Download - PVD Update for the Primary Care Provider
PVD Update for the Primary Care Provider
Ryan Hollenbeck, MD, FACC
October 21, 2017
Disclosure
I have no relevant financial relationships to disclose
Objectives
1) Review the prevalence, clinical presentation,
and natural history of PVD
2) Diagnosis
3) Management
Prevalence of PVD
• Of patients >70 yrs, or >50 yrs with DM or smoking, 1 of 3
has PVD
• Of patients with PVD, most are asymptomatic
– <50% of these patients are aware of their diagnosis
• 1/3 of those with asymptomatic PVD has a total
occlusion of a major artery
• First presentation for some with previously
asymptomatic PVD can be critical limb ischemia (CLI)
Natural History of PVD
• Of patients with CLI, 50% will be alive with 2
legs 12 months after diagnosis
– 12 month mortality 15-20%
– 30-35% amputation rate
• Of those who have amputation, only 22% will
walk again
Natural History of PVD
• How to patients with PVD die?
1) Heart attack
2) Stroke
These patients should be followed by a cardiologist!!!
Clinical Presentation
• Claudication: Pattern of fatigue, discomfort,
cramping or pain in the muscles of vascular origin that
is consistently induced by exercise and consistently
relieved within 10 minutes of rest
• Critical Limb Ischemia: Chronic ischemic rest pain
(>2wks), nonhealing wound, or gangrene
• Acute Limb Ischemia: Sudden decrease in limb
perfusion
Claudication
Critical Limb Ischemia (CLI)
Diagnosis
• History and physical exam
• Non-invasive Functional Studies
– ABI, TBI, segmental pressures, PVR
• Non-invasive Imaging Studies
– Duplex ultrasound, MRA, CTA
• Invasive Imaging (ie cath)
FUNCTIONAL ASSESSMENT
ROLE OF NONINVASIVE IMAGING
Non-invasive Anatomic Assessment
• Duplex ultrasound, CTA or MRA are
useful to diagnose anatomic location
and severity of stenosis for patients with
symptomatic PVD in whom
revascularization is considered
Non-invasive Anatomic Assessment
• Invasive and noninvasive angiography
(ie CTA, MRA) should not be performed
for the anatomic assessment of patients
with asymptomatic PVD
MANAGEMENT
Medical Therapy
1) Improve Symptoms – cilostazol
(improve walking distance)
2) Reduce Morbidity/Mortality (MI, CVA)
• Low dose ASA
• Statin
• Antihypertensive therapy
• ACEi/ARB
Management • Smoking Cessation
• Annual influenza vaccination
• Supervised exercise program
Supervised Exercise
• 111 patients with symptomatic PVD randomized
to OMT, OMT plus SE, or OMT plus ST
CLEVER
• Supervised exercise plus
OMT was similar to
endovascular therapy
plus OMT
• Both were superior to
OMT alone
ERASE
• 212 patients randomized to SE versus revascularization plus SE
• Greater improvement in walk distance and disease specific QOL
with combination therapy
Management
• Revascularization is reasonable for
patients with lifestyle limiting
claudication with inadequate response
to GDMT
• Revascularization should be
performed in patients with CLI to
minimize tissue loss
Revascularization
• Aortoiliac disease - Primary stenting is the usual
approach
• Femoropopliteal disease – Combination of
atherectomy, PTA, DCB, provisional stenting
(primary stenting class III)
• Infrapopliteal disease – nothing works very well
Drug Coated Balloon (DCB)
- Paclitaxel coated
My Approach
1. History
2. Physical Exam
3. ABI (rest/exercise)
4. Duplex Ultrasound
5. Revascularization if unacceptable response to
GDMT
– What about CTA/MRA?
CASES
Case study - IC
• 64yo M with hyperlipidemia and RLE
claudication
– Cramping pain in R calf walking 100’, relieved with
rest
• Exam – absent R pop, PT and DP pulses
• ABI – R 0.71, L 1.10
• Duplex – Subtotal occlusion of R SFA
BEFORE
AFTER
Case study - CLI
• 82 yo F with known CAD, CABG, DM
• Months of progressive right calf pain, now present at rest
• Nonhealing wound R great toe and R heel
• Exam – absent R pop, PT and DP pulses, wounds on R
great toe and R heel, minor tissue loss
• ABI – R 0.29, L 0.44
• Duplex – mod-severe diffuse R SFA plaque, probable
occlusion of popliteal and tibial vessels
BEFORE
AFTER
OTHER EXAMPLES
BEFORE
AFTER
BEFORE
AFTER
BEFORE
AFTER
Take Home Points
1) PVD is common and under recognized
2) Patients with PVD die of heart attack and stroke
3) ABI is the initial test to establish the diagnosis
of PVD (or exclude PVD)
4) Supervised exercise is effective in combination
with OMT and revascularization
QUESTIONS?