Approach to Peripheral Arterial Disease (PAD)

ISSN: 2581 – 3633 PubMed - National Library of Medicine - ID: 101745081 International Journal of Medical Science and Advanced Clinical Research (IJMACR) Available Online at:www.ijmacr.com Volume – 7, Issue – 2, April - 2024, Page No. : 36 – 43 Approach to Peripheral Arterial Disease (PAD) 1 Ketan Vagholkar, Professor, Department of Surgery, D. Y. Patil University School of Medicine, Navi Mumbai 400706. MS. India. 2 Tanay Purandare, Intern, Department of Surgery, D. Y. Patil University School of Medicine, Navi Mumbai 400706. MS. India. Corresponding Author: Ketan Vagholkar, Professor, Department of Surgery, D. Y. Patil University School of Medicine, Navi Mumbai 400706. MS. India. How to citation this article: Ketan Vagholkar, Tanay Purandare, “Approach to Peripheral Arterial Disease (PAD)”, IJMACR- April - 2024, Volume – 7, Issue - 2, P. No. 36 – 43. Open Access Article: © 2024, Ketan Vagholkar, et al. This is an open access journal and article distributed under the terms of the creative common’s attribution license (http://creativecommons.org/licenses/by/4.0). Which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Type of Publication: Original Research Article Conflicts of Interest: Nil Abstract A Peripheral arterial disease is a complex disease affecting investigation and treatment strategies is essential to the arterial system of the lower extremities. It has a reduce the morbidity in the form of limb loss and multifactorial etiology presenting with a wide spectrum mortality associated with vascular accidents such as of stroke and myocardial infarction (MI).[2] This article Clinical examination, laboratory approach to assessment, evaluation and imaging are essential for accurate provides the assessment of the severity of the disease. Treatment is presenting with peripheral arterial disease. multidisciplinary comprising medical therapy as well as Clinical assessment surgical intervention. The article provides a systematic Patient suffering from peripheral arterial disease can be approach to assessment and treatment of peripheral categorized into 4 groups, as per the guidelines outlined arterial disease. by Keywords: Peripheral, Arterial, Disease, Risk Factors, Association of Cardiology.[3] The guideline is specific Diagnosis, Treatment for PAD involving the lower extremity. The specific Introduction categories are as follows Peripheral arterial disease is a common problem faced 1. Patients with age 65 years or older by the general surgeon. Increased comorbidities such as 2. diabetes, hypertension and smoking are associated with American comprehensive clinical Heart approach to patient Association and American Patients with an age group ranging from 50 and 64 accompanied with risk factors for atherosclerosis rising incidence of peripheral arterial disease (PAD).[1] Corresponding Author: Ketan Vagholkar, ijmacr, Volume – 7 Issue - 2, Page No. 36 – 43 Page36 symptoms. systematic Ketan Vagholkar, et al. International Journal of Medical Sciences and Advanced Clinical Research (IJMACR) hypertension, hyperlipidemia or with a family history of PAD strokes, cardiac system for angina and any previous history of cardiac events including surgical 3. Patients younger than 50 years of age with diabetes interventions, renal system associated with uncontrolled mellitus predisposed to having 1 or more additional hypertension and mesenteric system presenting with post risk factor for atherosclerosis prandial abdominal angina and mesenteric vascular 4. Patientswith atherosclerosis involving other systems thrombosis.[6] A detailed evaluation of co-morbidities such as coronary, carotid, renal, subclavian and and their treatments along with level of response to mesenteric vessels. treatment is essential for developing an effective plan for History taking further management as this could impact a successful A detailed history is essential. History of PAD outcome. symptoms which include claudication, rest pain, non- Physical Examination joint related lower extremity symptom’s, impairment of Includes general and local examination. walking and non-healing wounds.[4] General Examination includes assessment of level of Intermittent claudication is the commonest symptom of cerebration followed by physical examination. PAD. Cramp like pain in the ischemic muscle on Assessment of all peripheral pulses which include exercising is diagnostic. The severity of claudication can carotid, subclavian, abdominal aortic, femoral, popliteal, be assessed by correlating the pain and exercise potential ankle pulses is pivotal in identifying the site of despite the pain. weakened vascularity. (Table 3) Two classification systems are commonly used to grade Scars of previous vascular interventions are also the severity of claudication which include important in order to quantify the severity of  Rutherford classification based on performance of 5- compromise. minute treadmill test at 2 mile per hour on 12-degree endarterectomy, scar of CABG on the chest, abdominal incline. (Table 1) [4,5] aneurysm surgery, iliofemoral and femoral-popliteal Fontaine classification which assigns based on bypass surgery. symptoms. (Table 2) [4,5] Local examination includes elaborate assessment of  This includes scar of carotid Rest pain is the end result of severe vascular peripheral pulses, temperature differentials