PERIPHERAL ARTERIAL DISEASE:Clinical Presentations: 5 types 
  • Asymptomatic- 40%, 
  • Claudication 10%, 
  • Atypical features 40-50%, 
  • CLI
    • Rest pain, ulcers or frank gangrene caused by arterial occlusive disease 
    • Typically multivessle disease 
    • Limb is threatened 
  • ALI
Clinical Implication:
  • 30 % 5 yr mortality 
  • 20 % MI in 5 yr 
  • Pain arising from arterial obstruction from other cause (Arterial Aneurysm, Arterial Dissection, Popliteal Entrapment Syndrome, Embolism, Adventitial cystic disease, Thromboangitis Obliteran, Other Vasculitis disorder)
  • Pain arising from non-arterial etiology (Musculosketal, Neuropathic, Chronic Venous Disease - venous insufficiency, venous claudication ) 
  • History: ROSE 2 Questions: 
    • Do you get PAD on walking?
    • Does it get better with 10 min rest?
    • If Both questions positive, PPV is 95%, but sensitivity is only 10%; 
  • PE: PTA pulse, if absent 90% specificity
  • ABI: Low ABI sensitive Specific in 70-90 %
    • For Diabetic patients, ABI itself is not adequate
  • Exercise ABI: will help determine if leg symptoms are due to PAD
    • Fall in ankle pressure after exercise (.30 mmgHg fall in pressure) 
  • Doppler waveform or Plethysmography waveform are better tests
  • CTA (not everyone needs it)
  • MRA (not everyone needs it)
Define the location of Disease; Know the Anatomy (Can be in more than one location)
Screen: AHA/ACC (a. Exertional leg sx b. Non-healing wounds, c. Age >65, d. <65 if smoker or DM?) but USPTF is against screening in c and d
Peripheral Artery Disease NEJM 2016

Case Discussion
59 yo M with COPD, DM 2, CAD, HTN, HLD, HFrEF with EF of 35 % is seen for leg pain that gets better with rest. Peripheral pulse is palpable but diminished. Given the risk factor for PAD, ABI is ordered. 

What is the interpretation?
  • Patient has Mild ABI. (See Table 1 above from NEJM 2016
What is the next step in the management?
  • Exercise test to assess functional capacity
The same patient, if ABI < 0.5, what would be the next step to perform
  • Transcutaneous oximetry (See Table 1 above from NEJM 2016
If the test came normal, i.e ABI 0.9 - 1.4, what would be the next step?
  • Exercise test to assess post-exercise ABI. 
  • For Diabetic patients, ABI itself is not adequate
  • Low ABI sensitive Specific in 70-90 %
How to manage this patient given ABI shows mild PAD 
  • (See Table 1 above from NEJM 2016)  Also, see below 
Case Discussion 2
44 yo M with DM1, ESRD, HIV,  seen for Rt LE non-healing ulcer underneath Rt toe. Pulse is not palpable. 
Examination is as shown

Doppler USG of LE is ordered. 

What is the next step in management? 

  • Exercise ABI given mild PAD in right leg. But, given LE ulcer, and and absent pulse, needs other tests especially as there is a concern of CLI. Especially, we know ABI is not sensitive. Hence, CTA to assess any occlusion for endovascular intervention will be needed. Note patient already has ESRD, hence Contrast should not be of any concern. 
Patient is on ASA 81 mg, Pravastatin 80 mg, Is NOT  on ACEI. what next can be done? LDL is 14, and TG 400. 

Case Discussion 3
85 yo with h/o CAD, HFpEF, HTN, HLD, DVT, chronic LE cellulitis is seen for intermittent claudication. PAD is suspected, and ABI is ordered. 

