1) Medical therapy including antiplatelets, statins, and structured exercise therapy is the primary treatment for peripheral arterial disease (PAD). Revascularization may be considered for lifestyle-limiting claudication that does not improve with medical therapy and exercise. 2) The goal of revascularization in critical limb ischemia (CLI) is to restore blood flow to the foot through at least one patent artery in order to reduce the risk of amputation and cardiovascular events. Endovascular and surgical revascularization have shown similar outcomes for amputation-free survival in CLI. 3) Acute limb ischemia is a medical emergency requiring prompt evaluation and revascularization within 6-24 hours to prevent limb loss.

1. GUIDELINES FOR MANAGEMENT OF
PERIPHERAL ARTERIAL DISEASE
REFERENCE –
2016 AHA/ACC GUIDELINES
FOR PAD
Dr Kunwar Sidharth Saurabh
Mch, CTVS (Resident)
VMMC & SJH

2. 3 MAJOR QUERIES LOOMS …
1. How much effective is medical therapy in peripheral
arterial disease, and what are the recommendations?
2. What is the effect of re-vascularisation compared with
optimal medical therapy and exercise training, on
functional outcome?
3. Which re-vascularisation strategy is superior –
Endovascular or Surgical?

3. Some Key Words -
• Claudication –
• Fatigue, discomfort, cramping, or pain of “vascular”
origin in the muscles of lower extremities that is
consistently induced by exercise and consistently
relieved by rest (within 10 min)

4. Key Words…
• Acute Limb Ischaemia (ALI) –
• Acute (<2wk), severe hypo perfusion of the limb
characterized by SVS grades.
• Tissue loss –
• Minor – Non healing ulcer, focal gangrene with diffuse
pedal edema
• Major – Extending above transmetatarsal level;
function of foot no longer salvagable

5. Key Words
• Critical Limb Ischaemia (CLI) –
• A condition characterized by chronic (>2 wk) ischemic
rest pain, non healing wound/ulcers or gangrene in one
or both legs attributable to objectively “proven” arterial
occlusive disease.
• In line blood flow –
• Direct arterial flow to foot excluding collaterals

6. Difference !
EMERGENCY URGENT
Life or limb is threatened if the patient is
not in the operating room or where there
is time for very limited clinical evaluation ,
typically within <6h.
There may be time for a limited clinical
evaluation, usually when life or limb is
threatened if the patient is not in the
operating room, typically between
6 – 24h.

7. Patients at Increased Risk of PAD
• Age > 65 Years
• Age 50 – 64 years, with risk factors for
atherosclerosis (smoking, DM, HTN), or family
history.
• Age < 50y, with DM and additional risk factor
for atherosclerosis
• Individual with known atherosclerotic disease
in another vascular bed.

8. Assessment of Pulses
• 0 – absent
• 1- diminished
• 2 – normal
• 3 - bounding

9. • Patients with confirmed diagnosis of PAD are
at increased risk for subclavian artery stenosis.
An inter-arm pressure difference of >15-
20mmHg is abnormal and suggestive of the
same.
• Knowing this is essential for measuring ABI.

10. Diagnostic Testing For Patient With
Suspected PAD
• Resting ABI is the initial diagnostic test for PAD
and may be the “only” test required to
establish the diagnosis and institute GDMT.
• Other tests (physiological) which may
supplement ABI are –
– Treadmill ABI testing
– Toe Brachial Index (TBI)
– Transcutaneous Oxygen Pressure (TcPO2)
– Skin Perfusion Pressure (SPP)

13. IMAGING
• Studies for anatomic imaging assessment
(Doppler, CT etc) are generally reserved for
highly symptomatic patients in whom
re- vascularisation is considered

16. Screening for Atherosclerotic disease
in Other Vascular Beds .
• PAD known risk factor for AAA (prevalence higher)
• Higher chances of Atherosclerosis in other vascular
beds (Renal , Coronary etc)
• “NO” evidence to demonstrate that screening all
patients with PAD for atherosclerosis in other
vascular beds improves outcome.

17. MEDICAL THERAPY IN PAD
• MOST IMPORTANT –

18. ANTIPLATELETS

19. ANTIPLATELETS

20. STATIN – INDICATED FOR ALL

21. ORAL ANTICOAGULATION

22. CILOSTAZOL, PENTOXIFYLLINE AND
CHELATION THERAPY

23. TO NOTE !

24. STRUCTURED EXERCISE THERAPY
• Risk- benefit ratio for supervised exercise in
PAD is favorable with an excellent safety
profile in patients.
• UN-structured community or home based
walking programs that consist of providing
general recommendations to patients with
claudication to simply “walk more” are NOT
efficacious.
• Interpretation – Physiotherapy is must!!!

25. MINIMIZING TISSUE LOSS IN PAD
• CONSISTS OF –
– PATIENT EDUCATION
– SELF CARE
– FOOT EXAMINATION
– PROMPT RECOGNITION OF INFECTION
– WOUND HEALING THERAPIES

26. REVASCULARISATION
• A minority of patients with claudication (10-
15%) over 5 years will progress to CLI.
• The role of re-vascularisation in claudication is
improvement in claudication symptoms and
functional status, and consequently QoL,
RATHER THAN LIMB SALVAGE.
• Remember that re-vascularisation is just one
part of the treatment and not the only
treatment.

27. Contd..
• Re-vascularization is reasonable when the
patient who is being treated with GDMT
(including exercise therapy) presents with
persistent “LIFESTYLE LIMITING
CLAUDICATION”
• Lifestyle limiting claudication is defined by
patient rather than by any test.

29. ENDOVASCULAR
LONG TERM PATENCY IS GREATER IN AORTOILLIAC THAN IN
FEMORO POPLITEAL SEGMENT

30. SURGICAL
• Reserved for individuals who –
– Do not derive adequate benefit from non surgical
therapy
– Have arterial anatomy favorable to obtain a
durable result with surgery
– Acceptable risk of perioperative adverse events.

32. MANAGEMENT OF CLI
• Patients with CLI are at increased risk of
amputation and major cardiovascular ischemic
events.
• “Goal” of revascularisation in CLI is to provide
in line blood flow to the foot through atleast 1
patent artery.
• In BASIL RCT – endpoint of amputation free
survival was the same in endovascular and
surgical arms.

34. • Although the angiosome concept is
theoretically satisfying, randomised data
comparing the establishment of in line flow
v/s angiosome guided therapy is yet to be
published.

38. Acute Limb Ischaemia - SNAPS

39. Acute Limb Ischaemia - SNAPS