PAD: Pills, stents & bypasses. ���(Pick one and then keep walking)

Dr Mark Wheatcroft Vascular Surgeon

St Michael’s Hospital

Introduction

•  PAD: demographics, natural history

•  Best medical therapy

•  Further investigation

•  Intervention - endovascular vs open

• Outcomes / Follow-up

Disclosure

• No conflict of interest

PAD: A definition •  What ankle brachial index (ABI) defines

PAD?

a). More than 1.0

b). Less than 1.0

c). Less than 0.9

d). Less than 0.5

Answer

c). ABI < 0.9

The burden of PAD •  27m people in N. America & Europe with PAD

•  4.3% > 40 years

•  14.5% >70 years

•  2 - 3% per annum non-fatal MI

•  CVS mortality rates: 1yr 12%

5yr 42%

10yr 65%

Natural history PAD

ABI < 0.9

Asymptomatic

Intermittent Claudication (IC)

Short distance IC

Rest pain

Tissue loss / ulcer / gangrene

Limb loss / death

Primary presentation

Natural history

Intermittent Claudication

50% Stable

25% Improve

25% Deteriorate

1 - 5% Amputation

PAD risk factors

•  The BIG FOUR:

SMOKING X 4

DIABETES X 2

HYPERTENSION X < 2

DYSLIPIDEMIA X 2

Best Medical Therapy •  Smoking cessation

•  Statin therapy (even if lipids normal)

•  Glycemic control in DM

•  Antihypertensives - ACE-I

•  ASA 81mg / clopidogrel 75mg

•  Exercise program

Management •  All PAD (inc. asymptomatic): BMT + Exercise

•  Symptomatic: Refer to vascular surgery

Intermittent claudication - routine

Critical limb ischemia - urgent

“rest pain”, “tissue loss”,

“ulcer”, “gangrene”.

• 

•  Need for arterial duplex prior to Vasc Surg questionable

Management - Vasc. Clinic

•  Full Hx, Exam.

•  Blood work (creat, lipids)

•  Arterial duplex with resting ABI +/- post exercise ABI

•  Assessment of severity, risks, benefits

•  Address risk factors

•  CTA, MRA, TFA.

Intervention: Medication

•  Pentoxifylline - 12% improvement in WD,

not clinically significant

•  Cilostazol - approx 25% improvement in WD

NOT available in Canada

•  Ramipril - studied for yrs, recent +ve trial

JAMA 2013; 309 (5): 453 - 460

Intervention: ���Revascularisation

•  Is patient suitable? - risks vs benefits

•  Is pathology suitable? location, severity, plaque morphology, distal run-off, conduit available?

Intermittent claudication

• Life-style limiting symptoms

• No imminent threat to life or limb

• Period of BMT + Exercise

• Intervention must be low risk

• MIMIC trial supports angioplasty for IC

• Improved WD (but not QoL) Eur. J. Vasc. Surg. 2008 Dec; 36(6): 660 - 668

Intermittent Claudication

•  Open procedures (more short dist IC):

Common femoral endarterectomy +/- profundaplasty - PTA resistant

•  NOT fem-pop / fem-distal bypass

- Only exceptional cases.

- Too risky for IC.

Critical ischaemia • Urgent!

• Angioplasty / stent vs open bypass

• Depends on lesion and patient fitness / prognosis

• BASIL 2: Primary bypass better if life expectancy > 2yrs

J. Vasc. Surg. 2010; 51: 5S - 17S

Endovascular

•  Minimally invasive - day case procedure

•  Well tolerated

•  Good for short lesions

•  Subintimal angioplasty and stenting for occlusions

•  Excellent results with iliac stents (70 - 80%)

•  SFA stents for longer lesions / occlusions (65% 3yr)

•  Tibial PTA less successful, but possible

Angioplasty

TASC II Classification of aorto-iliac disease

TASC II Classification of femoro-popliteal disease

Pre Post

Subintimal Angioplasty

•  Technique for crossing chronic occlusions

Endovascular

• Often requires multiple procedures

•  Close duplex follow up

•  High re-intervention rate

• Need anti-platelet and statin life long

Open Surgery •  Iliac disease:

Aorto-bi-iliac / femoral* (>80%)

Ilio-femoral*

Fem-fem X over (75%)

Axillo-bifemoral (71%)

Axillo-unifem (51%)

* rare due to stent success

•  CFA / PFA disease: Endarterectomy + patch plasty +/- PFA plasty

Refractory to PTA / stent

•  Ilio-femoral disease: Hybrid procedure

•  Infra-inguinal Bypass (5yr):

Vein Prosthetic

Fem - AK pop >85% 75%

Fem - BK pop 75% 65%

Fem - distal 70% 25%

Patency

Follow-up

•  Lifelong BMT + exercise

•  Duplex surveillance

•  Endovascular reintervention

•  Redo bypass

Worthy of a read......

Vascular Surgery at��� St Mikes

•  Dr Mark Wheatcroft

•  Dr Tony Moloney

•  Dr Wayne Tanner

•  Dr Mohammed Al Omran (Chief - Sept 2013)

•  Fax referrals to: 416 864 6012