Peripheral Artery Disease Flashcards
What is Peripheral Artery Disease?
- Occlusion or Stenosis of the Arteries of the Upper or Lower Extremities –AHA 2006 definition
- Distinct from Mesenteric, Renal and Cerebral Vascular arteries
- P.V.D. – includes arteries and veins
- Effects 8 to 12 million Americans –12% - 20% of Americans age 65 and older –Only 25% are undergoing treatment
- Effects males and females equally
- There is a poor awareness even by the physicians
- Most patients have never heard of it
PAD is a marker for? Severity of PAD is associated with?
- Is a marker for systemic atherosclerotic dis.
- Marker of Coronary Artery Disease & Cerebral Vascular Disease
- Severity of P.A.D. is closely associated with risk of: –Myocardial Infarction –Ischemic C.V.A. –Death from other vascular causes
PAD presence increases what?
- Presence of P.A.D. independently predicts increase in all-cause Mortality (3.1x) & Cardiovascular Mortality (5.9x)
- 2,200 Americans Die of Diseases of the HEART and BLOOD VESSELS each day, more than 800,000 each year –150,000 are under 65 years of age
PAD presents in which three ways?
– Acute Ischemia
– ChronicDisease
– Acutely Ischemic episode overshadowing Chronic Disease
In the lower extremities PAD is characterized by which three ways?
– Asymptomatic
– to Intermittent Claudication
– to Pain at Rest
When looking at a PAD symptom patient what else could it be?
- Arthropathies –D.J.D. / Osteoarthritis –Gout –Skeletal / Connective tissue disorders
- Tendonitis
- Achilles tendon injury
- Muscle tear
- Spinal or other Neuro-muscular Disorders –Caudaequina Syndrome (Pseudo-claudication)
- Neuropathy (Diabetes)
- Venous Disease –Deep Venous Thrombosis –Venous Insufficiency –Venous Stasis
- Extrinsic Pressure disorders –Popliteal Artery Entrapment Syndrome –Baker’s Cyst –Tumors / Masses
What is the anatomy of the normal vessel wall?
- Normal Vessel Wall
- Three Layers – Intima – Medial/Muscular – Adventia
- Vasa Vasorum
What is the occlusive disease that can lead to PAD?
- Embolic Disease
- Thrombotic Disease
- Atherosclerotic –Arteriosclerosis - Generic term for a number of diseases in which the arterial wall becomes Thickened & Loses Elasticity. –Atherosclerosis
What is Atherosclerosis?
- Greek: “Gruel”
- Mass of Fibrous Plaque of degenerated, thickened arterial Intima
- Extrudes into the arterial lumen
Cause of Atherosclerosis? Associated with? How much narrowing needs to happen before decreasing blood flow?
- No Known Cause - Many contributing Factors
- A Localized Finding of a Generalized / Systemic Process
- Associated Leading Cause of Death from – Heart Attacks – Stroke
- Arterial Narrowing of 20% - 25% before significant decrease in Blood Flow
- Sub-intimal Fibrosis with Hyaline Degeneration –Weakening of Elastic Lamella of the Wall of the Vessel –May Lead to Aneurysms
Common sites for PAD?
- Arterial Bifurcations common locations – Aortic Branches at their Take-offs – Common Carotid Artery Bifurcation – Aortic Bifurcation – Common Iliac Bifurcation – Common Femoral Bifurcation – Tibial - Peroneal Trifurcation
- Superficial Femoral Artery at Adductor (Hunter’s) Canal: – “Fem-Pop territory”.
Acute PAD symptoms?
- Acute sudden symptoms - Asymptomatic until: – Occlusion of vessel – Embolus from Heart or Blood Vessel – Thrombosis of a Vessel – Rupture of a Plaque – Plaque/Thrombus from an Aneurysm with embolus – or Rupture of an Aneurysm
- Lack of Collateral Blood Flow may exacerbate the Problem
Chronic PAD symptoms?
- Chronic – may be Asymptomatic: – Signs and Symptoms usually come on Slowly – Progress until Stenosis / Narrowing is significant
- Multi-Level often – Aortic - Iliac – Femoral – Popliteal (Hunter’s Canal) – Tibial - Peroneal
- Diabetic - Frequently below the Popliteal region
Evaluation of PAD?
