Medical Management of PAD
• Peripheral arterial disease (PAD) is common, affecting approximately 14% to 20% of adults; 25% of having symptoms of peripheral arterial disease and 75% of having no significant symptoms of peripheral arterial disease.
• Chronic (long-term history) of PAD includes both intermittent claudication (recurring cramping pains of the lower extremity with activity) and critical limb ischemia (CLI), which may result in inability to perform basic activities of daily living, cramping pains in the feet when lying down, or ulcers and/or gangrene changes of the legs and feet.
• Approximately 25% of intermittent claudication patients’ symptoms worsen in the first year after diagnosis of symptomatic PAD.
• Critical limb ischemia (CLI), a result of poor oxygenation of muscle and soft tissue due to blocked or nearly blocked arteries from plaque build-up, leads to amputation within the first year after diagnosis in approximately 30% of patients with CLI.
• The 5-year mortality for patients with CLI is 50% to 70%, with approximately 35% of deaths a result of cardiovascular disease (heart attack, stroke).
• Intermittent claudication, a result of peripheral arterial disease, reflects significant atherosclerosis in which the arteries supplying blood and oxygen to the heart and arteries supplying blood and oxygen to the brain may also be involved.
• Treatment of chronic leg ischemia due to atherosclerotic disease should include prevention for heart attacks (ischemia, infarction) and stroke-related events.
• Best medical treatment involves control of risk factors for heart-related and stroke-related events; including managing high cholesterol, hypertension (high blood pressure), diabetes, smoking cessation, and a supervised exercise program.
• Common medications used to manage PAD include Aspirin, clopidogrel, cholesterol-lowering medications, and angiotensin-converting enzyme inhibitors (blood-pressure medication(s) have been shown to be beneficial in preventing secondary events of heart-related and stroke-related events.
· Antiplatelet agents reduce the risk of both fatal and nonfatal cardiovascular (heart-related and stroke-related) events.
· Aspirin should be considered for all patients with PAD, with clopidogrel as an effective alternative treatment.
• Cilostazol has proven effective in improving walking distance in adults with intermittent claudication and beneficial in improving quality of life.
· A diagnosis of Intermittent Claudication (IC) is usually established by a vascular specialist through a history and physical examination.
· Common tests Dr Kendrick uses to confirm IC include blood pressure measurements just above the ankles and in the upper arms, and he compares these pressures as a ratio called an ankle–brachial index (ABI).
· A reduced ABI in symptomatic individuals confirms the diagnosis of significant PAD disease, with a lower ABI corresponding to increased severity.
· Lower extremity blood pressures may be artificially (falsely) elevated in individuals with diabetes and renal/kidney disease, as the arteries may be excessively calcified with atherosclerotic calcified plaque, resulting in higher blood pressures needed to fully compress/occlude the artery with the blood pressure cuff for measurement.
· Dr. Kendrick also performs toe pressures, segmental pressures, pulse volume readings to assess to confirm the presence of the significance of symptomatic PAD and artificially elevated blood pressures at the ankle.
· Evidence gathered by large studies over the last 50 years has demonstrated that only a 25% of patients with IC will ever have significant worsening PAD symptoms.
· Stabilization of symptoms in 75% of patients with IC is attributed to the development of small artery branches increasing in size, providing more oxygen to the muscles once receiving inadequate oxygen and blood flow from the previously smaller vessels.
· ABI is the best predictor for deterioration or progressive worsening of PAD.
· The risk of progression to severe ischemia or limb loss for patients with low ankle pressures of 40 to 60 mm Hg is 8.5% per year.
TREATMENT FOR INTERMITTENT CLAUDICATION
· California Vein Vascular and Diagnostic’s initial goals of treatment are to relieve the symptoms of pain on walking, to increase walking distance, and to improve quality of life.
· Control of risk factors for both claudication and heart-related and stroke-related disease is a critical factor to medically manage claudication.
· There is sufficient evidence-based medical research to justify risk factor modification in all patients with PAD, regardless of the severity of the individual’s symptoms.
· IC has been shown to affect sleep, emotional behavior, and social interactions, in addition to mobility.
· Most importantly, as a board-certified vascular surgeon, Edwin N. Kendrick, MD’s recommendations for surgery in adults with intermittent claudication depends on:
· Inhibition of the individual’s quality of life (i.e. a highly-active individual is no longer able to participate their common physical activities- golfing, hiking, running, sailing, etc.)
· The extent to which the symptoms interfere with the individual’s job duties and daily activities.
· Vascular specialists are critical in determining a diagnosis as peripheral vascular disease needs to be distinguished from other common causes of pain, such as spinal stenosis and neuropathy.
· At CAVVD, Duplex (ultrasound and Doppler) imaging is routinely used to determine if-and-when a surgical intervention is needed in individuals.
· Duplex imaging assists in determining the severity of atherosclerosis within the arteries and viable options for intervention (endovascular, open surgery).
· CAVVD reserves multi-slice computed tomography angiogram (CTA) and magnetic resonance angiography (MRA are valuable additional procedures for localizing areas of artery lumen narrowing from severe atherosclerosis.
*Disclaimer- The information provided is for informational purposes only.