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Peripheral Vascular Disease

Peripheral Vascular Disease. Israel Freeman, MD Associate Professor of Clinical Medicine . Peripheral Vascular Disease. A disorder that compromise blood flow to the limbs The prevalence of PVD increases with age 3% in persons younger than 60 years More than 20% in person 75 years or older

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Peripheral Vascular Disease

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  1. Peripheral Vascular Disease Israel Freeman, MD Associate Professor of Clinical Medicine

  2. Peripheral Vascular Disease • A disorder that compromise blood flow to the limbs • The prevalence of PVD increases with age • 3% in persons younger than 60 years • More than 20% in person 75 years or older • Long term survival is reduced in pts with PVD • Risk of death 2 – 4 fold (due to MI, CVA) • Pts with claudication have a 10 year survival of 50% • Pts with critical limb ischemic have 10 years survival of 25%

  3. Risk Factors • The risk factors are similar to those that cause CAD • These include : • Cigarette smoking • Diabetes • Dyslipidemia • HTN • Family History • Hyperhomocystinemia

  4. Risk Factors Cigarette Smoking: • The risk of developing intermittent claudication is 2 – 5 fold higher in smokers than non-smokers • Continued smoking : increases the risk of progression from stable claudication to severe limb ischemia and amputation. (2 – 4% of pts with claudication develop critical ischemia vs. 4 – 6 % in smokers)

  5. Risk Factors Diabetes • Diabetes is associated with 3 – 4 fold increase in the risk of developing PVD • The PVD is more severe and extensive and involves more frequently the tibial and peroneal arteries • Prognosis is poor for diabetics who with claudication; 30 – 40 % will develop critical limb ischemia in 6 years (vs 10 –20 years of non-diabetics)

  6. Risk Factors Dyslipidemia • Hypercholesterolemia in 40% of pts with PVD • Hypertriglyceridemia • Lp(a) • HTN: increases risk of claudication 2 folds in man and 4 folds in women. • Hyperhomocystinemia: increases risk of PVD by 2 fold.

  7. Claudication • Claudication (from the Latin claudicare “to limp”) is manifested by ischemic pain in the lower legs when walking. • It is the result of inadequate blood flow to the leg muscles from atherosclerotic narrowing of the arteries. • The annual incidence is 20 per 1,000 in persons older than 65 years. Clevland Clinic J of Med, 1997; 64:429-436

  8. Claudication - Evaluation History • Acuteness of symptom onset • ambulating distance before onset of pain • whether pain is relieved by standing Physical Exam • quality of femoral, popliteal, dorslis pedis pulses • signs of arterial insufficiency - coolness, scaling, paleness (especially with leg elevation), or ulcer • ankle-brachial index (ABI) Clevland Clinic J of Med, 1997; 64:429-436

  9. Clinical Presentation • Intermittent Claudication: Discomfort, pain, fatigue or heaviness that is felt in the affected extremity during walking and resolved at resting. • The location of the symptoms depend on the site of stenosis • Thigh, hip or buttock claudication (and impotence) develops with proximal occlusions – aorta or iliac arteries • Calf claudication develops with femoral and popliteal arteries occlusions. • Pedal Claudication – tibial and peroneal stenoses • Rest Pain : • Pain typically in the toes and foot • initially worse at night with persistent severe ischemia • Skin breakdown occurs, leading to ulcerations, necrosis and gangrene

  10. Ischemia in Right Foot

  11. Stage Symptoms I II Iia Iib III IV Asymptomatic Intermittent claudication Pain-free, claudication walking>200 m Pain-free, claudication walking < 200 m Rest and nocturnal pain Necrosis, gangrene Fontaine Classification of Chronic Limb Ischemia

  12. Intermittent ClaudicationClinical Features • Symptoms always exertional • Muscular discomfort: Fatigue, aching, cramping • Reproducible distance • Relief by standing still (minutes) • Location of discomfort aids in localizing disease • Diagnosis – pre / post – exercise ABI

  13. Intermittent ClaudicationDifferential Diagnosis

  14. PVD-Tests • ABI • Segmental B.P. measurement to assess the presence and severity of PVD • Pulse volume recording (Plethysmography) • Duplex ultrasonography • MRI • Angiography

  15. Ankle: Bronchial Index (ABI) Supine systolic BP: Ankle / Bronchial • Normal ABI  1.0 • Medical calcinusis (incopressability) falsely elevate ankle pressure • Low ABI (<0.9) associated with increased risk for • Stroke • Cardiovascular death • All cause mortality

  16. Ankle: Branchial Index (ABI)

  17. Assessment of Blood Flow to the Extremity Pulse volume recordings provide a qualitative assessment of blood flow to the extremity. A patient with right calf claudication and right foot pain, the pulse recordings- abnormal in the right calf, right ankle, and right metatarsal segments. the amplitude of the pulse is diminished and the rate of rise delayed. No pulse can be recorded in the right metatarsal segment. Pulses in the left leg are normal.

  18. Right Left BrachialUpper thighLower thighCalfAnkleAnkle:brachial ratio 1581609462420.27 1581621541161160.68 Leg Segmental Pressure Measurements in Patient with Right Calf Claudication and Right Foot Pain* *Findings are consistent with femoropopliteal and tibioperoneal artery stenoses in the right leg. The right ankle:brachial ratio indicates ischemia. Systolic pressure gradients between the lower thigh and calf and between the calf and ankle in the left leg are consistent with distal femoropopliteal artery and tibioperoneal artery stenoses. The left ankle:brachial ratio is consistent with symptoms of claudication. .