- Patient History
- Physical Exam – Undressed
- Non-invasive Testing
- Invasive Testing
What to ask with history of PAD?
- Risk Factors
2. Symptoms 1. Claudication 2. Rest Pain 3. Impotence – need to ask
Co-morbidities with PAD?
- Cardiac Symptoms (30% - C.A.D.) –Angina –Myocardial Infarction (20%) –Arrhythmias
- Cerebral Vascular –T.I.A. / Amaurosis Fugax –C.V.A. (7%)
Not controllable risk factors for PAD?
- Family History
- Diabetes Mellitus
- Hypertension
- Hypercholesterolemia / Hyperlipidemia
- Personality Type
- Age (>40years?)
- Race
- Clotting / Bleeding Disorders
- Male Sex
Controllable risk factors for PAD?
- Cigarette Smoking – Vasoconstriction – Effects are cumulative & irreversible
- Diabetes Mellitus
- Hypertension
- Hypercholesterolemia / Hyperlipidemia
- Personality Type
- Diet
- Obesity
- Reduced Physical Activity
- Stress
An acute event can lead to?
• Hyperkalemia • Lactic Acidosis • Rhabdomyolysis
Acute symptoms ask what?
- Pain –“When did it start”?
- Loss of Sensation
- Change of Temperature
- Hx of P.A.D. / Previous Acute Incident
- Symptoms of Chronic Disease prior to acute event
Physical exam findings for an acute PAD episode?
- PAIN
- PALLOR - Pale, Yellowish tone to the Skin
- PULSELESS
- PARESTHESIAS - Anoxia to Peripheral Nerves
- PARALYSIS - Late sign, Grave Prognosis – Inability to Dorsal Flex the foot
- COLD Extremity (Poikilothermia)
- Collapsed Superficial Veins (Phlebo-)
intermediate Claudication shows what from PAD?
- Intermittent Claudication:
- Muscle pain elicited by (fairly) reproducible amounts of exercise.
- Abates upon cessation of exertion – but often recurs with more exertion.
- It is “angina” of the legs
Chronic symptoms of claudication?
–Weakness –Tiredness –Aching –Cramping –Pain –Numbness
Many individuals adapt to claudication symptoms by?
- Many individuals adapt to their symptoms by becoming less active; –Often not recognizing that they have done so
- Sedentary individuals may not even experience ischemic leg symptoms
- 5% undergo amputation within 5 years
Questions to ask with claudication?
• Location? – Usually Calf or Hip – Foot if Distal Disease – Can be Hip or Lower Back
- Ask: “How far can you walk” before pain?
- Relief after resting?
- Relief with continued walking?
- Progression – Over what time frame has it developed?
Ischemic rest pain indicates?
- More Severe Disease
- Constant Arterial Insufficiency
- Usually Toes and Forefoot
- “Burning Pain”
- Worse at Night
- Worse in Recumbent Position or Elevated – Improves with Dependency – Gravity helps
- If Unrelieved – Imminent Tissue/Limb Loss
Physical exam signs of chronic PAD?
- Xanthomas
- Trophic Changes – Hair Loss – Skin Thin and Scaly – Nails Thicken
- Discoloration – Pallor
- Ulceration
- Gangrene
- Muscle Atrophy
- Limb Temperature may be Reduced
- Pulses – Poor Quality / Absent
- Bruits
- Capillary Refill may be Diminished
Which pulses are we looking for? what do we look for with them?
Presence - Quality • Carotid • Radial • Femoral • Popliteal • Dorsalis Pedis (DP) • Posterior Tibial (PT)
Which areas are we checking for bruits?
- Carotid
- Subclavian
- Abdominal –Renal –Iliac
- Femoral
What are non-invasive testing measures for PAD?
- Pressures – A.B.I. – Ankle Brachial Index (Ankle Arm Index)
- Doppler – Segmental Wave Forms
- Duplex Ultrasound – Wave forms – Images
- Toe Pressure -Evaluates for ability to heal a foot or heal ulcer
Explain the ankle brachial index?
