Peripheral Artery Disease

1. Dr Dinesh Pandey
MBBS, DNB (Gen Med). Fellow DrNB Cardiology

2. Peripheral artery disease (PAD) generally refers to acute or
chronic obstruction of the arteries supplying the lower or upper
extremities that, when severe, results in downstream ischemia and
potentially tissue loss.
• Most often caused by atherosclerosis
• PAD may also result from
• Thrombosis
• Embolism
• Vasculitis
• fibromuscular dysplasia (FMD)
• entrapment.

3. - 6% in persons 40 years and older
• 15% to 20% in those 65 years and older
• The annual increase of incidence and
prevalence of PAD are 2.69% and
12.02%, respectively.

4. • PAD affects some 8 to 10 million individuals in the United States
and more than 200 million people worldwide.
• The prevalence of PAD is greater in men than in women in most
studies.

5.  Age ≥65 y
 Age 50–64 y, with risk factors for atherosclerosis (e.g., diabetes mellitus, history
of smoking, hyperlipidemia, hypertension) or family history of PAD
 Age <50 y, with diabetes mellitus and 1 additional risk factor for atherosclerosis
 Individuals with known atherosclerotic disease in another vascular bed (e.g.,
coronary, carotid, subclavian, renal, mesenteric artery stenosis, or AAA)
Patients at Increased Risk of PAD

9. CLINICAL FEATURES
• Asymptomatic
• Atypical symptoms
• Intermittent claudication
• Critical limb ischemia (CLI) or chronic limb-threatening ischemia (CLTI)
• Rest Pain
• Ulceration
• Necrosis/Gangrene
• Acute limb ischemia: The five “P”s, defined by the clinical symptoms and signs that
suggest potential limb jeopardy:
 Pain
 Pulselessness
 Pallor
 Paresthesias
 Paralysis

10. Typical vs Atypical Symptoms
in Patients With Symptomatic PAD
33%2
>50%2
Atypical Symptoms1
• Exertional leg pain that
– may involve areas other than the calves
– may not stop the patient from walking
– may not resolve within
10 minutes of rest
Typical Symptoms1
Intermittent claudication
• Exertional calf pain that
– causes the patient to
stop walking
– resolves within 10 minutes of rest
1. McDermott MM et al. JAMA. 2001;286:1599-1606.
2. Hiatt WR. N Engl J Med. 2001;344:1608-1621.
Other nonspecific leg
symptoms that may be
indicative of PAD

11. Worsening
Claudication
16%
Natural History
Intermittent Claudication
Population > 55 yr
Intermittent
Claudication
5%
Peripheral Vascular
Outcomes
Other Cardiovascular
Morbidity/Total Mortality
Lower Extremity
Bypass Surgery
7%
Major
Amputation
4%
Nonfatal
Cardiovascular
Event
(MI/Stroke)
20%
5-yr
Mortality
30%
Cardiovascular
Cause
75%
Weitz JI et al. Circulation. 1996;94:3026–3049.

13. Ischemia in
Buttock, hip,
thigh
Thigh,
calf
Calf, ankle,
foot
Obstruction in
Aorta or
iliac artery
Femoral artery
or branches
Popliteal artery
or distal
Common Sites of Claudication

14. Does the Patient Have Intermittent Claudication?
Claudication Pseudoclaudication
Characteristic of
discomfort
Cramping, tightness, aching,
fatigue
tingling, burning, numbness
Location of
discomfort
Buttock, hip, thigh,
calf, foot
Same
Exercise-induced Yes Variable
Distance Consistent Variable
Occurs with standing No Yes
Action for relief Stand Sit, change position
Time to relief Less than 10 minutes Up to 30 minutes

16. Physical Findings
• A complete CV examination includes palpation of the peripheral pulses, inspection of
the extremities, including the feet, and auscultation of accessible arteries for bruits.
• Pulse abnormalities and bruits increase the likelihood of PAD.
• The legs of patients with chronic aorto iliac disease may show muscle atrophy.
• Additional signs of chronic low-grade ischemia include hair loss, dystrophic, thickened
and brittle toe nails, smooth and shiny skin, and atrophy of the subcutaneous fat of the
digital pads.