What is the interpretation?
  • Non-compressible disease. Severe lesion is likely. 
What is the next step?
  • Toe-Brachial Index. See Table 1 above from NEJM 2016
Patient is on ASA 81 mg, Eliquis 5 mg. Not on Statin or ACEI. What should be the next step. 
  • Add Statin
  • ACEI can be added if patient can tolerate
  • Given LLE cellulitis, even consider CTA for possible need of endovascular intervention 

Management: 3 main goal: 
      • 1. Survival advantage 
      • 2. Expectations on QOL, Job etc define the goal
      • 3. Protect the limb 
    • 1. Survival Advantage: 
      • Aggressive Risk Factor Modification to minimize MACCE i.e HTN, Atherosclerosis, DM, Smoking Cessation 
      • ACEI (IIa in symptomatic, IIb in asymptomatic) (HOPE Trial: MACE decreased by 22% on Ramipril)
        • In patient with normal BP
        • ONTARGET (ARB) Telmisetron
        • ABCD Trial 
        • Note: BB are not contraindicated
      • Statin (Heart Protection Study) Simva vs Placebo
        • Subset analysis: 20 % reduction in non-coronary revascularization
      • DM
        • Glycemic control is associated with amputation rate 
      • Smoking cessation:
        • Varnecline is not proven to have CV harm on meta analysis . Hence, it is 
      • Anti-platelets: 
        • Symptomatic PAD 
        • In asymptomatic patients benefit is not clear (IIa recommendation)
        • ATC, 2000 BMJ : ASA decreases MACE by 25 %
        • CAPRIE 1996, Lancet: Clopidogrel, slightly better than ASA
        • e role of dual anti-platelet therapy if not stented. 
        • ? CHARISMA Trial 
    • 2. Improving Quality of Life 
      • Phosphodiesterase type 3 Inhibitor (Cilostazole, 100 mg BID; Vasodilator and Mild-antiplatelet; 50 mg BID for few weeks then increase to 100 mg BID in few weeks)
        • Walking distance increases by 50% after 3-6 months of therapy
        • S.E: HA, Dizziness, Diarrhea, Palpitations
        • CI in Heart Failure
        • Pentoxifyllin was inferior to Cilastazole
      • Supervised Exercise better than home (like due to compliance)
        • 30-45 min 3 times a week for 12 weeks to see any benefit
    • 3. Protect the limbs 
      • Foot inspection
      • Percutaneous Interventions
        • Endovascular (Stents vs Baloon) vs End Aretectomy 
      • Bypass Surgery

Note: Disease severity classification is different in 2016 paper. 

67yo F is seen for acute leg pain. She has previously been diagnosed with PAD, and CTA 6/2016 showed Severe atherosclerotic disease with multiple levels of occlusion including the right iliac vessels and left superficial femoral artery. On the current visit, no pulse is palpable in left dorsal is pedis and popleteal. No gangrene is seen. Decreased capillary refill. 
What is the diagnosis
ALI, viable tissue

  • right iliac vessels: Aortofemoral bypass. 
  • left superficial femoral artery: 
    • atherectomy. 
    • if restenosis, Drug coated balloon angioplasty, DES, covered Stent, 
    • if extensive, and either approach is not doable, then femoral popleteal bypass should be done. 
Hypogastric artery: Occulded: 
Int I 
CF atery stenosis: endarterectomy 
PF: patient
SFA proximal stenosis with opening  in the mid SFA onwards
Anterior tibial 

posterior tibial artery and peroneal artery appeared occluded

Complete occlusion from CI to popliteal. PF remains patent giving collaterals.  

CI occlusion: Stent from Aorta to CI . Multiple Viabahn stents
Hypogastric artery: occulded 
Int I 
ExtI: Distal ExtI occlusion above the inguinal ligament: Baloon expandable Stent or Baloon angioplasty : Patient got stent : Patient 
CF : 
SFA : Dissection throughout. Flow limiting. Baloon angioplasty done. Alt would be Fem popliteal bypass, but is not necessary due to goo collaterals from PF. At the level of the adductor canal however the distal SFA regains a more normal caliber. 2/17: Occulded: 
Anterior tibial 

posterior tibial artery occulded  

peroneal artery appeared