Overview On Peripheral Artery Disease

Overview on Peripheral Artery Disease
Bayu setia
Major Classification of Vascular Disease
*Includes inflammatory, artery dysplasias, congenital, traumatic,

and infections,
• Peripheral Artery Disease (PAD)
Peripheral Artery Disease (PAD)
•Contents
– PAD is Serious Condition that is often Under-
diagnosed
• Understanding the impact of PAD
• Prevalence and risk factors
• Current management
– Detecting and Diagnosing PAD in Clinical Practice
• Practical advice on detecting and diagnosing PAD
– Increasing the Awareness and Detection of PAD
• PAD screening advice
PAD is Serious Condition that is often Under-diagnosed
• PAD is Serious Condition that is often Under-
diagnosed
– Understanding the impact of PAD
– Prevalence and risk factors
– Current management
• Detecting and Diagnosing PAD in Clinical Practice

– Practical advice on detecting and diagnosing PAD
• Increasing the Awareness and Detection of PAD

– PAD screening advice
PAD – A Manifestation of Systemic Atherosclerosis
Patients with symptomatic or asymptomatic lower limb PAD are likely

to have atherosclerosis in other vascular beds
Carotid
artery disease
Renal artery Abdominal aortic

disease disease
Lower limb disease:

Aorto-iliac
Femoro-popliteal
Tibio-peroneal
Atherosclerosis – Severe Consequences
Lower limb Intermittent claudication (IC)

Critical limb ischaemia (CLI)
Infection, gangrene, amputation
Carotid artery Transient ischaemic attack (TIA)

Stroke
Renal artery Hypertension, renal failure, dialysis
Abdominal aorta Abdominal aortic aneurysm

PAD is a Progressive Condition
Asymptomatic Critical event, e.g.:

Plaque formation and • CriticaI limb ischaemia
thrombus impedes blood flow • Myocardial infarction
to the peripheral vasculature • Stroke
• End-stage renal failure
Symptomatic
Ischaemia leads to symptoms,
cell death, and physical
impairment
Ross R. N Engl J Med1999; 340: 115-126.

PAD Most Commonly Presents in the Lower Limbs
• Atherosclerotic disease can cause both

Femoral artery partial and total obstructions in any
Deep
given vessel, resulting in a spectrum of
femoral ischaemic severity
artery
• Superficial femoral artery (SFA) is the
Popliteal artery most commonly diseased vessel,
responsible for >50% lower limb PAD
• Symptoms most often manifest below
the knee, specifically in the foot region
Posterior tibial artery
• Infra-inguinal, iliac, and lower aortic
Anterior tibial artery
occlusions can also result in restricted
Dorsalis pedis
perfusion of the leg
Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

Symptoms of PAD
• The most common symptom is intermittent claudication

– pain, cramping, or aching in the calves, thighs, or buttocks that appears
repeatedly during exercise and is relieved by rest
• More extreme presentations include:

– rest pain, tissue loss, or gangrene; these limb-threatening manifestations
are collectively termed critical limb ischemia (CLI)
• PAD is also a major risk factor for lower-extremity amputation,

especially in patients with diabetes
• Even for asymptomatic patients, PAD is a marker for systemic
atherosclerosis involving coronary, cerebral, and renal vessels,
leading to an elevated risk of myocardial infarction (MI), stroke, renal
failure and death

Overlap of Atherosclerotic Disease
• Frequency of disease with symptoms in the three vascular beds and

their overlap (CAPRIE study of 20,000 patients)
Coronary Cerebrovascular
artery disease 7% disease
30% 25%
3%
12% 4%
Peripheral Vascular
Disease
19%
CAPRIE Steering Committee. Lancet 1996; 348: 1329-1339.
Advanced Symptoms of Lower Limb PAD
Elevation Pallor
This intense paleness of the
foot represents severe
peripheral artery disease
Dependent Rubor
This intense red/purple colour,
along with the ulcer on the tip
of the left great toe,
represents advanced PAD
and critical limb ischaemia
Gangrene
This patient had
no pain, related to
diabetic vascular
disease and
neuropathy, and
was never
diagnosed with
peripheral artery
disease. This was
due to an ill-fitting
pair of shoes,
which resulted in
blisters and ulcer
formation
Progression and Outcomes with Lower Limb PAD
Peripheral Symptomatic
Artery Disease Disease Critical Limb Ischemia (CLI)
Pain at rest,
Clinical Intermittent Life-threatening
‘Silent’ gangrene,
presentation claudication infection
ulceration
Progression 27% within 5 15-20% over

