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The Cramping Leg Management of peripheral vascular disease Dr Patricia Yih Department of Surgery, Pamela Youde Nethersole Eastern Hospital Joint Hospital.

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Presentation on theme: "The Cramping Leg Management of peripheral vascular disease Dr Patricia Yih Department of Surgery, Pamela Youde Nethersole Eastern Hospital Joint Hospital."— Presentation transcript:

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 ( 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  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  Aspirin  Clopidogrel  Cilostazol (Pletaal TM )  Vasodilator, metabolic and antiplatelet activity  Increased walking distance 50-70m  Best evidence  Naftidrofuryl (Praxilene TM )  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 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 TASC classification Angioplasty Bypass If high risk for surgery

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 RatePostoperative 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!Thank you!


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