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Carol Bohanon DNP, FNP-BC,

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1 Carol Bohanon DNP, FNP-BC,
The Voyage to Peripheral Arterial Disease Management…Are We Missing the Boat? Carol Bohanon DNP, FNP-BC, CWS, CFCN September, 2014

2 Disclosure Relevant Financial Relationships NONE Off-Label Investigational Uses

3 Objectives Identify signs & symptoms of lower extremity peripheral arterial disease (PAD) Significance of early recognition and treatment options for PAD Discuss tests and interventions specific to arterial disease Describe pharmacologic therapies for treatment of arterial disease Review arterial wound care

4 Resources Guideline Statements for PAD:
Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations). J Am Coll Cardiol. 2013;60: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45 Suppl S:5A–67A. Performance measures for adults with peripheral artery disease. J Am Coll Cardiol. 2010;56:

5 Arterial Disease of the Lower Extremity

6 Arterial Occlusive Disease
Plaque in arterial blood vessel wall narrows over time

7 Arterial Occlusive Disease
Asymptomatic: Claudication: reproducible pain or tightness in calf or thigh after walking a certain predictable distance Rest Pain: pain that occurs with advanced atherosclerosis when limbs are in a supine position Tissue Damage: not enough oxygen to support tissue growth, ulcer occurs

8 Clinical Presentation of PAD
Adapted from Hirsch AT. Fam Pract Recertification. 2000;15(suppl):6-12.

9 Survival for PAD patients
Overall Mortality Rate: Claudicant patient 2.5 x ↑ Survival for PAD patients IC: intermittent claudication CLI: critical limb ischemia J Vasc Surg 2007;45,Suppl S

10 Risk Factors Race: Non-Hispanic blacks (2 fold) Gender: Male 2:1
Age: > 65 (2 fold) Smoking (3 fold) Diabetes mellitus (4 fold) Hypertension J Vasc Surg 2007; 45, Suppl S

11 Risk Factors Dyslipidemia (2 fold) Inflammatory markers
Hyperviscosity & hypercoagulable state Hyperhomocysteinemia Chronic renal insufficiency

12 Good History & Examination
Must specifically ask about leg pain, claudication, and rest pain symptoms Many patients/family think it is a normal part of aging.

13 Arterial Disease Presentation
Atrophic, shiny skin Lack of pedal hair Yellow, thickened nails Decreased pulses Ulcers Edema of extremity – dependency Use compression cautiously with PAD

14 Intermittent Claudication
“Exertional pain involving the calf that impedes walking, resolves within 10 minutes of rest, and neither begins at rest nor resolves on walking” “Rose Criteria” Bull World Health Organ 1962;27:645-58

15 Intermittent Claudication
Exertional pain: “Fatigue” “Cramping” “Tightness” Calf > Thigh > Buttock Relief with standing Symptoms consistent from day to day

16 Differentiating True from Pseudoclaudication
Intermittent Claudication Variable Pseudoclaudication Character Cramp, tight, fatigue Tingling, weak, clumsy Exertional yes yes or no Symptoms with standing no yes Relief Stop, stand Must sit Distance to symptoms Consistent Inconsistent

17 Arterial Pulse Exam 0 = absent pulse 1 = faint, but detectable 2 = reduced – can count pulse 3 = normal pulse 4 = bounding

18 Lower Extremity Arterial Pulse Exam
A: Femoral B: Popliteal (medial) C: Dorsalis pedis D: Post-tibial Indicate presence of bruit Symmetrical Asymmetrical

19 Ankle Brachial Index (ABI)

20 Categorize Severity Using ABI Criteria (Ankle Brachial Index)
Resting ABI ’s Normal Borderline Mild Moderate Severe <0.50 Values > 1.4 “non-compressible” JACC 2013;61:14

