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Peripheral Arterial Disease


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Patient talk I gave on peripheral arterial disease.

Patient talk I gave on peripheral arterial disease.

Published in: Health & Medicine
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  • 1. Peripheral Arterial Disease
    ArunJagannathan MD
    Vascular and Interventional Radiology
    Central Illinois Radiological Associates
  • 2. What is an Interventional Radiologist?
    Interventional radiologists are board-certified physicians who specialize in minimally invasive, targeted treatments. They offer the most in-depth knowledge of the least invasive treatments available coupled with diagnostic and clinical experience across all specialties. They use X-rays, MRI and other imaging to advance a catheter in the body, usually in an artery, to treat at the source of the disease non-surgically. As the inventors of angioplasty and the catheter-delivered stent, which were first used in the legs to treat peripheral arterial disease, interventional radiologists pioneered minimally invasive modern medicine.
  • 3. What is an Interventional Radiologist?
    Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with additional advanced training in minimally invasive, targeted treatments performed using imaging to guide them. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology.
  • 4. Other specialists that treat peripheral arterial disease
    Interventional Cardiologist: a specialist who treats coronary artery disease, peripheral artery disease and all aspects of atherosclerosis
    Vascular Surgeon: a specialist of surgical interventions of arteries and veins and of therapies for the peripheral vascular system
  • 5. Peripheral Arterial Disease
    Peripheral Artery Disease (PAD) is a serious problem
    PAD is often asymptomatic and therefore, is not always easy to detect
    Critical Limb Ischemia, a result of untreated PAD, accounts for the majority of all non-traumatic amputations in the US
  • 6. Peripheral Arterial 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
    1. Becker, GJ, et al. The Importance of Increasing Public and Physician Awareness of Peripheral Arterial Disease. J VascintervRadiol 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, 3333-3341.
    3. “Diagnosis of PAD is Important for People with Diabetes”, American Diabetes Association Consensus Statement, Diabetes Care, November 21, 2003,
    Disease (PAD)
  • 7. Risk Factors for Atherosclerosis
    Sedentary life style
    Age >50
    PVD (carotid stenosis, AAA)
    African Americans, Hispanics, and diabetics have the highest prevalence of PAD
    Sedentary life style
    Age >50
    PVD (carotid stenosis, AAA)
  • 8. 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
  • 9. 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.
  • 10. Why refer claudicating patients for treatment?
    Patients deserve a better quality of life
    Low risk options exist today
    Lesions are easier to treat in earlier stages
    Patients can exercise and improve overall health
    The prognosis for untreated intermittent claudication is not good
  • 11. Population >55 yr
    Peripheral VascularOutcomes
    Other CardiovascularMorbidity/Total Mortality
    Lower ExtremityBypass Surgery7%
    NonfatalCardiovascularEvent(MI/Stroke, 5-year Rate)20%
    Prognosis in Patients with Intermittent Claudication
    Adapted from Weitz JI et al.
    Circulation. 1996;94:3026-3049.
  • 12. Symptomatic and Asymptomatic PAD
    Newly Diagnosed PAD
    Prior Diagnosis of PAD
    PARTNERS Study
    Hirsch AT et al. JAMA. 2001;286:1317-1324.
  • 13. 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 CollCardiol 1994:23:1091-5)
    PAD, symptomatic or asymptomatic, is a powerful independent predictor of CAD and CVD
  • 14.
  • 15. What can we do?
    PAD Screening for Early Detection
    Examine patient medical, surgical, family history
    Question the patient about lifestyle changes and symptoms onset, characteristics, etc.
    Visual screening
    Non-invasive testing
    Referral to interventionalist for further workup
  • 16. Lifestyle Changes and Symptoms
    Questions for patients with possible lower extremity disease:
    What is your typical activity level?
    Do you experience any discomfort in the calf, thigh, buttock or hip area that occurs with walking, climbing stairs?
    Describe the symptom, onset, duration and resolution?
    Do you experience rest pain, leg pain when in bed?
    Have you had any sores or skin ulcerations that won’t heal?
    Any changes in the color, temperature or appearance of your skin?
    Any problems with impotence or pain in your genitals?
  • 17. Differentiating Leg Pain
  • 18. 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
  • 19.
  • 20. PAD Diagnostic Tests
    Non-invasive tests1
    ABI (Ankle/Brachial Index)
    Exercise Test
    Segmental Pressures
    Segmental Volume Plethysmography
    Duplex Ultrasonography
    MRA (Magnetic Resonance Arteriography)
    CTA (Computed TomographicArteriography)
    Invasive tests1
    Peripheral Angiography
    1. Krajewski and Olin Chapter 11 Peripheral Vascular Disease. 2nd ed. 1996
  • 21.
  • 22.
  • 23. ADA Consensus Panel
    Recommends ABI Screening for:
    Patients over the age of 50 years who have diabetes
    Patients with diabetes younger than 50 years of age who have other PAD risk factors (ie. Smoking, hypertension, hyperlipidemia, diabetes more than 10 years)
    ABI should be repeated in 5 years if normal
    If ABI is abnormal, then patient should be referred
    Source: Peripheral Arterial Disease in People with Diabetes, ADA, Consensus Statement, Diabetes Care, Volume 26, Number 12, December 2003.
  • 24. The Ankle-Brachial Index
    Lower extremity systolic pressure
    Brachial artery systolic pressure
    ABI =
    Normal 0.95-1.2
    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. PAD Treatment Options
    Risk Factor Modification*
    Exercise Therapy*
    Drug Therapy*
    Endovascular Therapy
    Peripheral Transluminal Angioplasty*
    Peripheral Stenting*
    Thrombolytic Therapy (adjunctive)
    Bypass Grafts*
    *Rosenfield K, Isner JM, Chap. 97 Textbook of Cardiovascular Medicine 1998
  • 26. SilverhawkAtherectomy
  • 27. Critical Limb Ischemia/ Limb Salvage
    100% SFA
    SFA post
    Patent peroneal with runoff to foot
    Zero runoff
  • 28. PAD Video