rate years lifetime
20% of CLI patients die within 6

Mortality rate 30% within 5 years
months of diagnosis
Progression is much faster in diabetic and end stage renal

disease populations

American Diabetes Association. Diabetes Care 2003; 26: 3333-3341.
Weitz JI et al. Circulation 1996; 94: 3026-3049.
Other Manifestations of Atherosclerosis:
Carotid Artery Disease
– Atherosclerotic disease at the

carotid bifurcation is responsible
for 25-35% of all ischaemic
strokes,1 and nearly 50% of all TIAs
– Transient ischaemic attacks caused
by carotid artery stenosis are also
a strong predictor of stroke3
– Warning signs often do not occur –
first symptom associated with
carotid artery disease may be a TIA
or catastrophic stroke
1. North American Symptomatic Endarterectomy Trial Collaborators. N Engl J Med 1991; 325: 445-453.
2. Weinberger J. CNS Spectr 2005; 10: 553–64.
3. Alpert J. Tex Heart Inst J 1991; 18: 93–97.
Renal Artery Disease
– Atherosclerotic renal artery disease

is an increasingly common cause of
hypertension and/or renal failure
– It is estimated to be the cause of
renal failure in 5% to 15% of adult
patients who begin dialysis yearly1-3
– Patients with renal artery stenosis
and renal failure only live for an
average of 22 months once
on dialysis
1. Dean RH, Tribble RW, Hansen KJ, et al. Ann Surg 1991; 213: 446–455.
2. Rimmer JM, Gennari FJ. Ann Intern Med 1993; 118: 712–719.
3. Mailloux LU. J Vasc Med Biol 1993; 4: 277–284.
Abdominal Aortic Disease
– More than 90 percent of

abdominal aortic aneurysms
(AAA) are associated with
atherosclerosis
– It is rarely associated with
symptoms until rupture
– Case fatality of rupture of an
abdominal aortic aneurysm is
around 80%1
. 1. Semmens J, Lawrence-Brown M, Norman P, et al. Aust N Z J Surg 1998; 68: 404-10.

Critical Issues in PAD Detection and Management
– PAD is a major risk factor for lower-extremity amputation, as well as a

high likelihood for symptomatic cardiovascular and cerebrovascular
disease
– Although highly prevalent, PAD remains largely under-diagnosed and
therefore under-treated:
• approximately 17% of men and 21% of women (almost 1
in 5) aged 55 and older have PAD when evaluated using
the ankle-brachial index (ABI <0.90)
– Ageing of the population and the increasing incidence of diabetes
means more patients will present with PAD
Federman DG et al. Ostomy Wound Management 1998; 44: 58-62.

Matthew C et al. J Vasc Interv Radiol 2002;1 3:25-35.
Belch JJF et al. Arch Intern Med 2003; 163: 884-892.
Norman PE et al. Med J Aust 2004; 181: 150-4.
• PAD is Serious Condition that is often Under-diagnosed


Majority of PAD Sufferers are Not Diagnosed
or Treated
Majority of patients are asymptomatic but these patients are
also at increased risk of cardiovascular and cerebrovascular
events
Asymptomatic Symptomatic
45%
55%
Hiatt WR. N Engl J Med 2001; 344:1608-1621.

Prevalence of PAD Based on Community Surveys
Study Age (years) Diagnosis Prevalence (%)
Fowkes Claudication 4.5

55-74
(1991) ABI ≤ 0.9 18.3
Boccalon
40-80 ABI ≤ 0.9 11
(2000)
≥70 or Claudication 12.7

PARTNERS
(2001) 50-69 + smoker
ABI ≤ 0.9 29.1
or diabetic
Diehm
≥65 ABI ≤ 0.9 19.8
(2004)
ABI = Ankle-Brachial Index, a useful measure for diagnosing PAD

Boccalon H, et al. J Mal Vasc 2000; 25: 38-46.
Fowkes FG, et al. Int J Epidemiol 1991; 20: 384-92.
Diehm C, et al. Atherosclerosis 2004; 172: 95-105.
Hirsch AT, Criqui MH, Treat-Jacobsen D et al. JAMA 2001; 286: 1317-1324.
Incidence of PAD Increases with Age
Mean incidence of intermittent claudication (IC) from five
large population-based studies [TASC]
6
Incidence/1000/yr
0
30-34 35-39 40-44 45-49 50-54 55-59 80-64 65-69 70-74
Age group (years)
TransAtlantic Inter-Society Consensus (TASC) on management of atherosclerosis, 2001.