- ABI (aka - Ankle / Arm Index) • Ratio • Cornerstone of P.A.D. diagnostic testing – 95% sensitive – 99% specific
- Screening evaluation - often • One of the most useful & easily administered tests in the Primary / Ambulatory Care setting (or elsewhere)
- A Non-Invasive measure of P.A.D. severity: –A Marker of Atherosclerosis –An Independent Predictor of Mortality –Lower the A.B.I. the greater the Risk of a Cardiovascular event • Its an “Index
- “1.0” is normal (0.90 to 1.30) • If hypo- or hyper-tensive ABI may be <1.0 • Ratio < 0.90 is considered abnormal – < 0.40 suggests Critical Leg Ischemia • Ratio > 1.30 suggests non-compressible Calcified vessel – Additional tests required to diagnose PAD
- Doppler Blood Pressure in each arm –Brachial with hand held doppler –Record the arm with the higher reading and •only use this number for your calculation • Only use the pressure from the arm that has the highest blood pressure reading • This is independent of which leg pressure you are evaluating
- Doppler Pressure in each Lower Extremity –Dorsalis Pedis (DP) –Posterior Tibial (PT) –Record higher reading of PT or DP • Then do the math
non-invasive Exams for PAD should be conducted by whom?
• Exams should be Performed by a Registered Vascular Technologist – RVT • Should be interpreted by a Qualified Physician • Should be an Accredited Vascular Laboratory!
indications for non-invasive testing for PAD?
Medical Necessity • (you must have a reason for the test) • Claudication • Rest pain
- Peripheral Vascular Disease • Physical findings of ischemia – Coolness – Pallor – Cyanosis • Slow or Non-healing Ulcers / Sores • Gangrene / Pre-Gangrene • Diminished or Absent pulses (with other findings)
- Aneurysm – suspected or known • Source of emboli • Pseudo-aneurysm– suspected or known • Dissections– suspected or known • Hematoma – suspected or known • Pre-operative evaluation of lower extremity prior to other surgery – Orthopedic surgery – Kidney transplant – Follow-up after vascular procedures • Arteritis • Vascular injury – Trauma – Interventions • Compression syndromes – Popliteal entrapment • Follow-up Surgical Revascularization • Follow-up Percutaneous Revascularization • Follow-up dialysis grafts / fistulas
What is segmental pressure test?
- Further localizes level of disease.
* Can classify into 4 groups: – No Disease – Aorto-Iliac Disease – Femoral-Popliteal Disease – Combined Disease
Duplex ultrasound exam serves an important role in what areas of PAD? Identifies what?
- Important Role In: –Initial Diagnosis of P.A.D. –Treatment Planning of P.A.D. –Follow-up of P.A.D. and Interventions • 95% Sensitivity • 99% Specificity
- Identifies: – Normal Flows – Occlusion • Absence of Flow – Stenosis • Location • Quantifies degree of Stenosis • Guides Treatment of Iatrogenic problems such as Arterial Pseudoaneurysms
CT angiography requires? Limited benefit when?
• C.T.A. • Commonly available • Requires contrast which has its risks –Renal toxicity –Allergic • Limited benefit if artery is heavily calcified
MRI with angiography in PAD?
• M.R.A. • Major advances • Intra-arterial contrast agents –Renal toxicity –Allergic
PAD in the lower extremities specific diseases?
- Aortic Occlusive Disease –Lerich’s Disease
- Aorto-Iliac Occlusive Disease
- Femoral-Popliteal Disease
- Femoral-Tibial Disease
What is Lerich’s Syndrome?
• “Lerich’s Syndrome” • Gradual Occlusion at the Terminal Aorta • Bilateral symptoms • Fatigue of the Legs with Exercise • Atrophy of the Leg Muscles • Trophic Changes of the Feet • Discoloration of the Skin of the Legs • Impotence
What is Aortic-Iliac Occlusive disease?
• “Inflow” Obstruction: –Aorta, Common &/or External Iliac Arteries • Collateral Vessels may provide flow into the legs • Hip, Thigh or Buttock Claudication • Impotence • Absence of Femoral Pulses or Diminished Pulses – Bruits +/
femoral popliteal or Tibial occlusive disease?
- Adductor Canal (Hunter’s Canal) –Most common location - 50%-60% of patients
- Profunda Femoris Artery take-off –Second most common lesion –P.F.A. is important Collateral Flow when S.F.A. is occluded
- Claudication - Calf Pain • Pain may be Reduced when the Limb is Dependent • also - Popliteal Entrapment Syndrome
Goals of treatment for Claudication?
