PVD

Question 1

PVD brief hx?

Answer 1

How far can you walk before you get the pain?

Where is the pain?

• -Foot claudication: Tibial or peroneal artery
• -Buttock and hip: Aorto-iliac disease
• -Thigh: Aorto-iliac or common femoral artery
• -Upper two-thirds of the calf: Superficial femoral artery
• -Lower one third of the calf: Popliteal artery

Question 2

PVD examination?

Answer 2

Feel for the CRT and pulses, looking for 6 P’s

Pulseless, Perishingly cold, Pale, Pain, Paresthesia, Paralysis

ABPI

1.0-1.3 = normal

<0.8: abnormal

<0.5: severe disease

>1.3: calcified vessels - needs duplex USS or angiography

Question 3

What are the complications of PVD? (4)

Answer 3

Ulcers - including Marjolin’s ulcer (aggressive skin Ca that grows from scars or poorly healing wounds)

Wound breakdown

Amputation

Gangrene

Sepsis

Question 4

What is your approach to managing PVD, having confirmed the diagnosis?

Answer 4

Goals: screen & treat complications, slow progression, improve symptoms

• Chol <4, LDL <1.8, HDL >1, BP <130/80

Screen for secondary associations & complications

• HBA1C, Lipids, BP, smoking diary (strongest risk factor)
• Hx, exam, ECG to look for IHD/CVD and investigate as needed

NP

• Smoking cessation*** - biggest and prevents Bueger’s (pronounced Burger’s) disease
• Supervised Exercise Program is recommended, substantially superior to Pentoxiphylline: claudication exercise rehab program → induces vascular angiogenesis, collateral circulation, increases the calf blood flow
  
  • 30-45 minutes, 3 times per week, 12 weeks minimum
• Refer to a high-risk foot clinic
• Lifestyle: diet, weight loss

P

• Aggressive lipid, DM, BP control
• Antiplatelet - data suggest only a modest improvement or no improvement in symptoms.
  
  • Main indication: secondary prevention of IHD/stroke
• Cilostazol (PDEi) - prevents PLT aggregation, arterial vasodilator (100mg BD) - watch interaction with diltiazem, PPI, grapefruit juice, warn dizziness + palpitation. Contraindicated in HF worsens mortality)
• Naftidrofuryl: the best, fewer side effects but not on PBS
• Pentoxifylline - evidence suggest that benefit is marginal, effect substantially less than supervised exercise program

Surgical intervention

• Stenting vs. surgical (preferred for multifocal stenosis, long-segment disease/occlusions)
• Resting pain, symptoms despite optimal Mx and impacts on life, critical limb ischaemia

Question 5

If the patient had stents for PVD, is/are single or dual antiplatelet therapy necessary? If so, what is the duration of DAPT required?

Answer 5

There are some evidence to suggest that the rate of restenosis/occlusion is reduced - but overall data are lacking.

In general, DAPT 1-3 months is recommended followed by life-long aspirin (for ongoing secondary prevention of CV disease in the future)

For DES - similar to CAD. 3-12 months DAPT generally recommended.

Question 6

What about patient already on DOAC for AF? and PVD stenting?

Answer 6

Individualised decision but even in absence of AF, there is an emerging data (COMPASS trial, involving >25,000 patients) suggesting that Rivaroxaban 2.5mg BD + Aspirin 100mg daily shown to use overall CV death, stroke or MI risk, with trial stopping due to superiority compared with aspirin alone

Question 7

Surveillance for PVD?

Answer 7

Clinical exam to feel pulses and ulcers

ABPI

Dupplex arterial doppler