Title: Peripheral Arterial Disease Guidelines: Management of Patients with Lower Extremity PAD
1Peripheral Arterial Disease Guidelines
Management of Patients with Lower Extremity PAD
A Collaboration of the American College of
Cardiology, the American Heart Association, the
American Association for Vascular Surgery/Society
for Vascular Surgery, Society for Cardiovascular
Angiography and Interventions, Society of
Interventional Radiology, Society for Vascular
Medicine and Biology, and the PAD Coalition.
SVMB
The PAD Coalition
2Based on the ACC/AHA Guidelines on the
Management of Patients With Peripheral Arterial
Disease A Collaborative Report from the American
Association for Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular
Angiography and Interventions, Society of
Interventional Radiology, Society for Vascular
Medicine and Biology, and the ACC/AHA Task Force
on Practice Guidelines. Endorsed by the
American Association of Cardiovascular and
Pulmonary Rehabilitation National Heart, Lung,
and Blood Institute Society for Vascular
Nursing TransAtlantic Inter-Society Consensus
and the Vascular Disease Foundation.
3- Supported by an educational grant from
Bristol-Myers Squibb and Sanofi - Pharmaceuticals Partnership.
- Bristol-Myers Squibb and Sanofi Pharmaceuticals
Partnership were not - involved in the development of this slide deck
and in no way influenced its - contents.
4Applying Classification of Recommendations and
Level of Evidence
5Applying Classification of Recommendations and
Level of Evidence
6Why A PAD Guideline?
- To enhance the quality of patient care
- Increasing recognition of the importance of
atherosclerotic lower extremity PAD - High prevalence
- High cardiovascular risk
- Poor quality of life
- Improved ability to detect and treat renal artery
disease - Improved ability to detect and treat AAA
- The evidence base has become increasingly robust,
so that a data-driven care guideline is now
possible
7Peripheral Arterial Disease GuidelineThe Target
Audiences Are Diverse
- Primary care clinicians
- Family practice
- Internal medicine
- PA, NP, nurse clinicians
- Cardiovascular/vascular medicine, vascular
surgical, interventional radiology trainees and
vascular specialists
This was not intended to be a procedural
guideline it is intended to provide a guide to
optimal lifelong PAD care.
8Defining a Population At Risk for Lower
Extremity PAD
- Age less than 50 years with diabetes, and one
additional risk factor (e.g., smoking,
dyslipidemia, hypertension, or hyperhomocysteinemi
a) - Age 50 to 69 years and history of smoking or
diabetes - Age 70 years and older
- Leg symptoms with exertion (suggestive of
claudication) or ischemic rest pain - Abnormal lower extremity pulse examination
- Known atherosclerotic coronary, carotid, or renal
artery disease
9The First Tool to Establish the PAD
DiagnosisThe HPI, ROS, and Physical Examination
- Individuals with asymptomatic PAD should be
identified in order to offer therapeutic
interventions known to diminish their increased
risk of myocardial infarction, stroke, and death.
- A history of walking impairment, claudication,
and ischemic rest pain is recommended as a
required component of a standard review of
systems for adults 50 years who have
atherosclerosis risk factors, or for adults 70
years.
10The First Tool to Establish the PAD
DiagnosisThe HPI, ROS, and Physical Examination
- Pulse intensity should be assessed and should be
recorded numerically as follows - 0, absent
- 1, diminished
- 2, normal
- 3, bounding
Use of a standard examination should facilitate
clinical communication
11Individuals with PAD Present in Clinical Practice
with Distinct Syndromes
This guideline recognizes that
- Asymptomatic Without obvious symptomatic
complaint (but usually with a functional
impairment). - Classic Claudication Lower extremity symptoms
confined to the muscles with a consistent
(reproducible) onset with exercise and relief
with rest. - Atypical leg pain Lower extremity discomfort
that is exertional, but that does not
consistently resolve with rest, consistently
limit exercise at a reproducible distance, or
meet all Rose questionnaire criteria.
12Individuals with PAD Present in Clinical Practice
with Distinct Syndromes
This guideline recognizes that
- Critical Limb Ischemia Ischemic rest pain,
non-healing wound, or gangrene - Acute limb ischemia The five Ps, defined by
the clinical symptoms and signs that suggest
potential limb jeopardy - Pain
- Pulselessness
- Pallor
- Paresthesias
- Paralysis ( polar, as a sixth p).
13Hemodynamic Noninvasive Tests
- Resting Ankle-Brachial Index (ABI)
- Exercise ABI
- Segmental pressure examination
- Pulse volume recordings
These traditional tests continue to provide a
simple, risk-free, and cost-effective approach
to establishing the PAD diagnosis as well as to
follow PAD status after procedures.
