sorting out claudication - inmed events€¦ · digital subtraction angiography •advantages...
TRANSCRIPT
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Sorting Out ClaudicationJason B. Lindsey, MD
Interventional CardiologySaint Luke’s Mid America Heart Institute
No Disclosures
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Definition of Claudication (OED)
• “limping”
• “condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries”
Approach to Patient with Lower Extremity Symptoms
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Assessing Symptoms• Diagnosis of PAD begins with
clinical suspicion• Uncommon before age 40• Smoker• DM • CAD• Typical claudication is
uncommon (11-15%)• Other symptoms
• Heaviness, weakness, fatigue, ache
• Rest pain or arterial insufficiency wounds
Beckman JA and MA Creager (2013). Ch 18: PAD: Clinical Eval. In Vascular Medicine, 2nd Ed. Philidelphia: Saunders
ROSE QUESTIONNAIRE• Pain begins while sitting or standing still? NO=IC
• Pain worse uphill or walking at rapid pace? YES=IC
• Pain at ordinary pace on level? YES=IC
• Does pain resolve w/ rest? YES=IC
• Location of pain? Calf, buttock, hip, thighs
Physical Exam
• Examine pules in all possible locations (carotid, radial, femoral, popliteal, dorsalis pedis, posterior tibial)• Categorize:• Easily palpable• Palpable but diminished • Non-palpable but Doppler +• Non-palpable and Doppler –
• Palpable pulses do NOT exclude hemodynamically significant PAD• Examine patient in supine position
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Appearance of the Lower Extremities
• Describe skin appearance (absence of lower extremity hair, shiny appearance of skin, changes in the nails)• Buerger Test:• Dependent rubor• Elevation pallor
• Ulceration or nonhealing wound (location, size, extent)
Etiologies of Leg Pain
• Peripheral Arterial Disease• Venous insufficiency• Myopathy/Myositis• Spinal stenosis (radiculopathy)• Neuropathy• Orthopaedic (osteoarthritis, etc…)• Lymphedema
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Implications of Peripheral Arterial Disease
PAD Awareness Low Among General Population
23 2737
67 69 73
90
0102030405060708090
100
PAD CysticFibrosis
ALS CHF CAD CVA HTN
"Very familiar/Somewhat familiar"
Hirsch A.T., Circ. 2007;116;2086-2094.
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Implications of PAD
• PAD is CV disease risk-equivalent• 5x risk of MI• 2-3x risk of CVA
• PAD is common • ~8.5 million in US over age 40• Strongly associated with advanced age, DM, and tobacco abuse
• PAD prevalence to increase with an aging and increasingly diabetic population
Heart Disease & Stroke Stats. Circ.2015;131(4):e29-232.
Poor Survival with PAD
Normal Subjects
Asymptomatic LV-PAD†
Symptomatic LV-PAD†
Severe Symptomatic LV-PAD†
1.00
0.75
0.50
0.25
0.00
0 2 4 6 8 10 12
Su
rviv
al
Year
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
From Criqui MH, et al. N Engl J Med. 1992;326:381-386.
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PAD mortality comparatively high
1.4%10%
20%30% 35% 41%
67%82%
0%10%20%30%40%50%60%70%80%90%
Prosta
te ca
ncer(1
)
Breast
canc
er(1)
Acute
myocar
dial…
PAD(4)
Colorecta
l can
cer(1
)
Stroke
(3)
Critica
l lim
b isc
hemia (5
)
Lung
canc
er(1)
% m
orta
lity
5-year All-Cause Mortality
1. https://seer.cancer.gov/statfacts/2. Bata IR. Can J Cardiol.2006;22(5):399-404.