along the compromise. Non healing wounds in the lower extremity lower extremities in order to localize the potential site of are suggestive of severe vascular compromise. Previous narrowing or block. In case of ulcerated lesions, history of healed ulceration and amputation which assessment of the ulcer as to whether it’s in healing include amputation of toes or major amputation. Erectile phase is important. As one can decide adjuvant therapy dysfunction also needs to be taken into consideration to accelerate the healing process. In case of diabetic while evaluating peripheral vascular disease. Many a patients, assessment of both the lower extremities is times symptoms of PAD maybe a local manifestation of essential to identify the foot at risk which necessitates a systemic problem. Therefore, other vascular beds need proper advice. to be evaluated. These include carotid for TIA’s and ©2024, IJMACR 37 smoking,diabetes, Page namely Ketan Vagholkar, et al. International Journal of Medical Sciences and Advanced Clinical Research (IJMACR) Variation in presentation of PAD Diagnostic Tests for PAD Asymptomatic PAD may occur in patients with Ankle Brachial Index (ABI) atherosclerotic disease in the absence of symptoms. The This is a diagnostic test to establish the diagnosis of purpose of identifying patients with asymptomatic PAD PAD.[11]First the systolic BP in both arms and from is important as such patients are at very high risk of both ankle pulses is obtained after the patient is at rest in vascular accidents.[7] Such patients may benefit by supine position for 10mins. ABI is calculated by cardiovascular risk modification. Symptoms may include dividing the highest systolic blood pressure in the foot limitation of by highest systolic BP in the arm. An abnormal ABI is comorbidities example, CCF and COPD. Altered pain less than or equal to 0.9 whereas borderline ranges from perception due to peripheral neuropathy in diabetics may 0.91 to 0.99. A Normal ABI ranges from 1.0-1.4.Non mask the symptoms of PAD. Atypical leg pain which is compressible atherosclerotic artery may exhibit an ABI of two types may be seen. [7.8] First type is pain on of 1.4. exertion and rest. This is distinct from rest pain in Exercise treadmill ABI chronic ischemia. Leg pain which is exertional which Patient with exertional non joint related symptoms who doesn’t stop the patient from continuation to walk. have normal or borderline ABI (0.9-1.4) should undergo Patient suffering from leg pain tend to have functional exercise treadmill test. Abnormal treadmill ABI is impairment and rapid decline. Incidence of leg pain defined as decrease in ABI by 20% or greater after accounts for about 40-50% in PAD.[7] exercise and is diagnostic for PAD. A normal exercise Acute limb ischemia (ALI) is sudden decrease in lower ABI is defined as no change in ABI or increased ABI limb perfusion which threatens limb viability in patients after exercise.[11] who present within 2 weeks of the insightingevent. [8,9] Absolute Toe pressure (TBI) Symptoms are pain, pallor, paresthesia, pulselessness, TBI is similar to ABI. [12,13]It is the ratio of systolic paralysis, poikilothermia BP of the great toe to higher of 2 arms brachial artery ALI a of ability surgical to exercise emergency by requiring virtue immediate pressure. TBI less than 0.5 is classified as abnormal. An treatment. [10] ALI is caused by thrombosis of a pre- abnormal TBI is specific for PAD. In patients with existing stenotic lesion and embolism. It may also result suspected PAD wherein ABI is greater than 1.4 due to from arterial dissection and thrombosis of the aneurysm thickened artery, TBI should be measured to confirm the or occlusion of the stent or bypass graft. diagnosis of PAD. This type of response is seen in Chronic ischemia (Critical limb ischemia) is a condition diabetes and end stage renal disease. TBI is also helpful characterized by presence of ischemic rest pain, in assessing the chance of wound healing and absolute nonhealing ulcers and gangrene over a period of 14 days. toe pressure above 30mm Hg favors better wound [11] Rest pain typically occurs in fore foot and is healing. However, in diabetic patients an absolute toe relieved on positioning it in dependent position. pressure of above 40-55mm Hg is necessary for ©2024, IJMACR Page 38 adequate healing.[14] Ketan Vagholkar, et al. International Journal of Medical Sciences and Advanced Clinical Research (IJMACR) Evaluation of pulse volume recording (PVR),  Quantity of collateral circulation transcutaneous O2 measurement (TCPO2) and skin  Distal runoff perfusion pressure (SPP) These are the four findings which need to be critically PVR wave forms are obtained non-invasively.The nature assessed. Patients of PAD with more proximal block, of the wave form reveals the severity of the disease at apparent collateral circulation and good distal runoff are each level of the leg. A normal PVR is characterized by ideal candidates for vascular intervention with promising a steep systolic upstroke with the sharp peak followed by outcomes. [18] a downstroke with prominent dichotic notch. Mild to Treatment moderate loss of systolic peak amplitude, dicrotic notch No single modality of treatment can is effective or and outward projection of the down stroke is seen in prevent complication arising from PAD. Every patient PAD. In severe PAD the amplitude of systolic peak is needs to be critically studied and multi-disciplinary severely diminished. [15] approach has to be planned. Each patient will exhibit a TCPO2 and SPP provide information on the status of better response to a particular modality. Therefore, tissue perfusion.