Risk Factors for PAD
• Risk factors for PAD are similar to risk factors for all other atherosclerotic
disease, such as cardiovascular disease
Modifiable Non-modifiable
– Hypertension • Age and male gender
– Smoking • Diabetes mellitus (DM)
– Hyperlipidaemia – 30-50% of patients with diabetes

have PAD and the rate of major
– Obesity limb amputation is four times
higher in PAD patients with DM
– Sedentary lifestyle
• Family history
Ouriel K. Lancet 2001; 358: 1257–1264.



Therapeutic Options in PAD
– A range of patients can be treated with lifestyle modification +/-

pharmacological treatment
• Risk factor modification
• Supervised exercise training
• Pharmacotherapy
– Since PAD is a progressive condition, certain patients will require
specialist intervention
• Minimally-invasive interventions: e.g. angioplasty/stenting
• Invasive interventions: e.g. surgery
Gey DC et al. Management of peripheral arterial disease. Am Fam Physician 2004; 69: 525–533.
Risk Factor Modification
Lifestyle changes
– Smoking cessation
– Control of diabetes mellitus
– Maintaining an exercise programme
– Reducing high blood pressure
– Lowering high cholesterol
– Maintaining ideal body weight
Pharmacological Management of PAD
Risk-reducing agents
– Antiplatelet drugs:
• ASA, clopidogrel, cilostazol
– Antihypertensives
– Lipid-altering drugs:
• fibrates, niacin, statins (simvastatin, lovastatin, pravastatin,
atorvastatin), bile acid sequestrants
Drugs for treatment of intermittent claudication

– Cilostazol
• in addition to antiplatelet activity, improves vasodilation, increases HDL-
cholesterol levels, and decreases plasma triglyceride levels
– Pentoxifylline
Pharmacological Management of PAD
Drug Dose Effect

ASA
81 to 325 mg
(with or without
per day orally
dipyridamole)
May have less side effects than ASA, less risk for
75 mg
Clopidogrel TTP (thrombotic thrombocytopenic purpura) than
per day orally
ticlopidine
1.2 g
Pentoxifylline Insufficient data to support use
per day orally
100 mg twice per Correct dosing is critical, especially in patients

Cilostazol
day orally taking calcium channel blockers
Invasive Vascular Surgery
Surgical techniques
– Surgery is usually considered for patients with severe symptoms

such as critical limb ischaemia to prevent limb loss
– Rarely required for the treatment of intermittent claudication
– Two main choices
• Surgical bypass and bypass grafting with autogenous veins
or prosthetic graft
• Endarterectomy
– Surgery may often be associated with extensive scarring
Ouriel K. Lancet 2001; 358: 1257–1264

Current Trends in Management of PAD
Minimally-invasive interventions
– Angioplasty and stent implantation are increasingly used in place

of invasive surgery
– These procedures are less traumatic than vascular surgery
and have proven effective in reducing disability
– Minimally-invasive interventions may also:
• Reduce peri- and post-interventional morbidity and mortality
• Lessen risks associated with general anaesthesia needed for surgical

treatment
• Reduce hospital stay – often the patient can return home the same day or
the next day
– The choice of surgical treatment or a minimally-invasive procedure is
based on patient and lesion characteristics
Endovascular Procedures
Percutaneous Transluminal Angioplasty (PTA)
– Balloon angioplasty is increasingly Balloon angioplasty

used for treating localised
atherosclerotic obstructive lesions
in the peripheral vasculature
Stenting
• Placement of a stent across the lesion can improve the long-term
results compared to PTA alone
Implantation of a stent
Kauffmann GW, Richter CM, Nöldge G et al. Radiologe 1991; 31: 202-209.
Palmaz JC, Laborde JC, Rivera FJ et al. Cardiovasc Intervent Radiol 1992; 15: 291-297.
Henry M, Amor M, Ethevenot G. Radiology 1995; 197: 167-174.
Stenting of the Superficial Femoral Artery
6 months f/u
Pre-procedure Post
Carotid Artery Stenting
Pre-procedure Post
Courtesy from Dr Fanelli

