PAD

PAD

occlusion in aorta or arteries of limbs that impairs blood supply and leads to peripheral ischemia

Causes of PAD

• atherosclerosis

• arterial thromboembolism

• vasculitis

• trauma

PAD Pathophys

• atheroscleotic lesions → decreased blood flow to extremities → O2 supply/demand mismatch → limb ischemia → lower extremity pain, impaired wound healing, tissue necrosis

Risk factors for PAD screening

• 65+

• 50-64 with atherosclerosis risk factors (smoking, DM, hyperlipidemia, HTN, CAD, family history)

• <50 with DM + additional risk factor

• pts with known atherosclerotic disease in other vascular beds

PAD S/SX

• Claudication

• exertional lower extremity sx

• ischemic rest pain

• nonhealing/slow healing wounds

• erectile dysfunction

Claudication

• pain in lower extremities

• consistent, does not improve during walking

• usually improves with 10 min of rest

• location of sx related to site of arterial occlusion

PAD physical exam findings

• abnormal lower extremity pulse palpitation

• vascular bruit

• nonhealing lower extremity wound

• lower extremity gangrene

• asymmetric hair growth

• changes in nail bed

• muscle atrophy

• elevation pallor

• dependent rubor

Abnormal ABI

0.9 or lower

Asymptomatic PAD

• no claudication

• may have functional impairment

• may self-limit activity

Chronic symptomatic PAD

• claudication

• ischemia related exertional leg sx

Chronic Limb-Threating Ischemia

• present for over 2 weeks

• pain at rest

• non-healing wounds/ulcers

• gangrene

Acute Limb Ischemia

• present for less than 2 weeks

• medical emergency (heart attack in legs)

• pain, pallor, pulselessness, poikiolothermia, parasthesias, paralysis

CV Complications of PAD

• MACE

• MI

• Stroke

• mortality

Limb-related Complications of PAD

• MALE

• acute limb ischemia/critical limb ischemia

• need for revascularization

• amputation

• also: wound infection, tissue necrosis/gangrene

PAD Goals of therapy

• mitigate sx

• increase function

• decrease risk of MACE/MALE

• improve QoL

Endovascular revascularization

• stent, angioplasty

• minimally invasive

Surgical revascularizaiton

• bypass grafting, endarterectomy

• more invasive, prone to complication

Symptomatic PAD without revascularization Tx

• SAPT with clopidogrel 75 PO daily or aspirin 81 mg PO daily → reduce MACE

  • clopidogrel pref

• rivaroxaban 2.5 PO BID + aspirin 81 mg PO daily → reduce MACE and MALE

  • increased bleed risk

Asymptomatic PAD tx

SAPT with clopidogrel or aspirin

Symptomatic PAD after revascularization Tx

• Rivaroxaban 2.5 mg PO BID + aspirin 81 mg po daily → reduce MACE/MALE

  • class 1 rec

• Aspirin 81 + P2Y12 → 1-6 months after endovascular revascularization (1 month after surgical)

  • class 2a rec

• Full intensity anticoag for another indication + SAPT → reasonable after revascularization if not high bleed risk

Full-intensity anticoag for PAD

NOT recommended except acute limb ischemia (cause harm)

Vorapaxar guidelines recommendation

• uncertain role in symptomatic pad

• may reduce CV risk but increases bleeding risk

Lipid lowering therapy in PAD

• high intensity statin (reduce MACE/MALE)

• 50% LDL reduction

• LDL goal < 70

HTN meds in PAD

ACEi/ARB pref to reduce MACE

Smoking cessation in PAD

rec to reduce MACE/MALE

Diabetes management in PAD

• GLP-1 agonist, SGLT-2 inhibitors

• reduce risk of MACE

Immunizations in PAD

• flu and covid shots

• reduce CV events and hospitalization, thrombotic events, and death associated with infection

Therapies with no benefit in PAD

• B-complex vitamin supplementation

• chelation therapy

• vitamin D supplementation

Management of leg symptoms

• cilotazol → improve symptoms, increase walking distance, may reduce restenosis

• not rec → pentoxifylline, chelation

Preventative Foot Care by patient

• visual exam

• washing/drying feet daily

• foot exercises

• protect feet from heat/cold

• avoid walking barefoot

• wear socks and appropriately fitting shoes

• do not wear compression socks

Preventive foot care by providers

• foot inspection at every visit

• comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputation

• recommend therapeutic footwear in high risk pts

• referral to foot care specialist

Risk factors for foot ulcers/amputation

• prior history

• foot deformities

• corns/calluses on feet

• diabetes with poor glycemic control

• CKD

• peripheral neuropathy

• smoking

Structured Exercise Programs

• improve function, QoL, and leg symptoms

• supervised exercise programs (in clinical settings), structured community or home based exercise programs (personal settings, self-directed)

CLTI management

• pharmacotherapy

• revascularization

• wound healing/foot care

  • wound care

  • infection management w antibiotics

  • pressure offloading

  • counseling on appropriate foot care

Acute Limb Ischemia management

• categories based on if limbs are salvegable

• parenteral anticoagulation → prevent thrombus propagation and decrease ischemia

• 1st line: UFH (tx dosing)

• 2nd line: IV direct thrombin inhibitors (argatroban, bivalirudin)

• other interventions: catheter directed thrombolysis, thrombectomy, amputation, monitor or treat for compartment syndromes after revascularization

Raynaud’s Phenomenon

• episodic vasoconstriction in fingers/toes

• reversible and usually bilaterial

• triggered by cold, emotional stress, vibtration

• more frequent in women

Raynaud’s causes

• idiopathic (primary): younger onset, symmetric

• secondary: connective tissue disorders, drug induced, endocrine disorders (can be asymmetric)

Raynaud’s Drug Inducers

• stimulant drugs

• parenteral vasoconstrictors

• decongestants

• anti-migraine drugs

• bromocriptine

• cytotoxic drugs

• non-selective beta-blockers (propranolol)

Clinical Presentation of Raynaud’s

• initial pallor

• redness

• demarcated areas of ischemia

Goals of Raynaud tx

• prevent sx, RP attacks

• prevent complications of prolonged vasoconstriction (ulcers, gangrene, necrosis)

Non-pharm management of Raynaud’s

• wear mittens/gloves/socks

• layer clothing

• avoid rapidly changing temps/cold

• dry skin thoroughly after washing hands

• guard against injuries to affected area

• avoid stressors

• avoid vasoconstricting drugs

• smoking cessation

Terminating RP attack

• place hands under warm water or under armpits

• make wide circles with arms

• rub/massage hands/feet

• wiggle fingers/toes

RP pharm management

• First-line → DHP CCBs (nifedipine is most well-studied)

• PDE-5 inhibitors

• Nitroglycerin 2% ointment

• other Anti-htn

• fluoxetine, ERTA, prostaglandin analogues