1. 1 Peripheral Arterial Occlusive Disease (PAOD) What is it and why should you be interested? John A. Colleran, D.O. Interventional Cardiologist CHI St. Vincent Heart Clinic Arkansas April 25, 2015

2. 2 Peripheral Arterial Occlusive Disease “Atherosclerosis of the peripheral arteries, or ‘arteriosclerosis obliterans,’ PAD, is the most common cause of symptomatic obstruction in the peripheral arterial tree.” 1 The prevalence of PAD increases with age: –3% 2 (40-59 years) –8% 2 (60-69 years) –19% 2 (over 70 years) 1. Rosenfield, K and Isner JM. Chap. 97 Textbook of Cardiovascular Medicine 1998 2. Criqui et al. Circulation 1985;71(3):510-515

3. 3 Peripheral Arterial Circulation

4. 4 Peripheral Vascular Disease Atherosclerotic Changes

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6. 6 PAOD Risk Factors Diabetes Smoking History of CAD Elevated cholesterol or decreased HDL Hypertension Sedentary lifestyle Obesity Increased plasma homocysteine Male gender Age Krajewski LP, Olin JW. Chap. 11 Peripheral Vascular Diseases 2nd ed. 1996

7. 7 Peripheral Vascular Disease Prevalence Asymptomatic 5 million Asymptomatic 5 million Symptomatic untreated 3.75 million Symptomatic untreated 3.75 million Symptomatic treated 1.25 million Symptomatic treated 1.25 million Pentecost, et al. “Guidelines for Peripheral Percutaneous Transluminal Angioplasty of the Abdominal Aorta and Lower Extremity Vessels”; 1993 Total ~ 10 million U.S. patients

8. 8 Prevalence of PAD in a defined population Criqui et al. Circulation 1985;71(3):510-5

9. 9 Coexistence of Diseased Vascular Beds * PAD: Peripheral arterial disease CHD: Coronary heart disease CBVD: Cerebrovascular disease 1. Damaraju et al. Texas Heart Institute Journal 1997;24:285-290 2. Tuttle et al. Am J Kidney Diseases. 1998;32:611-622 3. Erdoes et al. Am J Kidney Diseases 1996;27:496-503 4. Iyer et al. Abstract presented at Adv. Endovascular Therapies-1999 5. Mathur et al. Circulation 1998;97:1239-1245 6. Dietrich et al. J Endovascular Surgery 1996;3:42-62 PAD patients with CHDCBVD patients with CHD *Charts from The 1999 Advisory Board Company Damaraju 1 Tuttle 2 Erdoes 3 Iyer 4 Mathur 5 Diethrich 6

10. 10 Ness J et al. J Am Geriatr Soc. 1999;47:1255 Overlap of Atherothrombotic Disease

11. 11 PAOD: Detection

12. 12 PAOD How do you detect it? Screen appropriate patient population Patient History Physical examination Non-invasive tests Invasive tests

13. 13 PAOD Who should be screened? Patients with symptoms of PAOD Patients with history of coronary disease Older patients Patients with PAOD risk factors

14. 14 Patient History Questions to ask patients with possible lower extremity disease: –What is your typical activity level? –Do you experience any discomfort in the calf, thigh, buttock or hip area that occurs with walking, climbing stairs? –Describe the symptom, onset, duration and resolution? –Do you experience rest pain, leg pain when in bed? –Have you had any sores or skin ulcerations that won’t heal? –Any changes in the color, temperature or appearance of your skin? –Any problems with impotence or pain in your genitals?

15. 15 Intermittent Claudication Definition: –Exercise-induced lower extremity pain that is caused by ischemia and relieved by rest 1 Prevalence: –Approximately 3.4 million people in the US experience intermittent claudication 2 Primary symptom of lower-extremity occlusive disease 2 1. Santilli J et al. American Family Physician 1999;53(4):1245-53 2. Creager M, Hiatt W. Mgmt of Peripheral Artery Disease ACC 1999

16. 16 Differentiating True Claudication from Pseudoclaudication 1 Intermittent ClaudicationPseudoclaudication Character of discomfort Cramping, tightness, tiredness Same or tingling, weakness, clumsiness Location of discomfort Buttock, hip, thigh, calf, foot Same Exercise inducedYesYes or No Distance to claudication Same each timeVariable Occurs with standing NoYes ReliefStop walkingOften must sit or change body positions 1. Krajewski LP, Olin JW. Chap. 11 Peripheral Vascular Disease 2nd Ed. 1996

