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Peripheral Arterial Disease: Update 2009
William Downey, MD, FACCSanger Vascular Medicine and Adult Cardiology
Disclosures
• None
Why Is Peripheral Arterial Disease Important?
• Opportunity to identify and intervene upon vascular disease before a major event (MI, stroke).
• Sometimes debilitating but treatable symptoms.
PAD (Symptomatic or Asymptomatic) is a Coronary Artery Disease Risk Equivalent
0
5
10
15
20
25
30
35
40
45
50
>1.1 1.01-1.1 0.91-1.0 0.71-0.9 <0.71
ABI at baseline
Non-fatal MI
Non-fatal stroke
Death
BMJ 313:1340.
5 year event rate
“Do Your Legs Hurt When You Walk?”
>50% of Symptomatic patients don’t volunteer symptoms
How Do I Identify These Patients: ABI
Normal 0.9 – 1.3Claudication 0.5- 0.89Rest pain 0.21- 0.49Tissue loss < 0.20Calcified > 1.3Significant Δ 0.15
Two main limitations :•Calcified ankle vessels result in falsely “normal” ABI.
•Normal ABI in patients with aortoiliac disease; brought out only with exercise.
greater of DP/PT systolic pressuregreater of arm systolic pressuresABI=
When Should I Check an ABI?
• Anyone with suspected claudication.
• Patients at high risk for atherosclerosis who are not already being aggressively treated:– Framingham risk >10%.– ADA recommends all diabetics >55 (but these
should be aggressively treated already)
• Erectile dysfunction
Atherosclerosis Therapy• Smoking cessation
– Reduces risk of death, MI, CVA, and amputation.
– Questionable benefit on symptoms.
• Antiplatelet agent: aspirin and/or clopidogrel (CAPRIE)
– Reduces risk of death, MI, CVA.
– No effect on symptoms.
• Statin (HPS, 4S, others)
– In patients with PAD in 4S, simvastatin group had 38% reduction in development of or worsening of claudication.
• ACE-inhibitor (HOPE)
– 22% reduction in risk of major vascular event
• Hypertension control -blockers with caution only in severe ischemia (ABI<0.4).
Symptomatic Therapy• Exercise:
– Formal programs increase pain-free walking distance by 180%.– Walk repetitively to the onset of pain at least 3x per week.
• Cilastazol (Pletal):– Modest increases (50-70%) in pain-free walking distance.– Inhibits type III phosphodiesterase contraindicated in CHF.– Common side-effects usually resolve with continued treatment:
headache, palpitations (sinus tachycardia), diarrhea, dyspepsia. • Revascularization for:
– Life-style limiting symptoms which persist despite a trial of exercise and cilastazol.
– Limb-threatening ischemia.– Indications evolving with development of less-invasive
techniques.
Gardner AW and Poehlman ET. JAMA (1995) 274:975-980.Patel PD and Thompson PD. ACC Current Journal Review (2004) 13: 16-20.
42 yr old lady referred for evaluation of non-STEMI. Complains of > 1 year of bilateral calf pain with walking <2 blocks. At cardiac cath found to have right common iliac occlusion and severe left iliac stenosis.
PMH: diabetes, dyslipidemia, CAD s/p LAD stent, continued tobacco abuse.
Meds: aspirin, lopressor, Avandamet, Altace.
Exam: Normal cardiac exam. 2+ carotid pulses without bruit, femoral pulses trace bilaterally with no bruits, popliteal pulses not palpable, DP and PTs Dopplerable bilaterally.
Labs: creatinine 1.3, Hct 41, INR 1.0
Aortoiliac Disease
• Who to revascularize:– Limb-threatening ischemia and life-style
limiting claudication. – Relatively low threshold to treat.
• How to revascularize:– Consider comorbidities, anatomic factors.– In general, endovascular therapy is
preferred.
Revascularization Options for Aortoiliac DiseaseAorto-bifemoral bypass
Fem-fem bypass
Angioplasty +/- stenting
Aortoiliac disease
Stenting: – 5 year efficacy: 71% primary patency, 81% primary-
assisted patency. – <0.5% operative mortality– Usually done as outpatient procedure.
