The Diagnosis and Treatment of Peripheral Vascular Disease

The Diagnosis and Treatment of Peripheral Vascular Disease
Welcome to this presentation on The Diagnosis and Treatment of Peripheral Vascular Disease. This educational activity is designed to help communicate an important message to primary care practitioners. That message is: the importance of timely detection of peripheral arterial disease (PAD) in primary care and appropriate treatment strategies that can help reduce PAD related morbidity and mortality in your patient population.

Etiology Prevalence Risk Factors Diagnosis Treatment Options

The Pathophysiology of Atherosclerosis and Thrombosis
Atherosclerosis is the most common form of vascular disease seen by clinicians. This is a systemic disorder effecting blood vessels in the cerebral vascular circulation, coronary circulation, and lower extremity arterial circulation. These manifestations may result in stroke or TIA, acute coronary syndromes, intermittent claudication, or critical limb ischemia.

Pathologic Progression of PAD
Atherosclerosis > Thrombus Formation > Ischemia > Limb Pain > Impairment Atherosclerosis results from an extensive inflammatory and fibroproliferative response to insults within the vasculature leading to disruption of normal homeostasis of the endothelium. The dysfunctional endothelium leads to an increase in adhesiveness and procoagulant properties. Atherosclerotic lesions form and through progression of the disease eventually become atherosclerotic plaques. Activated platelets can amplify the inflammatory response and are an important component leading to vasoconstriction. Rupture of the atherosclerotic plaque occurs in advanced stages of the disease and results on the formation of a thrombus and arterial occlusion. Atherosclerotic plaque, thrombosis, and vasoconstriction of the arteries all lead to decreased blood flow in the periphery. Ischemia leads to painful symptoms that can be worsened as the demand of oxygen increases in response to activity such as walking. Painful symptoms at rest is a sign of progressive disease. Ischemia also results in cell death and tissue destruction. Progression of limb pain and destruction of tissue eventually leads to physical impairment. Ross R. Atherosclerosis—An inflammatory process. N Engl J Med. 1999;340: Atherosclerosis and platelet activation lead to the formation of a thrombus in arteries Narrowed arteries and formation of a thrombus impedes blood flow to the periphery and results in ischemia Ischemia leads to painful symptoms, cell death, and results in physical impairment Ross R. N Engl J Med. 1999; 340:

Major Manifestations of Vascular Disease and Thrombotic Events
Ischemic stroke Transient ischemic attack Myocardial infarction Angina pectoris (stable, unstable) Peripheral arterial disease Critical limb ischemia, rest pain, gangrene, necrosis Vascular disease is the result of a generalized process that affects multiple vascular beds, including the cerebral, coronary, and peripheral arteries. Coexistence of vascular disease in multiple beds increases the risk for developing ischemic events such as MI and stroke.[1] Vascular disease in cerebral arteries may precipitate a transient ischemic attack (TIA) or an ischemic stroke. A TIA, by definition, lasts for fewer than 24 hours, but the majority clear within 1 hour. A TIA may be a warning of an impending stroke, with the risk for a stroke being 4% to 8% during the first month following a TIA and 24% to 29% during the next 5 years.[2] Vascular disease in coronary arteries produces a spectrum of ischemic coronary syndromes that include stable angina, unstable angina, non–ST-segment elevation myocardial infarction (NSTEMI; also known as non–Q-wave MI), and ST-segment elevation (STEMI; also known as Q-wave MI). Cardiovascular disease is the single largest cause of death in the United States.[3] Vascular disease in peripheral vessels, peripheral arterial disease (PAD), produces a variety of symptoms ranging from intermittent claudication to pain at rest.[4] Patients with the most serious PAD have critical limb ischemia that produces pain at rest and threatens the viability of the limb by increasing the risk for gangrene and necrosis.[4] PAD is a strong marker for cardiovascular disease. Over a 10-year period, PAD increases risk for death due to cardiovascular disease approximately 6-fold.[5] 1.Aronow WS, Ahn C. Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women 62 years of age. Am J Cardiol. 1994;74:64-65. 2 Feinberg WM, Albers GW, Barnett HJM, et al. Guidelines for the Management of Transient Ischemic Attacks. Dallas, Tx: American Heart Association; 1994. 3. American Heart Association Heart and Stroke Statistical Update 4.Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation. 1996;94: 5.Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:

