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SSA Policy Conference Peripheral Arterial Disease Chronic Venous Insufficiency Jennifer A. Heller, M.D., F.A.C.S. Assistant Professor of Surgery Director,

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Presentation on theme: "SSA Policy Conference Peripheral Arterial Disease Chronic Venous Insufficiency Jennifer A. Heller, M.D., F.A.C.S. Assistant Professor of Surgery Director,"— Presentation transcript:

1 SSA Policy Conference Peripheral Arterial Disease Chronic Venous Insufficiency Jennifer A. Heller, M.D., F.A.C.S. Assistant Professor of Surgery Director, Johns Hopkins Vein Center Johns Hopkins University School of Medicine

2 OUTLINE Definition Definition Diagnosis Diagnosis Impact of Disease on Activities of Daily Living Impact of Disease on Activities of Daily Living

3 DEFINITION of PERIPHERAL ARTERIAL DISEASE (PAD) Hemodynamic Definition: Peripheral Arterial Disease: Resting ABI<.90 Hemodynamic Definition: Peripheral Arterial Disease: Resting ABI<.90

4 Does this definition work? In symptomatic pts, ABI is 95% sensitive in predicting “arteriogram positive” PAD In symptomatic pts, ABI is 95% sensitive in predicting “arteriogram positive” PAD Edinburgh Artery Study: 1/3 pts with asymptomatic PAD had complete occlusion of a major artery Edinburgh Artery Study: 1/3 pts with asymptomatic PAD had complete occlusion of a major artery The lower the ABI, the higher the risk of cardiovascular events The lower the ABI, the higher the risk of cardiovascular events Abnormal ABI identifies a high risk population that needs aggressive risk factor modification and antiplatelet therapy Abnormal ABI identifies a high risk population that needs aggressive risk factor modification and antiplatelet therapy

5 DIAGNOSIS Initial clinical assessment: History and Physical Initial clinical assessment: History and Physical A Careful History includes: Evaluation of risk factors Presence of Cardiac Disease Tobacco Use Family history

6 PHYSICAL EXAMINATION Measurement of BP on bilateral upper extremities Measurement of BP on bilateral upper extremities Assessment of cardiac murmurs, rubs gallops Assessment of cardiac murmurs, rubs gallops Changes in color, temperature of skin of feet Changes in color, temperature of skin of feet Muscle atrophy from inability to exercise Muscle atrophy from inability to exercise Decreased hair growth, hypertrophied slow growing nails Decreased hair growth, hypertrophied slow growing nails Radial, ulnar, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedal Radial, ulnar, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedal

7 DO WE HAVE A CLEAR DX AFTER THE H AND P? If the symptom of classic claudication is used to identify PAD, it will lead to a significant underdiagnosis of PAD If the symptom of classic claudication is used to identify PAD, it will lead to a significant underdiagnosis of PAD Palpable pedal pulses: negative predictive value of >90% Palpable pedal pulses: negative predictive value of >90% Pulse abnormality significantly overestimates true prevalence of PAD Pulse abnormality significantly overestimates true prevalence of PAD Objective testing is therefore warranted Objective testing is therefore warranted Primary test ABI Primary test ABI

8 Individuals with risks factors for PAD, limb symptoms on exertion or reduced limb function should undergo a vascular history to evaluate for symptoms of claudication or other limb symptoms that limit walking ability Individuals with risks factors for PAD, limb symptoms on exertion or reduced limb function should undergo a vascular history to evaluate for symptoms of claudication or other limb symptoms that limit walking ability Patients at risk for PAD or patients with reduced limb function should also have a vascular PE to evaluate peripheral pulses Patients at risk for PAD or patients with reduced limb function should also have a vascular PE to evaluate peripheral pulses Patients with a history or examination suggestive of PAD should proceed to objective testing including an ankle-brachial index Patients with a history or examination suggestive of PAD should proceed to objective testing including an ankle-brachial index

9 ABI SCREENING All patients with exertional leg symptoms All patients with exertional leg symptoms Subjects aged years who have cardiovascular risk factors (particularly diabetes or smoking) Subjects aged years who have cardiovascular risk factors (particularly diabetes or smoking) All patients over 70 years regardless of risk- factor status All patients over 70 years regardless of risk- factor status

10 ABI cm sphygmomanometer cuff placed just above ankle cm sphygmomanometer cuff placed just above ankle Doppler measures systolic pressure of the posterior tibial and dorsalis pedis arteries of each leg Doppler measures systolic pressure of the posterior tibial and dorsalis pedis arteries of each leg These pressures are then normalized to the higher brachial pressures of either arm to form the ankle- brachial index These pressures are then normalized to the higher brachial pressures of either arm to form the ankle- brachial index

11 ABI Decreased ABI in symptomatic patients confirms existence of hemodynamically significant occlusive disease between heart and ankle Decreased ABI in symptomatic patients confirms existence of hemodynamically significant occlusive disease between heart and ankle Patients with exercise related leg pain of non vascular causes will have a normal ABI at rest and after exercise Patients with exercise related leg pain of non vascular causes will have a normal ABI at rest and after exercise

