Duane S Pinto M D Director Peripheral Angiographic
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Duane S. Pinto, M. D. Director Peripheral Angiographic Core Laboratory, TIMI Data Coordinating Center Director, Cardiology Fellowship Training Program Interventional Cardiologist Beth Israel Deaconess Medical Center Assistant Professor of Medicine, Harvard Medical School Intermittent Claudication Diagnosis and Work-up Harvard Medical School
PAD is a common disorder § Occurs in approximately 1/3 of patients § Over age 70 § Over age 50 who smoke or have DM § Strong association with CAD § Obvious associated risk of stroke, MI, cardiovascular death § Progressive disease in 25% with progressive intermittent claudication/limb threatening ischemia § Outcomes § § § Impaired Qo. L Limb Loss Premature Mortality Harvard Medical School
Risk Factors for PVD: Framingham Heart Study Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia Fibrinogen Mean follow-up 38 years C- Reactive Protein Alcohol Relative Risk . 5 1 2 3 4 5 6 Harvard Medical School
PAD is Associated with Poor Outcomes Stroke Annual Incidence 0. 73 Prevalence Mortality/yr (%) 4. 6 28 TIA 0. 50 4. 9 6. 3 ACS 2. 3 12. 6 45 8 -12 4 -25% PAD Criqui M, et al. Circulation 1985; 71: 510 Harvard Medical School
Outcomes in PVD Patients Harvard Medical School
Diagnostic Modalities § History § Physical § Ankle Brachial Index (ABI) § Noninvasive vascular laboratory § Angiography: MRA, CT, DSA Harvard Medical School
Initial Assessment § Identifying risk factors and symptoms § Pulse palpability § Further assessment relies on functional noninvasive testing and radiological imaging § Determine not only the anatomic, but also the physiological aberration of peripheral vascular flow. Harvard Medical School
Intermittent Claudication § Intermittent claudication (derived from the Latin word for limp) § A reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest. § Supply ≠ Demand § Location depends upon the location of the disease. § Buttock, thigh, calf or foot claudication, either singly or in combination. Harvard Medical School
PVD Etiology § Large arteries § Atherosclerosis § Thromboembolism § Trauma § Arteritis of various types including § Buerger’s disease § Fibromuscular dysplasia § Takayasu’s Harvard Medical School
PVD Etiology § Medium and small vessel occlusions § Diabetes § Chronic recurrent trauma § Multiple small emboli § Collagen vascular diseases § Dysproteinemias § Polycythaemia vera § Pseudoxanthoma elasticum § Drug Reaction § Vasospasm Harvard Medical School
PVD Etiology § Specific to certain anatomical sites § Cystic adventitial disease of the popliteal artery § Popliteal artery entrapment § Iliac endofibrosis (cyclists) § Various neurovascular compression syndromes affecting the upper limb § Cervical rib § Costoclavicular syndrome § Scalenus tunnel syndrome § Hyperabduction syndrome § Quadrangular space syndrome Harvard Medical School
PVD Differential Diagnosis § Deep venous thrombosis § Musculoskeletal disorders § OA § Restless leg syndrome § Peripheral neuropathy § Spinal Stenosis (pseudoclaudication) § Worse with erect posture (lordosis) better sitting or lying down. § Can find relief by leaning forward and straightening the spine (pushing a shopping cart or leaning against a wall). Harvard Medical School
Differential Diagnosis of Intermittent Claudication Venous Claudication Neurogenic Claudication Quality of pain Cramping "Bursting" Electric shock-like Onset Gradual, consistent Gradual, can be immediate Can be immediate, inconsistent Relieved by Standing still Elevation of leg Sitting down, bending forward Location Muscle groups (buttock, thigh, calf) Whole leg Poorly localized, can affect whole leg Legs affected Usually one Often both Harvard Medical School
