Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "The Voyage to Peripheral Arterial Disease Management…Are We Missing the Boat? Carol Bohanon DNP, FNP-BC, CWS, CFCN September, 2014."— Presentation transcript:

1 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 NONE

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

7 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 Arterial Occlusive Disease

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

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

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

14 I NTERMITTENT C LAUDICATION “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”   Relief with standing   Symptoms consistent from day to day  Calf > Thigh > Buttock

16 Differentiating True from Pseudoclaudication Variable Intermittent Claudication Intermittent Claudication Pseudoclaudication Character Cramp, tight, fatigueTingling, weak, clumsy Exertional yesyes or no Distance to symptoms Consistent Inconsistent Symptoms with standing noyes Relief Stop, standMust sit

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

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

19 Ankle Brachial Index (ABI)

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

21 Right ABI 154/140= 1.1 Right ABI 154/140= 1.1 Left ABI 54/140 = 0.4 Left ABI 54/140 = 0.4 Right Arm Pressure 136 mm Hg Right Arm Pressure 136 mm Hg Highest Left Pedal Pressure 54 mm Hg Highest Left Pedal Pressure 54 mm Hg Left Arm Pressure 140 mm Hg Left Arm Pressure 140 mm Hg Highest Right Pedal Pressure 154 mm Hg Highest Right Pedal Pressure 154 mm Hg ABI= Lower extremity systolic pressure Highest brachial artery systolic pressure Ankle Brachial Index (ABI)

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

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

24 Transcutaneous Oximetry (TcP02) Supine (15 minutes) Elevation (3 minutes) Dependent (10 minutes) Healing range>40 Grey zone 20 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 %) Coronary artery disease(44.6 %) 25% symptomatic Cerebral artery disease (16.6 %) Cerebral artery disease (16.6 %) Renal artery disease(23-42%) Renal artery disease(23-42%) > 50 % stenosis > 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? Which of the following features will be most useful to distinguish between intermittent claudication and pseudoclaudication? 1.History of nicotine addiction 2.Symptoms brought on by exertion 3.Soft bruit over the right common femoral artery. 4.ABI of 0.8 on the right and 0.85 on the left. 5.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? Which of the following features will be most useful to distinguish between intermittent claudication and pseudoclaudication? 1.History of nicotine addiction 2.Symptoms brought on by exertion 3.Soft bruit over the right common femoral artery. 4.ABI of 0.8 on the right and 0.85 on the left. 5.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 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) 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 Drug class: Antiplatelet agent Contraindicated in patients with heart failure 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 Pentoxifylline (Trental) 400 mg ORALLY three times a day with meals Considered second-line alternative Considered second-line alternative Class: Hemorheologic Class: Hemorheologic Reduces blood viscosity and improves erythrocyte flexibility, microcirculatory flow, and tissue oxygen concentrations 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: 1. Encourage activity 2. Cilostazol 100 mg BID 3. Monitor & treat risk factors for PAD 4. Appropriate antiplatelet therapy 5. 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: 1. Encourage activity 2. Cilostazol 100 mg BID 3. Monitor & treat risk factors for PAD 4. Appropriate antiplatelet therapy 5. All of the above

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

37 Conventional Angiography Invasive Invasive Iodinated contrast Iodinated contrast Most sensitive Most sensitive (calcified vessels) Bad outcome 1:1000 Bad outcome 1:1000 Advantages Advantages Disadvantages Disadvantages Angioplasty/stenting Angioplasty/stenting

38 CLEVER STUDY SUPERVISED EXERCISE VS STENTING FOR INTERMITTENT CLAUDICATION CLEVER STUDY SUPERVISED EXERCISE VS STENTING FOR INTERMITTENT CLAUDICATION Circulation. 2012;125: Patients: Intermittent claudication due to aorto-iliac PAD months Change in peak walking 6 months Supervised exercise: 5.8 ± 4.6 minutes Stenting: 3.7 ± 4.9 minutes Opt med therapy (cilostazol): 1.2 ± 2.6 minutes P-value

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

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

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

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

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

44 5 Year Primary Patency Rates Bypass Grafting 80% Synthetic60% 40% 10% Angioplasty±Stenting 80% 70% 50% 60% 20% Vein70% 65% 50% Iliac Femoral Popliteal Tibial

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

46 Amputation-free survivalOverall 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 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) 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 Revascularize when possible   Endovascular angioplasty and/or stenting (proximal/smokers)   Surgical arterial bypass (distal/diabetes) Angioplasty Angioplasty 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 Aircast Arterial Flow ® ArtAssist™ Plexi- Pulse ®

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: 1. Medical management with supervised Canadian walking program 2. Arterial pumping of the lower extremity 3. Angiogram +/- angioplasty/stenting 4. 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: 1. Medical management with supervised Canadian walking program 2. Arterial pumping of the lower extremity 3. Angiogram +/- angioplasty/stenting 4. Vascular surgical consult for distal pedal arterial bypass

56 Treatment of Arterial Ulcers

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

58 Arterial ulcers 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 10% perioperative mortality mortality 1 year = 25% mortality 1 year = 25% 60% primary healing rate 60% primary healing rate 15% will need future AKA 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 Drainage Heavy Wound Drainage 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 Hydrogels: Curasol, Woun’Dres, Silvasorb, Biafine Gauze: Xeroform, Excilon, Nu Gauze, Adaptic, Curasalt, Gauze Alginates: Sorbsan, Restore, Kaltostat, Algicell Hydrofibers Aquacel, Aquacel AG, Maxorb AG Iodosorb: Mixed with Curasol Collagen: Fibracol, Promogran Prisma, Medifil Iodosorb Alginates: Sorbsan, Restore, Kaltostat, Algicell Hydrofibers Aquacel, Aquacel AG, Maxorb AG Foam: Allevyn, Mepilex, Mepilex Lite Collagen: Fibracol, Promogran Prisma, Medifil Iodosorb Gauze with: NS, DABS, Acetic Acid, Dakin’s Change 3-4x/ day Silver Dressings: Aquacel AG, Prisma, Silverlon, Acticoat 7, Maxorb AG

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 Upper Extremity Buerger’s Buerger’sDisease Premature PrematureAtherosclerosis Variable Foot Claudication Phlebitis Tobacco Age No NoYes Yes Yes Yes YesYes > 40 > 40 < 40

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


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

Similar presentations


Ads by Google