Overlap of Atherosclerotic Diseases
Coronary Artery Disease Cerebrovascular Disease Peripheral Arterial Disease 6% 16% 40% 11% 3% 15% 9.1% 38% overlap of 2 vascular beds Atherosclerosis often occurs in several vascular beds, including the coronary, cerebral, and peripheral arteries, and is the underlying condition that can lead to MI, stroke, or peripheral arterial disease (PAD). These atherosclerotic conditions often coexist in patients, increasing the risk for developing ischemic events such as MI and stroke. Aronow and Ahn prospectively evaluated the incidence and degree of overlap of coronary artery disease (CAD), peripheral arterial disease (PAD), and stroke in 1886 elderly patients (aged ³62years) in a long-term care facility. The results demonstrated a significant degree of overlap of these three atherosclerotic conditions: 25% of patients had at least two manifestations of their atherosclerotic disease. In patients with CAD, PAD and stroke were also present in 33% and 32% of patients, respectively. In patients with stroke, CAD and PAD were also present in 53% and 33% of patients, respectively. And, in patients with PAD, CAD and stroke were also present in 58% and 34% of patients, respectively. This study demonstrates that patients with one manifestation of atherosclerotic disease often have overlapping diseases in other vascular beds. For example, in the next 6 years., approximately 30% of patients with a MI will have another MI, while approximately 15% will have a stroke. Also 20% of patients with a cerebrovascular disease will have CAD. Ness, Aronow. JAGS. 1999;47: Aronow WS, Ahn C. Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women 62 years of age. Am J Cardiol. 1994;74:64-65.

Atherothrombotic Disease in the US
Annual Incidence (Millions) Prevalence (Millions) Mortality/Yr (%) Stroke 0.731 4.62 282 TIA 0.503 4.94 6.35 ACS 2.36* 12.62† 452‡ PAD --- 8-127 48,259§ Despite the improvement in the diagnosis and treatment of vascular disease (stroke, MI, and PAD), the incidence of these conditions still remains high. Each year about 730,000 Americans have a new or recurrent stroke, and 28% die from stroke each year, making stroke the third leading cause of death.1,2 In the United States, 4.6 million people have survived a stroke (2.3 million men and 2.3 million women), but 20% require help caring for themselves.2 Latest data from the Mayo Clinic reports that approximately 500,000 TIAs have occurred in the United States in And, according to a recent survey of 10,112 people conducted by the National Stroke Association and Roper Search Worldwide, 4.9 million of all adults age 18 and older (2.9%) have been diagnosed with TIA. Of those surveyed adults 65 years of age and older, 8.5% (or 2.6 million) reported that they had been diagnosed with a TIA.3,4 The average risk for death following a TIA is approximately 6.3%/year.5 MI is the largest single cause of death in the United States. An estimated 1.1 million Americans will have a new or recurrent MI this year, and more than 45% who experience a coronary attack will die within 1 year. Another 550,000 cases of angina will occur each year. Today, an estimated 12.6 million Americans have a history of MI, stable/unstable angina, or both and are at risk for developing subsequent ischemic events.2,4,6 The prevalence of PAD is thought to be even higher than that of MI and stroke. It is estimated that PAD affects approximately 8 to 12 million Americans.7 The mortality rate for established PAD is estimated to be approximately 4% per year.8 Patients with critical limb ischemia who have the lowest ankle-brachial index have an annual mortality of 25%.9 1. Broderick J, Brott T, Kothari R, et al. The greater Cincinnati/Northern Kentucky stroke study: preliminary first-ever and total incidence rates of stroke among blacks. Stroke. 1998;29: 2.American Heart Association Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2001. 3.Brown et al. American Stroke Association. 25th Int. Stroke Conference 4.National Stroke Assocation Press Release, April 25, 2000. 5.Dennis M, Bamford J, Sandercock P, Warlow C. Prognosis of transient ischemic attacks in the Oxfordshire Community Stroke Project. Stroke. 1990;21: 6.National Hospital Discharge Survey National Center for Health Statistics/Centers for Disease Control and Prevention. Series 13, No September 2001. 7.Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286: 8.Dormandy JA, Murray GD. The fate of the claudicant: a prospective study of 1969 claudicants. Eur J Vasc Surg. 1991;5: 9.Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med. 2001;344: TIA = transient ischemic attack; ACS = acute coronary syndrome; PAD = peripheral arterial disease. *Includes unspecified angina pectoris; †includes history of MI or stable/unstable angina pectoris or both; ‡CHD defined as MI or fatal CHD; §patients with critical limb ischemia, who have lowest ABI values, have an annual mortality rate of 25%. 1. Broderick J, et al. Stroke. 1998;29: ; 2. American Heart Association Heart and Stroke Statistical Update; 3. Brown et al. Amer. Stroke Assoc. 25th Int. Stroke Conference. 2000; 4. National Stroke Association Press Release. April 25, 2000; 5. Dennis M, et al. Stroke. 1990;21: ; 6. National Hospital Discharge Survey National Center for Health Statistics/Centers for Disease Control and Prevention. Series 13, No.151. September 2001; 7. Hirsch AT, et al. JAMA. 2001;286: ; 8. Dormandy JA, et al. Eur J Vasc Surg. 1991;5: ; 9. Hiatt WR. N Engl J Med. 2001;344:

