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PAD vs Venous Disease: Discrepancies & Similarities
Abraham Sadighi, MD, FACSGulfCoast Cardiothoracic & Vascular Surgeons Vein & Laser Treatment Center
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• Disorders of the circulatory system to the extremities, viscera and head
Peripheral Arterial Disease
(PAD)
Peripheral Arterial Disease
(PAD)
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Introduction
Atherosclerotic changes
Introduction
Atherosclerotic changes
Normal Artery Diseased Artery
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Introduction
Disease evolution
Introduction
Disease evolution• Claudication
• Rest pain
• Ulceration
• Gangrene
• Limb loss
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5 NEJM, 1991; 325:577-8
Introduction
Mortality
Introduction
Mortality• Life expectancy reduced 10 years
in patients with PVD
• Mortality rate
~ 25% at 5 years
~ 50% at 10 years
~ 75% at 15 years
• 75% of deaths caused by cardiovascular events
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PrevalencePrevalence
Asymptomatic5 million
Symptomaticuntreated
3.75 million
Symptomatictreated
1.25 million
Pentecost, et al. “Guidelines for Peripheral Percutaneous Transluminal Angioplasty of the Abdominal Aorta and Lower Extremity Vessels”; 1993
Total ~ 10 million U.S. patients
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PrevalencePrevalence
Peripheral Vascular Outcomes
Lower ExtremityBypass Surgery
7%
MajorAmputation
4%
WorseningClaudication
16%
Lim
b O
utco
mes
Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049.
Other CardiovascularMorbidity/Total Mortality
Nonfatal Cardiovascular Event(MI/Stroke, 5-yr Rate)
20%
5-yr Mortality 30%
Cardiovascular Cause 75%
Red
uce C
V R
isk
IntermittentClaudication
5%
Population >55 yr
Outcomes in Patients with Intermittent Claudication
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Risk FactorsRisk Factors
• Tobacco abuse
• Hypercholesterolemia
• Hypertension
• Diabetes
• Obesity
• Sedentary lifestyle
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9 Belch JJF, et al. Arch Intern Med. 2003;163:884-892.
Risk FactorsRisk FactorsMale Gender
Age (per 10 y)
Diabetes
Smoking
Hypertension
Hypercholesterolemia
Fibrinogen
Alcohol
Protective HarmfulOdds Ratio
-4 -3 -2 -1 0 1 2 3 4
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DiagnosisDiagnosis
• Patient history
• Physical examination
• Laboratory values
• Noninvasive vascular studies
• Angiography
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Patient HistoryPatient History
• Risk factors
• Exercise-induced symptoms
• Rest pain
• Ulceration
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• History—the most important aspect of the diagnostic evaluation of PAD
– Location of symptoms
– Description of discomfort
– Exacerbating/ameliorating characteristics
– Reproducible symptoms
Patient HistoryPatient History
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Patient HistoryPatient History
Historical clues to the diagnosis of intermittent claudication
Variable Symptom ComplexSymptoms in the legs that are provoked
by walking and relieved by rest
Pain Aches Tiredness
Tightness Soreness Weakness Numbness
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Is it vascular limb pain?
Patient HistoryPatient History
Historical Vascular NeurogenicClue Etiology Etiology
Onset Predictable Variable
Only withwalking? Yes No
Relief with stopping or Yes Variablestanding?
