Peripheral Vascular DiseasePeripheral Vascular Disease

Masrul SyafriDept Cardiology and Vascular Medicine

Perhipheral vascular disease is considered to

be any abnormality of the arteries and veins

outside of the skull and the heart.

Worldwide Causes of Worldwide Causes of DeathDeath

P A DP A DCharacterized by arterial stenosis and Characterized by arterial stenosis and occlusions in the peripheral arterial bedocclusions in the peripheral arterial bed

Can be symptomatic or asymptomaticCan be symptomatic or asymptomatic

Under diagnosed and under treated Under diagnosed and under treated diseasedisease

Patient and physician awareness is lowPatient and physician awareness is low

. . Ranges in severity from intermittent Ranges in severity from intermittent

claudication to Acute limb ischemiaclaudication to Acute limb ischemia

Patients have a decreased quality of Patients have a decreased quality of life due to a reduction in walking life due to a reduction in walking distance and speed leading to distance and speed leading to immobilityimmobility

Most cases of PAD are asymptomaticMost cases of PAD are asymptomatic

PrevalencePrevalence

27 million people in Europe and 27 million people in Europe and North America have PAD (16% North America have PAD (16% of the population 55 yrs or of the population 55 yrs or older)older) 10.5 million are symptomatic10.5 million are symptomatic 16.5 million are asymptomatic16.5 million are asymptomatic

PrevalencePrevalence Severity of symptoms has been found to Severity of symptoms has been found to

correlate with survivalcorrelate with survival San Diego Artery studySan Diego Artery study

Survival rates decreased with increasing severitySurvival rates decreased with increasing severity

Another study showed that patients with Another study showed that patients with symptoms had a 22% survival rate over a symptoms had a 22% survival rate over a 15 yr period compared to a 78% survival 15 yr period compared to a 78% survival rate of pts w/o symptomsrate of pts w/o symptoms

Belch et al, Arch Intern Med; April 2003; 884-892Belch et al, Arch Intern Med; April 2003; 884-892

ComponentsComponents Problems with veinsProblems with veins

Varicose veinsVaricose veins Blood clots and sequelaeBlood clots and sequelae

Arteries blocked by atherosclerosisArteries blocked by atherosclerosis Carotid, Legs. Kidneys, GI tractCarotid, Legs. Kidneys, GI tract

Arterial AneurysmsArterial Aneurysms Aorta and branchesAorta and branches

Natural History of PADNatural History of PAD Associated with significant mortality because of Associated with significant mortality because of

association with coronary and cerebrovascular association with coronary and cerebrovascular events including death, MI, and strokeevents including death, MI, and stroke

6x more likely to die within 10 yrs than patients 6x more likely to die within 10 yrs than patients without PADwithout PAD

5 yr mortality rate in pts with claudication is 5 yr mortality rate in pts with claudication is about 30%about 30%

Continued use of smoking results in a two fold Continued use of smoking results in a two fold risk of mortalityrisk of mortality

Why it is important to Why it is important to recognize patients with recognize patients with

PAD?PAD? PAD is a marker of PAD is a marker of

systemic systemic atherosclerosis atherosclerosis

Patients with Patients with either symptomatic either symptomatic or asymptomatic or asymptomatic PAD generally PAD generally have widespread have widespread arterial diseasearterial disease

Why it is important to Why it is important to recognize patients with recognize patients with

PAD?PAD? Coexisting vascular Disease:Coexisting vascular Disease: CAD-- 35 % to 92%CAD-- 35 % to 92% CVD-- 25 % to 50%CVD-- 25 % to 50%

Why it is important to Why it is important to recognize patients with recognize patients with

PAD?PAD? Cause of death:Cause of death: CAD– 40%-60%CAD– 40%-60% CVD– 10%-20% CVD– 10%-20% NNon-cardiovascular causes--on-cardiovascular causes--

Only 20% to 30 %Only 20% to 30 % Patients with PAD have a Patients with PAD have a 6 fold6 fold

increased risk of cardiovascular increased risk of cardiovascular disease mortality compared to disease mortality compared to patients without PADpatients without PAD