Other devices
Mechanical Thrombectomy
Rotational tips and/or suction to mechanically remove
thrombus
Laser
Pulsed excimer laser delivered intravascularly to ablate
atherosclerotic and thrombotic material
Cutting Balloon
Longitudinally mounted atherotomes on surface of
angioplasty balloon score lesion with incisions,
allowing balloon to dilate the vessel
Other devices
Cryoplasty
Angioplasty catheter that dilates and cools the plaque
and vessel wall by inflating the balloon with nitrous
oxide.
Brachytherapy
Therapeutic radiation therapy (gamma or beta
emitters) delivered intravascularly to delay and limit
the endothelialization process
Indications for Endovascular Revascularisation
– In patients with lower limb disease, an endovascular intervention may

be considered for:
• Claudication interfering with work or lifestyle
• Pain at rest
• Non-healing ulcers, limb threatening ischaemia
• Infection – recurrent
• Gangrene, limb salvage
American Diabetes Association. Diabetes Care 2003; 26: 3333–3338.
Sharafuddin M, Anguelov Z. Currents:Fall 2001; 2(4).


Detecting and Diagnosing PAD
in Clinical Practice
Detecting and Diagnosing PAD in Clinical Practice
– Identifying patients with PAD

– Diagnosis of PAD
• Patient history
• Clinical evaluation
• Diagnosis using ABI
– Referral for advanced diagnostics/imaging
Identifying Patients with PAD
•PAD should be considered in:

– Any patients with exertional leg pain
– Patients >50 years old with diabetes
– Patients >50 years old who are currently smoking
– All patients >70 years old
Identifying Patients with PAD
•PAD may also be present in patients with:

– Evidence of past transient ischaemic attack or previous stroke
(suspected carotid artery disease)
– Non-controlled hypertension, abnormal renal function tests
(renal artery disease)
– Diagnosed coronary artery disease
TASC JVS 2001.

TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 2000; 31: (1 Suppl): S1-S296.
Diagnosis of PAD
•Techniques used to diagnose PAD should include:

– Review of medical history (anamnesis)
– Physical examination
– Diagnostic tests if considered at-risk or are symptomatic
TASC JVS 2001.

Diagnosis of Lower Limb PAD
Intermittent claudication
•Typically
– Leg pain on exertion (e.g. walking uphill)
– Reproduced by the same degree of exertion
– Relieved by rest
•Lesions are usually found in arterial segment one level above affected muscle
group
– Calf claudication
• disease in femoral or popliteal arteries
• less commonly due to disease in or proximal to tibial or peroneal arteries
– Hip/thigh/buttock claudication
• due to aortoiliac disease
TASC JVS 2001.

Rest pain
•Typically interferes with sleep

– May also occur during the day when the patient is resting in supine
position
– The pain is localized mainly in the distal part of the foot or calf
– Partial relief may be obtained by
• short walk around the room
• the dependent position
– Often, patients sleep with their ischaemic leg hanging over
the edge of the bed, or sitting in an armchair all night
TASC JVS 2001.

Physical examination
– Peripheral pulses
– Auscultation for bruits that may signify stenosis
– Limb examination
TASC JVS 2001.

Clinical Examination of Lower Limbs
Pulse evaluation and auscultation of lower limbs
Palpation Auscultation
Normal ++ No Bruit
Mild stenosis ++ Bruit
Significant stenosis +/- Harsh Bruit
Occlusion - No Bruit
TASC JVS 2001.

Clinical Examination of Lower Limbs
Limb examination (and comparison with opposite limb)
– Hair loss on lower limbs

– Poor nail growth (brittle nails)
– Dry, scaly, atrophic skin
– Dependent rubor
– Pallor with leg elevation after one minute at 60 degrees
• normal colour should return in 10 to 15 seconds; longer than 40 seconds indicates
severe ischemia
– Ischaemic tissue ulceration
• punched-out, painful, with little bleeding, gangrene
– Additional examination by palpation and auscultation to detect
abdominal aortic aneurysm or bruit
TASC JVS 2001.

