Peripheral Arterial Disease

Pt age > 65 years h/o HTN, HLD, CVA, heart failure, chronic kidney disease, DM, smoking presents with calf pain/cramping during activity. Pain resolves after approximately 10 minutes rest. Diminished pulses, pallor, hair loss, and non-healing gangrenous wound on lower extremities; ankle-brachial index 1.3 < ABI < 0.9.

Acute limb ischemia due to arterial thrombosis. James Heilman, MD - Own work.

Acute limb ischemia due to arterial thrombosis. James Heilman, MD - Own work.

  • Obtain CBC, CMP, BNP

  • Lipid panel shows HDL < 50 mg/dL

  • EKG shows Q waves and ST segment changes

  • Treatment

    • Start supervised exercise therapy program

    • Start aspirin 81 mg qd, ramipril 2.5 mg qd x 1 week and then 5 mg qd, atorvastatin 80 mg qd

    • Continued pain s/p supervised exercise therapy and no h/o heart failure: Start cilostazol 100 mb BID; pt counseled about risk for dizziness, GI distress due to vasodilatory effects

  • Consults/Referral

    • Refer for abdominal aortic aneurysm (AAA) screening

    • Refer for surgical revascularization for cases of

      • Lifestyle limiting claudication with insufficient response to exercise/medical therapy

      • Ischemic rest pain x 2 weeks

    • Admit to hospital for emergent vascular surgery within 4 to 6 hours in cases of limb-threatening ischemia as indicated by painful, pale/dusky colored and cold extremity with absent pulses, motor weakness, sensory impairment

  • Pt advised to stop smoking and offered smoking cessation therapy


Notes

5 MHz vascular Doppler probe used for ABI

5 MHz vascular Doppler probe used for ABI

2 MHz fetal Doppler probe used for prenatal care after 14 WGA

2 MHz fetal Doppler probe used for prenatal care after 14 WGA

  • Epidemiology

    • Affects 50% of patients age > 85

    • Only 10% of PAD patients experience claudication

  • Diagnosis

    • Ischemic rest pain generally occurs when feet are elevated and resolves in the dependent position, e.g. sleeping pt must hang feet over side of bed

    • Ankle-brachial index (5-8 MHz vascular probe not 2-3 MHz fetal probe)

      • 94-97% sensitivity for detecting angiographically significant stenosis

      • Values > 1.3 suggest non-compressibility; use toe index with > 0.7 considered normal

    • HDL < 40 and 50 mg/dL in males/females receptively is associated with increased risk of death

    • Consider BNP to r/o heart failure before starting cilostazol

  • Treatment

    • Dual antiplatelet therapy is generally not more effective than aspirin

    • Heart Outcomes Prevention Study: ACE (ramipril) or ARB (telmisartan) reduced MI, stroke, and mortality in patients with PAD and no h/o heart failure

    • Statin NNT ~ 5 to reduce risk of long-term adverse outcome

    • Supervised exercise therapy can often be performed at a physical therapy center; otherwise, pt should walk until pain onset and then rest until pain subsides

    • Cilostazol contraindicated in heart failure