Location, Location! § Buttock/hip § Usually indicates aortoiliac occlusive disease (Leriche's syndrome) § Some cases, thigh claudication too § Question diagnosis of bilateral disease if erectile dysfunction is not present § Thigh § Occlusion of the common femoral artery leads to claudication in the thigh, calf, or both. § Calf § Symptoms in upper 2/3 is usually due to SFA § Lower 1/3 is due to popliteal disease. Harvard Medical School
PVD History § Use of the history alone to detect peripheral arterial disease will result in missing up to 90 percent of cases. § Asymptomatic patients with abnormal ABI have 50% increased risk of cardiovascular complications Hirsch AT, et al. JAMA 2001; 286: 1317 Hooi JD, et al. J Clin Epidem 2004; 57: 294 Harvard Medical School
Physical Exam § Trophic Signs § Skin atrophy, thickened nails, hair loss, dependent rubor § Ulceration, gangrene § Pulse exam § May miss more than 50% § Elevation and dependency test Criqui M, et al. Circulation, 1985: 71; 516 -521 Harvard Medical School
Physical Exam: Elevation and Dependency Test Color Return(s) Venous Filling(s) Normal 10 10 -15 Adequate Collaterals 15 -25 15 -30 Severe Ischemia >35 >40 Halperin, Throm Res. 2002; 106: V 303 -311 Harvard Medical School
Harvard Medical School Noninvasive Work-up
Ankle Brachial Index § Cornerstone of lower extremity vascular evaluation § Blood pressure cuffs, Doppler § Ankle (DP or PT) to brachial artery pressure Normal 0. 96 Claudication 0. 50 -0. 95 Rest Pain 0. 21 -0. 49 Tissue loss 0. 20 Significant change 0. 15 or more Harvard Medical School
Limitations § Noncompressible vessels § Diabetes § Renal Failure § ABI >1. 5 § Use toe-brachial index § Normal >0. 7 § Rest pain <0. 2 § Subclavian/Brachiocephalic Occlusive disease Harvard Medical School
Segmental Pressures § Pneumatic cuffs at multiple levels § Doppler pressure at pedal artery § Drop >30 mm Hg between levels § Drop >20 mm Hg between limbs § Reflects status of artery above drop in pressure § Inaccurate with calcified vessels Rose SC. J Vasc Interv Radiol. 2000; 11: 1107 -1114 Harvard Medical School
Duplex Doppler § Non-invasive method of evaluating the blood vessels using sound waves, similar to ultrasonography and echocardiography. § Can obtain both anatomic and hemodynamic information. § Anatomical detail § vessel wall § intraluminal obstructive lesions § perivascular compressive structures Harvard Medical School
Doppler Waveform Analysis: Hemodynamic Information § Sensitivity of 92. 6% and specificity of 97% (angiography gold standard) § Inaccurate at adductor canal and the aorto-iliac regions. § 95% accuracy in the detection of bypass graft stenosis, but can overestimate stenosis. Polack JF. Duplex Doppler in peripheral arterial disease. Radiol Clin N Amer 1995; 33 : 71 -88. Harvard Medical School
Doppler Waveform Analysis: Hemodynamic Information § Qualitative assessment of waveform analysis § Simple Equipment § Not affected by medial calcinosis § Supplements segmental pressures Harvard Medical School
Pulse Volume Recordings § Pneumatic Cuffs at Multiple Levels § Inflated to 65 mm Hg § Extremity Volume Increases in Systole § Changes pressure in cuff § Waveform Analysis § Not Impacted by Calcification Harvard Medical School
Pulse Volume Recordings § Advantanges § Widely available § Cheap § Reproducible § Disadvantages § Technician dependent § Time Consuming § Detection of Collaterals is low § Presence of gas and calcification degrade images Harvard Medical School
Is this enough? § Noninvasive lab documents presence and severity of disease § No comprehensive anatomic information § No ability to plan interventions Harvard Medical School
Radiologic Imaging: MRA and CTA § DSA (conventional angiography) remains the gold standard for evaluation of PVD § Newer modalities that match its accuracy are rapidly evolving § It is a matter of time before imaging replaces DSA, with the invasive angiographic techniques reserved for interventional procedures Harvard Medical School
MRA vs. DSA Harvard Medical School
