Peripheral Artery Disease

Emile R. Mohler, MD, MSVM, FACC, FAHA is Director of Vascular Medicine for the University of Pennsylvania Health System, and Professor of Medicine for the Perelman School of Medicine at the University of Pennsylvania, Philadelphia Pennsylvania, USA Michael R. Jaff, DO, FACP, FACC, FAHA, MSVM is Professor of Medicine, Harvard Medical School and President of Newton-Wellesley Hospital in Newton, Massachusetts, USA.

Contributors xi
Preface xiii
1 Epidemiology of Peripheral Artery Disease 1Wobo Bekwelem and Alan T. Hirsch
Definitions 1
PAD
Clinical Syndromes 2
Prevalence and Incidence 3
Asymptomatic PAD 8
Claudication 10
Atypical Leg Pain 12
Critical Limb Ischemia 12
Acute Limb Ischemia 13
Risk Factors for Development of PAD 13
Tobacco Use 14
Diabetes Mellitus 15
Dyslipidemia 15
Hypertension 16
Homocysteinemia 16
C ]Reactive Protein and Fibrinogen 17
Obesity 17
Other Risk Factors 18
Awareness of PAD in the Community 20
Progression, Natural History, and Outcomes of PAD 20
Progression 20
Natural History and Outcomes 22
Summary 24
References 26
2 Office Evaluation of Peripheral Artery Disease History and Physical Examination Strategies 37Maen Nusair and Robert S. Dieter
Introduction 37
Identifying At-Risk Individuals 37
Regional Symptom Analysis 38
Neurologic Symptoms 38
Thoracic Symptoms 40
Abdominal Pain 41
Extremity Pain 42
Skin Manifestations 44
Physical Examination 46
General Appearance 46
Head and Neck Examination 46
Chest 48
Abdominal Examination 48
Lower Extremity Examination 49
Palpating for Pulses 50
Auscultation 52
References 53
3 Vascular Laboratory Evaluation of Peripheral Artery Disease 57Thomas Rooke
Introduction 57
Anatomic 57
Hemodynamic 57
Functional 58
Physiological Testing 58
Background/History 58
Physiological Invasive Testing 58
Physiological Non ]Invasive Testing 58
Vascular Laboratory 59
Doppler 59
Motion Detection 59
Waveform Analysis 60
Plethysmography 60
PVR Amplitude 61
PVR Contour 62
Ankle Brachial Index (ABI) and Segmental Pressures 63
Tissue Perfusion 65
Transcutaneous Oximetry (TcPO2) 66
Duplex Scanning 67
Background/History 67
Imaging (Anatomy) 67
Doppler (Hemodynamic) 68
Vascular Laboratory Accreditation 69
References 69
4 Magnetic Resonance, Computed Tomographic, and Angiographic Imaging of Peripheral Artery Disease 73Thomas Le, Masahiro Horikawa and John A. Kaufman
Introduction 73
Computed Tomography Angiography 73
Basics 73
Image Acquisition and Interpretation 74
Protocol 74
Advantages 76
Pitfalls 76
Calcification 76
Artifacts 76
Radiation Exposure 76
Contrast ]Induced Nephropathy 76
Anaphylaxis 77
Magnetic Resonance Angiography 77
Basics 77
Image Acquisition and Interpretation 77
Protocol 77
Non ]Contrast ]Enhanced MRA 77
Contrast ]Enhanced MRA (CE ]MRA) 78
Post ]Processing and Interpretation 78
Advantages 78
Pitfalls 80
Time 80
Nephrogenic Systemic Fibrosis 80
Bolus Timing 80
Artifacts 80
Other Pitfalls 80
Conventional Angiography 81
Basics 81
Image Acquisition and Interpretation 81
Pre ]Procedure Patient Care 81
Protocol 81
Advantages 82
Pitfalls 82
Contrast ]Induced Nephropathy and Anaphylaxis 82
Artifacts 84
Other Disadvantages 84
Intravascular Ultrasonography 84
Basics 84
Advantages 85
Pitfalls 85
Results 85
Aortoiliac 85
CTA 85
MRA 86
Runoff 86
CTA 86
MRA 86
Pedal 87
CTA 87
MRA 87
Conclusion 87
References 87
5 Non-atherosclerotic Peripheral Artery Disease 91Mitchell D. Weinberg and Ido Weinberg
Introduction Presentation of Peripheral Artery Disease 91
When Should Non-atherosclerotic Causes of PAD Be Suspected? 92
Entities that Make up Non-atherosclerotic PAD 94
Popliteal Artery Entrapment Syndrome 94
External Iliac Artery Endofibrosis 98
Fibromuscular Dysplasia 99
Cystic Adventitial Disease 100
Vasculitis 101
Idiopathic Mid ]aortic Syndrome 102
Arterial Manifestations of Pseudoxanthoma Elasticum 102
Chronic Exertional Compartment Syndrome 103
Musculoskeletal Pathology 103
Diagnostic Evaluation of Patients with Leg Pain with Exertion 104
Treatment Considerations 105
Conclusions 105
References 105
6 Medical Therapy of Peripheral Artery Disease 111Lee Joseph and Esther S. H. Kim
Introduction 111
Atherosclerotic Risk Factor Management 111
Hypertension 112
Diabetes Mellitus 113
Hyperlipidemia 114
Tobacco Cessation 114
Antiplatelet Agents 116
Management of Claudication 117
Claudication Pharmacotherapy 118
Cilostazol 118
Exercise Therapy 118
Claudication Management Strategies: A Comparison 119
Lower Extremity Wound Care 120
Summary 121
References 121
7 Endovascular Treatment of Peripheral Artery Disease 129Vikram Prasanna, Jay Giri and R. Kevin Rogers
Introduction 129
Clinical Background 129
Intermittent Claudication 129
Critical Limb Ischemia 131
Limb Prognosis/Overall Survival 131
Typical Anatomy in Patients with CLI 131
Patency Issues 131
Indications for Endovascular Therapy for CLI 131
Background for Endovascular Therapy 132
Anatomy 132
Technical Background 136
Preprocedural Imaging 136
Access 138
Anticoagulation 139
Antiplatelet Management 141
Radiation 143
Chronic Total Occlusions 143
Clinical Evidence for Peripheral Intervention 145
Aorto ]Iliac Interventions 145
Angioplasty vs. Stent 146
Polytetrafluoroethylene (PTFE) ]Covered versus Bare Metal Balloon ]Expandable Stents 147
Femoropopliteal Interventions 147
Angioplasty versus Stenting 149
Drug ]Eluting Stents in Femoropopliteal Arteries 149
Drug ]Coated Balloon (DCB) Therapy in Femoropopliteal Disease 150
Covered Stents in Femoropopliteal Disease 151
Atherectomy 152
Specialty Balloons 153
Tibioperoneal and Pedal Interventions 153
Post-procedural Care 155
Conclusion 155
References 156
8 Surgical Management of Peripheral Artery Disease 163Julia Glaser and Scott M. Damrauer
When to Refer Patients with Claudication 163
When to Refer Patients with CLI 164
Revascularization Options and Results 166
Iliac Revascularizations 166
Femoropopliteal Disease 169
Tibioperoneal Disease 171
Complications of Revascularization 173
Preoperative Evaluation and Management 175
Conclusion 175
References 176
Index 179