3. Hankey GJ. Stroke. 2000;31(9):2080-6
4. Weitz JI et al. Circulation. 1996;94:3026–3049.
5. Ljungman C et al. Eur J Endovasc Surg. 1996;11:176-182
Diagnosis of Peripheral Arterial Disease
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Spectrum of Lower Extremity PAD
Asymptomatic Claudicant Critical limb ischemia
Rutherford-Becker Classification
Category Clinical description
0 Asymptomatic1 Mild claudication2 Moderate claudication3 Severe claudication4 Ischemic rest pain5 Minor tissue loss – non-healing ulcer, focal
gangrene; functional foot preserved6 Major tissue loss – ulcer extending above toes;
functional foot no longer salvageable
Rutherford RB, et al. J Vasc Surg. 1986;4(1):80-94
Criti
cal l
imb
ische
mia
(CLI
)
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Physiologic testing for PAD
• Ankle brachial index (ABI) & ankle systolic pressure• Toe brachial index (TBI) and toe systolic pressures• Plethysmography• Segmental limb pressures • Pulse volume recordings (PVR)
• Transcutaneous oximetry• Skin perfusion pressure
Ankle-brachial index (ABI)
• Proposed by Winsor (1950) as non-invasive diagnosis of PAD• Later shown to have powerful prognostic impact on CV risk,
even in the absence of symptoms
• An ABI ≤ 0.90 has > 90% sensitivity & specificity to detect PAD compared w/ DSA
Aboyans V, et al. Circ. 2012;126:2890-2909.
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Ankle-brachial index (ABI)
• ABI criteria• Elevated >1.40• Normal 1.0-1.40• Borderline 0.91-0.99• Abnormal ≤ 0.90
ABIHigher of bilateral
brachial SBP (mmHg)
Higher of ipsilateral ankle (dorsalis pedis or posterior
tibialis) SBP (mmHg)
Aboyans V, et al. Circ. 2012;126:2890-2909.
120 100
DP 80
PT120
DP 40
PT115
ABI (R) = 115/120ABI (R) = 0.96
ABI (L) = 120/120ABI (L) = 1.00
Exercise ABI testing
• Post-exercise ABI• Normally, ABI decreases
slightly (5%) w/ exercise and recovers promptly (1-2 min) back to baseline
• In PAD, ABI declines more dramatically after exercise
• Exercise ABI indicates PAD with: • ≥20% reduction from resting
ABI • >30 mmHg reduction from
resting ankle sys pressure• Long recovery period (5+
min)
Aboyans V, et al. Circ. 2012;126:2890-2909.
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Limitations of ABI
• Less accurate when ankle pressures are not assessed with Doppler• Accurate measurement dependent on appropriate cuff size • Unreliable in calcified, non-compressible arteries • Unreliable among patients with critical lower limb ischemia
Aboyans V, et al. Circ. 2012;126:2890-2909.
Anatomic testing for PAD
• Arterial Duplex• CTA, MRI/MRA• Digital subtraction
angiography – gold standard
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Duplex Ultrasonography
1. van der Heijden, et al. Eur J Vasc Surg. 19932. Edwards et al. J Vasc Surg. 1991
• Advantages• Non-invasive• Cost effective• No contrast• Good accuracy (84-94%)
• Disadvantages• Technically demanding• Dense calcification obscures flow• Reduced utility for infrapopliteal anatomy
Computed Tomography Angiography
Advantages
• Excellent sensitivity > 90%
• Visualizes calcium
• Guides PTA access and
treatment strategy
Disadvantages
• > 100 mL of iodinated contrast
• Visualizes calcium, blooming
artifact
• Overestimates severity in
infrapopliteal segments
• Reduced spatial resolution
compared to DSA
1. Ofer A, et al. Amer J Roentgenol. 2003; 180:719
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Magnetic Resonance Angiography (MRA)
Advantages
• Excellent sensitivity &
specificity > 90%
• Excellent for OM
• Guides PTA access and
treatment strategy
Disadvantages
• Artifact within stented
segments
• Overestimate stenosis
• Poorly accounts for
calcium
• Restrictions with metallic
implants
• Claustrophobia
Carpenter JP, et al. Surgery. 1994; 116:17-23
Quinn SF et al. J Magn Reson Imaging. 1997; 7:197-203
Ruehm SG et al. Amer J Roentgenol. 2000; 174: 1127
Meaney JF et al. Radiology. 1999; 211: 59
Digital Subtraction Angiography
• Advantages• Gold standard• Spatial resolution of lesion length, severity,
complexity• Infrapopliteal anatomy• Often less contrast than CTA• Treatment options
• Disadvantages• Invasive• Iodinated contrast• 3-dimensionality can be underappreciated
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My Approach• History• Physical Exam• High probability of PAD with advanced symptoms (Rutherford-Becker
4-6)• Direct to invasive angiography (unless prior bypass then assess anatomy for
vascular access planning)• If mild-moderate PAD (Rutherford-Becker 2-3) • Start with ABI/PVR and if conclusive and indicated proceed with invasive
angiography• If ABI/PVR inconclusive then proceed with either duplex ultrasound or CTA
Thank You
• Steven Laster, MD• Matt Bunte, MD
