simposium v. 1. pad management. dr. hariadi h. sppd spjpk

CURRICULUM VITAE

Nama : dr. Hariadi Hariawan SpPD SpJP (K)

Tempat, tanggal lahir : Lumajang, 18 Juni 1953

Current Education :

Internist : Universitas Gadjah Mada (1993)

Cardiologist : Universitas Indonesia (2006)

Cardiologist Consultant : Universitas Indonesia (2008)

Current Position:

Staf Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah Mada/RSUP

dr. Sardjito Yogyakarta

Kepala Program Studi Bagian Kardiologi dan Kedokteran Vaskular Universitas

Gadjah Mada/RSUP dr. Sardjito Yogyakarta

MEDICAL MANAGEMENT

AND REVASCULARIZATION

OF PERIPHERAL ARTERY

DISEASE

Hariadi HariawanDepartment of Cardiology and Vascular Medicine - Medical School

Universitas Gadjah Mada / RSUP Dr Sardjito

Yogyakarta

Peripheral Arterial Disease (PAD)

• PAD: is a manifestation of systemic atherosclerosis that is common

• Associated with an increased risk of death and ischemic events

• May be underdiagnosed in primary care practice.

PAD

• PAD : stenosis / occlusion of upper or lower-extremity arteries due to atherosclerotic or thromboembolic disease.1)

• In practice, the term PAD generally refers to chronic narrowing or blockage (also referred to as atherosclerotic disease) of the lower extremities

PAD

• PAD : 12-14% population

• >20% of patients >65 yo4)

• Male >

• Increasing with DM, Hipertension, DyslipidemiaSmoking .5)

PAD: PREVALENCE vs AGE

Criqui MH, et al, Circulation, 1985

Fontaine classification

• Stage I : No symptoms

• Stage IIa : Intermittent claudication >200 m of walking distance (mild)

• Stage IIb : Intermittent claudication <200 m of walking distance (moderate to severe)

• Stage 3 : Rest pain

• Stage 4 : Necrosis/gangrene

Rutherfort Classification

• Stage 0 : Asymptomatic

• Stage 1 : Mild claudication

• Stage 2 : Moderate claudication

• Stage 3 : Severe claudication

• Stage 4 : Rest pain

• Stage 5 : Ischemic ulceration not exceeding ulcer of the digits of the foot

• Stage 6 : Severe ischemic ulcers or frank gangrene

Individuals with PAD Present in Clinical Practice with Distinct Syndromes

Asymptomatic: Without obvious symptomatic complaint (but usually with a functional impairment).

Classic Claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest.

“Atypical” leg pain: Lower extremity discomfort that is exertional, but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance

Individuals with PAD Present in Clinical Practice with Distinct Syndromes

Critical Limb Ischemia: Ischemic rest pain, non-healing wound, or gangrene

Acute limb ischemia: The five “P’s, defined by the clinical symptoms and signs that suggest potential limb jeopardy:

Pain

Pulselessness

Pallor

Paresthesias

Paralysis

Thigh Claudication

60% Upper 2/3 Calf Claudication

Lower 1/3 Calf Claudication

Foot Claudication

30% Buttock & Hip Claudication±Impotence – Leriche’s Syndrome

What does the ABI mean?

ABI Clinical Correlation

>0.9 Normal Limb

0.5-0.9 Intermittent Claudication

<0.4 Rest Pain

<0.15 Gangrene

CAUTION: Patient’s with Diabetes + Renal Failure:

They have calcified arterial walls which can falsely elevate their ABI.

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 0.41 -0.95

Rest Pain 0.21-0.41

Tissue loss 0.20

Significant change 0.15 or more

ANGIOGRAPHY:

Non-invasive:• CT Angiogram• MR Angiogram

Invasive:• Digital Subtraction Angiography

Gold Standard Intervention at the same time

CTA of PVD

MRI

CT Angiography Digital Subtraction Angiography

Value of angiography

Localizes the obstruction

Visualize the arterial tree & distal run-off

Can diagnose an embolus:

Sharp cutoff, reversed meniscus or clot silhouette

Treatment of PADTherapies Based Upon Symptoms

Intermittent Claudication

• Exercise Therapy

• Drugs• Pentoxifylline

• Cilostazol

• Revascularization• Severe disability

Goal to provide relief of symptoms

Critical limb ischemia

• Wound care

• Antibiotics

• Revascularization• Endovascular

• Surgery

Goal to promote limb survival

Supervised Exercise Rehabilitation

• A program of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication.