How Common is PAD? 1 in 4 Americans have some form of Cardiovascular Disease Over 70 Million Americans Cardiovascular Disease accounts for more annual deaths than Cancer, Infection, and Trauma COMBINED One in four Americans have some form of cardiovascular disease representing at lease 70 million Americans. Cardiovascular disease accounts for more annual deaths than cancer, infection or trauma combined.

How Common is PAD? Responsible for:
275,000 hospital admissions per year Over 2,750,000 office visits per year Approximately 45,000 deaths per year Multiple hospitalizations, office visits, and mortalities are associated with peripheral arterial disease.

Carotid Artery Stenosis
Responsible for 35% of all strokes The major cause of loss of independent life for patients First symptom may be a catastrophic stroke Carotid artery disease of the large vessels outside the brain represents at least one third of all strokes. Strokes represent the major cause of loss of independent life for patients. Warning signs often do not occur and the first symptom associated with a carotid stenosis may be a catastrophic stroke.

How Common is PAD? More than 700,000 new STROKES occur each year
Approximately 20% are Recurrent There are more than 700,000 new strokes every year representing a huge health hazard. It is estimated that more than 1 million strokes will occur in the United States annually by the year 2050.

Aneurysms of the Abdominal Aorta (AAA)
A silent killer Ninth leading cause of death in the U.S. Familial Often causes no symptoms until rupture George C. Scott recently died of a ruptured abdominal aortic aneurysm Albert Einstein Abdominal aneurysms represent the 9th leading cause of death in the US. Symptoms are rare with this. Aneurysms occur in families and require aggressive screening. Many famous Americans have died from ruptured of abdominal aortic aneurysms.

