What is Peripheral Vascular Disease? Any vascular disease that - PDF document

10/10/2015 Peripheral Vascular Disease Ganesh Muthappan, MD, FACC Disclosures • I work for St. Charles Heart and Lung Center • I am trying to build a practice in central Oregon • I do own a small amount of St. Jude stock as part of a retirement portfolia – I use what I consider the best product available for my patients (including a Volcano corporation product where St. Jude and Volcano compete) What is Peripheral Vascular Disease? • Any vascular disease that isn’t in the heart • Areas of special concern include cerebral arteries, mesenteric arteries, renal arteries, and leg arteries • Usually due to atherosclerosis, but may be due to other disease as well (trauma, autoimmune) • Don’t pay as much attention to veins: bypassess are generally easier to form (with exceptions) 1

10/10/2015 Epidemiology • Risk factors include diabetes, tobacco use, renal disease, age • Up to 30% prevalence in patients with concomitant diabetes and tobacco use • Incidence increasing over time • Incidence increases with age; appx 15- 20% of persons older than 70 have LE PAD Natural History • Poor prognosis: diagnosis can lead to disease course modification • 5 year mortality rate for patients with intermittent lower extremity claudication is 30% • 5 year amputation rate is 4% • Continued smoking and poor diabetes control portends very severe prognosis Weitz et al. Circulation 1996; 94: 3026-49 Natural History Severity of peripheral arterial disease, as measured by ABI, has a strong correlation with mortality , as well as hard cardiovascular endpoints (stroke, heart attack) McDermott et alJ Gen Intern Med. 1994;9:445-44 2

10/10/2015 Lower Extremity Arterial Disease Symptoms of Lower Extremity Claudication (Intermittent) • Lower extremity claudication: crampy, achey pain that comes on (or worsens) with exertion and gets better with rest. Often unilateral • Pseudoclaudication (spinal stenosis): paresthetic pain that occurs both with standing and with walking, relieved by sitting and/or leaning forward. Almost always bilateral. Climbing steps will often not bring on the pain . Classification of Claudication 3

10/10/2015 Diagnosis of Lower Extremity Peripheral Arterial Disease • Ankle Brachial Index • Toe Brachial Index • Walking ABI • Lower Extremity Arterial Duplex • CT/MR angiography • The gold standard is invasive angiography Ankle Brachial Index • The higher of the DP or PT pressure for each leg divided by the higher arm pressure (brachial) 1.00 – 1.40 Normal 0.91 – 0.99 Borderline ≤ 0.90 PAD ≤ 0.60 Pain/Ulceration ≥ 1.40 Non-Compressible ACC/AHA 2011 PAD Management Guidelines Diagnostic Methods: Ankle-Brachial Index (ABI) • The resting ABI should be used to establish the diagnosis of patients at high risk for PAD, defined as patients - with exertional leg symptoms, - with nonhealing wounds, - who are 65 years and older, - or who are 50 years and older with a history of smoking or diabetes. 4

10/10/2015 What does a Normal ABI Mean? So what to do? • In a patient with exertional angina, treadmill stress test is much more revealing than resting ECG/echo • In a patient with exertional claudication, treadmill ABI is much more revealing than resting ABI • Treadmill ABI: patient walks at 1-2 MPH at 10% incline for 5 minutes; if ankle pressure decreases by 15 mmHg, then positive Duplex Ultrasonography • Most common secondary test for LE PAD at St. Charles • 5-7.5 MHx transducer • Painless • >90% sensitivity and specificity • Can be used to estimate severity of disease • May overestimate stenosis (especially following interventions) 5

10/10/2015 CTA and MRA • Highly sensitive and specific • CTA uses iodinated contrast • MRA may be limited by the presence of clips, pacemakers/defibrillators • I will often order prior to diagnostic angiography/intervention learn the lay of the land • However, selective angiography is the gold standard Catheter Based Angiography • Access is gained to the leg contralateral to the one where intervention is planned • A 5F or 6F sheath (2mm) is inserted into the common femoral artery • Pigtail catheter is advanced to the aortic bifurcation and digital subtraction angiography is performed • Catheter is then worked over the bifurcation and selective angiography is performed 6

