Simposium v. 1. pad management. dr. hariadi h. sppd spjpk

CURRICULUM VITAE
Nama : dr. Hariadi Hariawan SpPD SpJP (K)
Tempat, tanggal lahir : Lumajang, 18 Juni 1953
Current Education :
 Internist : Universitas Gadjah Mada (1993)
 Cardiologist : Universitas Indonesia (2006)
 Cardiologist Consultant : Universitas Indonesia (2008)
Current Position:
 Staf Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah Mada/RSUP
dr. Sardjito Yogyakarta
 Kepala Program Studi Bagian Kardiologi dan Kedokteran Vaskular Universitas
Gadjah Mada/RSUP dr. Sardjito Yogyakarta

MEDICAL MANAGEMENT
AND REVASCULARIZATION
OF PERIPHERAL ARTERY
DISEASE
Hariadi Hariawan
Department of Cardiology andVascular Medicine - Medical School
Universitas Gadjah Mada / RSUP Dr Sardjito
Yogyakarta

Peripheral Arterial Disease (PAD)
• PAD: is a manifestation of systemic
atherosclerosis that is common
• Associated with an increased risk of death and
ischemic events
• May be underdiagnosed in primary care
practice.

PAD
• PAD : stenosis / occlusion of upper or lower-
extremity arteries due to atherosclerotic or
thromboembolic disease.1)
• In practice, the term PAD generally refers to
chronic narrowing or blockage (also referred
to as atherosclerotic disease) of the lower
extremities

PAD
• PAD : 12-14% population
• >20% of patients >65 yo4)
• Male >
• Increasing with DM,
Hipertension, Dyslipidemia
Smoking .5)

PAD: PREVALENCE vs AGE
Criqui MH, et al, Circulation, 1985

Fontaine classification
• Stage I : No symptoms
• Stage IIa : Intermittent claudication >200 m of
walking distance (mild)
• Stage IIb : Intermittent claudication <200 m of
walking distance (moderate to severe)
• Stage 3 : Rest pain
• Stage 4 : Necrosis/gangrene

Rutherfort Classification
• Stage 0 : Asymptomatic
• Stage 1 : Mild claudication
• Stage 2 : Moderate claudication
• Stage 3 : Severe claudication
• Stage 4 : Rest pain
• Stage 5 : Ischemic ulceration not exceeding ulcer
of the digits of the foot
• Stage 6 : Severe ischemic ulcers or frank
gangrene

Individuals with PAD Present in Clinical
Practice with Distinct Syndromes
Asymptomatic: Without obvious symptomatic
complaint (but usually with a functional impairment).
Classic Claudication: Lower extremity symptoms
confined to the muscles with a consistent (reproducible)
onset with exercise and relief with rest.
“Atypical” leg pain: Lower extremity discomfort that is
exertional, but that does not consistently resolve with
rest, consistently limit exercise at a reproducible
distance

Individuals with PAD Present in Clinical Practice
with Distinct Syndromes
Critical Limb Ischemia: Ischemic rest pain, non-healing
wound, or 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

Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudication
±Impotence – Leriche’s Syndrome

What does the ABI mean?
ABI Clinical Correlation
>0.9 Normal Limb
0.5-0.9 Intermittent Claudication
<0.4 Rest Pain
<0.15 Gangrene
CAUTION:
Patient’s with Diabetes + Renal Failure:
They have calcified arterial walls which can falsely elevate their ABI.

Ankle Brachial Index
• Cornerstone of lower extremity vascular evaluation
– Blood pressure cuffs, Doppler
– Ankle (DP or PT) to brachial artery pressure
Normal 0.96
Claudication 0.41 -0.95
Rest Pain 0.21-0.41
Tissue loss 0.20
Significant change 0.15 or more

ANGIOGRAPHY:
Non-invasive:
• CT Angiogram
• MR Angiogram
Invasive:
• Digital Subtraction Angiography 
Gold Standard
 Intervention at the same time

CT Angiography Digital Subtraction
Angiography
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot
silhouette

Treatment of PAD
Therapies Based Upon Symptoms
Intermittent Claudication
• Exercise Therapy
• Drugs
• Pentoxifylline
• Cilostazol
• Revascularization
• Severe disability
Goal to provide relief of
symptoms
Critical limb ischemia
• Wound care
• Antibiotics
• Revascularization
• Endovascular
• Surgery
Goal to promote limb survival

Supervised Exercise Rehabilitation
• A program of supervised exercise training is
recommended as an initial treatment
modality for patients with intermittent
claudication.
• Supervised exercise training should be
performed for a minimum of 30 to 45
minutes, in sessions performed at least three
times per week for a minimum of 12 weeks.