Prevalence of PAD Increases with Age
1 2 Percentage of Patients with PAD The prevalence of peripheral arterial disease (PAD) is age-dependent. In the Rotterdam study[1] (n=5,450), the prevalence of PAD based on the ankle-brachial index (ABI) increased from 9% of subjects years of age to 57% of patients years of age.[2] Similarly, the prevalence of PAD (diagnosed using non-invasive tests [segmental blood pressure above-knee, below-knee, at ankle, at toe divided by brachial pressure and three measures of flow velocity in each of the femoral and posterior tibial arteries]) increased from 2.5% in subjects years of age to 18.8% of subjects years of age in the San Diego population study[3] (n=624). The incidence of PAD increases with age in both men and women. Some studies show an equal gender prevalence,3,5 and others show a higher prevalence in men.6,7 Key Take Aways: PAD is a highly prevalent disease. The prevalance increases with increasing age. AN estimated 1 out of every 5 people over the age of 70 may have PAD. 1. Meijer WT, Hoes A, Rutgers D, et al. Peripheral arterial disease in the elderly: The Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998;18: 2.Creager M. Management of Peripheral Arterial Disease. Medical, Surgical, and Interventional Aspects. London, England: ReMEDICA Publishing Limited; 2000. 3. Criqui MH, Arnost F, Barret-Connor E, et al. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71: 4. Dawson DL, et al: Peripheral Arterial Disease: Medical care and prevention of complications. Prev Cardiol 2002;5: 5.Newman AB, Siscovick DS, Manolio TA, et al. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Circulation. 1993;88: 6. Hiatt WR, Hoag S, Hamman RF. Effect of diagnostic criteria on the prevalence of peripheral arterial disease. Circulation. 1995;91: 7.Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham Study. J Am Geriatr Soc. 1985;33:13-18. Figure adapted from Creager M. Management of Peripheral Arterial Disease. Medical, Surgical, and Interventional Aspects 1 Criqui MH, Arnost F, Barret-Connor E, et al. Circulation. 1985;71: 2 Meijer WT, Hoes A, Rutgers D, et al. Arterioscler Thromb Vasc Biol. 1998;18:

Mortality in Patients With Severe PAD
Relative 5-Year Mortality 48 44 38 Patients (%) 15 Criqui et al showed a nearly 6-fold increase in relative risk of death from cardiovascular disease in patients with large-vessel PAD (average age 66 years) compared with those without. The elevated risk of death from all causes in patients with established PAD versus normal subjects was due mostly to increased rates of death from cardiovascular disease and coronary heart disease. Rates of death from other causes were not significantly elevated in PAD patients.1 There is a similar correlation between cerbrovascular disease and PAD. The incidence of ischemic stroke has been reported to be as high as 42% in patients with PAD[2]. PAD patients appear to have a poorer prognosis following a stroke than do those without PAD following a stroke[2]. 1. Criqui MH et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326: 2. Dawson DL, et al: Peripheral Arterial Disease: Medical care and prevention of complications. Prev Cardiol 2002;5: ²Breast Cancer ²Colon/Rectal Cancer ¹PAD ²Non-Hodgkin’s Lymphoma Belch JJF. Arch Intern Med 2003;163::884-92

PAD and Relative Risk of Death
6.6 ( ) 5.9 ( ) 3.1 ( ) Relative Risk (95% CI) Criqui et al showed a nearly 7-fold increase in relative risk of death from cardiovascular disease in patients with large-vessel PAD (average age 66 years) compared with those without. The elevated risk of death from all causes in patients with established PAD versus normal subjects was due mostly to increased rates of death from cardiovascular disease and coronary heart disease. Rates of death from other causes were not significantly elevated in PAD patients.1 There is a similar correlation between cerbrovascular disease and PAD. The incidence of ischemic stroke has been reported to be as high as 42% in patients with PAD[2]. PAD patients appear to have a poorer prognosis following a stroke than do those without PAD following a stroke[2]. 1. Criqui MH et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326: 2. Dawson DL, et al: Peripheral Arterial Disease: Medical care and prevention of complications. Prev Cardiol 2002;5: Cause of Death in Patients with PAD Belch JJF. Arch Intern Med 2003;163::884-92

Peripheral Arterial Disease
Symptomatic Disease 34% More than half of patients with PAD are asymptomatic. Only about 30-40% of PAD patients have noticeable symptoms. Even among patients with symptomatic disease, more than half of these patients may present with “atypical symptoms” including pain on exertion associated with reduced ambulatory activity and quality of life.[1] Less than 5 to 10% of patients with PAD have critical leg ischemia (described as ischemic pain in the distal foot, ischemic ulceration, or gangrene), and approximately one-third present with typical claudication. Key Take Away: Regardless of whether a patient has “symptoms” or not, patients with PAD are at high risk of CV morbidity and mortality. Being symptom free does not mean patient is CV risk free. Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med : Asymptomatic Disease 66% Hiatt WR. N Engl J Med. 2001;344:

What Diseases Put People at Risk for PAD?
Hypertension Tobacco Use High Cholesterol Diabetes Mellitus Family History CAD Major atherosclerotic risk factors also play a role in peripheral arterial disease. Diabetes and tobacco use represent the major risk factors for PAD.

