1. Going out on a Limb: Peripheral Arterial Disease in Primary Care
No Financial Disclosures
Adam M. Levine, D.O. FACC
Lourdes Cardiology Services
South Jersey Heart Group
September 13, 2014

2. Goals Who is at risk for development of PAD When and How to screen
How to treat

4. Peripheral Artery Disease (PAD)
PAD affects 12-20% of Americans age 65 and older.1
12 million with PAD in the U.S. alone2
3x greater risk in those with diabetes over the age of 50.3
4x greater risk in current or past smokers. 1
1. Becker, GJ, et al. The Importance of Increasing Public and Physician Awareness of Peripheral Arterial Disease. J Vasc interv Radiol 2002; 13[1];7-11.
2. “Peripheral Arterial Disease in People with Diabetes”, American Diabetes Association Consensus Statement, Diabetes Care, Volume 26, Number 12, December 2003,
3. “Diagnosis of PAD is Important for People with Diabetes”, American Diabetes Association Consensus Statement, Diabetes Care, November 21, 2003,

6. Defining a Population “At Risk” for Lower Extremity PAD
Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)
Age 50 to 69 years and history of smoking or diabetes
Age 70 years and older
Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain
Abnormal lower extremity pulse examination
Known atherosclerotic coronary, carotid, or renal artery disease

7. Presentations in Clinical Practice
Asymptomatic, may have functional impairment
Reproducible (typical) claudication
Atypical Leg Pain
Critical Limb Ischemia
Rest pain, tissue loss, threatened limb loss
Acute Limb Ischemia
Pain, Pulseless, Pallor, Parasthesias, Paralysis

8. CLI Impact and Mortality
1.5-2 million people in the US and Europe suffer from CLI1
Mortality rates for CLI patients2
at one year : 25%
two years : 31.6%
three years : 60%
40-50 % amputation rate within 1st year of Dx. 3
“Conquering Critical Limb Ischemia”, Michael R. Jaff, DO and Giancarlo Biamino, MD, Endovascular Today, February 2004, Volume 3, No. 2
3. Dormandy J.A., Heeck L., Vig S.: The fate of subjects with critical leg ischemia. Semin Vasc Surg ;

9. Symptomatic and Asymptomatic PAD
Prior Diagnosis of PAD
(n=366)
Newly Diagnosed PAD
(n=457)
PARTNERS Study
Hirsch AT et al. JAMA. 2001;286:

11. Prognosis in Patients with Intermittent Claudication
Peripheral Vascular Outcomes
Other Cardiovascular Morbidity/Total Mortality
Lower Extremity Bypass Surgery 7%
Major Amputation 4%
Worsening Claudication 16%
Population >55 yr
Intermittent Claudication
Nonfatal Cardiovascular Event (MI/Stroke, 5-year Rate) 20%
5-yr Mortality 30%
Cardiovascular Cause 75%
Adapted from Weitz JI et al.
Circulation. 1996;94:

12. Does “Asymptomatic” PAD Really Matter?
Coronary Artery Surgery Study (CASS) in patients with known CAD the presence of PAD increased Cardiovascular mortality by 25% during a 10 yr follow-up
(J AM Coll Cardiol 1994:23:1091-5)
PAD, symptomatic or asymptomatic, is a powerful independent predictor of CAD and CVD
(Vasc.Med.3,241,1998.)

13. Symptoms of PAD
Claudication: Dull cramping or pain in muscles of hips, thighs or calf muscles when walking, climbing stairs, or exercise which is relieved with cessation of activity
Fatigue in legs which may require patient to stop and rest while walking
Slow or shuffled gait & having difficulty keeping up with others

14. Symptoms of PAD Neuropathy or pain in feet with exercise
Rest pain or night pain that occurs when legs elevated in bed, relieved when placed in dependent position. Typically in the distal foot, possibly in vicinity of an ulcer
Impotence may be a sign of iliac disease and may see some relief with sildenafil citrate.

15. Differential Diagnosis of Exertional Leg Pain
Vascular Causes Atherosclerosis
Thrombosis Embolism Vasculitis Thromboangiitis obliterans Takayasu arteritis Giant cell arteritis Aortic coarctation Fibromuscular dysplasia Irradiation Endofibrosis of the external iliac artery Extravascular compression Arterial entrapment (e.g., popliteal artery entrapment, thoracic outlet syndrome) Adventitial cysts

19. Visual Cues to PAD and Arterial Insufficiency
Cool, dry, atrophic skin on legs
May have signs of cellulitis
Thickened or deformed nails-dystrophic
Hair loss or uneven distribution on legs
Muscle weakness or atrophy
Bruits on auscultation
Ulcers or wounds on lower extremities
Gangrene

20. The First Tool to Establish the PAD Diagnosis: The HPI, ROS, and Physical Examination
Pulse intensity should be assessed and should be recorded numerically as follows:
0 - absent
1 - diminished
2 - normal
3 - bounding

22. PAD Diagnostic Tests Non-invasive tests1 Invasive tests1
ABI (Ankle/Brachial Index)
Exercise Test
Segmental Pressures
Segmental Volume Plethysmography
Duplex Ultrasonography
MRA (Magnetic Resonance Arteriography),or CTA
Invasive tests1
Peripheral Angiography
1. Krajewski and Olin Chapter 11 Peripheral Vascular Disease. 2nd ed. 1996

23. Recommendations for ABI, Toe-Brachial Index, and Segmental Pressure Examination
IIa
IIb
III B
The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with 1 or more of the following: exertional leg symptoms, nonhealing wounds, age ≥65 years, or ≥50 years with a history of smoking or diabetes.
MODIFIED
2011 ACC/AHA Guideline for Management of PAD

24. The Ankle-Brachial Index
ABI =
Lower extremity systolic pressure
Brachial artery systolic pressure
Normal
PAD <0.90
Rest pain/ulceration <0.40
The Ankle-Brachial Index is 95% sensitive and 99% specific for PAD
Both ankle and brachial systolic pressures are obtained using a hand-held Doppler instrument
Source: Peripheral Arterial Disease in People with Diabetes, ADA, Consensus
Statement, Diabetes Care, Volume 26, Number 12, December 2003.