Predictors of Mortality in Predictors of Mortality in PADPAD

297 patients297 patients 213 had intermittent claudication213 had intermittent claudication 84 had CLI defined by gangrene, ulcerations or 84 had CLI defined by gangrene, ulcerations or

persistent rest pain > 2 weekspersistent rest pain > 2 weeks All subjects had ABI < 0.9All subjects had ABI < 0.9

ResultsResults Patients with CLI had a 1 yr death rate of 22%Patients with CLI had a 1 yr death rate of 22% 3 yr survival was 52% compared to 86% in pts with 3 yr survival was 52% compared to 86% in pts with

intermittent claudicationintermittent claudication Data suggests that pts with advance PAD have Data suggests that pts with advance PAD have

widespread arteriosclerotic diseasewidespread arteriosclerotic disease CLI was a stronger predictor of death than a low ABICLI was a stronger predictor of death than a low ABIPasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60

Risk Factors for AtherosclerosisRisk Factors for Atherosclerosis

AgeAge

DiabetesDiabetes

ObesityObesity

GeneticsGenetics

DyslipidemiaDyslipidemia

HypertensionHypertension

HyperhomocysteinHyperhomocysteinemiemiaa

Atheroscleroris

Atherosclerotic Disease and Complications(coronary, cerebrovascular, peripheral arterial events

SmokingSmoking

What is Peripheral What is Peripheral Arterial Disease?Arterial Disease?

PAD=POAD=PVDPAD=POAD=PVD Arteriosclerotic occlusive disease of aortoiliac Arteriosclerotic occlusive disease of aortoiliac

and/or femoropopliteal arterial systemand/or femoropopliteal arterial system ALI : Acute Limb Ischaemic ALI : Acute Limb Ischaemic CLI : Critical Limb IschaemicCLI : Critical Limb Ischaemic CI : Claudication IntermittentCI : Claudication Intermittent

Cardiac RiskCardiac Risk Pts with PVD have a 60% risk of Pts with PVD have a 60% risk of

CADCAD

Up to 30 % of pts have correctable 3 Up to 30 % of pts have correctable 3 vessel disease with reduced LVEFvessel disease with reduced LVEF

Patients with an ABI < 0.9 are twice Patients with an ABI < 0.9 are twice as likely to have CADas likely to have CAD

Clinical PresentationClinical Presentation Can vary from severe disabling discomfort at rest Can vary from severe disabling discomfort at rest

to a bothersome pain of seemingly little to a bothersome pain of seemingly little consequenceconsequence

Can present with buttock, thigh, calf or foot Can present with buttock, thigh, calf or foot claudication singly or in combinationclaudication singly or in combination

Diminished pulses with occasional bruits over Diminished pulses with occasional bruits over stenotic lesionsstenotic lesions

Poor wound healing, unilateral cool extremity, Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changesshiny skin, hair loss, and nail changes

ClaudicationClaudication Calf Calf

Cramping in upper 2/3 usually due to SFA stenosisCramping in upper 2/3 usually due to SFA stenosis

ThighThigh Usually occlusion of the common femoral arteryUsually occlusion of the common femoral artery

FootFoot Occlusive disease of the tibial and peroneal vesselsOcclusive disease of the tibial and peroneal vessels

Buttock and HipButtock and Hip Aortoiliac occlusive disease (Lariche’s syndrome)Aortoiliac occlusive disease (Lariche’s syndrome)

Diagnostic testsDiagnostic tests Ankle-brachial indexAnkle-brachial index

Measures the resting and post exercise systolic BP in Measures the resting and post exercise systolic BP in both the ankle and armsboth the ankle and arms

Normal > 1.0Normal > 1.0

Below 0.9 has a 95 % sensitivity for detecting Below 0.9 has a 95 % sensitivity for detecting angiogram positive PVDangiogram positive PVD

