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1. T A O F A N, MD
Current Management of Peripheral Artery Disease:
Focus on Lower Limb
WEBINAR
Functional Medical Staff – Vascular Medicine Division
Cardiology and Vascular Medicine Department
Faculty of Medicine Universitas Indonesia
National Cardiovascular Center Harapan Kita
10th September 2018

2. Peripheral artery disease (PAD)
• Peripheral artery disease (PAD) : disorder in which blood
supply to the lower or upper extremities is obstructed
• Most commonly caused by atherosclerosis,
• may also result from thrombosis, embolism,
vasculitis, fibromuscular dysplasia, or entrapment
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th edition.
Philadelphia: Elsevier Science, 2015.

3. Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the European Society for
Vascular Surgery (ESVS):

4. Usually a patient comes with…

5. Cause of Amputation

6. SCOPE OF VASCULAR MEDICINE
VASCULAR
MEDICINE
BLOOD
VESSELS
ARTERIES
AORTA
PERIPHERAL
ARTERIES
VEINS
LYMPH
VESSELS

7. VASCULAR DISEASES
VASCULAR
DISEASE
TARGET ORGAN
AORTA ARTERIES VEINS LYMPHS
ETIOLOGY
ATHEROSCLER
OSIS
THROMBOSIS
INFLAMMATION
CONGENITAL
AUTOIMMUNE
NEOPLASMA
TRAUMA

8. Management
Preventive Curative
Medical
Treatment
Definitive
Percutaneous
Intervention
Surgery
Rehabilitation
MANAGEMENT OF VASCULAR DISEASE

9. Epidemiology
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th edition. Philadelphia: Elsevier Science, 2015.

10. Epidemiology
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th edition. Philadelphia: Elsevier Science, 2015.

12. Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th edition. Philadelphia: Elsevier Science, 2015.

13. A Clinical Approach to the Management of
the Patient with Coronary (Co) and / or
Carotid (Ca) Artery Disease who
presents with Leg Ischaemia (Lis)
Denis L Clement, Henri Boccalon, John Dormandy,
Isabelle Durand-Zaleski, Gerry Fowkes, Lars Norgren,
P-F Plouin, Tim Brown
International Angiology 2000; 19: 97-125
The CoCaLis Document

14. Lower Limb Artery Disease Combined With …
Pts. Male / 57 years old
(Coronary)
(Lower Limb)
(Carotid)
(Renal)

15. Clinical Presentations of PAD
~15%
Classic (Typical)
Claudication
~33%
Atypical
Leg Pain
(functionally limited)
50%
Asymptomatic
1%-2%
Critical
Limb Ischemia
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th edition.
Philadelphia: Elsevier Science, 2015.

16. Pathophysiology
Supply Demand
≠
Imbalance between circulatory
supply and demand to skeletal
muscle
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th edition. Philadelphia: Elsevier Science, 2015.
• Intermittent Claudication  single
or multiple occlusive lesions in the
arteries supplying the limb.
• Normal at rest
• Obstructive lesions limit blood flow
and O2 delivery during exercise
• Critical limb ischemia  multiple
occlusive lesions that often affect
both proximal and distal limb
arteries
• The resting blood supply diminishes
and cannot meet the nutritional needs
of the limb

17. Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.

18. Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity
Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Circulation. 2017;135(12):e726-e779.

19. Diagnostic Vascular Test
• Non-Invasive
• ABI
• Exercise treadmill testing
• Segmental Limb pressure
• Segmental volume plethysmography
• Doppler US
• Contrast-enhanced MRA/CTA
• Invasive
• Angiography – Gold Standart

20. Ankle – Brachial
Index
Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s Heart Disease A Textbook of Cardiovascular Medicine. 10th ed. Elsevier Saunders, Philadelphia; 2015

21. Using the ABI: An Example
ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.
Right ABI
80/160=0.50
Brachial SBP
160 mm Hg
PT SBP 120 mm Hg
DP SBP 80 mm Hg
Brachial SBP
150 mm Hg
PT SBP 40 mm Hg
DP SBP 80 mm Hg
Left ABI
120/160=0.75
Highest
brachial SBP
Highest of PT
or DP SBP
ABI
(Normal >0.90)
Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e726-e779.