Bhatt, D. L. et al. J Am Coll Cardiol 2007;49:1982-1988
Effect of Dual Antiplatelet Therapy with Established
Atherosclerotic Disease

PCI/Surgery:
Indications/Considerations:
•Poor response to exercise rehabilitation + pharmacologic therapy.
•Significantly disabled by claudication, poor QOL
•The patient is able to benefit from an improvement in claudication
•The individual’s anticipated natural hx and prognosis
•Morphology of the lesion (low risk + high probabilty of operation success)
PCI:
•Angioplasty and Stenting
•Should be offered first to patients with significant comorbidities who are not
expected to live more than 1-2 years
Bypass Surgery:
•Reverse the saphenous vein for femoro-popliteal bypass
•Synthetic prosthesis for aorto-iliac or ilio-femoral bypass
•Others = iliac endarterectomy & thrombolysis
•Current Cochrane review = not enough evidence for Bypass>PCI
Amputation: Last Resort

Antiplatelet Therapy
Antiplatelet therapy is indicated to reduce the risk of myocardial
infarction, stroke, or vascular death in individuals with
atherosclerotic lower extremity PAD.
Aspirin, in daily doses of 75 to 325 mg, is recommended as safe
and effective antiplatelet therapy to reduce the risk of
myocardial infarction, stroke, or vascular death in individuals
with atherosclerotic lower extremity PAD.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Clopidogrel (75 mg per day) is recommended as an effective
alternative antiplatelet therapy to aspirin to reduce the risk of
myocardial infarction, stroke, or vascular death in individuals
with atherosclerotic lower extremity PAD.

Pharmacotherapy of Claudication
Cilostazol (100 mg orally two times per day) is
indicated as an effective therapy to improve
symptoms and increase walking distance in
patients with lower extremity PAD and
intermittent claudication (in the absence of
heart failure).

Endovascular procedures are indicated for
individuals with a vocational or lifestyle-limiting
disability due to intermittent claudication when
clinical features suggest a reasonable likelihood
of symptomatic improvement with endovascular
intervention and…
a. Response to exercise or pharmacologic therapy
is inadequate, and/or
b. there is a very favorable risk-benefit ratio (e.g.
focal aortoiliac occlusive disease)
Endovascular Treatment for Claudication

Endovascular intervention is not indicated if there
is no significant pressure gradient across a stenosis
despite flow augmentation with vasodilators.
Primary stent placement is not recommended in
the femoral, popliteal, or tibial arteries.
Endovascular intervention is not indicated as
prophylactic therapy in an asymptomatic patient
with lower extremity PAD.
Endovascular Treatment for Claudication

Surgery for Critical Limb Ischemia
Patients who have significant necrosis of the
weight-bearing portions of the foot, an
uncorrectable flexion contracture, paresis of the
extremity, refractory ischemic rest pain, sepsis, or a
very limited life expectancy due to co-morbid
conditions should be evaluated for primary
amputation.
Surgery is not indicated in patients with severe
decrements in limb perfusion in the absence of
clinical symptoms of critical limb ischemia.

For individuals with combined inflow and
outflow disease with critical limb ischemia,
inflow lesions should be addressed first.
When surgery is to be undertaken, an aorto-
bifemoral bypass is recommended for patients
with symptomatic, hemodynamically
significant, aorto-bi-iliac disease requiring
intervention.

Bypasses to the above-knee popliteal
artery should be constructed with autogenous
saphenous vein when possible.
Bypasses to the below-knee popliteal artery
should be constructed with autogenous vein
when possible.
Prosthetic material can be used effectively
for bypasses to the below knee popliteal
artery when no autogenous vein from ipsilateral
or contralateral leg or arm is available.

Acute Limb Ischemia (ALI)
Patients with ALI and a salvageable
extremity should undergo an emergent
evaluation that defines the anatomic level of
occlusion, and that leads to prompt
endovascular or surgical intervention.
Patients with ALI and a non-viable extremity
should not undergo an evaluation to define
vascular anatomy or efforts to attempt
revascularization.

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. Endovascular revascularization
more preferable (baloon, stents)
• Treatment for critical limb ischemia warrants
aggressive efforts at revascularization, including
surgery, to reduce the risk of amputation

Simposium v. 1. pad management. dr. hariadi h. sppd spjpk

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