0.4 to 0.9 suggests arterial obstruction0.4 to 0.9 suggests arterial obstruction Highly predictive of morbidity and mortality of CV events Highly predictive of morbidity and mortality of CV events

linked to PADlinked to PAD

Below 0.4 represents advanced ischemiaBelow 0.4 represents advanced ischemia

Diagnostic TestsDiagnostic Tests Segemental limb pressuresSegemental limb pressures

> 20 mmHg reduction significant> 20 mmHg reduction significant

Duplex U/SDuplex U/S

MRAMRA

Conventional angiographyConventional angiography

AngiographyAngiography Indicated for:Indicated for:

Defining vessel anatomyDefining vessel anatomy

Evaluating therapyEvaluating therapy

Documenting diseaseDocumenting disease

What are the risk factors What are the risk factors for PAD?for PAD?

Non-Modifiable Risk Factors:Non-Modifiable Risk Factors: Male genderMale gender Advanced ageAdvanced age Family historyFamily history

Modifiable Risk Factors:Modifiable Risk Factors: Major Major SmokingSmoking HypertensionHypertension DiabetesDiabetes HyperlipidemiaHyperlipidemia

MinorMinor HomocystenemiaHomocystenemia ObesityObesity Hypercoaguable stateHypercoaguable state Physical inactivityPhysical inactivity

PRIMARY SITES PRIMARY SITES OF OF INVOLVEMENTINVOLVEMENT

Femoral & Popliteal Femoral & Popliteal arteries: 80-90%arteries: 80-90%

Tibial & Peroneal Tibial & Peroneal arteries: 40-50%arteries: 40-50%

Aorta & Iliac arteries: Aorta & Iliac arteries: 30%30%

Harrison’s Principles of Int Med

Pathogenesis

PathogenesisPathogenesis

How do patients with PAD How do patients with PAD present?present?

AsymptomaticAsymptomatic

SymptomaticSymptomatic •Intermittent Intermittent

claudicationclaudication•Critical Limb IschemiaCritical Limb Ischemia Pain at restPain at rest Tissue lossTissue loss GangreneGangrene

How do patients with PAD How do patients with PAD present?present?

How do we diagnose How do we diagnose PAD?PAD?

SymptomaticSymptomatic

AsymptomaticAsymptomatic

ABI measurementABI measurement Non-invasive tests (arterial Non-invasive tests (arterial duplex, duplex, CTA, MRA)CTA, MRA) Invasive test (Conventional Invasive test (Conventional angiogram)angiogram) ABI ABI measurementmeasurement

HistoryHistoryPhysical ExaminationPhysical Examination

How do we diagnose How do we diagnose PAD?PAD?

Symptomatic 10%

Asymptomatic 90%

Ankle Brachial IndexAnkle Brachial Index

ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

Ankle Brachial IndexAnkle Brachial Index

ABI valueABI value IndicatesIndicates<0.9<0.9 AbnormalAbnormal0.8- 0.90.8- 0.9 Mild PADMild PAD0.5- 0.80.5- 0.8 Moderate PADModerate PAD<0.5<0.5 Severe PADSevere PAD<0.25<0.25 Very Severe PADVery Severe PAD

The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics

InvestigationsInvestigations

InvestigationsInvestigations

Natural HistoryNatural History Annual risk :Annual risk : - Mortality - Mortality 6.8%6.8% - MI - MI 2.0%2.0% - Intervention - Intervention

1.0%1.0% - Amputation - Amputation

0.4%0.4%

Ouriel K, Lancet 2001; 358: 1257-64.