• Goals of treatment for Claudication: –Relieve Exertional symptoms –Improve Walking Capacity –Improve Quality of Life
What are the goals of treatment for claudication is there is Critcal leg ischemia?
Goals if Critical Leg Ischemia: –Relief of Ischemic Pain at Rest –Healing of Ischemic Ulceration –Prevent Limb Loss
Explain the conservative therapy of PAD? Requires?
• Education - Provide information on P.A.D. –Etiology –Prevention strategies –Smoking Cessation –Available therapeutics
• Modification of known Risk Factors (that can be) – Smoking!! – Hypercholesterolemia • Support those Risk Factors that cannot be… • Facilitate lifelong lifestyle changes • Prevention of known atherosclerotic complications • Medication therapy as indicated
Exercise – Progressive • Walking – Cycling, water aerobics, etc. • Can be an organized / supervised program • 30 minutes per session – Up to 45 to 60 minutes a day • Three to five times per week • To the point of near-maximal discomfort
Requires motivated patient • Improvement is probably result of Increased collateral flow and Improved muscle function • It may take weeks to months of routine exercise before improvement is appreciated • Advise patience & not to become discouraged • Advise patients that claudication is not (necessarily) a warning sign of impending disaster
Medication therapy for PAD?
- Lipid Lowering Therapy –Has benefit
- Treatment of Diabetes Mellitus –May not directly effect PAD
- Treatment of Hypertension
- Aspirin - #1 medication –Reduced risk of non-fatal MI, Ischemic Stroke and Death from Vascular causes –May Favorably affect peripheral circulation –Improves Graft Patency –Low dose (75 - 325 mg / day) may be as effective as High dose (600 - 1500 mg / day
- Clopidogrel Bisulfate (Plavix®) –Inhibitor of ADP-induced platelet aggregation –FDA approval for prevention of ischemic complications of P.A.D.
- Cilostazol (Pletal®) • Aggrenox® (Dipyridamole / Aspirin) • Pentoxifylline (Trental®) • Dipyridamole (Persantine®) • Ticlopidine HCl (Ticlid®)
Therapy for an Acute event?
- Diagnosis –Non-invasive testing –Arteriogram (+/-)
- Anticoagulant: –Unfractionated Heparin - acute treatment –Low Molecular Weight Heparins • Daltaparin & Enoxaparin –Thrombin Inhibitors - Fondaparinox
- Thrombolytic Therapy –Thrombolysis • Thrombo-Embolectomy
When do you consider vascular reconstruction?
When Do You Consider Intervention? • Unable to perform normal daily activities • Failure of Conservative Treatment • Incapacitating - Claudication • Rest Pain • Tissue Compromise / Loss • Threatened Limb Viability • Life Threatening
what are some of the endovascular treatments?
- Percutaneous Transluminal Angioplasty / Stent (PTA) – Iliac Arteries - 80%-90% Patency rate at 5 years
- Atherectomy - De-bulk the lesion • Laser Angioplasty - Making a Resurgence
Aorto-iliac surgeries?
- Aorto-Bi-Femoral –Abdominal and Femoral (groin) Incisions
- Aorto-Bi-Iliac Bypass –Abdominal Incision
Femoral - Femoral Crossover Bypass • Bilateral Femoral (groin) Incisions • Can be Performed Under Local Anesthetic if Necessary
Femoral popliteal bypass?
- ‘Historically’ the Most Common form of Open Surgical Revascularization for the lower extremity
- 30% - 50% occlusion rate at five years
- Much less common now with increased use of percutaneous approach
- Above Knee – Polytetrafluoroethylene(PTFE - Gortex®) – Dacron – Autologous Saphenous Vein • In-situ vs R.S.V.G.
- Below Knee – Autologous Vein – Best Choice
PAD is a marker of? Patients with symptomatic extremity percent chance of PAD? patients with symptomatic CAD percent chance of PAD?
- Marker of CAD & CVD
- The association between cardiac and peripheral arterial disease is well established
- Patients with symptomatic extremity PAD – 75% will have CAD
- Patients with symptomatic CAD – 25% will have PAD