Evaluation of Lower Limb PAD Based on Severity
of Intermittent Claudication
Fontaine / Lerriche classification
– STAGE I: Asymptomatic
– STAGE II: Intermittent claudication
– STAGE III: Rest pain
– STAGE IV: Ulcers, necrosis and gangrene
Dieter RS et al. Clin Cardiol 2002; 25: 3-10.

Rutherford / Becker Classification

Treadmill test:
• Speed: 3.2 km/hour for 5 minutes – gradient 12%
• Intermittent claudication distance / absolute walking distance
Asymptomatic
0 (No hemodynamically significant Normal results of treadmill test
occlusive disease)
Treadmill exercise completed, post-exercise
1 Mild claudication ankle pressure (AP) is >50 mmHg but >25
mmHg less than normal
2 Moderate claudication Symptoms between those of categories 1 and 3
Treadmill exercise cannot be completed,

3 Severe claudication
post-exercise AP is <50 mmHg

Rutherford / Becker Classification
Resting AP <40 mmHg, flat or barely pulsatile

4 Ischaemic rest pain ankle or metatarsal plethysmographic tracing,
toe pressure <30 mmHg
Minor tissue loss Resting AP <60 mmHg, ankle or metatarsal

5 (non-healing ulcer, focal gangrene plethysmographic tracing flat or barely pulsatile,
with diffuse pedal ischaemia) toe pressure <40 mmHg
Major tissue loss

(extending above transmetatarsal
6 Same as for category 5
level, functional foot no longer
salvageable )

PAD with intermittent claudication

Clinical Critical Limb
presentation Asymptomatic Mild Moderate Severe
Ischemia
Fontaine
classification I II III IV
Rutherford-Becker
classification 1 2 3 4 5 6
Use of the Edinburgh Claudication Questionnaire
Diagnostic Tests for PAD
The Ankle-Brachial Index (ABI)
Peripheral vascular disease can be easily diagnosed by measuring the ankle-
brachial index (ABI)
Sacks D et al. J Vasc Interv Radiol 2003; 14: S389.

Role of ABI in Clinical Practice
– Confirms the diagnosis of PAD

– Provides a semi-quantitative assessment of:
• severity of PAD
• progression of PAD over time
• response to intervention for PAD
– Provides an indication of overall cardiovascular risk
– Can be performed using standard blood pressure cuffs (preferably with
Doppler)
– Relatively quick (5 minutes)
– An ABI index of less than 0.90 is strongly associated with limitations in
lower extremity functioning and physical activity tolerance
Hiatt WR. NEJM 2001; 344: 1608-1621.

Performing the ABI - Summary
Right ABI Left ABI

Higher of the two right ankle pressures Higher of the two left ankle pressures
Higher of the two arm pressures Higher of the two arm pressures
• Patient resting supine Right arm Left arm

for 5-10 minutes systolic systolic
pressure pressure
• Measure systolic BP
in both arms – higher
value is DENOMINATOR
of ABI
• Measure systolic BP
in DP and PT –
higher value is
Right ankle Left ankle
NUMERATOR systolic systolic
of ABI pressure pressure
DP = dorsalis pedis
PT = posterior tibial
Ankle-Brachial Index Values
highest systolic BP of ankle

ABI =
highest systolic BP of arm
≥0.90 Normal
0.90 to 0.75 Mild PVD
0.75 to 0.40 Moderate PVD (intermittent claudication)
≤0.40 Severe disease
Limitations:
Calcified ankle vessels result in artificially “normal” ABI > 1.2
Normal ABI in patient with aortoiliac disease - only becomes abnormal with exercise testing

Examination of Other Vascular Beds
– Aorta:
• Bruit
• Palpation
– Coronary artery disease:
• Chest pain
• ECG
– Cerebrovascular disease
• Bruit
• History of stroke/TIA
• Duplex ultrasound (DUS)
– Renal stenosis
• Hypertension
• Bruit
Diagnostic Algorithm for PAD
History, physical examination, Differential

No
symptoms suggestive of PAD diagnosis
YES ABI
Referral to
<0.9 <0.9 >1.3 vascular/interventional lab:
• Segmental pressures
• Pulse volume recordings
Still suspicious? • Treadmill
Referral to
PAD vascular/interventional lab:
Anatomic assessment:
• DUS, MRA, CTA
Jaff MR. Fellows Course in Interventional Cardiology. Boston, 2005.