Goals of treating patients Goals of treating patients with PADwith PAD

Relief symptomsRelief symptoms Improve quality of lifeImprove quality of life Limb salvageLimb salvage Prolong survival Prolong survival

Risk Factors Modification

Improve Lower Limb Circulation

Strategies in treating Strategies in treating patients with PADpatients with PAD

Risk Factors Modification• Diet and weight controlDiet and weight control• Exercise Exercise • Hypertension controlHypertension control• Diabetes controlDiabetes control• Lipid controlLipid control• Smoking CessationSmoking Cessation

Strategies in treating Strategies in treating patients with PADpatients with PAD

Improve Lower Limb Circulation• Conservative (Exercise Program)Conservative (Exercise Program)• Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting- Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass

Strategies in treating Strategies in treating patients with PADpatients with PAD

Percutanous Transluminal Percutanous Transluminal AngioplpastyAngioplpasty

PTAPTA

Surgical BypassSurgical Bypass

Acute Limb Acute Limb IschemiaIschemia

What is an Acute Limb What is an Acute Limb Ischemia?Ischemia?

Sudden decrease or worsening in Sudden decrease or worsening in the limb perfusion causing a the limb perfusion causing a potential threat to the limb viability potential threat to the limb viability resulting from a sudden obstruction resulting from a sudden obstruction of the arterial system of the arterial system

What are the causes of acute What are the causes of acute arterial occlusion ?arterial occlusion ?

EmbolusEmbolus ThrombosisThrombosis OthersOthers TraumaTrauma IatrogenicIatrogenic Arterial dissectionArterial dissection

What is the possible source for What is the possible source for an embolus? an embolus?

Spontaneous (80%) Cardiac source arrhythmias, MI, prosthetic valve, endocarditis Non-Cardiac source Proximal AS plaque, Proximal Aneurysm,

Paradoxical emboli

Iatrogenic (20%) Angiographic manipulation Surgical manipulation

What are the common sites for What are the common sites for embolus lodgment in the arterial embolus lodgment in the arterial

tree?tree?

How do patients with acute How do patients with acute limb ischemia present?limb ischemia present?

Sudden onset of diffuse and poorly Sudden onset of diffuse and poorly localized leg pain localized leg pain

6 Ps6 Ps Paresthesias Paresthesias Pain Pain Poikilothermia (coolness) Poikilothermia (coolness) Pallor Pallor Pulselessness Pulselessness ParalysisParalysis

InvestigationsInvestigations Acute Limb Ischemia is aAcute Limb Ischemia is a CLINICAL DIAGNOSISCLINICAL DIAGNOSIS If time allows, especially if If time allows, especially if

atherosclerotic thrombosis is atherosclerotic thrombosis is suggested, preoperative suggested, preoperative angiographyangiography is often wise is often wise

Goal of treating patients Goal of treating patients with Acute Limb Ischemiawith Acute Limb Ischemia

Rapid restoration of adequate Rapid restoration of adequate arterial perfusion without the arterial perfusion without the development of morbid local development of morbid local or systemic complicationsor systemic complications

TreatmentTreatment EMEGENCY (Golden time is 6 hours)EMEGENCY (Golden time is 6 hours) ABCABC IV Heparin (anticoagulation)IV Heparin (anticoagulation) Rapid surgical Rapid surgical

thromboembolectomythromboembolectomy +/ - surgical bypass+/ - surgical bypass +/- thrombolytic therapy+/- thrombolytic therapy +/- primary amputation+/- primary amputation

Surgical Thrmboemblectomy Surgical Thrmboemblectomy ProcedureProcedure

ThrombolysisThrombolysis

What do we worry about What do we worry about after revascularization?after revascularization?

Reperfusion InjuryReperfusion Injury Local Local Compartment SyndromeCompartment Syndrome Systemic Systemic HyperkalemiaHyperkalemia AcidosisAcidosis MyoglobulinuriaMyoglobulinuria

Claudication Claudication intermittentintermittent

ClaudicationClaudication Patients suffer from peripheral Patients suffer from peripheral

atherosclerosisatherosclerosis Symptomatic deficiency in blood Symptomatic deficiency in blood

supply to exercising muscle which is supply to exercising muscle which is relieved by restrelieved by rest

Largely a disorder of the elderlyLargely a disorder of the elderly Only 1-2% of those ages 37-69 Only 1-2% of those ages 37-69 Clinical history extremely importantClinical history extremely important

HOW DOES AN INTERMITTENT HOW DOES AN INTERMITTENT CLAUDICATION PATIENT CLAUDICATION PATIENT PRESENT CLINICALLY?PRESENT CLINICALLY?