12 MILD ISCHEMIA ABI DEGREE OF ISCHEMIA WAVEFORM PATTERN PHYSICAL LIMITATION None Triphasic or Biphasic No limitation or pseudoclaudication Mild Triphasic or Biphasic Claudication in calves or thighs. Walking distance greater than 3-4 blocks ModerateMonophasic Quick systolic acceleration Claudication in calves or thighs. Walking distance less than 3 blocks

13 MODERATE TO SEVERE ISCHEMIA Moderately Severe Monophasic, Slow systolic acceleration, Tardus parvus Claudication in calves or thighs. Walkiing distance less than 1 block Severe Monophasic Tardus parvus Ischemic pain at rest, limited ability to walk Critical Tardus parvus or no flow Ischemic pain at rest, loss of tissue, impending gangrene

14 Patients with PAD who do not have atypical symptoms, a reduced ABI is highly associated with reduced limb function, defined as reduced walking speed and/or a shortened walking distance during a timed 6 minute walk Patients with PAD who do not have atypical symptoms, a reduced ABI is highly associated with reduced limb function, defined as reduced walking speed and/or a shortened walking distance during a timed 6 minute walk

15 VALUE OF ABI Confirms diagnosis of PAD Confirms diagnosis of PAD Detects PAD in asymptomatic pts Detects PAD in asymptomatic pts Used in Ddx to identify a vascular etiology Used in Ddx to identify a vascular etiology Identifies patients with reduced limb function Identifies patients with reduced limb function Provides key information on long term prognosis, with ABI<.90 associated with a 3- 6 fold increased risk of cardiovascular mortality Provides key information on long term prognosis, with ABI<.90 associated with a 3- 6 fold increased risk of cardiovascular mortality

16 TOE PRESSURES Small occlusion cuff is placed on the first or second toe with a flow sensor Toe pressure normally 30mmHg less than the ankle pressure Abnormal toe brachial index <.7 Rest pain if absolute toe pressure <30mmHg Non healing if toe pressure <20-30mmHg

17 When are toe pressures important? Diabetes Diabetes Renal Insufficiency Renal Insufficiency Any etiology manifesting in vascular calcification Any etiology manifesting in vascular calcification Non-compressible vessels=>250mmHg ankle pressure, or ABI >1.40 Non-compressible vessels=>250mmHg ankle pressure, or ABI >1.40

18 LIMITATIONS OF TOE PRESSURES Amputation of Great and/ or second toe Amputation of Great and/ or second toe Extensive tissue loss Extensive tissue loss Ulceration Ulceration Skin Perfusion Pressure Laser doppler Probe Wrapped around Forefoot

19 EXERCISE TESTING Patients with claudication who have an isolated iliac stenosis may have no pressure decrease across the stenosis at rest, therefore a normal ABI will be present Patients with claudication who have an isolated iliac stenosis may have no pressure decrease across the stenosis at rest, therefore a normal ABI will be present Exercise will increase inflow velocity and make these lesions hemodynamically significant, and exercise will induce a decrease in the ABI that can be detected in the immediate recovery period and therefore establish the dx of PAD Exercise will increase inflow velocity and make these lesions hemodynamically significant, and exercise will induce a decrease in the ABI that can be detected in the immediate recovery period and therefore establish the dx of PAD

20 EXERCISE TESTING II How does it work? Obtain initial ABI at rest Obtain initial ABI at rest Patient then walks (treadmill at 3.2 km/h (2mph), 10-12% grade) until claudication pain occurs (or a maximum of 5 minutes) following which ankle pressure is then again measured Patient then walks (treadmill at 3.2 km/h (2mph), 10-12% grade) until claudication pain occurs (or a maximum of 5 minutes) following which ankle pressure is then again measured Decrease in ABI 15-20% is diagnostic of PAD Decrease in ABI 15-20% is diagnostic of PAD

21 ALTERNATIVES TO EXERCISE/TREADMILL TESTING Climbing stairs or walking in the hallway Climbing stairs or walking in the hallway Pts who cannot perform treadmill testing: active pedal plantar flexion Pts who cannot perform treadmill testing: active pedal plantar flexion Inflation of thigh cuff well above systolic pressure for 3-5 minutes to induce “reactive” hyperemia, not well tolerated, not recommednded Inflation of thigh cuff well above systolic pressure for 3-5 minutes to induce “reactive” hyperemia, not well tolerated, not recommednded

22

23 CAN WE QUANTIFY FUNCTION IN PATIENTS WITH PAD? Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001 Oct 3; 286(13): McDermott MM et al. Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001 Oct 3; 286(13): McDermott MM et al. Claudication distances and the Walking Impairment Questionnaire best describe the ambulatory limiatations in patients with symptomatic peripheral arterial disease. J Vasc Surg Mar; 47(3): Myers SA et al Claudication distances and the Walking Impairment Questionnaire best describe the ambulatory limiatations in patients with symptomatic peripheral arterial disease. J Vasc Surg Mar; 47(3): Myers SA et al