Absent pedal Variable Variablepulses at rest
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Patient History
Differential diagnosis of PAD
Patient History
Differential diagnosis of PAD• Intermittent claudication
– Atherosclerosis– Non-atherosclerotic
TAO/Buerger’s PAES CAD of the popliteal
artery FMD Vasculitis
• Neurogenic causes– Lumbar canal stenosis– Peripheral neuropathy
• Venous claudication
• Musculoskeletal causes– Arthritis– Bursitis– Tendonitis– Tight hamstring
/quadriceps musculature
• Podiatric causes– Plantar fasciitis
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Physical ExaminationPhysical Examination
• Pulses
• Bruits
• Ankle-Brachial Index (ABI)
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Physical Examination
Ankle-Brachial Index
Physical Examination
Ankle-Brachial Index• Simple, painless, accurate, highly
reproducible examination
• Clinically useful– Identifies patients with PAD
– Major indicator of premature MI, CVA, mortality
• Indications– Any patient with suspicion for PAD
– Any patient at risk of PAD Age 50 or greater with history of DM or tobacco use Age 70 or greater regardless of risk factors
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Right ArmPressure:
Left ArmPressure:
Pressure:
PT
DP
Pressure:
PT
DP
Physical Examination
Ankle-Brachial Index
Physical Examination
Ankle-Brachial Index• How to perform
– Patient resting supine for 5-10 minutes
– Continuous wave, hand-held Doppler
– Measure systolic BP in both arms
Higher value is DENOMINATOR of ABI
– Measure systolic BP in DP and PT
Higher value is NUMERATOR of ABI
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Physical ExaminationPhysical Examination
ABI = Ankle Systolic Pressure
Brachial Systolic Pressure
>0.9 = Normal
>0.4-0.9 = Moderate disease
<0.4 = Severe disease
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Above 0.90 — Normal
0.71-0.90 — Mild Obstruction
0.41-0.70 — Moderate Obstruction
0.00-0.40 — Severe Obstruction
Physical Examination
Interpretation and limitations of ABI
Physical Examination
Interpretation and limitations of ABI
ABI Interpretation Two Main Limitations
Calcified ankle vessels result in artificially “normal” ABI (DM, RF)
Normal ABI in patient with Aortoiliac Disease— only becomes abnormalwith exercise testing
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21 Dormandy JA. Cerebrovasc Dis. 1999;9 (Suppl 1):1–128.
ABI – inverse relationship with three-year risk of cardiovascular events and deaths
Physical Examination
ABI−Predictor of ischemic events
Physical Examination
ABI−Predictor of ischemic events
CAPRIE Study
10.2% relative risk increase per 0.1 decrease in ABI(P = 0.041)
1
1.5
2
2.5
0 0.2 0.4 0.6 0.8 1
ABPI
Ris
k R
elat
ive
to A
BP
I =
1
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Noninvasive Vascular StudiesNoninvasive Vascular Studies
• Vascular ultrasound
• CT angiography
• Magnetic resonance angiography
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Noninvasive Vascular Studies
Post-intervention iliac imaging
Noninvasive Vascular Studies
Post-intervention iliac imaging
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Noninvasive Vascular Studies
MRA in PAD
Noninvasive Vascular Studies
MRA in PAD
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RightFem-Pop
BPG
DSA(Pre-PTA)
LeftSFA
Stenosis
Noninvasive Vascular StudiesNoninvasive Vascular Studies
CTA
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Normal Abnormal
Noninvasive Vascular Studies
Diagnosis−angiography
Noninvasive Vascular Studies
Diagnosis−angiography
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TreatmentTreatment
• Goals
• Risk factor modification
• Medical management
• Minimally invasive techniques
• Case studies
• Surgical intervention
• Follow-up care
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GoalsGoals
Identify and treat systemic
atherosclerosis
Improve functional status and quality
of life
Preserve the limb
Prevent progression ofatherosclerosis
PAD Therapeutic Goals
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Risk Factor ModificationRisk Factor Modification
• Tobacco cessation
• Exercise
• Weight reduction
• Pharmacologic intervention– Hypercholesterolemia
– Hypertension
– Diabetes
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Medical ManagementMedical Management
• Symptom/Limb– Tobacco cessation– Foot care– Control of DM– Reduction in
cholesterol– Antiplatelet agents– Exercise– Cilostazol– Angiogenesis– Gingko biloba
• Life– Tobacco cessation– Control of DM– Reduction in
cholesterol– Reduction in BP– Antiplatelet agents– Exercise
Medical therapy forintermittent claudicationMedical therapy forintermittent claudication
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Medical Management
PAD risk reduction therapies
Medical Management
PAD risk reduction therapies • Smoking
– Complete cessation
• Diabetes mellitus– HbA1c <7.0%, treat other risk factors
• Dyslipidemia– LDL <100 mg/dL, modify HDL and TG
• Hypertension– BP <140/90 or <130/80 in diabetes
• ACE inhibitors• Antiplatelet therapy
– Aspirin or clopidogrel
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Minimally Invasive Techniques Minimally Invasive Techniques
• Percutaneous transluminal angioplasty (PTA)
• Stenting
• Thrombolysis
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Minimally Invasive Techniques Minimally Invasive Techniques
Guidewire placement
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Minimally Invasive Techniques Minimally Invasive Techniques
Guidewire advanced past lesion
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Balloon dilatation
Percutaneous Transluminal Angioplasty
Minimally Invasive Techniques Minimally Invasive Techniques
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Minimally Invasive Techniques Minimally Invasive Techniques
Stent expansion by a balloon catheter over a guidewire