Referral for Vascular Lab Diagnostics
•Quantitative assessments
– Pulse Volume Recordings (PVR)
– Treadmill testing
• Assessment of severity of intermittent claudication
•Localization of the disease and severity
– Duplex Ultrasound (DUS)
– CT Angiogram (CTA)
– Magnetic Resonance Angiography (MRA)
– Angiography

Vascular Lab Evaluations
Pulse Volume Recordings (PVR)
– Normal PVR appears similar to intra-arterial pressure waveform

• Rapid upstroke, rapid downstroke, dicrotic notch, narrow
complex
– Progressive PAD results in changes in PVR
• Decrease in amplitude of waveform
• Loss of dicrotic notch
• Widened waveform

Vascular Lab Evaluations
Exercise treadmill testing
– Important component of comprehensive vascular testing

– Requires programmable treadmill
– Standard protocol
• 3.2 km/hour, 12% gradient
• Maximum 5 minutes
– Gardner/Hiatt Protocols
• Constant speed
• Variable grade as exercise continues

Imaging Diagnostics
Arterial duplex ultrasonography
– Reproducible, reliable, accurate

– Painless, risk-free, relatively inexpensive
– Direct visualization and characterization of arterial stenosis,
occlusion, injury
– Excellent method to follow-up adequacy of revascularization
over time

Imaging Diagnostics
Duplex ultrasound of common femoral artery bifurcation
The top vessel is the superficial femoral artery and lower vessel the profunda
or deep femoral artery. The areas where colour does not
exist represents atherosclerotic plaque.
Imaging Diagnostics
Severe common iliac artery stenoses on angiography
PAD: A Call to ACTION
– PAD is an increasing epidemic and detection rates are low

– Both asymptomatic and symptomatic PAD patients are at
increased risk of cardiovascular and cerebrovascular events
– Prevention of critical events associated with PAD can be
addressed through:1
• Increased awareness of PAD and its consequences
• Improved identification of patients with symptomatic PAD
• Screening of at-risk patients for early detection of asymptomatic PAD
• Referral to specialist for further diagnostic information
• Improved treatment rates among patients
1. Belch JJF et al. Arch Intern Med, 2003; 163: 884–892.



Increasing the Awareness
and Detection of PVD: Screening
Benefits of Screening At-Risk or Elderly Patients
– Recent data from community surveys highlight the magnitude of

PAD and its under-treatment
– ABI is an effective diagnostic and risk assessment tool for detecting
PAD
– Substantial risk reduction can be achieved with timely diagnosis,
referral and intervention
Belch JJF et al. Arch Intern Med 2003; 163: 884–892.

Detection of PAD
– A large proportion of patients with significant PAD are

asymptomatic
– Patients with asymptomatic PAD also have increased
risk of cerebrovascular and cardiovascular events
– These patients can be detected by an ankle brachial
pressure index (ABI) of <0.9
– Screening is effective in identifying patients with
asymptomatic and symptomatic, undiagnosed PAD
PAD can be Detected and Diagnosed Using the Ankle-
Brachial Index (ABI)

Ankle–Brachial Index and Mortality
ABI is also an independent predictor of mortality
ABI
>1 1.0≤0.9 0.9≤0.8 <0.8
105
100
Patient Survival,%
95
90
85
80
75
70
1 2 3 4
Number of years of follow-up
Vogt MT et al. JAMA 1993; 270: 465-469.

Ankle–Brachial Index and Risk of Ischaemic Events
CAPRIE Study
ABI: inverse relationship with 3-year risk of cardiovascular events and death
2.5
Risk relative to an ABI of 1
2.0
1.5
1
0.25 0.5 0.75 1
ABI
10.2% relative risk increase per 0.1 decrease in ABI (p=0.041)
Dormandy JA. Cerebrovasc Dis 1999; 9 (Suppl 1): 1-128.