Leg pain caused and reproduced by a certain Leg pain caused and reproduced by a certain degree of exertiondegree of exertion

Relieved by restRelieved by rest Not affected by body positionNot affected by body position Atherosclerotic lesions usually found in arterial Atherosclerotic lesions usually found in arterial

segment one level above affected muscle groupsegment one level above affected muscle group Calf claudication more commonly due to Calf claudication more commonly due to

disease in femoral arteries and less commonly disease in femoral arteries and less commonly due to disease in popliteal or proximal tibial or due to disease in popliteal or proximal tibial or peroneal arteries; Hip/Thigh/Buttock peroneal arteries; Hip/Thigh/Buttock claudication due to aortoiliac diseaseclaudication due to aortoiliac disease

Am J Cardiol 2001; 87 (suppl): 3D-13D

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISCALFCALF

Venous occlusionVenous occlusion Tight bursting pain / Tight bursting pain /

dull ache that worsens dull ache that worsens on standing and on standing and resolves with leg resolves with leg elevationelevation

Positional pain reliefPositional pain relief Chronic compartment Chronic compartment

syndromesyndrome Tight bursting painTight bursting pain Positional pain reliefPositional pain relief

Nerve root compressionNerve root compression Positional pain reliefPositional pain relief

Baker’s cystBaker’s cyst Positional pain reliefPositional pain relief

HIP/THIGH/BUTTOCKHIP/THIGH/BUTTOCK• ArthritisArthritis

– Persistent pain, brought Persistent pain, brought on by variable amounts on by variable amounts of exerciseof exercise

– Associated symptoms in Associated symptoms in other jointsother joints

• Spinal cord compressionSpinal cord compression– History of back painHistory of back pain– Symptoms while Symptoms while

standingstanding– Positional pain reliefPositional pain reliefFOOTFOOT

• ArthritisArthritis• Buerger disease Buerger disease

(thromboangitis obliterans)(thromboangitis obliterans)Am J Cardiol 2001; 87 (suppl): 3D-13D

DIAGNOSISDIAGNOSIS History takingHistory taking Careful examination of legCareful examination of leg Pulse evaluationPulse evaluation Ankle-brachial index (ABI):Ankle-brachial index (ABI):

SBP in ankle (dorsalis pedis and posterior SBP in ankle (dorsalis pedis and posterior tibial arteries)tibial arteries)

______________________________________________________________________SBP in upper arm (brachial artery)SBP in upper arm (brachial artery)

Am J Cardiol 2001; 87 (suppl): 3D-13DNEJM 2001; 344: 1608-1621

Ankle-Brachial Index Ankle-Brachial Index Values and Clinical Values and Clinical

ClassificationClassification

Clinical PresentationClinical Presentation Ankle-Brachial IndexAnkle-Brachial Index

NormalNormal > 0.90> 0.90

ClaudicationClaudication 0.50-0.900.50-0.90

Rest painRest pain 0.21-0.490.21-0.49

Tissue lossTissue loss < 0.20< 0.20

Am J Cardiol 2001; 87 (suppl): 3D-13DNEJM 2001; 344: 1608-1621

Values >1.25 falsely elevated; commonly seen in diabetics

The history and physical examination The history and physical examination (pulse evaluation and careful (pulse evaluation and careful examination of the leg) are usually examination of the leg) are usually sufficient to establish the diagnosissufficient to establish the diagnosis