MRA: Current Technique § 3 D gradient echo (fast acquisition) § Gadolinium Enhanced § 20 -40 cc § Automated Scan delay § Renal arteries to toes § Stepping table or bolus chase § 45 -min exam Harvard Medical School
MRI Harvard Medical School
Limitations of MRI § Uncooperative patient § Claustrophobia § Metal artifact § Pacemakers/ICDs § Lack of visualization of calcium Harvard Medical School
CTA of PVD § Multidetector CT scanner necessary (4+) § Many hospitals now have 64 Slice § Iodinated contrast volume similar to conventional angiography § 80 -150 cc § Automated Scan Delay § Renal arteries to ankles § 20 -minute exam § High powered post processing software crucial Harvard Medical School
CTA of PVD Harvard Medical School
CTA of PVD § Large volumes of data are generated via CTA studies and displayed in various formats to refine the analysis of study results § Maximum Intensity Projection -MIP (most common) § Shaded surface display § 3 D Volume rendering Harvard Medical School
CT Limitations § With significant and dense calcifications, a false diagnosis of patency can result. § Uncooperative patient § Pregnancy § Bad Pump § Inconsistent pedal vessel visualization § Renal failure/contrast allergy Harvard Medical School
Digital Subtraction Angiography (DSA) § Gold standard of arterial imaging § Has almost totally replaced conventional cut film angiography § Compares a pre contrast image with a post contrast image using a computer, and "subtracts" elements common to both. § Prevents images of objects like bones etc from obscuring vascular details. § Contrast resolution is improved through use of image enhancement software. Harvard Medical School
Digital Subtraction Angiography (DSA) § Radiation exposure and contrast volumes are lower than conventional angiography § Images are immediately available for review. § Images are stored in digital format on computerized data storage media § Interventional procedures can be performed Harvard Medical School
Digital Subtraction Angiography (DSA) §Drawbacks precluding use as a screening modality §Technique is invasive and expensive. §Requires arterial puncture §Longer study than CT §Contrast nephrotoxicity Harvard Medical School
Medical Treatments for PAD Treatment Effect Smoking cessation 10 -year mortality ↓ 54% to 18%; at 7 years, rest pain drops from 16% to 0%* Antiplatelet agent 22%↓ in vascular events; possible increase in walking distance Diabetes control RR=0. 94 (0. 8 - 1. 1) for mortality; RR=0. 51 (0. 01 - 19. 64) for amputation BP to <140/85 mm Hg RR=0. 87 (0. 81 - 0. 94) for mortality; effect on PAD not known ACE inhibitors RR=0. 73 (0. 61 - 0. 86) for MI, stroke, or CV death Exercise program 24% ↓ in CV mortality; 150% further walking distance Cholesterol decrease RR=0. 81 (0. 72 - 0. 87) for MI, stroke, or revascularization; no clinical benefit in PAD† Cilostazol significant ↑ in walking distance *Survival Bias †Excepting Stroke Harvard Medical School
Suggested Algorithm for Work-up Harvard Medical School
Workup-Take-home § Noninvasive Vascular Lab is first line evaluation in nonacute patients § ABI is easy screening test § Beware noncompressible vessels in renal failure and diabetes § Segmental limb pressures often combined with doppler waveform anlaysis § Not sufficient to plan intervention Harvard Medical School
Workup-Take-home § MRA indicated for intervention planning § MRA (gadolinium enhanced) provides excellent renal to pedal imaging § Surpasses CT in the foot § Overestimation of stenoses in small vessels § Limited by metal artifact, magnetic field, and length of study Harvard Medical School
Workup-Take-home § CTA indicated for intervention planning § CTA provides excellent renal to ankle imaging § Pedal imaging poor § Soft tissues and bone also imaged § Small vessel calcification is limitation Harvard Medical School
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