Hypertension Risk Factors Increases stiffness of arteries
Promotes narrowing of blood vessels Increases risk of stroke, heart attack, kidney failure Silent Must consider kidney artery blockage as culprit Hypertension results in a progression of atherosclerosis with an increase in risk of stroke, myocardial infarction and renal failure. In patients with peripheral arterial disease who have hypertension, an underlying consideration to renal artery stenosis must be given.

Tobacco Use Risk Factors The major modifiable risk factor
Patients who smoke >15 cigarettes daily have a NINE-FOLD increase in risk of leg pain due to artery blockage Patients who smoke > 5 cigarettes daily close their leg artery bypass grafts more often than those patients who do not smoke Tobacco use represents the major modifiable risk factor for peripheral arterial disease. As you see here, only mild tobacco use represents a marked increased risk of progression of disease. Nicotine is toxic to the endothelial walls of blood vessels. If a patient with PAD stops smoking, the risk of severe leg pain and amputation is decreased. Physicians should do everything within their power to help PAD patients stop smoking.

High Cholesterol Risk Factors
New medical studies suggest that lowering cholesterol levels can halt the progression or even SHRINK plaque in the leg arteries Lowering cholesterol levels DECREASES the risk of Stroke! Hypercholesterolemia is an important modifiable risk factor for peripheral arterial disease. Recent national cholesterol education program guidelines demonstrate that patients with peripheral arterial disease should be treated as coronary heart equivalence, lowering cholesterol levels to coronary levels.

Diabetes Mellitus Risk Factors
Peripheral Artery Disease is FIVE TIMES more common in patients with DM 30 % of patients with DM have PAD Major limb amputation rate is FOUR TIMES HIGHER in patients with DM and PAD than with PAD alone Diabetes Mellitus is a serious risk factor for peripheral arterial disease. PAD is five times more common in patients with diabetes mellitus then without. 30% of patients with diabetes mellitus have PAD and their risk of major limb loss is dramatic.

Family History of PAD Risk Factors
Clear risk factor for other first degree relatives Must make every effort to modify risk factors Early diagnosis is key A family history of atherosclerosis increases the risk factor profile for patients with other risk factors. All efforts must be made to modify those risk factors, which can be altered.

What Symptoms do Patients Have With PAD?
Leg Arteries Pain, Ache, Tightness, Tiredness, Weakness, Numbness in legs brought on by walking and relieved by rest (claudication) Pain in feet at rest due to poor circulation (rest pain) Poorly healing wound Gangrene Symptoms of peripheral arterial disease include intermittent claudication. This is described as a pain, ache, tightness, tiredness, weakness, or numbness in the legs bought on by some activity and relieved by rest. When peripheral arterial circulation deteriorates to a severe degree, rest pain, non-healing wounds on gangrene may ensue.

What Symptoms do Patients Have With PAD?
Claudication Symptoms manifests a level below the vascular lesion Lesion Location Claudicating Muscle distal aorta buttocks common iliac thigh SFA calf tibials NONE!! In carotid disease, transient cerebral ischemia, or TIA’s represent temporary loss of vision in one eye, speech disorders, comprehension disorders, or sensory/motor disorders. These are often warning signs of an impending major stroke.

How Do We Diagnose PAD? Listen to the story
What kind of problems are you having? How long have you been having these problems? What makes the symptoms better/worse? Have you had any prior treatment for these problems? Are things getting worse? The first step in the diagnosis of peripheral vascular disease is to take a good thorough history. The patient’s symptoms are elicited along with the duration and quality of these symptoms. Exacerbating or ameliorating factors are elicited. Prior treatments that have worked or have not worked are reviewed and the tempo of the disease is noted.