21 Ankle Brachial Index (ABI)
Lower extremity systolic pressure ABI= Highest brachial artery systolic pressure Right Arm Pressure 136 mm Hg Left Arm Pressure 140 mm Hg Highest Right Pedal Pressure 154 mm Hg Highest Left Pedal Pressure 54 mm Hg Using the Ankle-Brachial Index The ankle-brachial index (ABI) is an indication of impaired arterial function in the lower extremities, and thus is diagnostic of PAD. The schematic diagram presents a guide to the determination of the ABI. This number is the systolic blood pressure at the ankle divided by the brachial systolic blood pressure. Determination of the ABI is a simple office procedure, using a standard blood pressure cuff and a handheld Doppler ultrasound device in the 5 to 7 MHz range. Two ABIs are obtained, one for each side of the body. The leg pressure is taken both at the posterior tibial and dorsalis pedis arteries. The value used for the calculation is the higher of the two. The brachial pressure used is whichever brachial pressure reading is the higher of the two, even if it is not on the same side of the body as the ankle pressure. Thus, in the example, the right ABI is the result of dividing the left brachial pressure, 160 mm Hg, by the ankle pressure at the right dorsalis pedis, 80 mm Hg, for an ABI of The left ABI is the result of dividing the same left brachial pressure by the ankle pressure at the left posterior tibial artery, 120 mm Hg, for an ABI of 0.75. (notes continue ) Right ABI 154/140= 1.1 Left ABI 54/140 = 0.4

22 Scenarios where ABI lack accuracy:
Non compressible vessels Elderly Diabetes Renal failure Iliac artery disease (isolated internal iliac) If claudication symptoms and normal ABI, exercise ABI should be done. Circulation 2006;113;e463

23 Arterial Vascular Study Doppler Waveform
Normal Doppler Arterial Signal Triphasic Biphasic Abnormal Doppler Arterial Signal Reduced Bi. Monophasic Absent

24 Transcutaneous Oximetry (TcP02)
Supine (15 minutes) Elevation (3 minutes) Dependent (10 minutes) Healing range >40 Grey zone to 40 Unlikely to heal <20

25

26 Survival is directly related with ABI severity
J Vasc Surg 2007;45 Suppl S:5A

27 Coexisting Vascular Disease
Coronary artery disease (44.6 %) 25% symptomatic Cerebral artery disease (16.6 %) Renal artery disease (23-42%) > 50 % stenosis J Vasc Surg 2007;45,Suppl S

28 60 year-old man is evaluated for a 1 year history of progressive right leg pain. Vascular examination reveals diminished pedal pulses. Which of the following features will be most useful to distinguish between intermittent claudication and pseudoclaudication? History of nicotine addiction Symptoms brought on by exertion Soft bruit over the right common femoral artery. ABI of 0.8 on the right and 0.85 on the left. Symptom relief with sitting only

29 60 year-old man is evaluated for a 1 year history of progressive right leg pain. Vascular examination reveals diminished pedal pulses. Which of the following features will be most useful to distinguish between intermittent claudication and pseudoclaudication? History of nicotine addiction Symptoms brought on by exertion Soft bruit over the right common femoral artery. ABI of 0.8 on the right and 0.85 on the left. Symptom relief with sitting only

30 Arterial Disease Initial Treatment
Risk Factor Modification: Reduce high cholesterol Tobacco cessation Tight glucose control Reduce hypertension Avoid sedentary lifestyle

31 Claudication Treatment TASC II Guidelines:
Cilostazol (Pletal) 100 mg PO daily First-line pharmacotherapy (3 – 6 months) for the relief of claudication symptoms (Inter-Society Consensus for the Management of. Peripheral Arterial Disease (TASC II) Drug class: Antiplatelet agent Contraindicated in patients with heart failure TASC II J Vasc Surg 2007;45 Suppl S:5A J Am Coll Cardiol 2011;58 (19)

32 Claudication Treatment TASC II Guidelines:
Pentoxifylline (Trental) 400 mg ORALLY three times a day with meals Considered second-line alternative Class: Hemorheologic Reduces blood viscosity and improves erythrocyte flexibility, microcirculatory flow, and tissue oxygen concentrations TASC II J Vasc Surg 2007;45 Suppl S:5A J Am Coll Cardiol 2011;58 (19)

33 Morbidity Reduction GOAL: reduce risk of MI, stroke, & vascular death in individuals with symptomatic (IC, CLI, IR or surgical revasc, amputation related to ischemia) & NONSYMPTOMATIC lower extremity PAD with ABI ≤ 0.90 Aspirin 325 mg daily and/or Clopidogrel 75 mg daily Assess bleeding risk NO benefit of anticoagulation therapy (warfarin) TASC II / JACC 2011;58(19)

34 Non-diabetic 76 year-old male with remote tobacco use presents with claudication at 3 block, reduced biphasic Doppler signals, and ABI of .89. No hx of CHF or ulcers. Initial treatment should include: Encourage activity Cilostazol 100 mg BID Monitor & treat risk factors for PAD Appropriate antiplatelet therapy All of the above