  19. Arteriogram of a patient with critical ischemia of the right foot. The panel shows a long, total occlusion of the right superficial femoral artery. The popliteal artery reconstitutes via collaterals.

  20. Arteriograms: Claudication of the Left Leg Arteriograms of a patient with disabling claudication of the left leg. A focal stenosis (arrow) of the superficial femoral artery is apparent (a). After percutaneous transluminal angioplasty, patency is restored (b).

  21. Intermittent Claudication5 Years Outcome • Mortality 29% • Claudication improves or stable 55% • Amputation 4% Anm Vasc. Surg evt 3: 273, 1989.

  22. Claudication - Natural History • Symptoms remain stable or improve with time in 65% - 70% of patients due to development of collateral vessels. • < 25% ever need surgery or angioplasty. • Low risk of losing a limb - only 1.4% per year progress to critical life-threatening ischemia (however, patients with diabetes have an increased overall amputation risk of 20%). Clevland Clinic J of Med, 1997; 64:429-436

  23. Intermittent Claudication Increased Risk of Limb Loss • Tobacco use • Diabetes mellitus • Ischemic rest pain • Ischemic ulceration • Gangrene

  24. Intermittent ClaudicationInitial Management • Aggressive modification of LV risk factors • Tobacco, diabetes, HTN, lipids • Diagnosis and treatment of associated • CAD (prevalence > 50%) • Carotid artery disease • Foot care and protection • Weight reduction (if obese) • Walking program

  25. Claudication - Evaluation • Evaluate for the presence of concomitant coronary and carotid arterial diseases • Refer for a functional study such as dobutamine stress echocardiography or thallium stress imaging • Assess for carotid disease with duplex ultrasonography (cervical bruit may be present in only 40% of patients with disease) • Screen for diabetes mellitus Clevland Clinic J of Med, 1997; 64:429-436

  26. Intermittent Claudication Outcome After 5 Years (Quitting Smoking) Ann Vasc Surgery 3:273, 1989

  27. Intermittent Claudication Pharmacologic Therapy • Antiplatelet therapy • Aspirin • Reduces risk of amputation • Reduces ischemic events • Reduces risk for revascularizaton • Clopidogrel • 8.71% relative risk reduction compared to aspirin. • Cilostazol • Improved claudication (modestly probably better then Pentoxifylline)

  28. Effect of Diabetes Mellitus • Amputation value (cumulative risk 25 years) • IDDM 11.2% • NIDDM 11.0% • 12 – fold increase risk: below knee amputation • 400 – fold increase risk: transphalangeal amputation • Account for 60% of amputations in a community Arch Inter Med 1994:154:772

  29. Indications for Revascularization • Elective • Disabling (life style limiting) symptoms • Indication to the physician • Diabetes with significant disease • Ischemic foot pain • Ischemic ulceration • Gangrene

  30. Percutaneous Transluminal Angioplasty • Peripheral arteries • Mortality 0.5% • Mobility 1 – 3 days • initial good results > 80% (iliac) • 2 – 3 years good results > 70% • Best results in • Short, partial occlusions • Proximal disease • Good distal run – off

  31. Clevland Clinic J of Med, 1997; 64:429-436

  32. Clinical Variables FavoringVascular Surgery • Long, diffusely stenotic, eccentric lesions • Long occlusions > 5 cm in the iliac artery > 10 cm in the superficial femoral artery > 2 cm in the tibial artery • Occlusions longer than 10 cm • Stenoses adjacent to aneurysms • Tibial occlusive lesions • Lesions causing atheromatous embolism Clevland Clinic J of Med, 1997; 64:429-436

  33. PVD Key Points • The prevalence of PAD is < 3% among persons younger than 60 years but increases to > 20% among persons older than 70 years. • Most patients with PAD do not have classic claudication. • Risk factors for PAD are similar to those for CAD and stroke. • Clinical symptoms and pulse palpation are not sensitive enough for detection of most cases of serious PAD. • The ABI is a valid, simple, noninvasive detection method and should be more widely used in evaluations of patients at risk. • Risk factor modification is indicated for all patients with PAD. •All patients with symptoms should be advised to undertake exercise rehabilitation. • Revascularization and limb loss are unusual outcomes of PAD. More emphasis should be placed on functional improvement, rehabilitation, and secondary prevention. • Drug therapy with cilostazol may relieve symptoms of claudication, but the other approaches listed are higher priorities in the care of most patients.

  34. Physical Diagnosis for Presence of Vascular Disease: Sensitivity and Specificity Finding Definition Disease Definition (ABI) Sensitivity (%) Specificity (%) Abnormal pedal pulses Both PT& DP pulse absent < 0.9 0.6 0.99 Femoral arterial bruit Bruit present < 0.8 0.2 0.96 Venous filling time > 20 s < 0.5 0.2 0.95 Cool skin Unilateral cool skin < 0.9 0.1 0.98 Color abnormality Pale red or blue < 0.9 0.35 0.87 Capillary refill time > 5 s < 0.5 0.25 0.84 ABI = ankle-brachial index; DP = dorsalis pedis artery; PT = posterior tibial artery Reprinted with permission from: McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158:1357-64.

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