14The Ankle-Brachial Index
- Lower extremity systolic pressure
- Brachial artery systolic pressure
ABI
- The ankle-brachial index is 95 sensitive and 99
specific for PAD - Establishes the PAD diagnosis
- Identifies a population at high risk of CV
ischemic events - Population at risk can be clinically
epidemiologically defined
- Exertional leg symptoms, non-healing wounds, age
70, age 50 years with a history of smoking or
diabetes. - Toe-brachial index (TBI) useful in individuals
with non-compressible pedal pulses
Lijmer JG. Ultrasound Med Biol 199622391-8
Feigelson HS. Am J Epidemiol 1994140526-34
Baker JD. Surgery 198189134-7 Ouriel K. Arch
Surg 19821171297-13 Carter SA. J Vasc Surg
200133708-14
15Exercise ABI
- Confirms the PAD diagnosis
- Assesses the functional severity of claudication
- May unmask PAD when resting the ABI is normal
16Arterial Duplex Ultrasound Testing
- Duplex ultrasound of the extremities is useful to
diagnose anatomic location and degree of stenosis
of peripheral arterial disease. - Duplex ultrasound is useful to provide
surveillance following femoral-popliteal bypass
using venous conduit (but not prosthetic grafts).
- Duplex ultrasound of the extremities can be used
to select candidates for - endovascular intervention
- surgical bypass, and
- to select the sites of surgical anastomosis.
However, the data that might support use of
duplex ultrasound to assess long-term patency of
PTA is not robust.
17Noninvasive Imaging Tests
Duplex Ultrasound
Duplex ultrasound of the extremities is useful to
diagnose the anatomic location and degree of
stenosis of PAD. Duplex ultrasound is
recommended for routine surveillance after
femoral-popliteal or femoral- tibial-pedal bypass
with a venous conduit. minimum surveillance
intervals are approximately 3,6, and 12 months,
and then yearly after graft placement.
18Noninvasive Imaging Tests
Magnetic Resonance Angiography (MRA)
MRA of the extremities is useful to
diagnose anatomic location and degree of stenosis
of PAD. MRA of the extremities should be
performed with a gadolinium enhancement. MRA of
the extremities is useful in selecting patients
with lower extremity PAD as candidates for
endovascular intervention.
19Noninvasive Imaging Tests
Computed Tomographic Angiography (CTA)
- CTA of the extremities may be considered
- to diagnose anatomic location and
- presence of significant stenosis in
- patients with lower extremity PAD.
- CTA of the extremities may be considered
- as a substitute for MRA for those patients
- with contraindications to MRA.
20Natural History of PAD Age 50 years
Cardiovascular Morbidity / Mortality
Limb Morbidity
Mortality 15-30
Worsening Claudication 10-20
Critical Limb Ischemia 1-2
Nonfatal CV Events 20
Stable Claudication 70-80
CV Causes 75
Non CV Causes 25
21Lipid Lowering and Antihypertensive Therapy
Treatment with an HMG coenzyme-A reductase
inhibitor (statin) medication is indicated for
all patients with peripheral arterial disease to
achieve a target LDL cholesterol of less than 100
mg/dl.
Antihypertensive therapy should be administered
to hypertensive patients with lower extremity PAD
to a goal of less than 140/90 mmHg
(non-diabetics) or less than 130/80 mm/Hg
(diabetics and individuals with chronic renal
disease) to reduce the risk of myocardial
infarction, stroke, congestive heart failure, and
cardiovascular death.
22Antiplatelet Therapy
Antiplatelet therapy is indicated to reduce the
risk of myocardial infarction, stroke, or
vascular death in individuals with
atherosclerotic lower extremity PAD.
Aspirin, in daily doses of 75 to 325 mg, is
recommended as safe and effective antiplatelet
therapy to reduce the risk of myocardial
infarction, stroke, or vascular death in
individuals with atherosclerotic lower extremity
PAD.
Clopidogrel (75 mg per day) is recommended as an
effective alternative antiplatelet therapy to
aspirin to reduce the risk of myocardial
infarction, stroke, or vascular death in
individuals with atherosclerotic lower extremity
PAD.
23Supervised Exercise Rehabilitation
A program of supervised exercise training is
recommended as an initial treatment modality for
patients with intermittent claudication.
Supervised exercise training should be performed
for a minimum of 30 to 45 minutes, in sessions
performed at least three times per week for a
minimum of 12 weeks.