35 Non-diabetic 76 year-old male with remote tobacco use presents with claudication at 3 block, reduced biphasic Doppler signals, and ABI of .89. No hx of CHF or ulcers. Initial treatment should include: Encourage activity Cilostazol 100 mg BID Monitor & treat risk factors for PAD Appropriate antiplatelet therapy All of the above

36 CLEVER Study Supervised Exercise vs Stenting for Intermittent Claudication
Patients: Intermittent claudication due to aorto-iliac PAD Supervised exercise 111 patients Primary Stenting Optimal medical management (cilostazol) Primary efficacy outcome 6 months Circulation. 2012;125:130-9.

37 Conventional Angiography
Advantages Most sensitive (calcified vessels) Angioplasty/stenting Disadvantages Invasive Iodinated contrast Bad outcome :1000

38 CLEVER STUDY SUPERVISED EXERCISE VS STENTING FOR INTERMITTENT CLAUDICATION
Patients: Intermittent claudication due to aorto-iliac PAD Change in peak walking 6 months P-value Supervised exercise: ± 4.6 minutes 0.04 Stenting: ± 4.9 minutes 0.001 0.02 Opt med therapy (cilostazol): ± 2.6 minutes Circulation. 2012;125:130-9.

39 Treatment Guidelines: Canadian Walking Program
Supervised exercise should be part of the initial treatment for all PAD patients Treadmill or track walking to reproduce symptoms 30 – 60 minutes/session, 3 sessions per week for 3 months TASC II J Vasc Surg 2007;45 Suppl S:5A J Am Coll Cardiol 2010;56;2147

40 Indications for Revascularization
Absolute: Rest Pain Non-healing ulceration Relative: Life-style limiting symptoms

41 Risk Factor Modification
Diagnose PAD Risk Factor Modification No limitation Life-style limiting claudication Critical limb ischemia* Exercise program Define anatomy: Angiogram, CTA, MRA Revascularize: Endovascular, Surgical *rest pain, non-healing ulcers, gangrene

42 CT Angiography Advantages Non-Invasive Accuracy Multi-assessment
Disadvantages No angioplasty/stenting Iodinated contrast

43 MR Angiography Non-invasive No iodinated contrast Less Specific
Advantages Non-invasive No iodinated contrast Disadvantages Less Specific (overcalls stenoses) No angioplasty/stenting Nephrogenic systemic fibrosis Creatinine clearance cutoff: 30 ml/min

44 5 Year Primary Patency Rates
Angioplasty±Stenting 80% 70% 50% 60% 20% Bypass Grafting 80% Iliac Vein 70% 65% 50% Synthetic 60% 40% 10% Femoral Popliteal Tibial

45 BYPASS VERSUS ANGIOPLASTY IN SEVERE ISCHAEMIA OF THE LEG (BASIL) TRIAL:
Severe lower limb ischemia (rest pain, ulceration, gangrene) Bypass surgery 452 patients Balloon angioplasty J Vasc Surg 2010;51:5S-17S

46 BYPASS VERSUS ANGIOPLASTY IN SEVERE ISCHAEMIA OF THE LEG (BASIL) TRIAL:
Amputation-free survival Overall survival J Vasc Surg 2010;51:5S-17S

47 Treatment Guidelines: Critical limb ischemia
Estimated life expectancy ≤ 2 years or autogenous vein is not available, balloon angioplasty is reasonable (II B) Estimated life expectancy > 2 years and autogenous vein is available, bypass surgery is reasonable (II B) JACC 2011;58:2020

48 Consultation with Vascular Surgeon or Interventional Radiologist
Angioplasty Consultation with Vascular Surgeon or Interventional Radiologist Revascularize when possible Endovascular angioplasty and/or stenting (proximal/smokers) Surgical arterial bypass (distal/diabetes) Bypass surgery

49 Poor Invasive or Surgical Candidate
Medical comorbidity Lack of suitable outflow vessel Patient preference

50 Therapies to augment arterial blood flow

51 Cardiac gaited pump Circulator Boot ®

52 Non-cardiac Gaited Pumps
ArtAssist™ Plexi- Pulse ® Aircast Arterial Flow ®

53 Arterial Ulcers Therapy
Hyperbaric Oxygen Therapy (HBOT) Indicated and insurance payment for: Osteomyelitis Diabetic ulcers not moving toward closure after 30 days Acute traumatic ischemia Enhancement of healing in selected problem wounds, infection