24 So…

25 VENOUS INSUFFICIENCY

26 VENOUS PHYSIOLOGY Venous system acts as a reservoir (60-75% of TBV in system) Venous system acts as a reservoir (60-75% of TBV in system) Venous pressures determined by gravity not by cardiac contractions Venous pressures determined by gravity not by cardiac contractions Venous system largely dependent on valvular function for transport Venous system largely dependent on valvular function for transport

27 WHAT IS CHRONIC VENOUS INSUFFICIENCY? Manifestation of valvular destruction and/or dysfunction resulting in venous hypertension of the extremity Manifestation of valvular destruction and/or dysfunction resulting in venous hypertension of the extremity

28 VENOUS HYPERTENSION Caused by: Reflux through incompetent valves Venous outflow obstruction Failure of the musculovenous calf pump

29 PREVALENCE 20+million 6 million 1 million 500, million 6 million 1 million 500,000

30 SOCIOECONOMIC IMPACT  10-35% of adults in the US have some form of chronic venous insufficiency (CVI)  Cost to the government for treatment amounts to 1 billion annually  2 million work days per year are lost due to venous related illnesses

31 CLASSIFICATION CEAP CEAP Venous Severity Score (VSS) Venous Severity Score (VSS)

32 CEAP Created in 1994 under the auspices of the American Venous Forum Created in 1994 under the auspices of the American Venous Forum Clinical-Etiologic-Anatomic-Pathophysiologic Clinical-Etiologic-Anatomic-Pathophysiologic Descriptive classification Descriptive classification Used to classify stages of venous disease Used to classify stages of venous disease Score directly correlates with CEAP clinical class Score directly correlates with CEAP clinical class

33 C in CEAP Clinical No venous disease Telangiectases Varicose Veins Edema Lipodermatosclerosis Healed ulcer Active ulcer

34 C1: Spider veins

35 C2:Varicose Veins

36 C3: Edema

37 C4: Hyperpigmentation, atrophie blanche

38 C5: Healed ulcer

39 C6: Active ulcer

40 E in CEAP Etiologic Congenital Congenital Primary Primary Secondary Secondary Present since birth Undetermined etiology Post-thrombotic

41 A in CEAP Anatomic distribution Superficial Superficial Deep Deep Perforator Perforator Great and small saphenous veins Cava, iliac, gonadal, femoral, profunda, popliteal, tibial Thigh and leg perforating veins

42 P in CEAP Pathophysiological Reflux Reflux Obstruction Obstruction Combination Combination Axial and perforating veins Acute and chronic Valvular dysfunction and thrombus

43 Venous Severity Scoring Developed in 2000 Venous Outcomes Committee of the AVF Developed in 2000 Venous Outcomes Committee of the AVF Numeric score based on 3 components: VCSS, the anatomic segment disease score, and the VDS Numeric score based on 3 components: VCSS, the anatomic segment disease score, and the VDS

44 Venous Severity Scoring VCSS Component Clinical Attributes Pain Pain Varicose veins Varicose veins  Venous edema Skin pigmentation Skin pigmentation Inflammation Inflammation Induration Induration Number of ulcers Number of ulcers Duration of ulcers Duration of ulcers Size of ulcers Size of ulcers Compressive therapy Compressive therapy 4 Grades Absent Mild Moderate Severe

45 Venous Severity Scoring Anatomic Segmental Score Assigns a numerical value to segments that manifest reflux and/or obstruction Assigns a numerical value to segments that manifest reflux and/or obstruction Based on imaging Based on imaging Weights 11 venous segments for their relative importance when involved with reflux and/or obstruction with a maximum score of 10 Weights 11 venous segments for their relative importance when involved with reflux and/or obstruction with a maximum score of 10

46 DOES A PATIENT WITH CHRONIC VENOUS INSUFFICIENCY REALLY HAVE PROBLEMS FUNCTIONING?

47 Venous Severity Scoring Venous Disability Score Ability to perform ADLs with or without compression stockings Ability to perform ADLs with or without compression stockings Eliminates 8 hour work day instead replaces with normal daily activities Eliminates 8 hour work day instead replaces with normal daily activities Refinement of the CEAP disability score Refinement of the CEAP disability score

48 NONINVASIVE PHYSIOLOGIC TESTING 2 Goals: to determine presence of obstruction, and presence of reflux in both the superficial and deep venous systems Doppler and duplex are utilized

49 NONINVASIVE PHYSIOLOGIC TESTING Non weight bearing calf compressed Compression with rapid release allows identification of valves and the presence of reflux Reflux will occur when calf compression is released Reflux will occur when calf compression is released Reflux=venous flow away from the heart (towards the feet) after release Mild reflux: seconds Severe reflux: >2.0 seconds Normal veins do not reflux with this technique

50 DIAGNOSIS

51 Thank you!


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