[16] Normal TCPO2 at the level of the planning a comprehensive algorithm for each patient is foot usually exceeds 50mm Hg. A TCPO2 of greater the mainstay of treating the patient suffering from than 50mm Hg suggest that the wound may heal whereas PAD.[18] a TCPO2 of less than 20mmHg indicates severe Medical ischemia and low probability of wound healing.Sucha Medical therapy plays a pivotal role. The main aim of patient medical ideal candidate for attempted therapy is the risk modification and revascularization. improvement in the functional status through this SPP less than 30mm Hg has good specificity and modification. Risk Modification includes cessation of sensitivity in diagnosing PAD. smoking, control More than 30mm Hg is associated with high probability cholesterol and diabetes. Anti-platelet and cilostazol are of wound healing. also needed. Smoking cessation is the most important Imaging for anatomical assessment of patients with PAD modality for treating PAD. Immediate, complete and is essential for selecting patient for vascular intervention permanent cessation of smoking prevents progression of only. Symptomatic patient may be considered for disease especially in cases of TAO. [19,20] revascularization. Duplex USG, CT-angiography, MR- Anti-hypertensive therapy is prescribed to all patients of angiography are helpful in determining the anatomical PAD location and severity of the disease.[17] Digital converting enzyme inhibitor and Angiotensin receptor subtraction angiography (DSA) is specifically useful in blocker significantly reduce cardiovascular events in patients with CLI. Arterial anatomy is best delineated by patients with PAD. In addition to the above, diuretics, B- DSA with respect to blockers and calcium channel blockers are also suitable  Site of the block in certain cases of hypertension. [20]  Length of the block ©2024, IJMACR suffering of from blood pressure, hypertension. control of Angiotensin 39 an Page is Ketan Vagholkar, et al. International Journal of Medical Sciences and Advanced Clinical Research (IJMACR) Statin therapy is to be always prescribed in patients Hyperbaric oxygen therapy (HBOT) is salvage for having patients with PAD wherein all modalities have been PAD. There is significant reduction in cardiovascular events including mortality in patients utilized with poor results. with PAD who are on stains.[20] HBOT controls infection and induces neo-angiogenesis Meticulous multispecialty treatment is essential for good thereby improving the glycemic control. It helps in lowering the rate of compromised limb. The number of sessions required amputation may be variable and needs to be decided based on and at the same time improves healing potential of the revascularization in patient suffering from CLI. [21] periodic clinical evaluation with respect to enhanced Long term antiplatelet therapy with aspirin alone(75- wound healing 350mg) or clopidogrel(75mg) is recommended in Conclusion symptomatic PAD. Clopidogrel shows better results in PAD is a very complex disease which concomitantly preventing CVS events.[22,23] affects various vascular beds.A critical and elaborate Cilostazol and pentoxyphylline is a phospho-diesterase vascular assessment is essential which include clinical inhibitor and is recommended for symptomatic treatment evaluation and laboratory testing including vascular of may imaging. Every patient needs to be individualized based vascular on the findings. A multi-modality approach is always symptoms with these medications. 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International Journal of Medical Sciences and Advanced Clinical Research (IJMACR) Legend Tables Table 1: Rutherford’s Classification Grade Clinical Inference 0 Asymptomatic 1 Mild claudication 2 Moderate Claudication 3 Severe Claudication 4 Ischemic rest pain 5 Minor tissue loss like non healing ulcers of limb, localized gangrene 6 Major tissue loss typically extending above trans-metatarsal Table 2: Fontaine’s Classification Grade Clinical Inference 1 Asymptomatic IIa Mild claudication IIb Moderate – Severe Claudication III Ischemic Rest Pain IV Ulceration or Gangrene Table 3: Assessment of Peripheral Pulses Peripheral Arterial Pulses Anatomical Landmark Superficial Temporal Just Anterior to the Tragus Carotid Palpate the carotid artery by placing your fingers near the upper neck between the stern mastoid and trachea roughly at the level of cricoid cartilage (Medial to sternocleidomastoid) Brachial palpated medial side of antecubital fossa, just medial to tendinous insertion of the biceps Radial Palpated Lateral to the Tendon of Flexor Carpi Radial is Muscle and medial to the styloid process of radius Femoral Inferior to the inguinal ligament and midway between ASIS and pubic symphysis Popliteal Deep in the popliteal fossa medial to the midline, Knee should be semi-flexed while examination Posteroinferior to the medial malleolus in the groove between the malleolus and the heel Dorsalis Pedis Lateral to the tendon of Extensor Hallucis Longus ©2024, IJMACR Page 43 Posterior Tibial Pulses