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Post-PTA/stent placement
Minimally Invasive Techniques Minimally Invasive Techniques
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Thrombolysis
Post-thrombolytic infusion revealing stenosis
Minimally Invasive Techniques Minimally Invasive Techniques
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Case Study #1Case Study #1
Aorto/iliac disease
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Case Study #1Case Study #1
Aorto/iliac disease
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Case Study #1Case Study #1
Aorto/iliac disease
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Case Study #1Case Study #1
Aorto/iliac disease
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43Aorto/iliac disease
Case Study #1Case Study #1
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Case Study #1Case Study #1
Aorto/iliac diseasepre-PTA stenting
Aorto/iliac diseasepost-PTA stenting
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Case Study #2Case Study #2
Subclavian disease
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Case Study #2Case Study #2
Subclavian disease
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Case Study #2Case Study #2
Subclavian diseasepre-PTA stenting
Subclavian diseasepost-PTA stenting
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Case Study #3Case Study #3
Pre-thrombolysis Post-thrombolysis
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Case Study #3Case Study #3
Angioplasty post-thrombolysis
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Surgical InterventionSurgical Intervention
• Bypass grafts
• Amputation
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Surgical InterventionSurgical Intervention
• Bypass grafts
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Venous Disease (CVI) Venous Disease (CVI)
Simple spider veins to complex dermal sclerosis and ulcer
formations.
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Venous AnatomyVenous Anatomy
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Hemodynamics Hemodynamics
The leg muscle pumps, of which the calf pump is the most important, generate high pressure during muscle contraction, which propels venous blood toward the heart. During relaxation, valves close and blood is prevented from refluxing down the leg and breaking up the hydrostatic pressure column
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The calf muscle pump includes the soleal and gastrocnemius muscles, their intramuscular venous sinusoids, and the superficial and deep veins. The soleal and gastrocnemius muscle sinusoids constitute the major “bellows” of the calf pump. Even in the standing position, contraction of the calf muscles produces enough pressure to eject blood and propel it toward the heart. Intramuscular veins are also affected because of the strong fascia investing the muscles.55
Calf Pump Calf Pump
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Venous Valves Venous ValvesPresence of
valves prevent reflux
Pressure generated in deep veins by the calf muscles are prevented from transmission to superficial veins by the valves
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Venous Pathology Venous Pathology
Obstruction
Reflux and/or incompetence
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Venous Obstruction Venous Obstruction
As a result of DVT or superficial phlebitis
As a result of extrinsic compression
1. Tumors
2. Vascular compression (May-Thurner
syndrome)
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Venous Reflux Venous Reflux
Spider Veins Varicose Veins
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Venous Reflux Venous Reflux
Edema Venous Statis w/wo Ulcer
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Venous History of Patient Venous History of Patient
Pain
Edema
Ulcers
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Physical Exam of Patient Physical Exam of PatientSupine and Standing
Objective findings of spider or varicose veins
Skin changes (hypopigmentation to atrophic blanch and atherosclerosis)
Edema (typically pitting)
Ulcer formation
Pulses62
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Diagnostic Testing
Duplex Scan
Diagnostic Testing
Duplex Scan
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Treatment Treatment
Medical Management
1. Leg elevation
2. Compression therapy
3. Exercise
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Interventional TherapyInterventional Therapy
Sclerotherapy
Endovenous Ablation
Surgical
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SclerotherapySclerotherapy
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Endovenous AblationEndovenous Ablation
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SurgicalSurgical
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Pelvic Congestion SyndromePelvic Congestion Syndrome
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TreatmentTreatment
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Similarities and Differences Similarities and Differences
Arterial symptoms produced by exercise and relieved by resting even standing
Venous symptoms worsened by standing and improved by exercise and leg elevation
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Venous Claudication Venous Claudication
Pain produced by prolonged exercise in the legs secondary to iliac vein obstruction and relieved by rest
Symptoms present with normal arterial findings
Exception:::: to venous symptoms
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Treatment Differences Treatment Differences
In the arterial system, treatment is aimed at opening and restoring blood flow
In the venous system, treatment is aimed at obstructing and eliminating dysfunctional blood vessels
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