22. Toe-Brachial Index
Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s Heart Disease A Textbook of Cardiovascular Medicine. 10th ed. Elsevier Saunders, Philadelphia; 2015

23. Pulse Volume Recording
• Normal  sharp systolic upstroke rising rapidly
to a peak, a dicrotic notch, and a concave
downslope that drops off gradually toward the
baseline
• PAD  loss of the dicrotic notch, a slower rate of
rise, a more rounded peak, and a slower descend
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th edition. Philadelphia: Elsevier Science, 2015.

24. Treadmill Exercise Test
• Can be used to evaluate the clinical significance of PAD stenoses and provide
objective evidence of the patient’s walking capacity.
• The claudication onset time  symptoms of claudication first develop, and the
peak walking time occurs when the patient is no longer able to continue
walking because of severe leg discomfort
• Ankle and brachial SBP is measured during resting conditions before treadmill
exercise, within 1 minute after exercise, and repeatedly until baseline values
are reestablished.
• Normal  increase BP during exercise should be the same in both the upper
and lower extremities, with a constant ABI of 1.0 or greater.
• PAD  ABI decreases because the increase BP in the arm is not matched
compare to ankle BP
• ≥ 25% decrease in the ABI after exercise  PAD
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th edition. Philadelphia: Elsevier Science,
2015.
Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report
of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e726-e779.

25. Transcutaneous Oxymetry (TCPO2/ TCOM)
• Measure the local O2 tension in
the skin deriving from the local
capillary ( nutritive) blood
perfusion
• TcPO2 is not affected by arterial
calcification and is particularly
useful in evaluating PAD in
diabetic patients
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th edition. Philadelphia: Elsevier Science, 2015.

26. Duplex-Doppler Ultrasound Imaging
Duplex ultrasonography
(DUS) is a commonly used
noninvasive method to
visualize and assess the
extent of arterial stenoses
and the corresponding
reductions in blood flow
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th edition. Philadelphia: Elsevier
Science, 2015.
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases

27. Computed Tomographic Angiography (CTA)
• Not recommended for
screening purposes due to
the high doses of
radiation used, potential
contrast nephrotoxicity
• Nephrotoxicity can be
limited by minimizing the
volume of contrast agents
and adequate hydration
before and after imaging.
CTA in a patient with complete occlusion of the
aorta and both iliac arteries. The common
femoral arteries have been reconstituted.
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th edition. Philadelphia: Elsevier Science, 2015.

28. Magnetic Resonance Angiography (MRA)
MRA usefulness: evaluation of symptomatic patients to assist in decision making
before endovascular and surgical intervention or in patients at risk for renal, allergic,
or other complications during conventional angiography
Gadolinium-enhanced 2D-MRA of the aorta and both legs extending from the thighs to above the ankle.
A, Aortoiliac atherosclerosis with a stenosed left common iliac artery.
B, Bilateral superficial femoral artery occlusion with reconstitution of the distal portion of the right and left superficial
femoral arteries.
C. The anterior tibial, posterior tibial, and peroneal arteries, which are patent in each leg.
Mann DL, Libby PP, Bonow RO,Zipes DP. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th edition. Philadelphia: Elsevier Science, 2015.

29. Management
Smoking Cessation
Lipid lowering theraphy
Treatment of Diabetes
Blood Pressure Control
Antiplatelet theraphy
Exercise Rehabilitation
Pharmacotheraphy
Endovascular treatment
Surgery
Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration
With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral,
Mesenteric, Renal, Upper and Lower Extremity Arteries. Eur Heart J 2017;Aug 26:[Epub ahead of print]

30. • Cilostazol
• PDE-3 inhibitor
• Improvement of walking impairment due to claudication
• Side effects include  headache, diarrhea, dizziness, and
palpitations and in 1 trial, 20% of patients discontinued cilostazol
within 3 months
• CI : heart failure
• Pentoxifilline
• Xanthine derivative
• For patients with intermittent claudication ability to decrease
blood viscosity and to improve erythrocyte deformability
• Antiinflammatory and antiproliferative effects
Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease:
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation.
2017;135(12):e726-e779.
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases

31. Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration
With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral,
Mesenteric, Renal, Upper and Lower Extremity Arteries. Eur Heart J 2017;Aug 26:[Epub ahead of print]

32. Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration
With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral,
Mesenteric, Renal, Upper and Lower Extremity Arteries. Eur Heart J 2017;Aug 26:[Epub ahead of print]

33. CRITICAL LIMB ISCHEMIA

34. Critical Limb Ischemia (CLI)
• A condition characterized by chronic (≥2weeks) ischemic rest pain,
nonhealing wound/ulcers, or gangrene in 1 or both legs
attributable to objectively proven arterial occlusive disease.
• The term CLI implies chronicity and is to be distinguished from ALI
Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity
Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Circulation. 2017;135(12):e726-e779.

35. Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A
Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e726-
e779.

36. Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity
Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Circulation. 2017;135(12):e726-e779.

37. WIFI Classification risk for amputation
Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the
European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral, Mesenteric, Renal, Upper
and Lower Extremity Arteries. Eur Heart J 2017;Aug 26:[Epub ahead of print]

38. WIFI estimation risk for amputation at 1
year and benefit from revascularization
Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent
Radiol. 2014;31:378–88.

39. Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the
Diagnosis and Treatment of Peripheral Arterial Diseases, in
Collaboration With the European Society for Vascular Surgery (ESVS):

40. Acute Limb Ischemia (ALI)
• Acute (<2 wk), severe hypoperfusion of the limb
characterized by these features: pain, pallor,pulselessness,
poikilothermia (cold), paresthesias, and paralysis
• One of these categories of ALI is assigned:
• Viable Limb is not immediately threatened; no sensory loss; no
muscle weakness; audible arterial and venous Doppler
• Threatened  Mild-to-moderate sensory or motor loss; inaudible
arterial Doppler; audible venous Doppler; may be further divided into
IIa (marginally threatened) or IIb (immediately threatened)
• Irreversible  Major tissue loss or permanent nerve damage ;
profound sensory loss, anesthetic; profound muscle weakness or
paralysis (rigor); inaudible arterial and venous Doppler
Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity
Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Circulation. 2017;135(12):e726-e779.

41. Clinical Manifestations
6P
Pain
Paresthesia
Pallor
Pulselessness
Poikilothermia
Paralysis
• Clinical Manifestations related to occlusion location and caused by
decreased perfusion
• Pain elicited rapidly on distal part of occlusion
• Onset less than 14 days
SYMPTOMS
Pain
Tingling
Weakness
SIGNS
Loss of Pulse
Pallor
Cold Skin
Decreased
motoric and
sensoric
Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s Heart Disease A Textbook of Cardiovascular Medicine. 10th ed. Elsevier Saunders,
Philadelphia; 2015

42. Findings Doppler Signals
Category Description,
prognosis
Sensory Loss Muscle
Weakness
Arterial Venous
I. Viable Not immediately
threatened
None None audible Audible
II. Threatened
a. Marginally Salvageable if
treated promptly
Minimal
(toes) or
none
None (Often)
inaudible
Audible
b. Immediately Salvageable with
immediate
revascularization
More than
toes, rest
pain
Mild, moderate (Usually)
inaudible
Audible
III. Irreversible Major tissue loss or
permanent nerve
damage inevitable
Profound,
anesthetic
Profound,
paralysis (rigor)
Inaudible Inaudible
Table Clinical Categories of Acute Limb Ischemia
Aboyans V, Ricco JB, Bartelink ML, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration
With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral,
Mesenteric, Renal, Upper and Lower Extremity Arteries. Eur Heart J 2017;Aug 26:[Epub ahead of print]

43. ESC Guidelines on the diagnosis and treatment of peripheral artery
diseases 2017

44. ESC Guidelines on the diagnosis and treatment of peripheral artery
diseases 2017