PERIPHERAL ARTERIAL DISEASE PATHWAY Map of Medicine/ELIC

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PERIPHERAL ARTERIAL DISEASE PATHWAYMap of
Medicine/ELIC

• Mr Paul Flora
• Consultant Vascular and General surgeon
• BLT
• Dominic Roberts
• GP Lower Clapton

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PAD Shared care Pathway

• Case 1
• Salient points of shared care pathway
• Mr Flora
• Medications for PVD
• Use of duplex scans
• Case 2
• ELIC vascular surgery advice service

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Case 1

• 63 yr old male retired bus driver.
• 6/12 Hx of bilateral intermittent calf pains on
  walking 30m.
• Pain relieved by rest. Reproduced on exertion.
• BMI 28, BP 128/78, smoker

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Examination

• Foot pulses not palpable
• No skin changes
• No AAA
• No Radio-femoral delay
• No renal, femoral or carotid bruits
• Management? / Further examination?
• Referral?

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Ankle brachial pressureindex(ABPI)

• Blood pressure taken around calf/ankle using
  Dorsalis Pedis pulse
• Dorsalis Pedis BP / Brachial BP ABPI
• Clinical status
  ABPI
• Symptom free
  1 or more
• Intermittent claudication
  0.5 -0.95
• Rest pain
  0.3 - 0.5
• Gangrene and ulceration
  lt0.2

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Ankle brachial pressure index (ABPI)

• Identify patients that can remain in primary care
  management
• 95 sensitivity / 99 specificity
• Strong indicator of CVS disease

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ABPI

• Brachial systolic 128
• Dorsalis pedis systolic 90
• ABPI 90 / 128 0.7
• RL
• Management?

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Shared care!

• Diet and lifestyle
• Smoking cessation
• Exercise therapy
• Control risk factors DM, BP lt140/90
• Full assessment of CV risk profile
• Medications
• Review after 3 months

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• ABPI 0.6-0.9 shared care
• ABPI gt 1.0 consider different diagnosis
• List of differentials in guidance
• ABPI lt 0.6 Refer to vascular surgeon

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Exercise And Diet

• Stop smoking and keep walking (Housley 1988)
• Structured, supervised exercise programme
• Improvement in walking distance mean 105, SD 56
  (Robeer 1998)
• Improvement vs no exercise groups (Robeer 1998)

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Medications
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Antiplatelets
ADP Pathway
ADP
Clopidogrel Inhibits ADP platelet aggregation
pathway
C
PLATELET
ADP Receptor
Dipyridamole Inhibits phosphodiesterase induced
cAMP release
COX
Aspirin Inhibits thromboxaneA2 platelet
aggregation pathway
TXA2 Receptor
cAMP Pathway
TXA2
TXA2 Pathway
Phosphodiesterase
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Statins

• Cholesterol lowering actions
• Endothelial protective effect
• Plaque stabilization
• Diabetes Mellitus
• CAD, CVD, PAD

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Medications

• Low dose aspirin
• (clopidogrel only if not tolerated)
• Statin if total cholesterol lt3.5mmol/L
• High risk of future CVS events

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Cilostazol

• Phosphodiesterase III inhibitor
• NOx mediated cAMP pathways
• Inhibition of platelet aggregation
• Increased vasodilatation
• Inhibitor of smooth-muscle cell proliferation

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Cilostazol vs Pentoxifylline
Dawson et al. Am J Med 2000 109 523 - 30
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Medications cont..

• Cilostazol
• GI and neuro side effects
• CI in heart failure
• Stop if no better after 3/12
• Naftidrofuryl
• Use if poor quality of life.
• Cost

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Algorithm for PAD management
Peripheral Arterial Disease

• Risk factor modification
• Smoking cessation
• LDL cholesterol lt 100 mg/dL
• LDL lt 70mg/dL if high risk
• HbA1c lt 7.0
• BP lt 140/90 mmHg
• BP lt 130/80 mmHg if diabetic or renal disease
• Antiplatelet therapy

• No limitation to quality of life or reduced
  exercise capacity
• Monitor patient for loss of function

• Limitation that affects quality of life
• History of significant exercise limitation
• Or
• Reduced treadmill performance
• Or
• Reduced function by questionnaire

• Claudication medical therapy
• Supervised exercise or pharmacotherapy

Suspected proximal lesion

• Localise the lesion
• Conventional angio
• MRA or CTA
• Ultrasound
• Hemodynamic localisation

Improved symptoms
Symptoms not improved or deteriorated
Continue

• Revascularization
• Endovascular
• Surgical

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Use of duplex scans

• In health duplex US of lower limbs
• When to use?

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Case 2

• 71 yr old male presents with sudden onset of
  pain, paraesthesia and weakness rt lower leg
• O/E
• Rt lower leg - Pale, cold, no pulses palpable
• Management?

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Sudden acute limb ischaemia

• Often caused by embolism
• Urgent immediate referral
• Limb threatening

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Vascular surgeon advice service

• Harpaul.flora_at_nhs.net

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Current Vascular service network
Homerton 240,000
Whipps Cross 350,000
BLT 300,000
Newham 240,000
Staff Vascular Surgeons 6 Interventional
Radiologists 5 Vascular Technologists 4 Vascular
Nurse Specialists 3
AAA operative workload EVAR 94 (2000-07) Open
120 (2003-07)
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Questions?

• Thank You