Best Dx/Best Rx: Peripheral Artrosclerosis

From: Subject: Best Dx/Best Rx: Peripheral Artrosclerosis Date: Wed, 3 Jun 2009 21:43:23 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0224_01C9E494.51FCE230" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0224_01C9E494.51FCE230 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0116.htm Best Dx/Best Rx: Peripheral Artrosclerosis

Peripheral = Artery=20 Diseases

Mark A. Creager, MD
Harvard Medical School=20

Defin= ition/Etiology
Epide= miology/Prognosis
Clini= cal=20 Presentation
Best = Tests
Best = Therapy
Best = References

Definition/Etiology

Perpheral artery diseases = (PAD)=20 include disorders that reduce blood flow to the limb=20
Atherosclerosis is the most = common=20 cause of limb artery obstruction=20
80% of stenoses are in = femoropopliteal=20 artery, 30% in aorta or iliac arteries, 40% in tibioperoneal = artery=20
Most patients have multiple=20 stenoses=20
Other causes of PAD=20
- Thrombus=20
- Embolism=20
- Vasculitis=20
- Adventitial cysts=20
- Fibromuscular = dysplasia=20
- Arterial dissection =
- Trauma=20
- Vasospasm =

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Epidemiology/Prognosis

Prevalence increases with = age, to >=20 20% at > 75 yr of age=20
Risk of death increases = twofold to=20 fourfold=20
Risk factors=20
- Cigarette smoking=20
- Diabetes mellitus=20
- Dyslipidemia=20
- Hypertension=20
- Metabolic syndrome=20
- Chronic renal = insufficiency=20
- Hyperhomocysteinemia=20
- Low vitamin D = levels=20
- Elevated C-reactive = protein=20

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Clinical=20 Presentation

Intermittent claudication: = discomfort,=20 pain, fatigue, or heaviness felt in the affected extremity during = walking and=20 resolving with rest
Rest pain, typically in the = toes or=20 foot, initially worse at night
Symptoms may be absent =

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Best=20 Tests

Physical Examination

Palpate for decreased or absent pulses=20
- Femoral=20
- Popliteal=20
- Posterior tibial=20
- Dorsalis pedis
Patterns of pulse abnormality may indicate = sites of=20 stenosis
Auscultate for bruits, which may indicate = arterial=20 stenosis=20
- Abdomen=20
- Pelvis=20
- Inguinal areas
Check for foot pallor=20
- At rest=20
- With leg elevation=20
- After exercise of the calf muscles =
Signs of chronic limb ischemia=20
- Subcutaneous atrophy=20
- Hair loss=20
- Coolness=20
- Pallor=20
- Cyanosis, dependent rubor, or both=20
- Petechiae, fissures, ulceration, and = gangrene with=20 critical limb ischemia

Noninvasive Tests

Ankle:Brachial Index (ABI)=20
- Sensitive indicator of peripheral artery=20 disease=20
- ABI ≤ 0.90 is abnormal=20
- The lower the ankle:brachial ratio, the = higher the=20 risk of a cardiovascular event=20
- Low ABI relates to decreased leg = function=20
Segmental pressure measurements=20
- Determines systolic pressure in segments of = the thigh,=20 calf, and ankle=20
- Pressure gradients between contiguous cuffs = inidicates=20 location of stenosis
Pulse volume recordings=20
- Utilizes plethysmography to measure change = in limb=20 volume that occurs with each pulse=20
- Distal to the site of an arterial stenosis, = the=20 amplitude of the pulse volume waveform is diminished (may be absent = in=20 severe ischemia)
Doppler ultrasonography=20
- Can identify vessels with stenotic = lesions=20
- When stenosis is present, this triphasic = waveform is=20 altered distal to the stenosis=20
  - Amplitude is decreased=20
  - Rate of rise is delayed=20
  - Reverse-flow component disappears=20
Duplex ultrasound scanning=20
- B-mode ultrasonography plus pulsed Doppler=20 ultrasonography=20
- B-mode scan identifies areas of intimal = thickening,=20 plaque formation, and calcification
- Color Doppler imaging detects blood-flow = abnormalities=20 caused by arterial stenoses=20
- Increase > twofold in systolic velocity = indicates a=20 hemodynamically significant stenosis
Transcutaneous oximetry=20
- Assess severity of skin ischemia=20
- Normal transcutaneous oxygen tension of the = resting=20 foot is ~ 60 mm Hg; often < 40 mm Hg in patients with = ischemia=20

Angiography

MR and CT computed angiography can be used to = evaluate=20 the location and severity of peripheral atherosclerosis To help = determine=20 appropriateness of endovascular intervention=20
Each may help to determine appropriateness of=20 endovascular intervention=20
MR angiography more widely used than CT but=20 slower=20
- May not be feasible in obese patients or = those with=20 pacemakers or defibrillators=20
- Gadolineum may causenephrogenic systemic = fibrosis in=20 patients with renal insufficiency
CT angiography=20
- Requires iodinated contrast and radiation=20 exposure=20
- Contraindicated for patients with renal = insufficiency=20 or contrast allergy
Conventional cathter-based contrast = angiography is used=20 when diagnosis is in doubt or before endovascular interventions or = surgical=20 reconstruction

