1. The Cramping Leg Management of peripheral vascular disease
Dr Patricia Yih
Department of Surgery, Pamela Youde Nethersole Eastern Hospital
Joint Hospital Surgical Grand Round 04/2009

2. Epidemiology General prevalance 3-10% (ABI < 0.9)
>70 years old: 15-20%
Asymptomatic 75%
Symptomatic:
Intermittent claudication
Critical limb ishcemia

3. Clinical Course
Hirsch AT et al. J Am Coll Cardiol

4. Asymptomatic PVD
Vascular disease progression related to baseline ABI Identical to symptomatic patients
Coexisting vascular disease (atherosclerotic)
Coronary artery disease
CVA
Risk: MI/CVA 5-7%/year, mortality 2%/year
Also related to baseline ABI
Management:
Intensive risk factor modifiation
Antithrombotic therapy
Mehler PS et al. Circulation 2003

5. Intermittent Claudication
Only about 25% deteriorate ever
Disease progression related to:
ABI (<0.50  >2x more likely need intervention/amputation)
Low ankle pressure (40-60mmHg  8.5% limb loss/year)
At 5 years:
Hirsch AT et al. J Am Coll Cardiol 2006; 47:

6. Risk Factor Modification
Stop smoking
Control of BP
Control of DM
Control of hyperlipidemia
Weight reduction

7. Exercise Rehabilitation
Supervised
Program:
Treadmill or track walking to bring on claudication
Followed by rest until pain subsided
Then resume
30-60 minute sessions
3 times/week, for 3 months (TASC II guidelines, Recommendation 14)
Selective exercise of most ischemic muscles
Doubles claudication distance in 80% of patients
Stewart K et al. N Engl J Med 2002

8. Drugs Antiplatelet agents Cilostazol (PletaalTM)
Aspirin
Clopidogrel
Cilostazol (PletaalTM)
Vasodilator, metabolic and antiplatelet activity
Increased walking distance 50-70m
Best evidence
Naftidrofuryl (PraxileneTM)
Improve muscle metabolism, reduce RBC/platelet aggregation
Increased walking distance by 26%
Pentoxifylline
Similar to placebo
Regensteiner J et al. J Am Geriatr Soc 2002
Lehert P et al. J Cardiovasc Pharmacol 1994

9. Indications for Intervention
Severe, lifestyle-limiting claudication
Failed drug therapy and exercise
Prerequisite:
Inflow satisfactory
Distal runoff patent

10. “Stupid Femoral Artery” High failure rate after intervention
SFA Disease
“Stupid Femoral Artery”
High failure rate after intervention

11. Factors affecting result of intervention
Multiple lesions
Long segment stenosis
Complete occlusion
Below knee

12. Choice of intervention
Surgical bypass
Vein graft
Prosthetic graft
Endovascular
Angioplasty
Primary stenting
Arthrectomy

13. Outcome Measures Usually considered together with critical ischemia
Patency rate
ABI
Limb salvage
Mortality

14. Surgical Bypass vs Angioplasty
If high risk for surgery
Bypass
TASC classification

15. Surgical Bypass – Conduit
Autogenous vs prosthetic materials:
De Vries S et al, J Vasc Surg 1997
In-situ vs reversed vein graft:
No difference
Mamode N et al, Cochrane Database Syst Rev. 2000

16. Angioplasty vs Stenting
Meta-analysis: no difference
1-Year Patency Rate
Postoperative ABI
Mwipatayi et al, Journal of Vascular Surgery, Feb 2008

17. Conclusion
Clinical course/deterioration, systemic disease related to baseline ABI
When to intervene?
Lifestyle limiting claudication, failure of conservative management
Radiological confirmation of adequate inflow and runoff required
Bypass or angioplasty?
Depends on disease location, extent
Angioplasty: to stent or not?
No difference
Depends on expertise available, patient condition

18. Thank you!