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Harvard Medical School Duane S. Pinto, M.D. Director Peripheral Angiographic Core Laboratory, TIMI Data Coordinating Center Director, Cardiology Fellowship.

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Presentation on theme: "Harvard Medical School Duane S. Pinto, M.D. Director Peripheral Angiographic Core Laboratory, TIMI Data Coordinating Center Director, Cardiology Fellowship."— Presentation transcript:

1 Harvard Medical School 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 Harvard Medical School PAD is a common disorder Occurs in approximately 1/3 of patients Occurs in approximately 1/3 of patients Over age 70 Over age 70 Over age 50 who smoke or have DM Over age 50 who smoke or have DM Strong association with CAD Strong association with CAD Obvious associated risk of stroke, MI, cardiovascular death Obvious associated risk of stroke, MI, cardiovascular death Progressive disease in 25% with progressive intermittent claudication/limb threatening ischemia Progressive disease in 25% with progressive intermittent claudication/limb threatening ischemia Outcomes Outcomes Impaired QoL Impaired QoL Limb Loss Limb Loss Premature Mortality Premature Mortality

3 Harvard Medical School Risk Factors for PVD: Framingham Heart Study Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia Fibrinogen C- Reactive Protein Alcohol Relative Risk Mean follow-up 38 years

4 Harvard Medical School PAD is Associated with Poor Outcomes Annual Incidence Prevalence Mortality/yr (%) Stroke TIA ACS PAD % Criqui M, et al. Circulation 1985; 71:510

5 Harvard Medical School Outcomes in PVD Patients

6 Harvard Medical School Diagnostic Modalities History History Physical Physical Ankle Brachial Index (ABI) Ankle Brachial Index (ABI) Noninvasive vascular laboratory Noninvasive vascular laboratory Angiography: MRA, CT, DSA Angiography: MRA, CT, DSA

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

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

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

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

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

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

13 Harvard Medical School 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 Often both

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

15 Harvard Medical School PVD History Use of the history alone to detect peripheral arterial disease will result in missing up to 90 percent of cases. 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 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; 57:294

16 Harvard Medical School Physical Exam Trophic Signs Trophic Signs Skin atrophy, thickened nails, hair loss, dependent rubor Skin atrophy, thickened nails, hair loss, dependent rubor Ulceration, gangrene Ulceration, gangrene Pulse exam Pulse exam May miss more than 50% May miss more than 50% Elevation and dependency test Elevation and dependency test Criqui M, et al. Circulation, 1985: 71;

17 Harvard Medical School Physical Exam: Elevation and Dependency Test Halperin, Throm Res. 2002; 106: V Color Return(s) Venous Filling(s) Normal Adequate Collaterals Severe Ischemia >35 >35>40

18 Harvard Medical School Noninvasive Work-up

19 Harvard Medical School Ankle Brachial Index Cornerstone of lower extremity vascular evaluation Cornerstone of lower extremity vascular evaluation Blood pressure cuffs, Doppler Blood pressure cuffs, Doppler Ankle (DP or PT) to brachial artery pressure Ankle (DP or PT) to brachial artery pressure Normal0.96 Claudication Rest Pain Tissue loss 0.20 Significant change 0.15 or more

20 Harvard Medical School LimitationsLimitations Noncompressible vessels Noncompressible vessels Diabetes Diabetes Renal Failure Renal Failure ABI >1.5 ABI >1.5 Use toe-brachial index Use toe-brachial index Normal >0.7 Normal >0.7 Rest pain <0.2 Rest pain <0.2 Subclavian/Brachiocephalic Occlusive disease Subclavian/Brachiocephalic Occlusive disease

21 Harvard Medical School Segmental Pressures Pneumatic cuffs at multiple levels Pneumatic cuffs at multiple levels Doppler pressure at pedal artery Doppler pressure at pedal artery Drop >30 mm Hg between levels Drop >30 mm Hg between levels Drop >20 mm Hg between limbs Drop >20 mm Hg between limbs Reflects status of artery above drop in pressure Reflects status of artery above drop in pressure Inaccurate with calcified vessels Inaccurate with calcified vessels Rose SC. J Vasc Interv Radiol. 2000; 11:

22 Harvard Medical School Noninvasive Functional Assessment Targeted towards evaluating the arterial flow dynamics in the affected area, and are invariably supplemented with radiological depiction of anatomic abnormality Targeted towards evaluating the arterial flow dynamics in the affected area, and are invariably supplemented with radiological depiction of anatomic abnormality Pressure measurements (ABI) Pressure measurements (ABI) Plethysmography Plethysmography Continuous wave Doppler Continuous wave Doppler

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

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

25 Harvard Medical School Doppler Waveform Analysis: Hemodynamic Information Qualitative assessment of waveform analysis Qualitative assessment of waveform analysis Simple Equipment Simple Equipment Not affected by medial calcinosis Not affected by medial calcinosis Supplements segmental pressures Supplements segmental pressures

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

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

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

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

30 Harvard Medical School MRA vs. DSA

31 Harvard Medical School MRA: Current Technique 3D gradient echo (fast acquisition) 3D gradient echo (fast acquisition) Gadolinium Enhanced Gadolinium Enhanced cc cc Automated Scan delay Automated Scan delay Renal arteries to toes Renal arteries to toes Stepping table or bolus chase Stepping table or bolus chase 45-min exam 45-min exam

32 Harvard Medical School MRIMRI

33 Harvard Medical School Limitations of MRI Uncooperative patient Uncooperative patient Claustrophobia Claustrophobia Metal artifact Metal artifact Pacemakers/ICDs Pacemakers/ICDs Lack of visualization of calcium Lack of visualization of calcium

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

35 Harvard Medical School CTA of PVD

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

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

38 Harvard Medical School Digital Subtraction Angiography (DSA) Gold standard of arterial imaging Gold standard of arterial imaging Has almost totally replaced conventional cut film angiography 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. 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. Prevents images of objects like bones etc from obscuring vascular details. Contrast resolution is improved through use of image enhancement software. Contrast resolution is improved through use of image enhancement software.

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

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

41 Harvard Medical School Medical Treatments for PAD TreatmentEffect Smoking cessation 10-year mortality 54% to 18%; at 7 years, rest pain drops from 16% to 0%* Antiplatelet agent 22% in vascular events; possible increase in walking distance Diabetes control RR=0.94 ( ) for mortality; RR=0.51 ( ) for amputation BP to <140/85 mm Hg RR=0.87 ( ) for mortality; effect on PAD not known ACE inhibitors RR=0.73 ( ) for MI, stroke, or CV death Exercise program 24% in CV mortality; 150% further walking distance Cholesterol decrease RR=0.81 ( ) for MI, stroke, or revascularization; no clinical benefit in PAD RR=0.81 ( ) for MI, stroke, or revascularization; no clinical benefit in PAD Cilostazol significant in walking distance *Survival Bias Excepting Stroke

42 Harvard Medical School Suggested Algorithm for Work-up

43 Harvard Medical School Workup-Take-homeWorkup-Take-home Noninvasive Vascular Lab is first line evaluation in nonacute patients Noninvasive Vascular Lab is first line evaluation in nonacute patients ABI is easy screening test ABI is easy screening test Beware noncompressible vessels in renal failure and diabetes Beware noncompressible vessels in renal failure and diabetes Segmental limb pressures often combined with doppler waveform anlaysis Segmental limb pressures often combined with doppler waveform anlaysis Not sufficient to plan intervention Not sufficient to plan intervention

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

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


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