17. 17 Rest Pain Characteristics: Usually occurs at night when the person lies supine Dull aching sensation in the toes or forefoot Pain is relieved when legs are lowered to floor Indicative of severe arterial insufficiency and usually involves multiple arterial segments * Krajewski LP, Olin JW. Chap. 11 Peripheral Vascular Disease 2nd Ed. 1996

18. 18 PAOD Diagnostic Tests Non-invasive tests 1 –ABI (Ankle/Brachial Index) –Exercise Test –Segmental Pressures –Segmental Volume Plethysmography –Duplex Ultrasonography –MRA (Magnetic Resonance Arteriography) Invasive tests 1 –Peripheral Angiogram 1. Krajewski and Olin Chapter 11 Peripheral Vascular Disease. 2nd ed. 1996

19. 19 PAOD Diagnostic Test ABI (Ankle-Brachial Index) Courtesy of: Fred St. Goar MD, CVI Medical Group Inc., Mountain View, CA

20. 20 PAOD Diagnostic Test Segmental Pressure Test Courtesy of: Fred St. Goar MD, CVI Medical Group Inc., Mountain View, CA

21. 21 PAOD Diagnostic Test Duplex Scanning Courtesy of: Fred St. Goar MD, CVI Medical Group Inc., Mountain View, CA

22. 22 What are the current treatment options for PAOD ?

23. 23 PAOD Medical Treatment Risk Factor Modification * Exercise Therapy * Drug Therapy * –Trental (pentoxifylline) * –Pletal ® (cilostazol) § –Vasodilator agents * –Antiplatelet agents * –ASA and lipid lowering agents * §Relatively recent market release * Rosenfield K, Isner JM, Chap. 97 Textbook of Cardiovascular Medicine 1998

24. 24 PAOD Endovascular Therapy Peripheral Transluminal Angioplasty Peripheral Stenting Atherectomy Thrombolytic Therapy –Streptokinase –rt-PA *Rosenfield K, Isner JM, Chap. 97 Textbook of Cardiovascular Medicine 1998

25. 25 Why does endovascular therapy make sense? Technological advances Cost-saving approach Viable alternative to surgery w/ reduced morbidity Change in threshold of intervention Rosenfield K, Isner JM. Chap. 97 Textbook of Cardiovascular Medicine, 1998

26. 26 Advantages of endovascular therapy in PAOD Treatments Potential advantages of peripheral angioplasty over surgery in peripheral vascular disease 1 : –No general anesthesia or lengthy incisions –Shorter hospitalization –Lower morbidity and mortality –Earlier intervention in the course of the disease –Less complicated reapplication w/ recurrence 1. Dietrich EB. Surg Today 1994;24(11):949-56

27. 27 Peripheral Vascular Disease Treatment - Minimally Invasive Techniques Guidewire placement

28. 28 Peripheral Vascular Disease Treatment - Minimally Invasive Techniques Guidewire advanced past lesion

29. 29 Peripheral Vascular Disease Treatment - Minimally Invasive Techniques Balloon dilatation Percutaneous Transluminal Angioplasty Balloon dilatation Percutaneous Transluminal Angioplasty

30. 30 PAOD Aorto-Iliac and Femoro- Popliteal Arterial Diseases

31. 31 Lower Extremity Disease

32. 32 Aorto-Iliac Disease Clinical Symptoms Isolated aorto-iliac occlusion : –Diminished femoral pulses –Claudication in buttocks and thighs –Impotence in men Multisegment disease involving the aorto-iliac, femoro-popliteal as well as tibial occlusive disease: –Short-distance claudication –Pain at rest –Ischemic necrosis of the feet * Krajewski LP, Olin JW. Chap. 11 Peripheral Vascular Disease 2nd Ed. 1996

33. 33 Femoro-popliteal Disease Clinical Symptoms 1 Intermittent Claudication Pain at rest * Ischemic ulceration * Gangrene * Ischemic neuropathy * Muscle mass atrophy in lower extremity and foot * *Obstructive process involves multiple levels 1 Krajewski LP, Olin JW. Chap. 11 Peripheral Vascular Disease 2nd Ed. 1996

34. 34 Aorto-Iliac Stent Results Pre-procedurePost-procedure Courtesy of Don Schwarten, MD

35. 35 Femoro-Popliteal PTA Results Pre-procedurePost-procedure Courtesy of Don Schwarten, MD

36. 36 Peripheral Vascular Disease

37. 37 Peripheral Vascular Disease

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40. Conclusions Identify the patient with PAD Aggressive Risk Factor modification. Antiplatelet therapy Exercise program Vascular Intervention Surgery 40