24Pharmacotherapy of Claudication
Cilostazol (100 mg orally two times per day) is
indicated as an effective therapy to improve
symptoms and increase walking distance in
patients with lower extremity PAD and
intermittent claudication (in the absence of
heart failure).
25Endovascular Treatment for Claudication
- Endovascular procedures are indicated for
individuals with a vocational or
lifestyle-limiting disability due to intermittent
claudication when clinical features suggest a
reasonable likelihood of symptomatic improvement
with endovascular intervention and - Response to exercise or pharmacologic therapy is
inadequate, and/or - b. there is a very favorable risk-benefit ratio
(e.g. focal aortoiliac occlusive disease)
26Endovascular Treatment for Claudication
Endovascular intervention is recommended as the
preferred revascularization technique for TASC
type A iliac and femoropopliteal lesions.
Femoropopliteal
Iliac
TASC A (PTA recommended)
TASC B (insufficient data to recommend)
27Endovascular Treatment for Claudication Iliac
Arteries
Provisional stent placement is indicated for use
in iliac arteries as salvage therapy for
suboptimal or failed result from balloon dilation
(e.g. persistent gradient, residual diameter
stenosis 50, or flow-limiting
dissection). Stenting is effective as primary
therapy for common iliac artery stenosis and
occlusions. Stenting is effective as primary
therapy in external iliac artery stenosis and
occlusions.
28Endovascular Treatment for Claudication
Endovascular intervention is not indicated if
there is no significant pressure gradient across
a stenosis despite flow augmentation with
vasodilators. Primary stent placement is not
recommended in the femoral, popliteal, or tibial
arteries. Endovascular intervention is not
indicated as prophylactic therapy in an
asymptomatic patient with lower extremity PAD.
29Surgery for Critical Limb Ischemia
Surgery is not indicated in patients with severe
decrements in limb perfusion in the absence of
clinical symptoms of critical limb ischemia.
- Patients who have significant necrosis of the
weight-bearing portions of the foot, an
uncorrectable flexion contracture, paresis of the
extremity, refractory ischemic rest pain, sepsis,
or a very limited life expectancy due to
co-morbid conditions should be evaluated for
primary amputation.
30Surgery for Critical Limb Ischemia
- For individuals with combined inflow and
- outflow disease with critical limb ischemia,
- inflow lesions should be addressed first.
- When surgery is to be undertaken, an aorto-
- bifemoral bypass is recommended for patients
- with symptomatic, hemodynamically
- significant, aorto-bi-iliac disease requiring
- intervention.
31Surgery for Critical Limb Ischemia
- Bypasses to the above-knee popliteal
- artery should be constructed with autogenous
- saphenous vein when possible.
- Bypasses to the below-knee popliteal artery
- should be constructed with autogenous vein
- when possible.
- Prosthetic material can be used effectively
- for bypasses to the below knee popliteal
- artery when no autogenous vein from ipsilateral
- or contralateral leg or arm is available.
32Surgery for Critical Limb Ischemia
- Femoral-tibial artery bypasses should be
- constructed with autogenous vein, including
- ipsilateral greater saphenous vein, or if
- unavailable, other sources of vein from the leg
- or arm.
- Composite sequential femoropopliteal-tibial
- bypass, or bypass to an isolated popliteal
- arterial segment that has collateral outflow to
- the foot, are acceptable methods of
- revascularization and should be considered
- when no other form of bypass with adequate
- autogenous conduit is possible.
33Acute Limb Ischemia (ALI)
- Patients with ALI and a salvageable
- extremity should undergo an emergent
- evaluation that defines the anatomic level of
- occlusion, and that leads to prompt
- endovascular or surgical intervention.
- Patients with ALI and a non-viable extremity
- should not undergo an evaluation to define
- vascular anatomy or efforts to attempt
- revascularization.
34ACC/AHA Guidelines for the Management of
PADMajor Contributions to Improved Care
Standards
- Population at risk is now defined by
epidemiologic criteria applied to practice.
- Presentation-specific algorithms will expedite
care (e.g., asx, atypical leg pain, classic
claudication, critical limb ischemia, acute
arterial occlusion).
- Use of exercise, pharmacologic, endovascular, and
surgical interventions are emplaced in care as
defined by evidence.
35The PAD Guidelines the PAD CoalitionAn
Ideal Health Partnership To Foster Clinician and
Public PAD Education
The PAD Coalition A public, interdisciplinary
Coalition devoted to creating a national PAD
public awareness campaign and to coordinating
PAD public physician education.
www.padcoalition.org