25. The Ankle-Brachial Index
Performing a resting ankle-brachial index measurement
ABI >1.30
(abnormal)
ABI 0.91 to1.30
(borderline &normal
ABI <= to 0.90
Confirmation of PAD
diagnosis
Measure ABI
After exercise test
PVR, Toe-brachial index
Duplex ultrasonography
Decreased post-exercise
ABI
MRA,or CTA
Peripheral Angiography
MRA, or CTA

26. Exercise ABI Confirms the PAD diagnosis
Assesses the functional severity of claudication
May “unmask” PAD when the resting ABI is normal

28. Arterial Duplex Ultrasound Recommendations
IIa
IIb
III A
Duplex ultrasound of the extremities is useful to diagnose anatomic location and degree of stenosis of peripheral arterial disease.
Duplex ultrasound is useful to provide surveillance following femoral-popliteal bypass using venous conduit (but not prosthetic grafts).
2011 ACC/AHA Guideline for Management of PAD

29. Arterial Duplex Ultrasound Testing
Duplex ultrasound of the extremities can be used to select candidates for:
endovascular intervention;
surgical bypass, and
to select the sites of surgical anastomosis.
However, the data that might support use of duplex ultrasound to assess long-term patency of PTA is not robust.

30. Surveillance post Bypass or Endovascular Procedure
Duplex Ultrasound 3, 6, 12 months post and at yearly intervals
Early Failure Rates 9-47% after PTA
If recognized secondary patency rates > 90%
Indications for restudy
Worsening ABI ( 0.15) is an indication for restudy
Decreased flow less then 40 cm/sec
PSV >180 cm/sec, Vr > 2

33. Magnetic Resonance Angiography
MRA of the extremities is useful to diagnose anatomic location and degree of stenosis of PAD. 
MRA of the extremities should be performed with gadolinium enhancement. (Level of Evidence: B)
MRA of the extremities is useful in selecting patients with lower extremity PAD as candidates for endovascular intervention.  I
IIa
IIb
III A

35. Computed Tomographic Angiography
Computed tomographic angiography (CTA) of the extremities may be considered to diagnose anatomic location and presence of significant stenosis in patients with lower extremity PAD.
CTA of the extremities may be considered as a substitute for magnetic resonance angiography (MRA) for those patients with contraindications to MRA. I
IIa
IIb
III B

36. Lower Extremity Angiography
Contrast angiography provides detailed information about arterial
anatomy and is recommended for evaluation of patients with lower
extremity PAD when revascularization is contemplated. (Class I, LOE B)

37. Summary of Diagnostic tests
Suspected PAD
exertional leg symptoms or non-healing wounds
Age ≥65 years
Age ≥50 years with a history of smoking or diabetes.
ABI/PVR
If normal and symptomatic then Exercise ABI
Duplex ultrasound
MRA
CTA
Angiogram

38. Treatment Risk Factor Modification Hypertension - BP < 140/90
Diabetes – HgA1c ≤ 7%
Hyperlipidemia – LDL ≤ 100
Smoking Cessation
Supervised Exercise Program (30-45 min/day, 3 days/week)
Class I, LOE A

41. Pharmacotherapy
Antiplatlet to reduce risk of MI, stroke, vascular death in PAD
Symptomatic
Aspirin (Class I, LOE B)
Clopidogrel (Class I, LOE B)
Asymptomatic
If ABI ≤ 0.90 (Class IIa, LOE C)
Cilostazol (Class I, LOE A)
Indicated to improved symptoms and increase walking distance in PAD
Contraindicated in CHF
100mg BID

45. Revascularization Options
Endovascular
Advantage
Local anesthesia
No vein grafts needed
Fast recovery
Potential for Hybrid approach
Disadvantage
Lower Patency rates
Need for repeat procedures
Surgical
Advantage
Less interventions
Better patency
Disadvantage
General anesthesia
Need vein grafts
Longer recovery
Higher systemic complications

46. Comparative Intervention Treatment Options
1 year primary patency
2 year primary patency
Percutaneous Transluminal Angioplasty (PTA)
58%
51%
Stents
65-85%
55-68%
Bypass
77-81%
66-77%
SilverHawk has a one-year patency of 79-88%.
Angioplasty is not close to that level. Stents are not recommended for the legs by the ACC/AHA Guidelines. Bypass is not a good option for some patients.
Source: J Endovas There 2004;11(suppl II):II-107-II-127 “Lower Extremity Endovascular Interventions” Bates and AbuRahma

48. Summary Who is at risk for development of PAD When and How to screen
Diabetes, known vascular disease, Smokers, Older age
When and How to screen
Exertional leg symptoms or nonhealing wounds
Anyone age ≥65 years or ≥50 years with a history of smoking or diabetes.
ABI and doppler ultrasound is first line
How to treat
Aspirin, exercise, risk factor modification, cilostazol, revascularization

50. Conclusion Prevention is KEY!!!!!
When in doubt, refer to your local vascular specialist.