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Duane S. Pinto, M.D.

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Interventional Cardiologist Beth Israel Deaconess Medical Center ... the anatomic, but also the physiological aberration of peripheral vascular flow. ... – PowerPoint PPT presentation

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Title: Duane S. Pinto, M.D.


1
Duane S. Pinto, M.D.
Director Peripheral Angiographic Core
Laboratory, TIMI Data Coordinating Center
Director, Cardiology Fellowship Training
Program Interventional Cardiologist Beth Israel
Deaconess Medical Center
Assistant Professor of Medicine, Harvard Medical
School
Intermittent Claudication Diagnosis and Work-up
2
PAD is a common disorder
  • Occurs in approximately 1/3 of patients
  • Over age 70
  • Over age 50 who smoke or have DM
  • Strong association with CAD
  • Obvious associated risk of stroke, MI,
    cardiovascular death
  • Progressive disease in 25 with progressive
    intermittent claudication/limb threatening
    ischemia
  • Outcomes
  • Impaired QoL
  • Limb Loss
  • Premature Mortality

3
Risk Factors for PVD Framingham Heart Study
Mean follow-up 38 years
4
PAD is Associated with Poor Outcomes
Annual Incidence Prevalence Mortality/yr ()
Stroke 0.73 4.6 28
TIA 0.50 4.9 6.3
ACS 2.3 12.6 45
PAD 8-12 4-25
Criqui M, et al. Circulation 1985 71510
5
Outcomes in PVD Patients
6
Diagnostic Modalities
  • History
  • Physical
  • Ankle Brachial Index (ABI)
  • Noninvasive vascular laboratory
  • Angiography MRA, CT, DSA

7
Initial Assessment
  • Identifying risk factors and symptoms
  • Pulse palpability
  • Further assessment relies on functional
    non-invasive testing and radiological imaging
  • Determine not only the anatomic, but also the
    physiological aberration of peripheral vascular
    flow.

8
Intermittent Claudication
  • Intermittent claudication (derived from the Latin
    word for limp)
  • A reproducible discomfort of a defined group of
    muscles that is induced by exercise and relieved
    with rest.
  • Supply ? Demand
  • Location depends upon the location of the
    disease.
  • Buttock, thigh, calf or foot claudication, either
    singly or in combination.

9
PVD Etiology
  • Large arteries
  • Atherosclerosis
  • Thromboembolism
  • Trauma
  • Arteritis of various types including
  • Buergers disease
  • Fibromuscular dysplasia
  • Takayasus

10
PVD Etiology
  • Medium and small vessel occlusions
  • Diabetes
  • Chronic recurrent trauma
  • Multiple small emboli
  • Collagen vascular diseases
  • Dysproteinemias
  • Polycythaemia vera
  • Pseudoxanthoma elasticum
  • Drug Reaction
  • Vasospasm

11
PVD Etiology
  • Various neurovascular compression syndromes
    affecting the upper limb
  • Cervical rib
  • Costoclavicular syndrome
  • Scalenus tunnel syndrome
  • Hyperabduction syndrome
  • Quadrangular space syndrome
  • Specific to certain anatomical sites
  • Cystic adventitial disease of the popliteal
    artery
  • Popliteal artery entrapment
  • Iliac endofibrosis (cyclists)

12
PVD Differential Diagnosis
  • Deep venous thrombosis
  • Musculoskeletal disorders
  • OA
  • Restless leg syndrome
  • Peripheral neuropathy
  • Spinal Stenosis (pseudoclaudication)
  • Worse with erect posture (lordosis) better
    sitting or lying down.
  • Can find relief by leaning forward and
    straightening the spine (pushing a shopping cart
    or leaning against a wall).

13
Differential Diagnosis of Intermittent
Claudication
Intermittent Claudication Venous Claudication Neurogenic Claudication
Quality of pain Cramping "Bursting" Electric shock-like
Onset Gradual, consistent Gradual, can be immediate Can be immediate, inconsistent
Relieved by Standing still Elevation of leg Sitting down,bending forward
Location Muscle groups (buttock, thigh, calf) Whole leg Poorly localized,can affect whole leg
Legs affected Usually one Usually one Often both

14
Location, Location, Location!
  • Buttock/hip
  • Usually indicates aortoiliac occlusive disease
    (Leriche's syndrome)
  • Some cases, thigh claudication too
  • Question diagnosis of bilateral disease if
    erectile dysfunction is not present
  • Thigh
  • Occlusion of the common femoral artery leads to
    claudication in the thigh, calf, or both.
  • Calf
  • Symptoms in upper 2/3 is usually due to SFA
  • Lower 1/3 is due to popliteal disease.

