Surgery Kansas City Review April 3-5 th 2014. Peripheral Vascular Disease. A disorder that compromise blood flow to the limbs The prevalence of PVD increases with age

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peripheral vascular disease review for the general surgeon

Peripheral Vascular Disease Review For The General Surgeon

Elizabeth Pensler, DO

Vascular Surgery

Kansas City Review April 3-5th 2014

peripheral vascular disease
Peripheral Vascular Disease
  • A disorder that compromise blood flow to the limbs
  • The prevalence of PVD increases with age
    • 3% in persons younger than 60 years
    • More than 20% in person 75 years or older
slide3

Long term survival is reduced in pts with PVD

    • Risk of death 2 – 4 fold (due to MI, CVA)
    • Pts with claudication have a 10 year survival of 50%
    • Pts with critical limb ischemic have 10 years survival of 25%
risk factors
Risk Factors
  • The risk factors are similar to those that cause CAD
  • These include :
    • Cigarette smoking
    • Diabetes
    • Dyslipidemia
    • HTN
    • Hyperhomocytinemia
    • Family History
risk factors1
Risk Factors

Cigarette Smoking:

  • Developing intermittent claudication 2 – 5 fold higher in smokers than non-smokers
  • Continued smoking : increases the risk of progression from stable claudication to severe limb ischemia and amputation.
  • (2 – 4% of pts with claudication develop critical ischemia vs. 4 – 6 % in smokers)
risk factors2
Risk Factors

Diabetes

  • Diabetes is associated with 3 – 4 fold increase developing PVD
  • Infrapopliteal
  • Prognosis is poor for diabetics who with claudication; 30 – 40 % will develop critical limb ischemia in 6 years (vs 10 –20 years of non-diabetics)
risk factors3
Risk Factors

Dyslipidemia

  • Hypercholesterolemia in 40% of pts with PVD
  • Hypertriglyceridemia
  • HTN: increases risk of claudication 2 folds in man and 4 folds in women.
  • Hyperhomocystinemia: increases risk of PVD by 2 fold.
claudication
Claudication
  • Latin claudicare“to limp”
  • Ischemic pain lower legs when walking
  • Inadequate blood flow leg muscles from atherosclerotic narrowing of the arteries
  • Annual incidence is 20 per 1,000 in persons older than 65 years.
claudication evaluation
Claudication - Evaluation

History

  • Acuteness of symptom onset
  • Ambulating distance before onset of pain
  • Whether pain is relieved by standing

Physical Exam

  • quality of femoral, popliteal, dorslis pedis pulses
  • signs of arterial insufficiency - coolness, scaling, paleness (especially with leg elevation), or ulcer
  • ankle-brachial index (ABI)

Clevland Clinic J of Med, 1997; 64:429-436

clinical presentation
Clinical Presentation
  • Intermittent Claudication:
  • Discomfort, pain, fatigue or heaviness that is felt in the affected extremity during walking and resolved at resting.
slide11

The location of the symptoms depend on the site of stenosis

    • Thigh, hip or buttock claudication (and impotence) develops with proximal occlusions – aorta or iliac arteries
    • Calf claudication develops with femoral and popliteal arteries occlusions.
    • Pedal Claudication – tibial and peroneal stenoses
slide12

Rest Pain :

    • Pain typically in the toes and foot
    • initially worse at night with persistent severe ischemia
    • Skin breakdown occurs, leading to ulcerations, necrosis and gangrene
intermittent claudication clinical features
Intermittent ClaudicationClinical Features
  • Symptoms always exertional
  • Muscular discomfort: Fatigue, aching, cramping
  • Reproducible distance
  • Relief by standing still (minutes)
  • Location of discomfort aids in localizing disease
  • Diagnosis – pre / post – exercise ABI
pvd tests
PVD-Tests
  • ABI
  • Segmental B.P. measurement to assess the presence and severity of PVD
  • Pulse volume recording (Plethysmography)
  • Duplex ultrasonography
  • MRI
  • Angiography
ankle brachial index abi
Ankle: Brachial Index (ABI)

Supine systolic BP: Ankle / Brachial

  • Normal ABI  1.0
  • Medial calcinosis (incompressability) falsely elevate ankle pressure
  • Low ABI (<0.9) associated increased risk for
    • Stroke
    • Cardiovascular death
    • All cause mortality
intermittent claudication 5 years outcome
Intermittent Claudication5 Years Outcome
  • Mortality 29%
  • Claudication improves or stable 55%
  • Amputation 4%

Anm Vasc. Surg evt 3: 273, 1989.