17. • Patients with severe limb ischemia have cool
skin and may also have petechiae, persistent
cyanosis or pallor, dependent rubor, pedal
edema resulting from prolonged
dependency, skin fissures, ulceration, or
gangrene.
• The ulcers caused by PAD typically have a
pale base with irregular borders and usually
involve the tips of the toes or the heel of
the foot or develop at sites of pressure
• These ulcers vary in size and may be as
small as 3 to 5 mm.
Arterial ulcer. Discrete, circumscribed,
necrotic ulcer located on the great toe.

19. Diagnostic Testing
 Ankle-brachial index
 Segmental limb pressures
 Pulse volume recordings
 Doppler velocity waveform analysis
 Functional testing
 Treadmill exercise testing
 Duplex scanning
 Advanced imaging techniques

20. How to Perform and
Calculate the ABI
≥1.0 — Normal
0.81-0.90 — Mild Obstruction
0.41-0.80 — Moderate Obstruction
≤0.40 — Severe Obstruction
Right Arm
Pressure:
Left Arm
Pressure:
Pressure:
PT
DP
Right ABI
Higher Right Ankle Pressure mm Hg
Higher Arm Pressure mm Hg
Left ABI
Higher Left Ankle Pressure mm Hg
Higher Arm Pressure mm Hg
Pressure:
PT
DP

21. Ankle-Brachial Index
• An ABI of 0.90 or lower has a specificity of 83% to 99% and a sensitivity of 61% to
73% in detecting stenosis greater than 50%.
• A low ABI is associated with shorter walking distance and lower speed
• An ABI higher than 1.40 indicates a noncompressible artery, and the test is not
informative for either confirming or excluding PAD.
• In this case, a toe-brachial index (TBI) may be informative, with a ratio of 0.70 or
higher reflecting normal perfusion pressure

22. Segmental Pressure Measurement
• Simplest noninvasive measures
• BP gradient in excess of 20 mm Hg between
successive cuffs is generally used as evidence of
arterial stenosis in the lower extremity, whereas a
gradient of 10 mm Hg indicates a stenosis
between sequential cuffs in the upper extremity.
• Approximately 90% of the cross-sectional area of
the aorta must be narrowed before a pressure
gradient develops.
• In smaller vessels, such as the iliac and femoral
arteries, a 70% to 90% decrease in cross-
sectional area will cause a resting pressure
gradient sufficient to decrease SBP distal to the
stenosis

23. Treadmill Exercise Testing
• To evaluate the clinical significance of peripheral artery stenosis and provide
objective evidence of the patient’s walking capacity
• Treadmill testing can determine whether arterial stenosis contribute to the patient’s
symptoms of exertional leg pain.
• Post exercise ABI <0.90 or a drop of ABI >20% or ankle pressure drop >30 mm Hg are
usually considered as diagnostic.

24. Physiological Testing
COR LOE Recommendations
I B-NR
TBI should be measured to diagnose patients with suspected PAD when
the ABI is greater than 1.40.
I B-NR
Patients with exertional non–joint-related leg symptoms and normal or
borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill
ABI testing to evaluate for PAD.
IIa B-NR
In patients with PAD and an abnormal resting ABI (≤0.90), exercise
treadmill ABI testing can be useful to objectively assess functional status.

25. Physiological Testing (cont’d)
COR LOE Recommendations
IIa B-NR
In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the
setting of nonhealing wounds or gangrene, it is reasonable to diagnose CLI
by using TBI with waveforms, TcPO2, or SPP.
IIa B-NR
In patients with PAD with an abnormal ABI (≤0.90) or with
noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of
nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be
useful to evaluate local perfusion.

