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Peripheral Arterial Disease Guidelines: Management of Patients with Lower Extremity PAD

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Title: Peripheral Arterial Disease Guidelines: Management of Patients with Lower Extremity PAD


1
Peripheral 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
2
Based 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.

4
Applying Classification of Recommendations and
Level of Evidence
5
Applying Classification of Recommendations and
Level of Evidence
6
Why 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

7
Peripheral 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.
8
Defining 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

9
The 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.

10
The 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
11
Individuals 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.

12
Individuals 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).

13
Hemodynamic 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.
14
The 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
15
Exercise ABI
  • Confirms the PAD diagnosis
  • Assesses the functional severity of claudication
  • May unmask PAD when resting the ABI is normal

16
Arterial 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.
17
Noninvasive 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.
18
Noninvasive 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.
19
Noninvasive 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.

20
Natural 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
21
Lipid 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.
22
Antiplatelet 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.
23
Supervised 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.
24
Pharmacotherapy 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).
25
Endovascular 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)

26
Endovascular 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)
27
Endovascular 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.
28
Endovascular 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.
29
Surgery 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.

30
Surgery 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.

31
Surgery 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.

32
Surgery 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.

33
Acute 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.

34
ACC/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.

35
The 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
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