• Supervised exercise training should be performed for a minimum of 30 to 45 minutes, in sessions performed at least three times per week for a minimum of 12 weeks.

Bhatt, D. L. et al. J Am Coll Cardiol 2007;49:1982-1988

Effect of Dual Antiplatelet Therapy with Established Atherosclerotic Disease

PCI/Surgery:Indications/Considerations:•Poor response to exercise rehabilitation + pharmacologic therapy.•Significantly disabled by claudication, poor QOL•The patient is able to benefit from an improvement in claudication•The individual’s anticipated natural hx and prognosis•Morphology of the lesion (low risk + high probabilty of operation success)

PCI:•Angioplasty and Stenting•Should be offered first to patients with significant comorbidities who are not expected to live more than 1-2 years

Bypass Surgery:•Reverse the saphenous vein for femoro-popliteal bypass•Synthetic prosthesis for aorto-iliac or ilio-femoral bypass•Others = iliac endarterectomy & thrombolysis•Current Cochrane review = not enough evidence for Bypass>PCI

Amputation: Last Resort

Some Bypass Options:

Antiplatelet Therapy

Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

Aspirin, in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

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Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

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Pharmacotherapy of Claudication

Cilostazol (100 mg orally two times per day) is

indicated as an effective therapy to improve

symptoms and increase walking distance in

patients with lower extremity PAD and

intermittent claudication (in the absence of

heart failure).

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Endovascular procedures are indicated for individuals with a vocational or lifestyle-limiting disability due to intermittent claudication when clinical features suggest a reasonable likelihood of symptomatic improvement with endovascular intervention and…

a. Response to exercise or pharmacologic therapy is inadequate, and/or

b. there is a very favorable risk-benefit ratio (e.g. focal aortoiliac occlusive disease)

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Endovascular Treatment for Claudication

Endovascular intervention is not indicated if there is no significant pressure gradient across a stenosisdespite flow augmentation with vasodilators.

Primary stent placement is not recommended in the femoral, popliteal, or tibial arteries.

Endovascular intervention is not indicated as prophylactic therapy in an asymptomatic patient with lower extremity PAD.

Endovascular Treatment for Claudication

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Surgery for Critical Limb Ischemia

Patients who have significant necrosis of the weight-bearing portions of the foot, an uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or a very limited life expectancy due to co-morbid conditions should be evaluated for primary amputation.

Surgery is not indicated in patients with severe decrements in limb perfusion in the absence of clinical symptoms of critical limb ischemia.

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Surgery for Critical Limb Ischemia

For individuals with combined inflow and outflow disease with critical limb ischemia, inflow lesions should be addressed first.

When surgery is to be undertaken, an aorto-

bifemoral bypass is recommended for patients

with symptomatic, hemodynamically

significant, aorto-bi-iliac disease requiring

intervention.

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Surgery for Critical Limb Ischemia

Bypasses to the above-knee popliteal artery should be constructed with autogenoussaphenous vein when possible.

Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible.

Prosthetic material can be used effectively for bypasses to the below knee popliteal artery when no autogenous vein from ipsilateral or contralateral leg or arm is available.

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Acute Limb Ischemia (ALI)

Patients with ALI and a salvageable

extremity should undergo an emergent

evaluation that defines the anatomic level of

occlusion, and that leads to prompt

endovascular or surgical intervention.

Patients with ALI and a non-viable extremity

should not undergo an evaluation to define

vascular anatomy or efforts to attempt

revascularization.

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Summary of PAD and Its Management

• PAD is common and has a significant impact upon cardiovascular outcomes

• Treatment of PAD, even asymptomatic, should focus on risk factor modification/risk reduction

• Treatment of intermittent claudication should include exercise therapy, drug therapy and selective use of revascularization. Endovascular revascularization more preferable (baloon, stents)

• Treatment for critical limb ischemia warrants aggressive efforts at revascularization, including surgery, to reduce the risk of amputation

Terima Kasih