26. Pulse Volume Recording
SAGE Open Medicine Volume 4: 1–9 © The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2050312116659088 smo.sagepub.com

27. Doppler Ultrasonography
• The normal Doppler waveform has three components:
• a rapid forward-flow component during systole
• a transient flow reversal during early diastole
• a slow anterograde component during late diastole.
• The Doppler waveform becomes altered if the probe is placed distal to an arterial
stenosis and is characterized by deceleration of systolic flow, loss of the early
diastolic reversal, and diminished peak frequencies.
• Arteries in a limb with critical ischemia may not show any Doppler frequency shift.

28. Duplex Ultrasound Imaging
• Provides a direct, noninvasive means of assessing both the anatomic characteristics of
peripheral arteries
• An effective means of localizing peripheral arterial stenosis
• Normal arteries have laminar flow, with the highest velocity occurring at the center of the
artery.
• In the presence of an arterial stenosis, blood flow velocity increases .
• A two fold or greater increase in peak systolic velocity indicates a 50% or greater stenosis
• A three fold increase in velocity suggests a 75% or greater stenosis.
• An occluded artery generates no Doppler signal.
• Duplex ultrasound imaging for identification of sites of arterial stenosis has approximately 89%
to 99% specificity and 80% to 98% sensitivity.

29. FIGURE 43.5 Duplex ultrasonogram of the common femoral artery (CFA) bifurcation into the superficial
femoral artery (SFA) and deep femoral artery. A, Normal gray-scale image of the artery in which the intima is
not thickened and the lumen is widely patent. B, Recording of the pulse Doppler velocity sampled from the
superficial femoral artery. The triphasic profile is apparent, the envelope is thin, and peak systolic
velocity is within normal limits.

31. Advanced Vascular Imaging
CT Angiography
• CTA permits imaging of
peripheral arteries with
excellent spatial resolution
during a relatively short time
and with limited amounts of
radiocontrast material
• Image reconstructions in three
dimensions permit rotation to
optimize visualization of
arterial stenosis.
• Compared with conventional
contrast-enhanced angiography,
the sensitivity and specificity for
stenosis greater than 50% or
occlusion reported for CTA
using multidetector technology
are 95% and 96%, respectively
MR Angiography
• Magnetic resonance angiography (MRA)
can visualize the aorta and peripheral
arteries noninvasively.
• Resolution of the vascular anatomy with
gadolinium-enhanced MRA approaches
that of conventional contrast-enhanced
digital subtraction angiography (DSA).
• Comparison of MRA with intra-arterial
DSA found a sensitivity of 95% and a
specificity of 96% .

32. Contrast-Enhanced Angiography
• Conventional angiography can aid in evaluation of the arterial anatomy before
a revascularization procedure.
• It still has occasional usefulness when the diagnosis is in doubt.
• Most contemporary angiography laboratories use digital subtraction
techniques after intra-arterial administration of contrast material to enhance
resolution.

34. Treatement
• Risk Factor Modification
• Diet modification
• Weight optimization
• Exercise
• Smoking cessation
• Optimization of risk factors such as
• Hypertension
• Dyslipidemia.
• Glucose management
• Drugs

37. Statin Agents
COR LOE Recommendations
I A
Treatment with a statin medication is indicated for all
patients with PAD.

38. Antihypertensive Agents
COR LOE Recommendations
I A
Antihypertensive therapy should be administered to patients
with hypertension and PAD to reduce the risk of MI, stroke,
heart failure, and cardiovascular death.
IIa A
The use of angiotensin-converting enzyme inhibitors or
angiotensin-receptor blockers can be effective to reduce the
risk of cardiovascular ischemic events in patients with PAD.

39. Oral Anticoagulation
COR LOE Recommendations
IIb B-R
The usefulness of anticoagulation to improve patency after lower extremity
autogenous vein or prosthetic bypass is uncertain.
III: Harm A
Anticoagulation should not be used to reduce the risk of cardiovascular
ischemic events in patients with PAD.

40. Smoking Cessation
COR LOE Recommendations
I A
Patients with PAD who smoke cigarettes or use other forms of tobacco should
be advised at every visit to quit.
I A
Patients with PAD who smoke cigarettes should be assisted in developing a
plan for quitting that includes pharmacotherapy (i.e., varenicline,
buproprion, and/or nicotine replacement therapy) and/or referral to a
smoking cessation program.
I B-NR
Patients with PAD should avoid exposure to environmental tobacco smoke at
work, at home, and in public places.

