Presentation on theme: "Intermittent Claudication"— Presentation transcript:
1Intermittent Claudication Duane S. Pinto, M.D.Director Peripheral Angiographic Core Laboratory,TIMI Data Coordinating CenterDirector, Cardiology Fellowship Training ProgramInterventional Cardiologist Beth Israel Deaconess Medical CenterAssistant Professor of Medicine, Harvard Medical SchoolIntermittent ClaudicationDiagnosis and Work-up
2PAD is a common disorder Occurs in approximately 1/3 of patientsOver age 70Over age 50 who smoke or have DMStrong association with CADObvious associated risk of stroke, MI, cardiovascular deathProgressive disease in 25% with progressive intermittent claudication/limb threatening ischemiaOutcomesImpaired QoLLimb LossPremature MortalityTemporal Arteritis is very rare before 45 years. Buerger’s unheard of under 55. Raynaud’s patients or varicose will usually remember symptoms starting before 30.
3Risk Factors for PVD: Framingham Heart Study Reduced IncreasedSmokingDiabetesHypertensionHypercholesterolemiaHyperhomocysteinemiaFibrinogenC- Reactive ProteinAlcoholRelative RiskData from the Framingham Heart Study of 381 men and women who were followed for 38 years revealed that the odds ratio for developing intermittent claudication was 2.6 for diabetes mellitus, 1.2 for each 40 mg/dL (1 mmol/L) elevation in the serum cholesterol concentration,1.4 for each 10 cigarettes smoked per day, and 1.5 for mild and 2.2 for moderate hypertension . In addition, diabetic patients have worse arterial disease and a poorer outcome than nondiabetics .Mean follow-up 38 years
4PAD is Associated with Poor Outcomes Annual IncidencePrevalenceMortality/yr (%)Stroke0.734.628TIA0.504.96.3ACS2.312.645PAD8-124-25%Criqui M, et al. Circulation 1985; 71:510
7Identifying risk factors and symptoms Pulse palpability Initial AssessmentIdentifying risk factors and symptomsPulse palpabilityFurther assessment relies on functional non-invasive testing and radiological imagingDetermine not only the anatomic, but also the physiological aberration of peripheral vascular flow.
8Intermittent 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 ≠ DemandLocation depends upon the location of the disease.Buttock, thigh, calf or foot claudication, either singly or in combination.
9PVD Etiology Large arteries Atherosclerosis Thromboembolism Trauma Arteritis of various types includingBuerger’s diseaseFibromuscular dysplasiaTakayasu’s
10Medium and small vessel occlusions PVD EtiologyMedium and small vessel occlusionsDiabetesChronic recurrent traumaMultiple small emboliCollagen vascular diseasesDysproteinemiasPolycythaemia veraPseudoxanthoma elasticumDrug ReactionVasospasm
11Specific to certain anatomical sites PVD EtiologySpecific to certain anatomical sitesCystic adventitial disease of the popliteal arteryPopliteal artery entrapmentIliac endofibrosis (cyclists)Various neurovascular compression syndromes affecting the upper limbCervical ribCostoclavicular syndromeScalenus tunnel syndromeHyperabduction syndromeQuadrangular space syndrome
12PVD Differential Diagnosis Deep venous thrombosisMusculoskeletal disordersOARestless leg syndromePeripheral neuropathySpinal 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).Pain can be excruciating and is usually located in the dorsal aspect of the toes. The foot may become pale with exercise.
13Differential Diagnosis of Intermittent Claudication Venous ClaudicationNeurogenic ClaudicationQuality of painCramping"Bursting"Electric shock-likeOnsetGradual, consistentGradual, can be immediateCan be immediate, inconsistentRelieved byStanding stillElevation of legSitting down, bending forwardLocationMuscle groups (buttock, thigh, calf)Whole legPoorly localized, can affect whole legLegs affectedUsually oneOften both
14Location, Location, Location! Buttock/hipUsually indicates aortoiliac occlusive disease (Leriche's syndrome)Some cases, thigh claudication tooQuestion diagnosis of bilateral disease if erectile dysfunction is not presentThighOcclusion of the common femoral artery leads to claudication in the thigh, calf, or both.CalfSymptoms in upper 2/3 is usually due to SFALower 1/3 is due to popliteal disease.
