This document discusses peripheral arterial disease (PAD), including: 1. PAD affects 12-20% of Americans over age 65 and those with diabetes have a 3x higher risk. PAD is often asymptomatic so it can be difficult to detect. 2. Symptoms of PAD include claudication (leg pain with exercise), fatigue, numbness, and rest pain. Untreated PAD can lead to critical limb ischemia and amputation. 3. Screening for PAD through ankle-brachial index measurements is recommended for diabetics over 50 and younger diabetics with risk factors to detect disease early before complications arise. 4. Treatment options for PAD include lifestyle changes, medications, endovascular procedures like

1. Peripheral Arterial Disease ArunJagannathan MD Vascular and Interventional Radiology Central Illinois Radiological Associates www.radclinic.com

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. www.radclinic.com

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. www.radclinic.com

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 www.radclinic.com

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 www.radclinic.com

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, www.diabetes.org. Disease (PAD) www.radclinic.com

7. Risk Factors for Atherosclerosis PAD Smoking Diabetes Hypertension Dyslipidemia Sedentary life style Age >50 Obesity PVD (carotid stenosis, AAA) African Americans, Hispanics, and diabetics have the highest prevalence of PAD CAD Smoking Diabetes Hypertension Dyslipidemia Sedentary life style Age >50 Obesity PVD (carotid stenosis, AAA) www.radclinic.com

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 www.radclinic.com

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. www.radclinic.com

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 www.radclinic.com

11. Population >55 yr IntermittentClaudication Peripheral VascularOutcomes Other CardiovascularMorbidity/Total Mortality Lower ExtremityBypass Surgery7% MajorAmputation4% WorseningClaudication16% NonfatalCardiovascularEvent(MI/Stroke, 5-year Rate)20% 5-yrMortality30% CardiovascularCause75% Prognosis in Patients with Intermittent Claudication Adapted from Weitz JI et al. Circulation. 1996;94:3026-3049. www.radclinic.com

12. Symptomatic and Asymptomatic PAD Newly Diagnosed PAD (n=457) Prior Diagnosis of PAD (n=366) 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 (Vasc.Med.3,241,1998.)

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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 www.radclinic.com

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? www.radclinic.com

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 Gangrene www.radclinic.com

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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 www.radclinic.com

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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. www.radclinic.com

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. www.radclinic.com

25. PAD Treatment Options Medical Risk Factor Modification* Exercise Therapy* Drug Therapy* Endovascular Therapy Peripheral Transluminal Angioplasty* Peripheral Stenting* Atherectomy Thrombolytic Therapy (adjunctive) Surgery Bypass Grafts* Amputation* Endarterectomy* *Rosenfield K, Isner JM, Chap. 97 Textbook of Cardiovascular Medicine 1998 www.radclinic.com

26. SilverhawkAtherectomy www.radclinic.com

27. Critical Limb Ischemia/ Limb Salvage Frontrunner 100% SFA SFA post Patent peroneal with runoff to foot Silverhawk Zero runoff

28. PAD Video www.radclinic.com