42. Glycemic Control
COR LOE Recommendations
I C-EO
Management of diabetes mellitus in the patient with PAD should be
coordinated between members of the healthcare team.
IIa B-NR
Glycemic control can be beneficial for patients with CLI to reduce limb-
related outcomes.

43. Cilostazol, Pentoxifylline, and Chelation Therapy
COR LOE Recommendations
Cilostazol
I A
Cilostazol is an effective therapy to improve symptoms and increase
walking distance in patients with claudication.
Pentoxifylline
III: No
Benefit
B-R
Pentoxifylline is not effective for treatment of claudication.
Chelation Therapy
III: No
Benefit
B-R
Chelation therapy (e.g., ethylenediaminetetraacetic acid) is not
beneficial for treatment of claudication.

44. Homocysteine Lowering
Medical Therapy for the Patient With PAD
COR LOE Recommendation
III: No
Benefit
B-R
B-complex vitamin supplementation to lower homocysteine levels
for prevention of cardiovascular events in patients with PAD is not
recommended.

45. Influenza Vaccination
Medical Therapy for the Patient With PAD
COR LOE Recommendation
I C-EO Patients with PAD should have an annual influenza vaccination.

46. Structured Exercise Therapy
COR LOE Recommendations
I A
In patients with claudication, a supervised exercise program is
recommended to improve functional status and QoL and to reduce leg
symptoms.
I B-R
A supervised exercise program should be discussed as a treatment option for
claudication before possible revascularization.
IIa A
In patients with PAD, a structured community- or home-based exercise program
with behavioral change techniques, can be beneficial to improve walking ability
and functional status.
IIa A
In patients with claudication, alternative strategies of exercise therapy, including
upper-body ergometry, cycling, and pain-free or low-intensity walking that
avoids moderate-to-maximum claudication while walking, can be beneficial to
improve walking ability and functional status.

48. Minimizing Tissue Loss in Patients With PAD
COR LOE Recommendations
I C-LD
Patients with PAD and diabetes mellitus should be counseled about self–foot
examination and healthy foot behaviors.
I C-LD
In patients with PAD, prompt diagnosis and treatment of foot infection
are recommended to avoid amputation.
IIa C-LD
In patients with PAD and signs of foot infection, prompt referral to an
interdisciplinary care team can be beneficial.
IIa C-EO
It is reasonable to counsel patients with PAD without diabetes mellitus about
self-foot examination and healthy foot behaviors.
IIa C-EO
Biannual foot examination by a clinician is reasonable for patients with
PAD and diabetes mellitus.

49. Revascularization for Claudication
2016 AHA/ACC Lower Extremity PAD Guideline
COR LOE Recommendation
IIa A
Revascularization is a reasonable treatment option for the patient
with lifestyle-limiting claudication with an inadequate response to
GDMT.

50. Endovascular Revascularization for Claudication
COR LOE Recommendations
I A
Endovascular procedures are effective as a revascularization option for
patients with lifestyle-limiting claudication and hemodynamically significant
aortoiliac occlusive disease.
IIa B-R
Endovascular procedures are reasonable as a revascularization option for
patients with lifestyle-limiting claudication and hemodynamically significant
femoropopliteal disease.
IIb C-LD
The usefulness of endovascular procedures as a revascularization option for
patients with claudication due to isolated infrapopliteal artery disease is
unknown.
III: Harm B-NR
Endovascular procedures should not be performed in patients with PAD
solely to prevent progression to CLI.

51. Surgical Revascularization for Claudication
COR LOE Recommendations
I A
When surgical revascularization is performed, bypass to the popliteal artery
with autogenous vein is recommended in preference to prosthetic graft
material.
IIa B-NR
Surgical procedures are reasonable as a revascularization option for patients
with lifestyle-limiting claudication with inadequate response to GDMT,
acceptable perioperative risk, and technical factors suggesting advantages over
endovascular procedures.
III: Harm B-R
Femoral-tibial artery bypasses with prosthetic graft material should not be used
for the treatment of claudication.
III: Harm B-NR
Surgical procedures should not be performed in patients with PAD solely to
prevent progression to CLI.