15PVD HistoryUse 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 complicationsHirsch AT, et al. JAMA 2001; 286: 1317Hooi JD, et al. J Clin Epidem 2004; 57:294
16Elevation and dependency test Physical ExamTrophic SignsSkin atrophy, thickened nails, hair loss, dependent ruborUlceration, gangrenePulse examMay miss more than 50%Elevation and dependency testCriqui M, et al. Circulation, 1985: 71;
17Physical Exam: Elevation and Dependency Test Color Return(s)Venous Filling(s)Normal1010-15Adequate Collaterals15-2515-30Severe Ischemia>35>40Halperin, Throm Res ; 106: V
19Ankle Brachial IndexCornerstone of lower extremity vascular evaluationBlood pressure cuffs, DopplerAnkle (DP or PT) to brachial artery pressureNormal0.96ClaudicationRest PainTissue loss0.20Significant change0.15 or more
21Segmental Pressures Pneumatic cuffs at multiple levels Doppler pressure at pedal arteryDrop >30 mm Hg between levelsDrop >20 mm Hg between limbsReflects status of artery above drop in pressureInaccurate with calcified vesselsRose SC. J Vasc Interv Radiol. 2000; 11:
22Noninvasive Functional Assessment Targeted towards evaluating the arterial flow dynamics in the affected area, and are invariably supplemented with radiological depiction of anatomic abnormalityPressure measurements (ABI)PlethysmographyContinuous wave Doppler
23Duplex DopplerNon-invasive method of evaluating the blood vessels using sound waves, similar to ultrasonography and echocardiography.Can obtain both anatomic and hemodynamic information.Anatomical detailvessel wallintraluminal obstructive lesionsperivascular compressive structures
24Doppler 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 :
25Doppler Waveform Analysis: Hemodynamic Information Qualitative assessment of waveform analysisSimple EquipmentNot affected by medial calcinosisSupplements segmental pressures
26Pulse Volume Recordings Pneumatic Cuffs at Multiple LevelsInflated to 65 mm HgExtremity Volume Increases in SystoleChanges pressure in cuffWaveform AnalysisNot Impacted by Calcification
27Pulse Volume Recordings AdvantangesWidely availableCheapReproducibleDisadvantagesTechnician dependentTime ConsumingDetection of Collaterals is lowPresence of gas and calcification degrade images
28Is this enough?Noninvasive lab documents presence and severity of diseaseNo comprehensive anatomic informationNo ability to plan interventions
29Radiologic Imaging: MRA and CTA DSA (conventional angiography) remains the gold standard for evaluation of PVDNewer modalities that match its accuracy are rapidly evolvingIt is a matter of time before imaging replaces DSA, with the invasive angiographic techniques reserved for interventional procedures
33Limitations of MRIUncooperative patientClaustrophobiaMetal artifactPacemakers/ICDsLack of visualization of calcium
34CTA of PVD Multidetector CT scanner necessary (4+) Many hospitals now have 64 SliceIodinated contrast volume similar to conventional angiographyccAutomated Scan DelayRenal arteries to ankles20-minute examHigh powered post processing software crucial
36CTA of PVDLarge volumes of data are generated via CTA studies and displayed in various formats to refine the analysis of study resultsMaximum Intensity Projection -MIP (most common)Shaded surface display3D Volume renderingA 3D model of the study in any projection and from any angle in order to evaluate the patient for the presence of a stenosis or aneurysm.
37CT LimitationsWith significant and dense calcifications, a false diagnosis of patency can result.Uncooperative patientPregnancyBad PumpInconsistent pedal vessel visualizationRenal failure/contrast allergy
38Digital Subtraction Angiography (DSA) Gold standard of arterial imagingHas almost totally replaced conventional cut film angiographyCompares 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.
39Digital Subtraction Angiography (DSA) Radiation exposure and contrast volumes are lower than conventional angiographyImages are immediately available for review.Images are stored in digital format on computerized data storage mediaInterventional procedures can be performed
40Digital Subtraction Angiography (DSA) Drawbacks precluding use as a screening modalityTechnique is invasive and expensive.Requires arterial punctureLonger study than CTContrast nephrotoxicity
41Medical Treatments for PAD EffectSmoking cessation10-year mortality ↓ 54% to 18%; at 7 years, rest pain drops from 16% to 0%*Antiplatelet agent22%↓ in vascular events; possible increase in walking distanceDiabetes controlRR=0.94 ( ) for mortality; RR=0.51 ( ) for amputationBP to <140/85 mm HgRR=0.87 ( ) for mortality; effect on PAD not knownACE inhibitorsRR=0.73 ( ) for MI, stroke, or CV deathExercise program24% ↓ in CV mortality; 150% further walking distanceCholesterol decreaseRR=0.81 ( ) for MI, stroke, or revascularization; no clinical benefit in PAD†Cilostazolsignificant ↑ in walking distance*Survival Bias†Excepting Stroke
43Noninvasive Vascular Lab is first line evaluation in nonacute patients Workup-Take-homeNoninvasive Vascular Lab is first line evaluation in nonacute patientsABI is easy screening testBeware noncompressible vessels in renal failure and diabetesSegmental limb pressures often combined with doppler waveform anlaysisNot sufficient to plan intervention
44Workup-Take-homeMRA indicated for intervention planningMRA (gadolinium enhanced) provides excellent renal to pedal imagingSurpasses CT in the footOverestimation of stenoses in small vesselsLimited by metal artifact, magnetic field, and length of study
45CTA indicated for intervention planning Workup-Take-homeCTA indicated for intervention planningCTA provides excellent renal to ankle imagingPedal imaging poorSoft tissues and bone also imagedSmall vessel calcification is limitation