15
PVD History
  • Use of the history alone to detect peripheral
    arterial disease will result in missing up to 90
    percent of cases.
  • Asymptomatic patients with abnormal ABI have 50
    increased risk of cardiovascular complications

Hirsch AT, et al. JAMA 2001 286 1317 Hooi JD,
et al. J Clin Epidem 2004 57294
16
Physical Exam
  • Trophic Signs
  • Skin atrophy, thickened nails, hair loss,
    dependent rubor
  • Ulceration, gangrene
  • Pulse exam
  • May miss more than 50
  • Elevation and dependency test

Criqui M, et al. Circulation, 1985 71 516-521
17
Physical Exam Elevation and Dependency Test
Color Return(s) Venous Filling(s)
Normal 10 10-15
Adequate Collaterals 15-25 15-30
Severe Ischemia gt35 gt40
Halperin, Throm Res. 2002 106 V303-311
18
Noninvasive Work-up
19
Ankle Brachial Index
  • Cornerstone of lower extremity vascular
    evaluation
  • Blood pressure cuffs, Doppler
  • Ankle (DP or PT) to brachial artery pressure

Normal 0.96
Claudication 0.50-0.95
Rest Pain 0.21-0.49
Tissue loss 0.20
Significant change 0.15 or more
20
Limitations
  • Noncompressible vessels
  • Diabetes
  • Renal Failure
  • ABI gt1.5
  • Use toe-brachial index
  • Normal gt0.7
  • Rest pain lt0.2
  • Subclavian/Brachiocephalic Occlusive disease

21
Segmental Pressures
  • Pneumatic cuffs at multiple levels
  • Doppler pressure at pedal artery
  • Drop gt30 mm Hg between levels
  • Drop gt20 mm Hg between limbs
  • Reflects status of artery above drop in pressure
  • Inaccurate with calcified vessels

Rose SC. J Vasc Interv Radiol. 2000 111107-1114
22
Noninvasive Functional Assessment
  • Targeted towards evaluating the arterial flow
    dynamics in the affected area, and are invariably
    supplemented with radiological depiction of
    anatomic abnormality
  • Pressure measurements (ABI)
  • Plethysmography
  • Continuous wave Doppler

23
Duplex Doppler
  • Non-invasive method of evaluating the blood
    vessels using sound waves, similar to
    ultrasonography and echocardiography.
  • Can obtain both anatomic and hemodynamic
    information.
  • Anatomical detail
  • vessel wall
  • intraluminal obstructive lesions
  • perivascular compressive structures

24
Doppler Waveform Analysis Hemodynamic Information
  • Sensitivity of 92.6 and specificity of 97
    (angiography gold standard)
  • Inaccurate at adductor canal and the aorto-iliac
    regions.
  • 95 accuracy in the detection of bypass graft
    stenosis, but can overestimate stenosis.

Polack JF. Duplex Doppler in peripheral arterial
disease. Radiol Clin N Amer 1995 33 71-88.
25
Doppler Waveform Analysis Hemodynamic Information
  • Qualitative assessment of waveform analysis
  • Simple Equipment
  • Not affected by medial calcinosis
  • Supplements segmental pressures

26
Pulse Volume Recordings
  • Pneumatic Cuffs at Multiple Levels
  • Inflated to 65 mm Hg
  • Extremity Volume Increases in Systole
  • Changes pressure in cuff
  • Waveform Analysis
  • Not Impacted by Calcification

27
Pulse Volume Recordings
  • Advantanges
  • Widely available
  • Cheap
  • Reproducible
  • Disadvantages
  • Technician dependent
  • Time Consuming
  • Detection of Collaterals is low
  • Presence of gas and calcification degrade images

28
Is this enough?
  • Noninvasive lab documents presence and severity
    of disease
  • No comprehensive anatomic information
  • No ability to plan interventions