How Do We Diagnose PAD? Perform an examination Feel pulses
Feel for aneurysms Listen for noises over arteries that can signify blockage Look at feet A full thorough physical examination is performed including a full pulse examination, palpation for aneurysms, and auscultation for bruits. One often overlooked but critically important examination step is an examination of the feet. Elevation pallor and dependant rubor must be performed, as these are markers of advanced peripheral arterial disease.

Elevation Pallor/Dependent Rubor
This is an example of elevation pallor and dependant rubor. The panel on the left demonstrates the patient laying supine and the foot being elevated 60 degrees above the level for one minute. This intense paleness of the foot represents severe peripheral arterial disease. The panel on the right represents the same foot allowing to hang in a dependant position. This intense red/purple color known as rubor, along with the ulcer on the tip of the left great toe represents advanced PAD and critical limb ischemia.

Don’t Wait For This To Happen...
This is a slide of a patient with diabetes mellitus. You will note gangrene of the great toes along with an ischemic ulcer on the plantar aspect of the right toe. This patient had no pain and was never diagnosed with peripheral arterial disease. This was due to an ill-fitting pair of shoes, which resulted in blisters and ulcer formation.

How Do We Diagnose PAD? Non-Invasive Testing Blood Pressure Cuffs
Duplex Ultrasound Magnetic Resonance Arteriography Computed Tomographic Angiography The methods of imaging include thorough physical examination, ankle brachial index, ultrasound examinations, MRA and CT angiography.

The Ankle-Brachial Index
Probably the most useful, although underutilized diagnostic tool for detecting peripheral arterial disease in the office setting is the Ankle Brachial Index or ABI. This utilizes a hand-held Doppler device to help accurately measure the severity of lower extremity arterial disease. In the patient presenting with signs and symptoms of PAD, it is important to palpate all pulses in the lower extremities when performing a physical examination. Any asymmetry in the quality of the pulses may be an indicator of peripheral arterial disease.

Office Measurement of the Ankle–Brachial Index (ABI)
The ratio of: Highest arm pressure (over) The Doppler instrument is used to locate the pulses in both arms and ankles, and systolic pressures are obtained using similar blood pressure cuffs. The cuff is inflated until the Doppler signal is lost, and then deflated until the signal returns. That measurement is recorded for each arm and each ankle. Use the higher systolic arm pressure and the higher systolic ankle pressure to calculate the Ankle- Brachial Index. In the patient without peripheral arterial disease, systolic pressure in the ankle should be the same or higher than arm pressure. Pressure: PT DP Pressure: PT DP

Ankle – Brachial Index > 0.9 Normal 0.9 to 0.75 Mild PVD
0.75 to 0.4 Moderate PVD (IC) < 0.4 Severe Disease The Ankle-Brachial Index is calculated by dividing the highest systolic ankle pressure by the highest systolic arm pressure. An index at or greater than 0.9 is considered normal. An index at or greater than 0.5 and less than 0.9 is indicative of mild to moderate PAD with claudication, and an ABI of less than 0.5 indicates the likelihood of severe peripheral arterial disease. In addition, systolic pressures in the toes of less than 30 millimeters of mercury indicate a strong likelihood that foot wounds or ulcers will not heal.

