Overview On Peripheral Artery Disease - Final
Overview On Peripheral Artery Disease - Final
Overview On Peripheral Artery Disease - Final
Bayu setia
Major Classification of Vascular Disease
•Contents
– PAD is Serious Condition that is often Under-
diagnosed
• Understanding the impact of PAD
• Prevalence and risk factors
• Current management
– Detecting and Diagnosing PAD in Clinical Practice
• Practical advice on detecting and diagnosing PAD
– Increasing the Awareness and Detection of PAD
• PAD screening advice
PAD is Serious Condition that is often Under-diagnosed
• PAD is Serious Condition that is often Under-
diagnosed
– Understanding the impact of PAD
– Prevalence and risk factors
– Current management
Carotid
artery disease
Coronary Cerebrovascular
artery disease 7% disease
30% 25%
3%
12% 4%
Peripheral Vascular
Disease
19%
CAPRIE Steering Committee. Lancet 1996; 348: 1329-1339.
Advanced Symptoms of Lower Limb PAD
Elevation Pallor
This intense paleness of the
foot represents severe
peripheral artery disease
Advanced Symptoms of Lower Limb PAD
Dependent Rubor
This intense red/purple colour,
along with the ulcer on the tip
of the left great toe,
represents advanced PAD
and critical limb ischaemia
Advanced Symptoms of Lower Limb PAD
Gangrene
This patient had
no pain, related to
diabetic vascular
disease and
neuropathy, and
was never
diagnosed with
peripheral artery
disease. This was
due to an ill-fitting
pair of shoes,
which resulted in
blisters and ulcer
formation
Progression and Outcomes with Lower Limb PAD
Peripheral Symptomatic
Artery Disease Disease Critical Limb Ischemia (CLI)
Pain at rest,
Clinical Intermittent Life-threatening
‘Silent’ gangrene,
presentation claudication infection
ulceration
1. North American Symptomatic Endarterectomy Trial Collaborators. N Engl J Med 1991; 325: 445-453.
2. Weinberger J. CNS Spectr 2005; 10: 553–64.
3. Alpert J. Tex Heart Inst J 1991; 18: 93–97.
Other Manifestations of Atherosclerosis:
Renal Artery Disease
1. Dean RH, Tribble RW, Hansen KJ, et al. Ann Surg 1991; 213: 446–455.
2. Rimmer JM, Gennari FJ. Ann Intern Med 1993; 118: 712–719.
3. Mailloux LU. J Vasc Med Biol 1993; 4: 277–284.
Other Manifestations of Atherosclerosis:
Abdominal Aortic Disease
Asymptomatic Symptomatic
45%
55%
6
Incidence/1000/yr
0
30-34 35-39 40-44 45-49 50-54 55-59 80-64 65-69 70-74
Age group (years)
• Risk factors for PAD are similar to risk factors for all other atherosclerotic
disease, such as cardiovascular disease
Modifiable Non-modifiable
– Hypertension • Age and male gender
– Smoking • Diabetes mellitus (DM)
Gey DC et al. Management of peripheral arterial disease. Am Fam Physician 2004; 69: 525–533.
Risk Factor Modification
Lifestyle changes
– Smoking cessation
– Control of diabetes mellitus
– Maintaining an exercise programme
– Reducing high blood pressure
– Lowering high cholesterol
– Maintaining ideal body weight
Gey DC et al. Management of peripheral arterial disease. Am Fam Physician 2004; 69: 525–533.
Pharmacological Management of PAD
Risk-reducing agents
– Antiplatelet drugs:
• ASA, clopidogrel, cilostazol
– Antihypertensives
– Lipid-altering drugs:
• fibrates, niacin, statins (simvastatin, lovastatin, pravastatin,
atorvastatin), bile acid sequestrants
Gey DC et al. Management of peripheral arterial disease. Am Fam Physician 2004; 69: 525–533.
Pharmacological Management of PAD
1.2 g
Pentoxifylline Insufficient data to support use
per day orally
Gey DC et al. Management of peripheral arterial disease. Am Fam Physician 2004; 69: 525–533.
Invasive Vascular Surgery
Surgical techniques
• Reduce hospital stay – often the patient can return home the same day or
the next day
– The choice of surgical treatment or a minimally-invasive procedure is
based on patient and lesion characteristics
Endovascular Procedures
Stenting
• Placement of a stent across the lesion can improve the long-term
results compared to PTA alone
Implantation of a stent
Kauffmann GW, Richter CM, Nöldge G et al. Radiologe 1991; 31: 202-209.
Palmaz JC, Laborde JC, Rivera FJ et al. Cardiovasc Intervent Radiol 1992; 15: 291-297.
