Peripheral artery disease is one of those diagnoses that you know about, but maybe don’t feel comfortable diagnosing and managing. Listen as our esteemed guest Dr. Vladimir Lakhter @VladLakhter (Temple Health) talks us through its diagnosis and management. Dr. Lakhter gives us a straightforward framework for categorizing and triaging peripheral artery disease and talks us through the important components of medical management and who benefits from revascularization.
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Time Stamps*
*Note: Time Stamps refer to ad-free version.
Intro, disclaimer, guest bio- 00:33
Guest one-liner- 3:25
Dr. Lakhter book recommendations- 5:36
Case from Kashlak- 8:35
Definition and background for PAD- 10:25
Classification schema for PAD- 12:45
The physical examination- 21:05
ABIs and PVR in the diagnosis of PAD- 33:50
Exercise program for PAD- 46:08
Medication therapy- 52:05
Revascularization- 1:02:50
Outro- 1:08:45
Peripheral Artery Disease Pearls
The initial step in the identification of peripheral artery disease is to identify whether patients have critical limb ischemia or claudication.
Risk factor identification and mitigation are the critical first steps in the management of peripheral artery disease.
Ongoing tobacco cessation is mandatory for patients with peripheral artery disease who smoke.
A structured exercise program should be offered as an additional therapy for all patients with peripheral artery disease.
Aspirin and high-dose statin therapies should be used in all patients with peripheral artery disease.
Revascularization should be considered for patients with peripheral artery disease who continue to have lifestyle-limiting symptoms despite exercise and medical therapy.
Peripheral Artery Disease Notes
Definitions and background
Peripheral artery disease: atherosclerotic involvement of the peripheral arteries that causes flow-limiting blockages in the peripheral arterial circulation
Most commonly refers to lower extremities, but also includes carotid and renal arteries as well
30-50% of patients with coronary artery disease will have comorbid peripheral artery disease (Poredos, 2007)
Common risk factors include older age, tobacco use, hypertension, diabetes, hyperlipidemia, obesity, and family history
The Fontaine and Rutherford classifications are used to classify peripheral artery disease (Hardman, 2014)
Both systems include a classification for asymptomatic disease, and both have progressive grades for worsening claudication
Both have specific classifications for critical limb ischemia
In the initial evaluation, the most important branch points are determining asymptomatic versus symptomatic disease
If symptomatic disease is found, the next important branch point is determining if this is claudication or critical limb ischemia
Claudication is any pain that occurs with exertion and resolves with rest
Critical limb ischemia is characterized by rest pain, nocturnal pain, ulceration, or gangrene
Critical limb ischemia warrants more urgent revascularization, whereas more conservative management is used initially for claudication
Typical claudication is characterized by exertional symptoms, and this can include the buttock, hip, or thigh (suggesting aortoiliac disease) and calf or foot (suggesting femoral popliteal or tibial disease)
The location is determined by the level of disease
Pseudoclaudication can occur with sciatic disease or structural back disease, but the symptoms are usually not exertional and are classically positional
The shopping cart sign, characterized by relief of pain by leaning forward, is suggestive of pseudoclaudication
Physical Examination
The physical examination often begins with blood pressure taken in both arms
Pulses assessment can give clues to the vascular level of disease
Pulses are graded from 0-3
0 = absent
1 = diminished
2 = normal
3 = bounding
Bounding pulses are suggestive of an aneurysm or high pulse pressure like in aortic regurgitation
Absent pulses are suggestive of disease at a higher level of the vascular tree
Arterial ulcers can be seen in the toes
“Kissing ulcers” are found on the inner aspects of the toes
Initial Work-up of Peripheral Artery Disease
Typically starts with testing of the ankle-brachial index (ABI)
This is calculated by determining the systolic blood pressure at the brachial artery and at the level of the posterior tibial and dorsalis pedis (Aboyans, 2012)
The value given is the posterior tibial or dorsalis pedis blood pressure (whichever is higher) divided by the brachial systolic pressure
A value of 1.0-1.4 is considered normal
Anything less than 0.9 is abnormal
Exercise ABI can be considered if the index is normal but suspicion remains high
The level of disease can be determined by increasing the number of levels checked with the ABI or by doing a pulse volume recording
The pulse volume recording is measured at varying arterial levels, and the waveform is evaluated (for decreased amplitude, absent dicrotic notch) to determine possible level of pathology
Initial Management of Peripheral Artery Disease
Screen and manage any comorbid risk factors, like hypertension, diabetes, hyperlipidemia, and tobacco use
A discussion of tobacco cessation is absolutely requisite for patients who smoke
An exercise program is critical to the management of claudication