Ankle–Brachial Index and Mortality
~1500 Women Over Age 65 in Osteoporosis Study 70 75 80 85 90 95 100 105 1 2 3 4 Number of Years of Follow-up Patient Survival,% >1 1.0->0.9 0.9->0.8 <0.8 The ankle brachial index is not only a marker of atherosclerosis in the lower extremities but an independent predicator of mortality. This study represents patients who had an ankle brachial index obtained and then were followed for four years. You will note that even a mild reduction in the ABI represents a marked reduction in blood pressure. This was a study of over 1,500 women over age 65 who had ABI’s performed as a sub-study for an osteoporosis drug trial. This same finding was found in men of either older or younger age populations. Vogt MT et al. JAMA 1993;270:

Peripheral Arterial Disease
Duplex Ultrasound of Common Femoral Artery Bifurcation This is a duplex ultrasound of the common femoral artery bifurcation. You will notice that the top vessel is the superficial femoral artery and lower vessel the profunda or deep femoral artery. The areas where color does not exist represents atherosclerotic plaque. From lateral to medial the anatomic order is: Nerve, Artery, Vein, Empty space, Lymphatics (NAVEL)

Magnetic Resonance Arteriography
Saccular AAA This is a magnetic resonance arteriogram demonstrating very clearly the renal arteries, abdominal aorta, and iliac arteries. You will notice a saccular abdominal aortic aneurysm. Incidentally noted is severe left common iliac artery disease and an aneurysm of the right external iliac artery.

Inferior Epigastic Artery
Angiogram Severe Right Common Iliac Artery Stenosis Inferior Epigastic Artery External Iliac Artery Internal Iliac Artery This is an angiogram in a patient who presented with right buttocks claudication and a normal ankle brachial index at rest. However with exercise his ankle brachial index markedly deteriorated on the right leg. Because of the benefits of endovascular therapy for iliac disease, an angiogram was performed demonstrating a severe right common iliac artery stenosis and a moderate left common iliac artery stenosis. This right common iliac artery lesion was treated with endovascular stenting with an excellent angiographic and clinical result. Common femoral artery

Angiogram of an AAA This is an angiogram of the abdominal aorta demonstrating a fusiform abdominal aortic aneurysm in the infra renal position. This is a patient who was considered for an endovascular abdominal aortic stent graft.

Stenosis of the Carotid Artery
Duplex US of Severe ICA Stenosis Post CEA This is a correlation slide looking at the accuracy of MR angiography and contrast angiography. On the left is the MRA demonstrating a carotid artery stenosis. You will notice on the right excellent correlation with the angiogram. Options for therapy are generally medical treatments, surgical therapy and endovascular therapy.

What Are the Indications for Therapy?
Critical Limb Ischemia Ischemic Ulceration Disabling Claudication Exercise should not be overlooked in a treatment plan for patients with intermittent claudication. Exercise therapy is effective in increasing walking distance. An appropriate exercise program for these patients includes daily or intermittent walking until the pain is near maximum. The exercise program should continue more than six months, and walking should be the sole form of formal exercise performed by the patient. There are two major categories of interventional approaches to the management of peripheral arterial disease—surgical bypass and endovascular treatment. Endovascular treatment options include percutaneous transluminal angioplasty, stent implantation, thrombolytic therapy for patients with a total occlusion, atherectomy, and adjuvant brachytherapy. When compared with surgical intervention, endovascular procedures offer the potential of reduced risk, shorter recovery and hospitalization periods, and increased cost-effectiveness

Medical Therapy for Intermittent Claudication
Symptom/Limb Tobacco Cessation Foot Care Control of DM Statins Antiplatelet Agents Exercise Cilostazol Life Tobacco Cessation Control of DM Reduction in Cholesterol Reduction in BP Antiplatelet Agents Exercise The medical therapy for intermittent claudication is divided into treatments for life and limb. For prolonging life, aggressive risk factor modification and anti-platelet therapy is critical. For treatment of intermittent claudication, similar risk factor modification, exercise, and consideration to pharmaco therapy like Cilostazol or Platol should be given.

Angioplasty and Stenting of the Iliac Arteries
This is a slide demonstrating the results of bilateral iliac stenting in a patient with significant buttocks and hip claudication bilaterally. The image on the left is before and on the right after this procedure.

Balloon Angioplasty of the SFA
This is a slide demonstrating endovascular PTA of a tibial artery stenosis. If plaque burden is too great for angioplasty , Femoral to Popliteal artery bypass with vein (preferabl) or PTFE is indicated.

The Diagnosis and Treatment of Peripheral Vascular Disease

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