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Peripheral Arterial Disease: Update 2009

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    1. Peripheral Arterial Disease: Update 2009 William Downey, MD, FACC Sanger Vascular Medicine and Adult Cardiology

    3. Why Is Peripheral Arterial Disease Important? Opportunity to identify and intervene upon vascular disease before a major event (MI, stroke). Sometimes debilitating but treatable symptoms.

    4. PAD (Symptomatic or Asymptomatic) is a Coronary Artery Disease Risk Equivalent

    5. Do Your Legs Hurt When You Walk? >50% of Symptomatic patients dont volunteer symptoms

    7. When Should I Check an ABI? Anyone with suspected claudication. Patients at high risk for atherosclerosis who are not already being aggressively treated: Framingham risk >10%. ADA recommends all diabetics >55 (but these should be aggressively treated already) Erectile dysfunction

    8. Atherosclerosis Therapy Smoking cessation Reduces risk of death, MI, CVA, and amputation. Questionable benefit on symptoms. Antiplatelet agent: aspirin and/or clopidogrel (CAPRIE) Reduces risk of death, MI, CVA. No effect on symptoms. Statin (HPS, 4S, others) In patients with PAD in 4S, simvastatin group had 38% reduction in development of or worsening of claudication. ACE-inhibitor (HOPE) 22% reduction in risk of major vascular event Hypertension control ?-blockers with caution only in severe ischemia (ABI<0.4).

    9. Symptomatic Therapy Exercise: Formal programs increase pain-free walking distance by 180%. Walk repetitively to the onset of pain at least 3x per week. Cilastazol (Pletal): Modest increases (50-70%) in pain-free walking distance. Inhibits type III phosphodiesterase ?contraindicated in CHF. Common side-effects usually resolve with continued treatment: headache, palpitations (sinus tachycardia), diarrhea, dyspepsia. Revascularization for: Life-style limiting symptoms which persist despite a trial of exercise and cilastazol. Limb-threatening ischemia. Indications evolving with development of less-invasive techniques.

    10. 42 yr old lady referred for evaluation of non-STEMI. Complains of > 1 year of bilateral calf pain with walking <2 blocks. At cardiac cath found to have right common iliac occlusion and severe left iliac stenosis. PMH: diabetes, dyslipidemia, CAD s/p LAD stent, continued tobacco abuse. Meds: aspirin, lopressor, Avandamet, Altace. Exam: Normal cardiac exam. 2+ carotid pulses without bruit, femoral pulses trace bilaterally with no bruits, popliteal pulses not palpable, DP and PTs Dopplerable bilaterally. Labs: creatinine 1.3, Hct 41, INR 1.0

    11. Aortoiliac Disease Who to revascularize: Limb-threatening ischemia and life-style limiting claudication. Relatively low threshold to treat. How to revascularize: Consider comorbidities, anatomic factors. In general, endovascular therapy is preferred.

    13. Revascularization Options for Aortoiliac Disease

    14. Aortoiliac disease Stenting: 5 year efficacy: 71% primary patency, 81% primary-assisted patency. <0.5% operative mortality Usually done as outpatient procedure. Surgery (aortobifemoral bypass): 5 year patency: 90% 2-4% operative mortality Substantial post-operative morbidity

    16. Carotid Artery Disease

    17. 11%11%

    18. CEA in Symptomatic Patients: Consistent Benefit

    19. More Than 80% of Strokes are Unheralded

    20. Revascularization for Asymptomatic Carotid Stenosis ACAS: >60% stenosis (n=1662) Perioperative death/stroke: 2.3% ACST: >70% stenosis (n=3120) Perioperative stroke: 3.1%

    21. Indications for Screening Cervical bruit Symptoms - Amaurosis fugax or TIA/Stroke Syncope (if vertibrobasilar insufficiency or bilateral carotid disease is suspected a very rare cause of syncope) Known subclavian stenosis Previous CEA Pre-operative evaluation for CABG

    22. Carotid Stenting

    23. Sapphire:

    24. So I need revascularization, stent or CEA? Currently, only patients at high risk for CEA:

    25. Carotid Revascularization Who to revascularize: Symptomatic: >60% stenosis. Asymptomatic: >80% stenosis. How to revascularize: Consider comorbidities, anatomic factors. Stenting currently reserved for patients at high risk for CEA. Trials currently evaluating carotid stenting vs. CEA for all patients.

    26. Where should I refer my carotid disease? Trials of CEA have a peri-operative stroke rate of =3%. Medicare data shows national peri-op stroke rate of 6%. Know the stroke rate of the program that you send your patients to. Refer to programs where both carotid stenting and CEA are done commonly.

    27. Take Home Points: PAD is a coronary risk equivalent Ask about symptoms Feel for pulses Low threshold to check ABI Stroke is devastating and revascularization works Check carotid duplex in symptomatic patients. Get carotid revascularization done where results are excellent.