Awareness Increases PAD Detection Rates
– Three studies demonstrate detection rates of PAD > 20%

in at-risk groups:
• POPADAD study (diabetics)1 20.1%
• Minnesota Regional Screening Program2 26.5%
• US Partners program3 29%
1. Prevention of progression of arterial disease and diabetes (POPADAD).

2. Belch JJF et al. Arch Intern Med 2003; 163: 884-92.
3. Hirsch AT, Criqui MH, Treat-Jacobsen D et al. JAMA 2001; 286: 1317-1324.
The Need to Identify and Treat PAD Patients
– Symptomatic and asymptomatic PAD patients have a high

incidence of cardiovascular and cerebrovascular morbidity
and mortality1
– Symptomatic PAD carries a 30% risk of death within 5 years, and
nearly 50% within 10 years2
– Many patients with PAD assume their symptoms are part
of growing old and do not present to their physician
– PAD can be easily detected in clinical practice
– Awareness of the importance of PAD also needs to be increased
amongst patients3
1. Weitz JI et al. Circulation 1996; 94: 3026-3049.

2. Sharafuddin M, Anguelov Z, Currents: Fall, 2001, Volume 2, Number 4.
3. Stansby G et al. Vascular Disease Prevention, 2005; 2: 177–179.
Thank You

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*Includes inflammatory, artery dysplasias, congenital, traumatic,

• Detecting and Diagnosing PAD in Clinical Practice

• Increasing the Awareness and Detection of PAD

Patients with symptomatic or asymptomatic lower limb PAD are likely

Renal artery Abdominal aortic

Lower limb disease:

Lower limb Intermittent claudication (IC)

Carotid artery Transient ischaemic attack (TIA)

Renal artery Hypertension, renal failure, dialysis

Abdominal aorta Abdominal aortic aneurysm

Asymptomatic Critical event, e.g.:

Ross R. N Engl J Med1999; 340: 115-126.

• Atherosclerotic disease can cause both

Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

• The most common symptom is intermittent claudication

• More extreme presentations include:

• PAD is also a major risk factor for lower-extremity amputation,

Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

• Frequency of disease with symptoms in the three vascular beds and

Progression 27% within 5 15-20% over

20% of CLI patients die within 6

Progression is much faster in diabetic and end stage renal

Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

– Atherosclerotic disease at the

– Atherosclerotic renal artery disease

– More than 90 percent of

. 1. Semmens J, Lawrence-Brown M, Norman P, et al. Aust N Z J Surg 1998; 68: 404-10.

– PAD is a major risk factor for lower-extremity amputation, as well as a

Federman DG et al. Ostomy Wound Management 1998; 44: 58-62.

• Detecting and Diagnosing PAD in Clinical Practice

• Increasing the Awareness and Detection of PAD

Hiatt WR. N Engl J Med 2001; 344:1608-1621.

Study Age (years) Diagnosis Prevalence (%)

Fowkes Claudication 4.5

≥70 or Claudication 12.7

ABI = Ankle-Brachial Index, a useful measure for diagnosing PAD

TransAtlantic Inter-Society Consensus (TASC) on management of atherosclerosis, 2001.

– Hyperlipidaemia – 30-50% of patients with diabetes

Ouriel K. Lancet 2001; 358: 1257–1264.

• Detecting and Diagnosing PAD in Clinical Practice

• Increasing the Awareness and Detection of PAD

– A range of patients can be treated with lifestyle modification +/-

Drugs for treatment of intermittent claudication

Drug Dose Effect

100 mg twice per Correct dosing is critical, especially in patients

– Surgery is usually considered for patients with severe symptoms

Ouriel K. Lancet 2001; 358: 1257–1264

– Angioplasty and stent implantation are increasingly used in place

• Lessen risks associated with general anaesthesia needed for surgical

Percutaneous Transluminal Angioplasty (PTA)

– Balloon angioplasty is increasingly Balloon angioplasty

Courtesy from Dr Fanelli

– In patients with lower limb disease, an endovascular intervention may

• Detecting and Diagnosing PAD in Clinical Practice

• Increasing the Awareness and Detection of PAD

– Identifying patients with PAD

•PAD should be considered in:

•PAD may also be present in patients with:

TASC JVS 2001.

•Techniques used to diagnose PAD should include:

TASC JVS 2001.

TASC JVS 2001.