Guidelines for Treatment of Claudication Patrick Geraghty, MD, - - PDF document

4/17/2018 1

Guidelines for Treatment of Claudication

Patrick Geraghty, MD, FACS, RPVI Professor of Surgery and Radiology

Conflicts

• Cook Medical

trial PI

• Bard/Lutonix

trial PI, consulting

• Boston Scientific

trial PI, consulting

• Intact Vascular

trial PI

• Pulse Therapeutics

stock holder

• Zimmer Biomet

consulting

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2015 SVS Guidelines Document PAD: Patterns of Presentation

• Asymptomatic PAD
• Claudication
• Chronic Limb‐Threatening Ischemia (CLTI)

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Asymptomatic PAD

• In general, no intervention is required
• Value of ABI screening for asymptomatic patients

is contentious

– USPSTF and SVS do not support; AHA supports – Maximizing CV risk stratification, or trolling for cases?

• ABI is a marker for systemic CV disease

– Deaths primarily result from MI and CVA, not limb loss – “Golden window” for modifying risk factors

Risk Factors for PAD

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Natural History of Claudication Confirming the Diagnosis

• Careful history and physical examination

– Induced by exercise, relieved by rest – Reproducible; not positional; not present at rest – Consistent with pulse exam (and waveforms) – Rule out diseases that may mimic PAD

• Spinal stenosis
• Venous claudication
• Ankle‐Brachial Index

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Ankle‐Brachial Index

• 0.9‐1.3

Normal Range

• 0.5‐0.8

Claudication

• < 0.4

CLTI and

• Non‐compressible/Calcified/>1.4

– Waveform Analysis/Digit Pressures

Confirming the Diagnosis, Part 2

• Symptoms are consistent with claudication,

but the resting ABI value is normal

• Exercise ABI (treadmill study)

– Postexercise ABI < 0.9 – Absolute pressure drop of > 30 mm Hg – Drop of 20% of baseline ABI – Delayed recovery (> 3 minutes) of resting ABI

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When to Image?

• Lesion localization and characterization
• Arterial duplex, CTA, MRA, angiography
• Imaging studies usually do not change the plan

for risk factor modification, ergo…

• Imaging studies are best reserved for those

patients for whom revascularization is being considered

First Principles of IC Management

• ALL patients should receive maximal risk

factor modification

– Reduction in CV morbidity and mortality – Better results with subsequent intervention

• SOME patients should receive intervention

– Variable QOL benefit – Employment and critical ADLs – Symptom progression

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Smoking Cessation

• Continued smoking results in:

– Increased amputation rates – Increased rates of death, stroke, and MI – 2x‐3x increase in the failure rate of lower extremity bypass grafts

• “Set the hook” at the first clinic visit

Dyslipidemia Management

• Mounting evidence suggests that all

symptomatic PAD patients should receive high‐intensity statin therapy

• Additional benefit for periprocedural
• utcomes with statin therapy

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Value of High‐Intensity Statins in PAD

• Arya et al, Circulation 2018; 137:1435-1446.

High‐Intensity Statins in PAD: Mortality

• Arya et al, Circulation 2018; 137:1435-1446.

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High‐Intensity Statins in PAD: Amputation

• Arya et al, Circulation 2018; 137:1435-1446.

Diabetes Management

• Amputation rates in DM + PAD are 5x‐10x

higher than in nondiabetic PAD population

– Sensory neuropathy – Increased susceptibility to infection

• Need further studies to demonstrate

reduction in adverse CV events via optimal DM control

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Other Risk Factors

• Hypertension management

– Ramipril

• 25% reduction in cardiac events in HOPE study
• Thrombophilia management

– ASA – ASA + clopidogrel

• CAPRIE study showed additional 24% reduction in CV

events

Symptom Management

• Cilostazol

– rule out CHF – surface echocardiogram if needed – 10% or more are intolerant – does NOT replace exercise therapy

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Symptom Management

• Structured exercise therapy

– 50‐200% improvement in walking ability – finally compensation although rates are highly variable among payers – 6 month program produces better results than shorter periods of training

• Patient‐initiated exercise therapy

– goal of 30 minutes per session, 4x per week – climate controlled, space to stand/sit

Revascularization for IC

• Cut the losers from the herd:

– those who are minimally symptomatic from IC – those whose activity is otherwise restricted and will see little benefit from revascularization

• COPD, spinal stenosis, arthritis

– those who lack adequate GSV for bailout bypass

• 3 mm conduit extending beyond your intervention

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Revascularization for IC

• Cut the losers from the herd:

– those who are at prohibitive cardiac risk

• angina, severe valvular disease

– those who are very young or very old

• maintain focus on risk factors, surveillance

– those who have small diameter arteries

• SFA 4 mm or less

Revascularization for IC

• Critically assess the arterial anatomy

– Personal preference: CTA – Delineates aneurysms – Provides a clear picture of calcium burden – Can usually assess flow patterns to trifurcation despite Ca++

• Stage your options

– visualize the sequential endo/OR options that will yield the least risk and the best long‐term patency

• Endovascular approach first if the expected patency is >

50% at 2 years

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Revascularization for IC

• Don’t skimp on surgical approaches!
• Concomitant CFA disease usually best treated

by endarterectomy & paching with bypass or endovascular inflow (hybrid procedure)

Revascularization for IC

• Endo Patency: Aortoiliac > SFA > Popliteal
• Endovascular: avoid heavy CFA disease, flush
• cclusions, small diameter arteries, extension

through trifurcation, jailing of patent vessels (PFA!)

• “No Metal Left Behind” vs “Patency Is King”

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How Do I Manage Claudication?

• Initial visit

– address risk factors – scare them off tobacco and link delayed intervention to tobacco abstinence – trial of cilostazol and exercise therapy

• Reevaluate at 3 months

– intervene if disabling and anatomy is favorable – CTA of aorta/iliacs/lower extremities – GSV mapping

How Do I Manage Claudication?

• Performing leg interventions for 20 years
• The proportion of my lower extremity cases

has steadily been shifting towards CLTI

• The CLTI epidemic will keep all of us busy;

be selective and goal‐oriented with your claudication interventions

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QUESTIONS?