10/10/2015 How to Treat Lower Extremity PAD • Lifestyle changes • Prevent cardiac/cerebral morbidity/mortality (aspirin, statin, ace inhibitor) • Decrease symptoms (exercise therapy, cilostazole, endovascular intervention) • Limb salvage (endovascular intervention, open revascularization) Exercise Therapy Works • Monitored exercise program (treadmill walking) • Control patients had a 60% decrease in walking distance over the course of 6 months • Exercise therapy patients had a 80% improvement in walking distance over 6 months • Insurance generally does not pay Gardner AW, Poehlman ET. JAMA . 1995;274:975- 980. Cilostazole • Phosphodiesterase 3 inhibitor • Has both antiplatelet as well as vasodilating properties • Increases walking distance by approximately 80% over placebo • Often limited by side effects (nausea, diarrhea, headaches). CONTRAINDICATED WITH LOW EF • 100 mg BID • Approximately $120 for a month’s supply 7

10/10/2015 Endovascular Intervention • CLASS IA indication for endovascular intervention for lifestyle limiting claudication when the patient has failed conservative measures and/or there is a very favorable risk/benefit ratio for endovascular intervention (e.g focal aorto-iliac occlusive disease) • Technology and technique continues to improve: superficial femoral arterial disease is now just as safe (or safer) than aorto-iliac disease Aortoiliac Disease • Symptoms in hips, buttocks, thighs • Can occur in younger patients – In patients in their 50s with claudication, I think of aortoiliac disease first – Often healthier than patients with PAD involving more peripheral arteries Open vs. Endovascular Approach for Aorto-iliac disease • Surgery is the gold standard. Excellent success rate (80-90% at 5 years), but carries 1-3% mortality in major trials (these are sick patients!) • Endovascular approach: good patency (70%) at 5 years, similar morbidity and mortality • Endovascular technology improves every year 8

10/10/2015 Procedural Considerations • Usually ipsilateral access (if femoral artery is patent) • Retrograde wire • Balloon angioplasty • Stenting with either self expanding or balloon expandable stents is often preferred • If truly aortoiliac disease, “kissing” stents are often used Sample Case • Left external iliac lesion • Left CFA approach • Cross lesion with wire • Angioplasty/stent Femoropopliteal Disease • This anatomical location is more prone to scarring/thrombosis • Surgery has appx. 70% 5 year patency for reverse vein grafts, appx. 40% 5 year patency for PTFE grafts • Endovascular approach: 70% 2 year patency for drug coated stent, 50% 2 year patency for angioplasty alone. • Current generation of drug coated stents are being improved, and atherectomy/drug coated balloon success rates are still being tabulated (80% 2 year success rates) • Endovascular approach carries less morbidity/mortality than open approach 9

10/10/2015 Procedural Considerations • Usually contralateral access • Crossover and place a sheath just proximal to area of disease • Cross disease with wire • Deliver equipment • Angioplasty alone is preferred, but stenting often used as well • Self expanding stents have greater resiliency in this location Sample Case 1 • 67 year old man with poorly controlled diabetes, CAD s/p CABG, prior tobacco use and ongoing marijuana (smoked) use. • Referred for nonhealing ulcer x 3 months with noxious smell. • No palpable pulses on either foot 10

10/10/2015 Sample Case 1 Sample Case 1 Sample Case 1 • Post procedure had booming dorsalis pedis pulse • Wound did heal several months post procedure (sugars in 200s) • Angiogram 3 months later of LLE did not show significant popliteal disease 11

10/10/2015 Sample Case 2 • 68 year old man with longstanding history of tobacco use (ongoing), dyslipidemia, well controlled diabetes, coronary artery disease s/p CABG with EF 35% • 6 months of left calf aching, initially >50 yards but now 10 yards (can’t walk around his house without having to stop and rest his calf) • Had bilateral iliac stenting in March, but still with left calf symptoms and now nonhealing ulcer Sample Case 2 12

10/10/2015 • Patient with barely dopplerable pulse before procedure, now had palpable pulse after procedure • Able to walk around house, but still limited by pain with >100 yards of walking So my patient has had a LE procedure for claudication: what should I do? • Aspirin 81 mg daily indefinitely • Clopidogrel 75 mg daily for at least one month (depending on intervention, complexity of stent left behind) – Bigger vessels with more flow are less likely to thrombose • Refer to PAD rehab if possible (the magic unicorn) • Encourage patient to walk • Follow up exam/imaging at 1 month, 3-6 months, then yearly Critical Limb Ischemia • Limb threatening ischemia seen in 1-2% of patients with PAD >50 years old Circulation. 2006;113(11):e463 . • At 1 year, 25% of these patients are dead and 25% have had an amputation • Most of these patients have significant comorbidities 13