Peripheral Arterial Disease

A Case study

By Dr Chris Arden

Presented by Dr Ivan Benett

Case study

• Ralph is a 58 year old male

• exertional left calf discomfort at 200 yards

• symptoms occur reproducibly with exertion and relieved by rest

• PH: • DM

• HTN

• Smoker 5/day

Rx • Ramipril • Amlodipine • Metformin

Examination:

• palpable femoral pulses without bruits,

diminished popliteal and distal pulse on left, and no positional colour changes, skin intact

Case study

How do we establish a diagnosis of PAD and assess severity?

Clinical Presentation

• Asymptomatic

• Atypical symptoms

• Intermittent claudication

• Critical limb ischemia

– Rest Pain

– Ulceration

– Necrosis/Gangrene

• Acute limb ischemia

The Spectrum of Manifestations of PAD

Classification of Preipheral Arterial Disease severity

Rutherford Stage Symptoms Fontaine stage Symptoms

0 Asymptomatic I Asymptomatic

1 Claudication - mild II Intermittent Claudication

2 Claudication - moderate

IIa IC >200m

3 Claudication - severe IIb IC <200m

4 Rest Pain IV Rest pain

5 Minor tissue loss V Necrosis or gangrene

6 Major tissue loss

Typical vs Atypical Symptoms

in Patients With Symptomatic PAD

Other nonspecific leg symptoms that

may be indicative of PAD

Typical Symptoms1

Intermittent claudication

• Exertional calf pain that

– causes the patient to

stop walking

– resolves within 10 minutes

of rest

Atypical Symptoms1

• Exertional leg pain that

– may involve areas other than

the calves

– may not stop the patient from

walking

– may not resolve within

10 minutes of rest

33%2

>50%2

1. McDermott MM et al. JAMA. 2001;286:1599-1606.

2. Hiatt WR. N Engl J Med. 2001;344:1608-1621.

Examination of the peripheral vascular system

Auscultation

Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication

1 in 5 people over 65

has PAD†

Only 1 in 10 of these

patients has classical

symptoms of intermittent

claudication (IC)

† ABI<0.9

Diehm C et al. Atherosclerosis 2004; 172; 95-105.

Pathophysiology

Common Sites of Claudication

Obstruction in

Aorta or

iliac artery

Femoral artery

or branches

Popliteal artery

or distal

Ischaemia in

Buttock, hip,

thigh

Thigh,

calf

Calf, ankle,

foot

Independent Risk Factors for PAD

Relative Risk vs the General Population

Reduced Increased

Diabetes

Smoking

Hypertension

Dyslipidaemia

4.05

2.55

1.51

1.10

PAD diagnosis based on ABI <0.90.

Newman AB, et al. Circulation. 1993;88:837-845

Diagnostic Tests

≥1.0 — Normal

0.81-0.90 — Mild Obstruction

0.41-0.80 — Moderate Obstruction

≤0.40 — Severe Obstruction

How to Perform and

Calculate the ABI

How to Perform and

Calculate the ABI

Treadmill test

He is sent for ABI/PVR and arterial duplex revealing ABI 0.5 on left with femoral-popliteal involvement

Why sould we care about his diagnosis of PAD?

Case study

Mortality is very high in patients with severe PAD

Relative 5-year mortality

Pati

en

ts (

%)

0

5

10

15

20

25

30

35

40

45

50

Colon/rectal

cancer1

Breast

cancer1

Severe

PAD2

Non-Hodgkin’s

lymphoma3

15

38 44

48

1. Criqui MH. Vasc Med 2001; 6 (suppl 1): 3–7.

2. McKenna M et al. Atherosclerosis 1991; 87: 119–28.

3. Ries LAG et al. (eds). SEER Cancer Statistics Review, 1973–1997. US: National Cancer Institute; 2000.

There is a strong two-way association between decreased ABI and increased risk for

cardiovascular death

All-cause mortality

CVD Mortality

Perc

en

t

Baseline ABI*

*Mean participant follow-up 8.3 years Resnick HE et al. Circulation 2004; 109: 733-739.

70

60

50

40

30

20

10

0

What should we be thinking about in his treatment?

Case study

Smoking cessation

Weight reduction

Total cholesterol <4.5 mmol/L

LDL cholesterol <2.6 mmol/L

HbA1c < 53 mmol/mol

Blood pressure (BP) <140/90 mm Hg

– For patients with diabetes BP < 130/80mm Hg

Anti-platelet therapy

Risk factor management approach

Effect of Smoking Cessation on Survival in PAD

131 Patients Followed After Bypass Graft or Lumbar Sympathectomy Surgery

0 1 2 3 4 5

0

20

40

60

80

100

Australian Census

Tobacco Abstinence

Continued Tobacco UsersCu

mu

lati

ve

Su

rviv

al

(%)

Years Postoperative

Faulkner et al. Med J Aust 1983;1:217.

Treatment of PAD Effect of Exercise Training Meta-analysis of 21 Studies

80

60

40

20

0

100

120

140

160

180

200

Ch

ange

in T

read

mill

Wal

kin

g D

ista

nce

(%

)

Onset of Claudication Pain

Maximal Claudication Pain

Exercise Training

Control

Gardner AW. JAMA. 1995;274:975-980.

Exercise for PAD?

Offer supervised exercise training should be the initial treatment

• 30-45 minute sessions • 3 or more times per week • At least 12 weeks

Effect of Antiplatelet Therapy on Cardiovascular Events in PAD

• 42 clinical trials

• 9,214 patients with PAD

• 23% reduction in serious adverse vascular events (P=0.004)

• Benefits similar among PAD subtypes (intermittent claudication, peripheral grafting, and peripheral angioplasty)

Antithrombotic Trialists’ Collaboration. BMJ. 2002;324:71-86.

Recommendations for Antiplatelet and Antithrombotic Drugs

• Antiplatelet therapy is indicated to reduce the risk of MI, stroke, and vascular death in symptomatic PAD

• Aspirin 75mg daily is recommended as an effective antiplatelet therapy

• Clopidogrel (75 mg per day) is recommended as an alternative antiplatelet therapy to aspirin

Risk Reduction with ACE-inhibitors, Statins,

and Antiplatelet Therapy in PAD

No. of Patients

(>9000)

(>6000)

(4051)

(2701)

APTC*

CAPRIE*

HOPE*

HPS*

0 1 2 3 4 5 6 7

Event Rate (% per year)

APTC Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81-106.

CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.

HOPE Study Investigators. N Engl J Med. 2000;342:145-153.

Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22.

Placebo 6.0%

Aspirin 4.9% Clopidogrel 3.7%

Placebo 4.4%

Ramipril 3.4% P < 0.001

Placebo 6.1% Simvastatin 4.9% P < 0.001

You put him on Atorvastatin 40mg and Aspirin

75mg daily and advised to perform interval

exercise training but claudication remains at 100

meters

After three months his symptoms are no better.

What should we consider next?

Case study

Treatment Approach to Intermittent Claudication

Assess severity of claudication

Mild to moderate claudication

Exercise & drug therapy

Symptoms improve

Symptoms debilitating

Continue present therapy

Severe claudication

Localise lesion

Aortoiliac or femoral dz

Popliteal-tibial dz

Consider percutaneous intervention

Exercise & drug therapy unless

debilitating

Angiography – occlusion of left popliteal artery with collaterals

Occlusion managed by angioplasty

Left popliteal artery after angioplasty

Occlusion of right common Iliac Artery before and after stent

Revascularization for Aorto-Iliac Arterial Disease

Aortofemoral Bypass

• Primary patency at 5 years of 81-85%

1

• Perioperative mortality 5-8%1

• Reserved for severe diffuse disease cases2

• Indicated for Rutherford class 32

1. Raptis S. et al. Eur. J. Vasc. Endovasc. Sur. 1995; 9: 97-102

2. Rosenfield K and Isner JM. Chap 97 in Textbook of Cardiovascular Medicine 1998

Percutaneous Intervention

• Patency at 5 years of 65-80%1

• Perioperative mortality 0.1%1

• Treatment of choice3

• Indicated for Rutherford class 22

1. Becker GJ et al. Radiology 1989;170:921-940

2. Belli A-M et al. Clin Radiol 1990;41:380-3

3. Rosenfield K and Isner JM. Chap97 in Textbook of Cardiovascular Medicine 1998

Summary of PAD and Management

• PAD is common and has a significant impact upon cardiovascular outcomes

• Treatment of PAD, even asymptomatic, should focus on risk factor modification/risk reduction

• Treatment of intermittent claudication should include exercise therapy, drug therapy and selective use of revascularization

• Treatment for critical limb ischemia warrants aggressive efforts at revascularization, including surgery, to reduce the risk of amputation

Overall learning points

PAD is a reliable warning sign that a patient is at high risk for life threatening cardiovascular and cerebrovascular events

PAD is easily overlooked by both patients and clinicians – assess whether patients presenting with symptoms or

associated risk factors have PAD

Treatments are available to protect the patients with PAD from future MI or stroke