54 78 year-old nondiabetic man with thigh/calf claudication, smoker, renal cancer, Cr 0.9 who presents with a traumatic plantar surface foot ulcer. Doppler signals are abnormal at the superficial femoral level with TCPO2s of 30/10/40, pulse exam: fem 3, pop 1. Most expedient treatment to improve arterial blood flow: Medical management with supervised Canadian walking program Arterial pumping of the lower extremity Angiogram +/- angioplasty/stenting Vascular surgical consult for distal pedal arterial bypass

55 78 year-old nondiabetic man with thigh/calf claudication, smoker, renal cancer, Cr 0.9 who presents with a traumatic plantar surface foot ulcer. Doppler signals are abnormal at the superficial femoral level with TCPO2s of 30/10/40, pulse exam: fem 3, pop 1. Most expedient treatment to improve arterial blood flow: Medical management with supervised Canadian walking program Arterial pumping of the lower extremity Angiogram +/- angioplasty/stenting Vascular surgical consult for distal pedal arterial bypass

56 Treatment of Arterial Ulcers

57 Arterial Ulcers Discrete edge •Pale base / eschar • Atrophic skin
• Lack of pedal hair • Severe pain – rest pain • Located on heel, toe, foot, trauma

58 Arterial ulcers Proactive care Natural warmth Control edema
Optimize blood flow Proactive care Natural warmth Control edema Consider debridement Pain Management

59 Indications for Amputation
Absolute: Severe rest pain with no revascularization option Limb gangrene Life threatening infection Relative: Life-style limiting symptoms

60 Amputation for Critical Limb Ischemia
Below knee: 10% perioperative mortality mortality 1 year = 25% 60% primary healing rate 15% will need future AKA TASC II J Vasc Surg 2007;45 Suppl S:5A

61 Wound Dressing Decision Tree
Dry Wound Minimal Wound Drainage Moderate Wound Heavy Wound Infected Wound Hydrogel: Curasol Wound’ Dres, Silvasorb, Biafine Hydrogels: Curasol, Woun’Dres, Silvasorb, Biafine Gauze: Xeroform, Excilon, Nu Gauze, Adaptic Alginates: Sorbsan, Restore, Kaltostat , Algicell Hydrofibers Aquacel, Aquacel AG, Maxorb AG Iodosorb: Mixed with Curasol Collagen: Fibracol, Promogran, Prisma, Medifil Nu Gauze, Adaptic, Curasalt, Gauze Fibracol, Promogran Iodosorb Foam: Allevyn, Mepilex, Mepilex Lite Gauze with: NS, DABS, Acetic Acid, Dakin’s Change 3-4x/ day Silver Dressings: Aquacel AG, Prisma, Silverlon, Acticoat 7,

62 WOUND FILLERS Absorbent Moist healing environment
Facilitates debridement Eliminates dead space Softens eschar and liquefies slough Easy to apply

63 WOUND FILLERS Difficult to remove Not for dry eschar or light exudate
(unless goal is to desiccate the ulcer bed) Can dehydrate wound bed Requires secondary dressing Not for deep or sinus tracting wounds

64

65 Take home points Early identification of peripheral arterial disease
Early intervention of peripheral arterial disease Proactively protect from injury Do not hydrate/macerate eschar (dead tissue) Do not debride if moderate to severe ischemia

66 Treatment Options Identify etiology of wound and treat appropriately
Create proper wound environment for healing Current therapies available Goals of the patient Insurance rules

67 Atypical Arterial Disease
Thromboangiitis Obliterans/Buerger’s disease Nonatherosclerotic, segmental, inflammatory (vasculitis), occlusive disease that affects the small & medium arteries and veins and is strongly associated with tobacco exposure (cigarettes, cannabis, tobacco chewing)

68 Demographics: Young smokers years old Male (9:1) Presentation: Foot claudication Rest pain / Digital ulcers Superficial phlebitis

69 Upper extremity involvement

70 Buerger’s Disease Premature Atherosclerosis Variable Upper Extremity No Yes > 40 < 40 Foot Claudication Phlebitis Tobacco Age

71 Treatment Smoking cessation Digit protection Arterial pumping Non-surgical candidate Wound care Auto amputation


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