WHY IS IT NECESSARY TO WHY IS IT NECESSARY TO TREAT INTERMITTENT TREAT INTERMITTENT

CLAUDICATION ?CLAUDICATION ? Symptoms worsen in 25% of patientsSymptoms worsen in 25% of patients Approximately 5% will require Approximately 5% will require

amputation within 5 yearsamputation within 5 years Around 5-10% have critical limb Around 5-10% have critical limb

ischemia; risk of limb lossischemia; risk of limb loss Increased risk of mortality, primarily Increased risk of mortality, primarily

for cardiovascular causesfor cardiovascular causes

Am J Cardiol 2001; 87 (suppl): 3D-13DAm J Cardiol 2001; 87 (suppl): 3D-13D

IMPACT ON QUALITY OF LIFEIMPACT ON QUALITY OF LIFE

Functional status severely impairedFunctional status severely impaired Gradual process of decline if symptoms are ignoredGradual process of decline if symptoms are ignored Symptoms considered a normal part of aging Symptoms considered a normal part of aging

processprocess Leveraged “disability”Leveraged “disability” Detrimental to quality of life; affects both leisure Detrimental to quality of life; affects both leisure

and work activitiesand work activities

Peak exercise performance is about 50% that of age-Peak exercise performance is about 50% that of age-matched controls, equivalent to moderate to severe matched controls, equivalent to moderate to severe heart failure patientsheart failure patients

Am J Cardiol 2001; 87 (suppl): 14D-18DAm J Cardiol 2001; 87 (suppl): 14D-18D Am J Med 2002; 112: 49-57Am J Med 2002; 112: 49-57

GOALS OF TREATMENTGOALS OF TREATMENT To relieve exertional symptoms To relieve exertional symptoms

and improve walking capacityand improve walking capacity To improve quality of lifeTo improve quality of life To reduce total mortality as well To reduce total mortality as well

as cardiac and cerebrovascular as cardiac and cerebrovascular morbidity and mortalitymorbidity and mortality

NEJM 2001; 344: 1608-21

MANAGEMENTMANAGEMENT Risk factor modificationRisk factor modification Exercise therapyExercise therapy Antiplatelet therapyAntiplatelet therapy Medical therapy targeted at Medical therapy targeted at

symptomssymptoms Revascularisation proceduresRevascularisation procedures

Natural History of PAD in US Natural History of PAD in US PopulationPopulation

Adapted from Weitz JI. Circulation 1996;94:3026-49.

Population Aged >55y

AsymptomaticABI <0.9

10%

Intermittentclaudication

5%

Critical leg ischemia1%

PADoutcomes (5-year outcomes)

Cardiovascularmorbidity/mortality

Stableclaudication

73%

Worseningclaudication

16%

Leg bypasssurgery

7%

Majoramputation

4%

Nonfatal events(MI/stroke)

20%

Mortality30%

Intervention for Tissue Loss/Intervention for Tissue Loss/Rest Pain, Severe ClaudicationRest Pain, Severe Claudication

• Medications• Risk factor assessment & reduction• Exercise program• PTA/Stents• Operation

MODIFICATION OF RISK MODIFICATION OF RISK FACTORSFACTORS

Smoking cessationSmoking cessation Diabetes control (FBG 80-120 mg/dl, PPG Diabetes control (FBG 80-120 mg/dl, PPG <<

180 mg/dl, HbA 180 mg/dl, HbA1c1c < 7%) < 7%) Dyslipidemia management (LDL < 100 Dyslipidemia management (LDL < 100

mg/dl, TG < 150 mg/dl): Statins (RR 38%; mg/dl, TG < 150 mg/dl): Statins (RR 38%; 4S)4S)

Hypertension control (BP < 130/85 mmHg)Hypertension control (BP < 130/85 mmHg) Ramipril [RR 28%; HOPE (n=4051)]Ramipril [RR 28%; HOPE (n=4051)]

Am J Cardiol 2001; 87 (suppl): 3D-13DNEJM 2001; 344: 1608-21Am J Med 2002; 112: 49-57

EXERCISE PROGRAMEXERCISE PROGRAM Improves walking abilityImproves walking ability Requires motivation and personalised Requires motivation and personalised

supervisionsupervision Benefits lost if not maintained on Benefits lost if not maintained on

regular basisregular basis Overall effectiveness limitedOverall effectiveness limited

NEJM 2001; 344: 1608-21

Compartment SyndromeCompartment Syndrome

Thank YouThank You

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PathogenesisPathogenesis