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The Cramping Leg Management of peripheral vascular disease

The Cramping Leg Management of peripheral vascular disease. Dr Patricia Yih Department of Surgery, Pamela Youde Nethersole Eastern Hospital Joint Hospital Surgical Grand Round 04/2009. Epidemiology. General prevalance 3-10% (ABI < 0.9) >70 years old: 15-20% Asymptomatic 75%

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The Cramping Leg Management of peripheral vascular disease

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  1. The Cramping Leg Management of peripheral vascular disease Dr Patricia Yih Department of Surgery, Pamela YoudeNethersole Eastern Hospital Joint Hospital Surgical Grand Round 04/2009

  2. Epidemiology General prevalance 3-10% (ABI < 0.9) >70 years old: 15-20% Asymptomatic 75% Symptomatic: Intermittent claudication Critical limb ishcemia

  3. Clinical Course Hirsch AT et al. J Am Coll Cardiol

  4. Asymptomatic PVD Vascular disease progression related to baseline ABIIdentical to symptomatic patients Coexisting vascular disease (atherosclerotic) Coronary artery disease CVA Risk: MI/CVA 5-7%/year, mortality 2%/year Also related to baseline ABI Management: Intensive risk factor modifiation Antithrombotic therapy Mehler PS et al. Circulation 2003

  5. Intermittent Claudication Only about 25% deteriorate ever Disease progression related to: ABI (<0.50  >2x more likely need intervention/amputation) Low ankle pressure (40-60mmHg  8.5% limb loss/year) At 5 years: Hirsch AT et al. J Am Coll Cardiol 2006; 47: 1239-1312

  6. Risk Factor Modification • Stop smoking • Control of BP • Control of DM • Control of hyperlipidemia • Weight reduction

  7. Exercise Rehabilitation • Supervised • Program: • Treadmill or track walking to bring on claudication • Followed by rest until pain subsided • Then resume • 30-60 minute sessions • 3 times/week, for 3 months (TASC II guidelines, Recommendation 14) • Selective exercise of most ischemic muscles • Doubles claudication distance in 80% of patients Stewart K et al. N Engl J Med 2002

  8. Drugs • Antiplatelet agents • Aspirin • Clopidogrel • Cilostazol (PletaalTM) • Vasodilator, metabolic and antiplatelet activity • Increased walking distance 50-70m • Best evidence • Naftidrofuryl (PraxileneTM) • Improve muscle metabolism, reduce RBC/platelet aggregation • Increased walking distance by 26% • Pentoxifylline • Similar to placebo Regensteiner J et al. J Am Geriatr Soc 2002 Lehert P et al. J Cardiovasc Pharmacol 1994

  9. Indications for Intervention • Severe, lifestyle-limiting claudication • Failed drug therapy and exercise • Prerequisite: • Inflow satisfactory • Distal runoff patent

  10. SFA Disease “Stupid Femoral Artery” High failure rate after intervention

  11. Factors affecting result of intervention • Multiple lesions • Long segment stenosis • Complete occlusion • Below knee

  12. Choice of intervention • Surgical bypass • Vein graft • Prosthetic graft • Endovascular • Angioplasty • Primary stenting • Arthrectomy

  13. Outcome Measures • Usually considered together with critical ischemia • Patency rate • ABI • Limb salvage • Mortality

  14. Surgical Bypass vs Angioplasty Angioplasty If high risk for surgery Bypass TASC classification

  15. Surgical Bypass – Conduit • Autogenous vs prosthetic materials: De Vries S et al, J Vasc Surg 1997 • In-situ vs reversed vein graft: • No difference Mamode N et al, Cochrane Database Syst Rev. 2000

  16. Angioplasty vs Stenting • Meta-analysis: no difference 1-Year Patency Rate Postoperative ABI Mwipatayi et al, Journal of Vascular Surgery, Feb 2008

  17. Conclusion • Clinical course/deterioration, systemic disease related to baseline ABI • When to intervene? • Lifestyle limiting claudication, failure of conservative management • Radiological confirmation of adequate inflow and runoff required • Bypass or angioplasty? • Depends on disease location, extent • Angioplasty: to stent or not? • No difference • Depends on expertise available, patient condition

  18. Thank you!

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