The CLEVER trial demonstrated that a supervised exercise program was just as effective as revascularization for patients with claudication from aortoiliac disease
Patients can attend an outpatient structured exercise program for up to 3 times per week for 12 weeks
This should be offered before revascularization is considered
If access is an issue, patients can be instructed to walk for 30-40 minutes, walking until claudication symptoms occur, and then resting until symptoms resolve
This likely works by a combination of ischemic preconditioning (conditioning tissues to less blood flow) and the development of collateral circulation
All patients with peripheral artery disease should be on aspirin 81 mg, if possible (Gerhard-Herman, 2017)
This reduces adverse limb events and adverse cardiovascular events such as stroke and heart attack
Patients with peripheral artery disease should also be prescribed a high dose statin (either 80 mg atorvastatin or 40 mg rosuvastatin)
Cilostazol has been shown to increase claudication-free walking distance in patients with claudication symptoms from peripheral artery disease (Bedenis, 2014)
Contraindicated in patients with heart failure
Headache, diarrhea, and palpitations are potential side effects
Generally, dual antiplatelet therapy is not specifically indicated for most patients with peripheral artery disease of the lower extremities
The CHARISMA trial showed some benefit for high-risk patients (e.g. for those with multiple interventions in the past)
Dr. Lakhter will place patients on clopidogrel for 30 days following revascularization
There is significant practice variation in this realm
The VOYAGER trial showed that rivaroxaban at a dose of 2.5 mg twice daily plus aspirin in patients who had undergone lower-extremity revascularization was associated with a significantly lower incidence of limb and atherosclerotic events
This was at the expense of a significantly increased bleeding risk
There has not been broad uptake in the prescription of direct oral anticoagulants at the time of this episode
The WAVE trial did not show benefit to adding warfarin to antiplatelet therapy
Revascularization for Peripheral Artery Disease
Revascularization should be considered for patients who have lifestyle–limiting symptoms of claudication despite maximal medical therapy and exercise program
Determining the specific vascular level is critical in determining the intervention
CT angiography of the abdomen and pelvis is a good initial modality when planning an intervention
This can be limited by calcification and a “blooming artifact”
Other modalities include MR angiography or interventional angiography
The determination to pursue endovascular versus surgical intervention is determined by patient preference, risk factors, and location of the anatomical lesion
Listeners will outline the diagnosis and medical management of peripheral artery disease, as well as identify who will benefit from revascularization
Learning objectives
After listening to this episode listeners will…
Differentiate between claudication and critical limb ischemia
Recognize and mitigate important risk factors for peripheral artery disease
Perform the appropriate physical examination to identify and stratify peripheral artery disease
Order appropriate initial diagnostic tests for peripheral artery disease
Identify the importance of an exercise program in the early management of claudication
Outline the appropriate medication management of peripheral artery disease
Recognize which patients with peripheral artery disease are appropriate for revascularization
Disclosures
Dr. Lakhter reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Citation
Kieserman JM, Williams PN, Brigham SK, Watto MF. “#260 Peripheral Artery Disease with Dr. Vlad Lakhter”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date March 8, 2021.
Comments
March 9, 2021, 8:28am Josh Schor writes:
Paul. Long time no talk....i was the guy who used to enjoy commenting on your made up literary/historical names like rosa luxembourg etc....Covid happened and as Med Dir for a SNF, i was somewhat tied up. Anyway, i'm back listening to you amazing guys. I Have been writing some pieces for Doximity too. Hey, your point to "Vlad" about why not just start with peripheral DP pulses and if they were normal, stop there....i thought was very Vladi (Valid). His answer about there being potential collateral flow seemed a bit pat to me. I always thought that collateral flow like this was "damped down" and pulses per se were not discernible...but maybe i was totatlly wrong. Thoughts?
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Comments
Paul. Long time no talk....i was the guy who used to enjoy commenting on your made up literary/historical names like rosa luxembourg etc....Covid happened and as Med Dir for a SNF, i was somewhat tied up. Anyway, i'm back listening to you amazing guys. I Have been writing some pieces for Doximity too. Hey, your point to "Vlad" about why not just start with peripheral DP pulses and if they were normal, stop there....i thought was very Vladi (Valid). His answer about there being potential collateral flow seemed a bit pat to me. I always thought that collateral flow like this was "damped down" and pulses per se were not discernible...but maybe i was totatlly wrong. Thoughts?