claudication natural history
Claudication - Natural History
  • Symptoms remain stable or improve with time 65% - 70% due to development of collateral vessels.
  • < 25% ever need surgery or angioplasty.
  • Low risk of losing a limb - only 1.4% per year progress to critical life-threatening ischemia
  • Diabetes increased overall amputation risk of 20%
intermittent claudication increased risk of limb loss
Intermittent Claudication Increased Risk of Limb Loss
  • Tobacco use
  • Diabetes mellitus
  • Ischemic rest pain
  • Ischemic ulceration
  • Gangrene
intermittent claudication initial management
Intermittent ClaudicationInitial Management
  • Aggressive modification of risk factors
    • Tobacco, diabetes, HTN, lipids
  • Diagnosis and treatment of associated
    • CAD (prevalence > 50%)
    • Carotid artery disease
  • Foot care and protection
  • Weight reduction (if obese)
  • Walking program
hypertension
Hypertension
  • Associated with a 2-3X risk of PAD
  • RF for stroke, CAD, CHF and CRF
  • < 140/90 mm Hg in high-risk groups (PAD)
  • < 130/80 mm Hg diabetes or renainsufficiency
  • Normotensive state
  • Multiple agents for control
effect of diabetes mellitus
Effect of Diabetes Mellitus
  • Amputation value (cumulative risk 25 years)
    • IDDM 11.2%
    • NIDDM 11.0%
  • 12 – fold increase risk: BKA
  • 400 – fold increase risk: transphalangeal amputation
  • Account for 60% of amputations in a community
intermittent claudication pharmacologic therapy
Intermittent Claudication Pharmacologic Therapy
  • Antiplatelet therapy
    • Aspirin
      • Reduces risk of amputation
      • Reduces ischemic events
      • Reduces risk for revascularizaton
    • Clopidogrel
      • 8.71% relative risk reduction compared to aspirin.
pharmacotherapy for claudication
Pharmacotherapy for Claudication

FDA Approved Drugs:

  • Pentoxifylline
  • Cilostazol

There is inadequate evidence of clinical efficacy or a therapeutic role for:

L-arginine, propionyl-L-carnitine, gingko biloba, oral prostaglandins,

vitamin E, or chelation therapy.

slide31

Effect of Cilostazol on Walking Distance in Patients With Claudication

*

260

MaximalWalking Distance

*

240

*

220

Cilostazol 100 mg bid

(n=140)

Cilostazol 50 mg bid

(n=139)

Placebo (n=140)

*

200

*

*

*

180

*

*

160

*

Meters (mean)

*

140

*

*

*

120

*

Pain-FreeWalking Distance

*

*

100

*

*

*

80

* P < 0.05 vs. placebo

60

0

4

8

12

16

20

24

Weeks of Treatment

Beebe, et al. Arch Internal Medicine. 1999;159:2041-50.

cilostazol vs pentoxifylline relative efficacy to improve walking distance in claudication
Cilostazol vs. Pentoxifylline: Relative Efficacy to Improve Walking Distance in Claudication

Cilostazol 100 mg 2 times/day (n=227)

Pentoxifylline 400 mg 3 times/day (n=232)

Placebo (n=239)

50

*

40

30

Percentage Change From Baseline MWD (mean)

20

10

0

0

4

8

12

16

20

24

Treatment (weeks)

MWD=maximal walking distance.*P<0.001 vs pentoxifylline.

Reprinted from Dawson DL, etal. Am J Med. 2000;109:523-530 with permission from Elsevier.

slide33

Pharmacotherapy of Claudication

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

intermittent claudication exercise therapy supervised
Intermittent Claudication:Exercise Therapy (Supervised)
  • Frequency: 3–5 supervised sessions/week
  • Duration: 35–50 minutes of exercise/session
  • Type of exercise: treadmill or track walking to near-maximal claudication pain
  • Length:6 months
  • Results: 100%–150% improvement in maximal walking distance and associated improvement in quality-of-life

Stewart KJ et al. N Eng J Med. 2002;347:1941-1951.

surgical and interventional treatment options
SURGICAL AND INTERVENTIONAL TREATMENT OPTIONS

Arterial reconstructions

Endarterectomy

Patch angioplasty

Bypass (autologous vein graft, prosthetic graft)

Endovascular techniques

Thrombectomy

Atherectomy

Balloon angioplasty

Stent placement

Endograft (covered stent)

indications for revascularization
Indications for Revascularization
  • Elective
    • Disabling (life style limiting) symptoms
  • Indication to the physician
    • Diabetes with significant disease
    • Ischemic foot pain
    • Ischemic ulceration
    • Gangrene
percutaneous transluminal angioplasty
Percutaneous Transluminal Angioplasty
  • Peripheral arteries
    • Mortality 0.5%
    • Mobility 1 – 3 days
    • initial good results > 80% (iliac)
    • 2 – 3 years good results > 70%
  • Best results in
    • Short, partial occlusions
    • Proximal disease
    • Good distal run – off
clinical variables favoring vascular surgery
Clinical Variables FavoringVascular Surgery
  • Long, diffusely stenotic, eccentric lesions
  • Long occlusions
  • Stenoses adjacent to aneurysms
  • Tibial occlusive lesions
  • Lesions causing atheromatous embolism
  • Vein is best
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