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Best=20 Therapy

Risk-Factor Modification

Smoking cessation=20
Aggressive lipid-lowering therapy to achieve = LDL=20 cholesterol < 100 mg/dl=20
Antihypertensive agents to achieve = normotensive=20 range=20
Excessive reduction of blood pressure (> 20 = mm Hg)=20 may aggravate symptoms=20
Beta blockers may exacerbate critical limb = ischemia but=20 do not worsen intermittent claudication=20
Aggressive treatment of diabetes mellitus = reduces=20 microvascular comlications, but may not reduce risk of myocardial = infarction=20 or death=20
ACE inhibitors may reduce risk of adverse = cardiovascular=20 events in patients with atherosclerosis

Antiplatelet Therapy

May reduce risk of acute peripheral arterial=20 occlusion=20
Reduces risk of adverse cardiac events=20
- Clopidogrel may be more effective than = aspirin for=20 patients with peripheral artery disease
Reduces cardiovascular mortality in patients = with=20 atherosclerosis

Hygiene and Physical Therapy

Prevent skin ulceration and foot = infection=20
- Keep feet clean and moisturized=20
- Inspect frequently and treat minor abrasions = promptly=20
- Avoid elastic hose=20
- Shoes should be carefully fitted=20
- For patients with critical limb ischemia, = maintain=20 limbs in a dependent position below heart level to increase = perfusion=20 pressure=20
- Use cotton wicks between the toes and = sheepskin=20 beneath the heels=20
- Warm environment reduces vasoconstriction =
- Keep ulcerations and necrotic areas dry and=20 covered=20
- Drain infections
Avoid local antibiotics=20
Treat pain with analgesics=20
Supervised exercise training=20
- Improves walking capacity=20
- Treadmill exercise for ~ 1 hr three times a = week for=20 at least 3 mo=20
- Encourage walking outside the supervised=20 program

Pharmacotherapy of Claudication and Critical = Limb=20 Ischemia

Drug therapy has generally not successful in = improving=20 symptoms of claudication or reducing complications of critical limb=20 ischemia=20
Pentoxifylline, controlled release: improved = exercise=20 capacity in some but not all clinical trials=20
- Reported to improve RBC flexibility and = decrease blood=20 viscosity=20
- Dose: 400 mg t.i.d.
Cilostazol: may increase distance walked = before onset of=20 claudication and also maximal walking distance=20
- Vasodilator and antiplatelet properties, but = mechanism=20 of action in PAD is not known=20
- Dose: 50=96100 mg b.i.d. =

Revascularization

Indicated for patients with disabling = claudication,=20 ischemic rest pain, or impending limb loss=20
Catheter-based revascularization=20
- Percutaneous transluminal angioplasty = (PTA)/stenting=20 of iliac arteries=20
  - Initial success rate 90%=20
  - Patency rates after 4=965 yr ~ 60%=9680%, = higher with=20 stents
- PTA/stenting of femoral and popliteal = arteries
  - Initial success rate < 90%=20
  - Patency rates: 1 yr, 60%; 3 yr, 50%; 5 yr, = 45%
- PTA of tibial and peroneal arteries
  - Poorer outcome than PTA of more proximal=20 lesions=20
  - Limb salvage rates of 1=962 yr: = 50%=9675%=20
Surgical reconstruction=20
- Aortobifemoral bypass with a bifurcated = Dacron or=20 polytetrafluoroethylene prosthetic graft=20
  - Standard treatment for aortoiliac = disease=20
  - Operative mortality 1%=963% at centers = with expertise=20 in this technique=20
  - Long-term patency and relief of symptoms = > 80%=20 over 10 yr
- Intra-abdominal aortoiliac reconstructive = surgery not=20 feasible in patients whose comorbid conditions pose excessive = surgical risk=20
- Axillobifemoral bypass can circumvent the = abdominal=20 aorta and achieve revascularization of both legs
- Femorofemoral bypass for unilateral iliac = artery=20 obstruction
  - Can be performed with regional anesthesia=20
- Infrainguinal bypass
  - Femoropopliteal and femoral-tibioperoneal=20 reconstruction=20
  - Femoropopliteal reconstruction most = successful when=20 the distal anastomosis is constructed proximal to the knee
  - 5-year patency rate ~ 75%=9680% (higher in = claudicants=20 than in patients with critical limb ischemia; lower for synthetic=20 grafts)=20
  - Operative mortality 1%=963% =
- Antiplatelet agents should be administered = to maintain=20 graft patency after bypass grafts

Amputation

Alternative for advanced limb ischemia when=20 revascularization is not possible or has failed
Selection of amputation level requires = assessment of=20 perfusion
Overall prognosis after major leg amputation = is poor,=20 usually because of coexisting coronary and cerebrovascular = disease=20

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Best References

Norgren L, et al: J Vasc Surg 45 Suppl S:S5, 2007 = [PMID=20 17223489]

Hirsch AT, et al: J Am Coll Cardiol 47:1239, 2006 = [PMID=20 16545667]

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The author has received grant or research = support from=20 Sanofi-Aventis and Merck; he has served as a consultant for Biomarin, = Genzyme,=20 Sanofi-Aventis, and Sigma Tau.

December=20 2008

=A9 BC Decker Inc. 2008 BC = Decker Inc. 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