Henry M, Amor M, Ethevenot G. Radiology 1995; 197: 167-174.
Stenting of the Superficial Femoral Artery
6 months f/u
Pre-procedure Post
Carotid Artery Stenting
Pre-procedure Post
Other devices
Mechanical Thrombectomy
Rotational tips and/or suction to mechanically remove
thrombus
Laser
Pulsed excimer laser delivered intravascularly to ablate
atherosclerotic and thrombotic material
Cutting Balloon
Longitudinally mounted atherotomes on surface of
angioplasty balloon score lesion with incisions,
allowing balloon to dilate the vessel
Endovascular Procedures
Other devices
Cryoplasty
Angioplasty catheter that dilates and cools the plaque
and vessel wall by inflating the balloon with nitrous
oxide.
Brachytherapy
Therapeutic radiation therapy (gamma or beta
emitters) delivered intravascularly to delay and limit
the endothelialization process
Indications for Endovascular Revascularisation
Hirsch AT, Criqui MH, Treat-Jacobsen D et al. JAMA 2001; 286: 1317-1324.
American Diabetes Association. Diabetes Care 2003; 26: 3333–3338.
Sharafuddin M, Anguelov Z. Currents:Fall 2001; 2(4).
• PAD is Serious Condition that is often Under-diagnosed
– Understanding the impact of PAD
– Prevalence and risk factors
– Current management
Hirsch AT, Criqui MH, Treat-Jacobsen D et al. JAMA 2001; 286: 1317-1324.
Identifying Patients with PAD
Intermittent claudication
•Typically
– Leg pain on exertion (e.g. walking uphill)
– Reproduced by the same degree of exertion
– Relieved by rest
•Lesions are usually found in arterial segment one level above affected muscle
group
– Calf claudication
• disease in femoral or popliteal arteries
• less commonly due to disease in or proximal to tibial or peroneal arteries
– Hip/thigh/buttock claudication
• due to aortoiliac disease
Physical examination
– Peripheral pulses
– Auscultation for bruits that may signify stenosis
– Limb examination
Palpation Auscultation
Normal ++ No Bruit
Occlusion - No Bruit
– STAGE I: Asymptomatic
– STAGE II: Intermittent claudication
– STAGE III: Rest pain
– STAGE IV: Ulcers, necrosis and gangrene
Fontaine
classification I II III IV
Rutherford-Becker
classification 1 2 3 4 5 6
Use of the Edinburgh Claudication Questionnaire
Diagnostic Tests for PAD
The Ankle-Brachial Index (ABI)
Peripheral vascular disease can be easily diagnosed by measuring the ankle-
brachial index (ABI)
DP = dorsalis pedis
PT = posterior tibial
Ankle-Brachial Index Values
≥0.90 Normal
Limitations:
Calcified ankle vessels result in artificially “normal” ABI > 1.2
Normal ABI in patient with aortoiliac disease - only becomes abnormal with exercise testing
– Aorta:
• Bruit
• Palpation
– Coronary artery disease:
• Chest pain
• ECG
– Cerebrovascular disease
• Bruit
• History of stroke/TIA
• Duplex ultrasound (DUS)
– Renal stenosis
• Hypertension
• Bruit
Diagnostic Algorithm for PAD
YES ABI
Referral to
<0.9 <0.9 >1.3 vascular/interventional lab:
• Segmental pressures
• Pulse volume recordings
Still suspicious? • Treadmill
Referral to
PAD vascular/interventional lab:
Anatomic assessment:
• DUS, MRA, CTA
•Quantitative assessments
– Pulse Volume Recordings (PVR)
– Treadmill testing
• Assessment of severity of intermittent claudication
•Localization of the disease and severity
– Duplex Ultrasound (DUS)
– CT Angiogram (CTA)
– Magnetic Resonance Angiography (MRA)
– Angiography
The top vessel is the superficial femoral artery and lower vessel the profunda
or deep femoral artery. The areas where colour does not
exist represents atherosclerotic plaque.
Imaging Diagnostics
Severe common iliac artery stenoses on angiography
PAD: A Call to ACTION
Hirsch AT, Criqui MH, Treat-Jacobsen D et al. JAMA 2001; 286: 1317-1324.
PAD can be Detected and Diagnosed Using the Ankle-
Brachial Index (ABI)
ABI
>1 1.0≤0.9 0.9≤0.8 <0.8
105
100
Patient Survival,%
95
90
85
80
75
70
1 2 3 4
Number of years of follow-up
CAPRIE Study
ABI: inverse relationship with 3-year risk of cardiovascular events and death
2.5
Risk relative to an ABI of 1
2.0
1.5
1
0.25 0.5 0.75 1
ABI