54. Revascularization for ALI
COR LOE Recommendations
I C-LD
In patients with ALI, the revascularization strategy should be
determined by local resources and patient factors (e.g., etiology and
degree of ischemia).
I A
Catheter-based thrombolysis is effective for patients with ALI and a
salvageable limb.
I C-LD
Amputation should be performed as the first procedure in patients with a
nonsalvageable limb.
I C-LD
Patients with ALI should be monitored and treated (e.g., fasciotomy) for
compartment syndrome after revascularization.

55. Revascularization for ALI (cont’d)
COR LOE Recommendations
IIa B-NR
In patients with ALI with a salvageable limb, percutaneous mechanical
thrombectomy can be useful as adjunctive therapy to thrombolysis.
IIa C-LD
In patients with ALI due to embolism and with a salvageable limb,
surgical thromboembolectomy can be effective.
IIb C-LD
The usefulness of ultrasound-accelerated catheter-based thrombolysis for
patients with ALI with a salvageable limb is unknown.

56. Management of CLI
2016 AHA/ACC Lower Extremity PAD Guideline
CLI Definition:
A condition characterized by chronic (≥2 wk) ischemic rest pain, nonhealing
wound/ulcers, or gangrene in one or both legs attributable to objectively proven arterial
occlusive disease.
• The diagnosis of CLI is a constellation of both symptoms and signs. Arterial disease can be
proved objectively with ABI, TBI, TcPO2, or skin perfusion pressure. Supplementary
parameters, such as absolute ankle and toe pressures and pulse volume recordings, may also
be used to assess for significant arterial occlusive disease. However, a very low ABI or TBI does
not necessarily mean the patient has CLI. The term CLI implies chronicity and is to be
distinguished from ALI.

58. Revascularization for CLI
Management of CLI
COR LOE Recommendation
I B-NR
In patients with CLI, revascularization should be performed
when possible to minimize tissue loss.
I C-EO
An evaluation for revascularization options should be performed by
an interdisciplinary care team before amputation in the patient
with CLI.

59. Endovascular Revascularization for CLI
COR LOE Recommendations
I B-R
Endovascular procedures are recommended to establish in-line
blood flow to the foot in patients with nonhealing wounds or
gangrene.
IIa C-LD
A staged approach to endovascular procedures is reasonable in
patients with ischemic rest pain.
IIa B-R
Evaluation of lesion characteristics can be useful in selecting the
endovascular approach for CLI.
IIb B-NR
Use of angiosome-directed endovascular therapy may be
reasonable for patients with CLI and nonhealing wounds or
gangrene.

60. Surgical Revascularization for CLI
COR LOE Recommendations
I A
When surgery is performed for CLI, bypass to the popliteal or
infrapopliteal arteries (i.e., tibial, pedal) should be constructed
with suitable autogenous vein.
I C-LD
Surgical procedures are recommended to establish in-line blood
flow to the foot in patients with nonhealing wounds or
gangrene.
IIa B-NR
In patients with CLI for whom endovascular revascularization has
failed and a suitable autogenous vein is not available, prosthetic
material can be effective for bypass to the below-knee popliteal
and tibial arteries.
IIa C-LD
A staged approach to surgical procedures is reasonable in patients
with ischemic rest pain.

61. PROGNOSIS

68. Summary of PAD and Its Management
 PAD is common and has a significant impact upon cardiovascular outcomes
 Treatment of PAD, even asymptomatic, should focus on risk factor modification/risk
reduction
 Treatment of intermittent claudication should include exercise therapy, drug therapy
and selective use of revascularization
 Treatment for critical limb ischemia warrants aggressive efforts at revascularization,
including surgery, to reduce the risk of amputation

69. Thank you…..