Surgery (aortobifemoral bypass): – 5 year patency: 90% – 2-4% operative mortality– Substantial post-operative morbidity
Back MR et al. Ann Vasc Surg. 2003; 17: 596-603. Murphy TP et al. Radiology. 2004; 231: 243-249.Rutherford et al. Semin Vasc Surgery. 1994; 7: 11.TASC-2.
2 weeks post:
•Walking 2 miles/day without claudication.•Able to participate in cardiac rehab.•Stopped smoking.
4 years later: Continued patency.
Carotid Artery Disease
0 10 20 30 40
2y s
troke
rate
by
% s
teno
sis string sign
90-99%
80-89%
70-79%
0 5 10 15
2y s
troke
rate
by
% s
teno
sis 90-99%
80-89%
70-79%
60-69%
0-59%
11%
34%
28%
20%
10%
7%
3%
3%
3%
Symptomatic Asymptomatic
2y Event Risk
Data from NASCET and Chambers; NEJM ’86;315:860-5.
Risk of Stroke Depends Upon:1. Symptomatic Status
2. Stenosis Severity
CEA in Symptomatic Patients:Consistent Benefit
n Follow-up (months)
RR (%) p
NASCET 658 18 26 0.001
ECST 778 36 17 0.0001
VA Cooperative 193 12 19 0.01
For stenosis >70%: NNT=6.350-69%: NNT =16.1
More Than 80% of Strokes are Unheralded
Revascularization for Asymptomatic Carotid Stenosis
5.1
11
6.4
11.8
0
4
8
12
ACAS ACST
CEA
Medical tx
5 year CVA
JAMA 1995; 273: 1421.Lancet 2004; 363:1491.
(p<0.0001)(p=0.004)
• ACAS: – >60% stenosis (n=1662)– Perioperative death/stroke: 2.3%
• ACST:– >70% stenosis (n=3120)– Perioperative stroke: 3.1%
Indications for Screening
• Cervical bruit• Symptoms - Amaurosis fugax or
TIA/Stroke• Syncope (if vertibrobasilar insufficiency or
bilateral carotid disease is suspected – a very rare cause of syncope)
• Known subclavian stenosis• Previous CEA• Pre-operative evaluation for CABG
Carotid Stenting
Sapphire:
0
2
4
6
8
10
%
MAE Death MajorIpsi CVA
MinorIpsi CVA
MI
StentCEA
Yadav et al. NEJM 2004: 351:1493.
So I need revascularization, stent or CEA?
Currently, only patients at high risk for CEA:
Patient factors:
•CHF: NYHA ¾•EF <30•MI <24 hours and <4 weeks•Active unstable angina•Planned cardiac surgery w/in 6 weeks•Severe pulmonary disease
•Chronic O2
•FEV1 or DLCO <50%•Contralateral laryngeal palsy
Anatomic features:
•CEA restenosis•Contralateral carotid occlusion•Prior cervical XRT•Diffucult surgical access
(high or low lesion)_
Carotid Revascularization
Who to revascularize:– Symptomatic: >60% stenosis.
– Asymptomatic: >80% stenosis.
How to revascularize:– Consider comorbidities, anatomic factors.
– Stenting currently reserved for patients at high risk for CEA.
– Trials currently evaluating carotid stenting vs. CEA for all patients.
Where should I refer my carotid disease?
• Trials of CEA have a peri-operative stroke rate of ≤3%.
• Medicare data shows national peri-op stroke rate of 6%.
• Know the stroke rate of the program that you send your patients to.
• Refer to programs where both carotid stenting and CEA are done commonly.
Take Home Points:
• PAD is a coronary risk equivalent– Ask about symptoms– Feel for pulses– Low threshold to check ABI
• Stroke is devastating and revascularization works– Check carotid duplex in symptomatic patients.– Get carotid revascularization done where results are
excellent.