29
Radiologic Imaging MRA and CTA
  • DSA (conventional angiography) remains the gold
    standard for evaluation of PVD
  • Newer modalities that match its accuracy are
    rapidly evolving
  • It is a matter of time before imaging replaces
    DSA, with the invasive angiographic techniques
    reserved for interventional procedures

30
MRA vs. DSA
31
MRA Current Technique
  • 3D gradient echo (fast acquisition)
  • Gadolinium Enhanced
  • 20-40 cc
  • Automated Scan delay
  • Renal arteries to toes
  • Stepping table or bolus chase
  • 45-min exam

32
MRI
33
Limitations of MRI
  • Uncooperative patient
  • Claustrophobia
  • Metal artifact
  • Pacemakers/ICDs
  • Lack of visualization of calcium

34
CTA of PVD
  • Multidetector CT scanner necessary (4)
  • Many hospitals now have 64 Slice
  • Iodinated contrast volume similar to conventional
    angiography
  • 80-150 cc
  • Automated Scan Delay
  • Renal arteries to ankles
  • 20-minute exam
  • High powered post processing software crucial

35
CTA of PVD
36
CTA of PVD
  • Large volumes of data are generated via CTA
    studies and displayed in various formats to
    refine the analysis of study results
  • Maximum Intensity Projection -MIP (most common)
  • Shaded surface display
  • 3D Volume rendering

37
CT Limitations
  • With significant and dense calcifications, a
    false diagnosis of patency can result.
  • Uncooperative patient
  • Pregnancy
  • Bad Pump
  • Inconsistent pedal vessel visualization
  • Renal failure/contrast allergy

38
Digital Subtraction Angiography (DSA)
  • Gold standard of arterial imaging
  • Has almost totally replaced conventional cut film
    angiography
  • Compares a pre contrast image with a post
    contrast image using a computer, and "subtracts"
    elements common to both.
  • Prevents images of objects like bones etc from
    obscuring vascular details.
  • Contrast resolution is improved through use of
    image enhancement software.

39
Digital Subtraction Angiography (DSA)
  • Radiation exposure and contrast volumes are lower
    than conventional angiography
  • Images are immediately available for review.
  • Images are stored in digital format on
    computerized data storage media
  • Interventional procedures can be performed

40
Digital Subtraction Angiography (DSA)
  • Drawbacks precluding use as a screening modality
  • Technique is invasive and expensive.
  • Requires arterial puncture
  • Longer study than CT
  • Contrast nephrotoxicity

41
Medical Treatments for PAD
Treatment Effect
Smoking cessation 10-year mortality ? 54 to 18at 7 years, rest pain drops from 16 to 0
Antiplatelet agent 22? in vascular eventspossible increase in walking distance
Diabetes control RR0.94 (0.8 - 1.1) for mortalityRR0.51 (0.01 - 19.64) for amputation
BP to lt140/85 mm Hg RR0.87 (0.81 - 0.94) for mortality effect on PAD not known
ACE inhibitors RR0.73 (0.61 - 0.86) for MI, stroke, or CV death
Exercise program 24 ? in CV mortality150 further walking distance
Cholesterol decrease RR0.81 (0.72 - 0.87) for MI, stroke, or revascularization no clinical benefit in PAD
Cilostazol significant ? in walking distance
Survival Bias Excepting Stroke
42
Suggested Algorithm for Work-up
43
Workup-Take-home
  • Noninvasive Vascular Lab is first line evaluation
    in nonacute patients
  • ABI is easy screening test
  • Beware noncompressible vessels in renal failure
    and diabetes
  • Segmental limb pressures often combined with
    doppler waveform anlaysis
  • Not sufficient to plan intervention

44
Workup-Take-home
  • MRA indicated for intervention planning
  • MRA (gadolinium enhanced) provides excellent
    renal to pedal imaging
  • Surpasses CT in the foot
  • Overestimation of stenoses in small vessels
  • Limited by metal artifact, magnetic field, and
    length of study

45
Workup-Take-home
  • CTA indicated for intervention planning
  • CTA provides excellent renal to ankle imaging
  • Pedal imaging poor
  • Soft tissues and bone also imaged
  • Small vessel calcification is limitation
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