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

ABI

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?