S. mehta peripheral vascular disease and intervention
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Transcript of S. mehta peripheral vascular disease and intervention
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Peripheral Arterial DiseaseDiagnosis and Management
Sam Mehta MDDirector of Cardiology- St. Anthony’s Hospital
Interventional CardiologistColorado Heart and Vascular PC
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DisclosuresSpeakers Bureau: Bard Vascular
Cardiovascular Systems Inc
Dermasciences
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Disclosures cont
I like legs
3Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
Relative Risk
Smoking
Diabetes
Hypertension
Hypercholesterolemia
Hyperhomocysteinemia
C-Reactive Protein
Reduced Increased
Risk Factors for PAD
1 2 3 4 5 60
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60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudication±Impotence – Leriche’s Syndrome
Thigh Claudication
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Chronic PVD History
1. INTERMITTENT CLAUDICATION• Derived from the Latin word ‘to limp’• “Reproducible pain on exercise which is relieved by rest”• Pain can also be reproduced by elevating the leg• “my legs get sore at night and feel better when I hang them over the edge of the bed”
2. OTHER SYMPTOM/SIGNS:• A burning or aching pain in the feet (especially at night)• Cold skin/feet• Increased occurrence of infection• Non-healing Ulcers• Asymptomatic
3. CRITICAL STENOSIS = >60%, IMPENDING ACUTE ISCHEMIC LIMB:• - rest pain• - ischemic ulceration• - gangrene
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Examination: What To Do:
InspectionExpose the skin and
lookfor:
• Thick, Shiny Skin• Hair Loss• Brittle Nails• Color Changes (pallor)• Ulcers• Muscle Wasting
Palpation • Temperature (cool,bilateral/unilateral)• Pulses:? Regular,? AAA• Capillary Refill• Sensation/Movement
Auscultation • Femoral Bruits
Ankle Brachial Index (ABI)
= Systolic BP in ankle Systolic BP in brachial artery
Buerger’s Test • Elevate the leg to 45°- and look for pallor• Place the leg in a dependent position 90° & look for a red
flushed foot before returning to normal•Pallor at <20° = severe PAD.
Physical Examination:
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CAUTION:Patient’s with Diabetes + Renal Failure:
They have calcified arterial walls which can falsely elevate their ABI.
What does the ABI mean?
Figure 1. PAQ summary scores.
David M. Safley et al. Circulation. 2007;115:569-575
Copyright © American Heart Association, Inc. All rights reserved.
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Wounds will not heal without blood supply!
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Avoid at all Cost!
• BKA patient has 50% mortality at 5 years• Estimated > 50% increase in energy expenditure in order
to• Ambulate after BKA
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Treatment goals
• Pain relief
• Heal wounds
• Avoid amputation
• Limit level of amputation
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I found a pedal pulse, so patient should heal…
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Avoid at all Cost!
• BKA patient has 50% mortality at 5 years• Estimated > 50% increase in energy expenditure in order to• Ambulate after BKA
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Goals of vascular therapy in foot ulcers
•Provide straight line flow to the wound (angiosome directed therapy)
•Often requires multilevel revascularization
•It is suboptimal to get larger arteries revascularized and hope wound will heal
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•
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Noninvasive Testing
• ABIs
• Pulse Volume recordings
• Arterial ultrasound
• CT Angiogram
• MR Angiogram
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• No noninvasive test is perfect
• Frankly, they are all fraught with imperfections, physical exam and wound location trumps all noninvasive testing
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• If suspected vascular wound, refer to vascular specialist early, rather than ordering further testing.
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Who Should I Refer to???
• Vascular Surgeon?
• Interventional Cardiologist?
• Interventional Radiologist?• Cardiothoracic Surgeon???
Case 1• 55 yo diabetic female, experienced
sudden cardiac death after a myocardial infarction.
• atherosclerotic risk factors include diabetes, family history, dyslipidemia and tobacco abuse.
• Prolonged hospital stay, requiring vasopressor agents.
Case 1 cont
• Referred from cardiologist (my partner) to podiatrist for gangrenous 2nd toe (dry but painful)
• Referred back to me from podiatrist as he was unable to palpate pedal pulses
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Case 1
• Though images look suboptimal for flow, wound completely healed.
Case 2
• 58 yo male, hx DM and tobacco abuse.
• nonhealing great toe, ulcer. patient ignored, now gangrene.
Anterior Tibial lesion in CLI
Before and After
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Take Home Message
• For patients who present with CLI, it is imperative to move quickly and consult an endovascular specialist
• Positive outcomes require the cohesive team of endovascular specialists, podiatry, wound care, infectious disease specialists, and primary care physicians.
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