Josh McKay, MD, FACC, Austin Heart Interventional Cardiologist, discusses peripheral artery disease (PAD) - screening, diagnosis, management and intervention.
so quite a few slides to get through. I'm gonna try to get a quick, But if you have any questions, feel free to kind of interrupt and asked us. So just kind of an overview of what will be talking about going to start off with some of the epidemiology, which is kind of some of the boring stuff. But the important numbers and facts behind it, followed by the the clinical signs and symptoms followed by the screening and diagnosis. What test order and the pros and cons of each on. But what you do, once you find out someone has Ph. D, how do you treat manage these people and then following? And then finally, um, after you've been managing them and the medications etcetera are working. What do we do next as faras revascularization S o p. A. D. Effects about 8 to 12 million people in the U. S. That's a pretty wide range, you know, by four million people there off. And that's because the majority of those people are mostly asymptomatic eso. Although they say it affects 8 to 12 million people, that number is probably grossly underestimated because most people are just undiagnosed. Um, this is a disease much like cardiovascular disease. That happens. Maura's We get into the elderly population Andi not even so elderly, but just get older. About 20% of people over the age of 60 are are affected. Um, the interesting thing about Ph. D is that being diagnosed with PD confirms the six times greater risk of death from cardiovascular disease. And I think that's something that's missed A lot. Is even if you're asymptomatic, Um, that's not a benign process that, by itself confirms worse outcomes that's shown here on these Kaplan Meier survival curves. You can see that broken down by normal subjects asymptomatic, peripheral vascular disease versus symptomatic versus severely symptomatic at every step along the way mortality is affected and to the point that a symptomatic Ph. D. Patient is a 25% mortality rate. It about two years, um, and I think that gets people's attention is the minute you're diagnosed with symptomatic Ph. D. If I say there's a one in four chance will be dead in two years, that tends to get people's attention, and you say, Well, that's probably because of other co morbidity is because of their age because they have coronary disease, heart failure, etcetera. If you adjust for those factors on these curves, all look exactly the same, meaning that P. A. D really by itself is an independent predictor of both morbidity and mortality. Um, so that's why we kind of care about it then. Now how do we pick up on it? And what do we do about it? So the risk factors for P A. D or very similar to our other cardiovascular disease, you know, age, high blood pressure, Hyperloop, academia, smoking, diabetes. But when broken down by individual traits, you can really start to see at least some more granular data that people with diabetes or four times more likely to have Ph. D and people's that are smokers are 2.5 times more likely to have P a D for hypertension, hyper lymphedema or a little bit less predictive. And so, really, the brunt of these patients are the diabetics and particularly the smokers and diabetics. So the typical symptoms of P 80 to kind of be looking out for the classic symptoms will be leg pain or cramping with walking that improves with rest. Other things outside of the typical qualification would be poor wound healing skin discoloration, uh, temperature differences. Patients will often notice my feet feel colder. Um, and then poor nail and or hair growth should all kind of at least tip you off that maybe you need to look into this a little bit. So the typical symptoms of P A. D or defined as exertion all calf pain that causes a patient to stop walking and resolved within 10 minutes. That's kind of the textbook definition. A. Typical symptoms basically be paying in any other area, not just the calf. It may not resolve in 10 minutes, but more typically of what I see in patients in the office is not so much pain. But they complain. Mawr of leg fatigues, leg heaviness. The legs go numb. It feels the main legs they're gonna go out on me on. I think a large part of that is why a lot of this is undiagnosed or missed is because oftentimes patients don't come to the office and complain that my legs feel tired. Uh, this is something that they just go to the grocery store and get the shopping or get the motorized shopping card and ride that because they can't walk around the entire store because their legs get tired and they don't think that there's something wrong. They think that because they're out of shape, they don't walk enough. They're overweight, they don't exercise. And and that's really what the problem is. When you really start kind of diving deeper and questioning these people, they really will describe kind of classic symptoms of p 80. But it's not pain. It's that the leg is tired of heavy or numb. And so I think that's an important thing to kind of keep in mind when you're pushing some of these people about symptoms and then, of course, other atypical symptoms of your wounds or non healing ulcers. And then, of course, there's a large percentage of the population with PhD that air asymptomatic, so they actually have no symptoms, no matter how hard to push him. And so what is the breakdown of this like? And I think this is important is that the people that have the textbook typical qualification symptoms Onley represent 10% of P 80. About 50% have atypical symptoms, and like I said, that's The majority of what I see in my practice is not so much pain but more fatigue, heaviness, numbness. And then for it. Like I said, 40%. So almost half of the population is actually a symptomatic, which is another reason why obviously it's under diagnosed, um, not recognized because you're not gonna find it unless you look for it because they're not gonna tell you anything about it. Eso some kind of clinical findings, if you will, not just what the patient reports to you, but this is a kind of a classic example of deepened in room bar. So if you look at the picture on the left, you can kind of see that the toes of the foot or kind of this deep, dark red color or the room bar that you're you're used to. And that's when his foot is hanging off the edge of the bed and gravity is basically pulling the blood flow down to the foot. Now the picture on the right. That's after I've raised the foot up to kind of above the bed height for a few minutes, and you notice that the entire foot is now pale and gaunt. able. Um, this is kind of a classic finding of rather severe p a d which is a dependent room, bar of the foot with power on elevation. Um, and if you kind of believe the findings, then you know the length of time it takes for the foot to go from pale to root bar when you make independent, um, it's kind of a little bit more predictive of the severity of the P a. D. Meaning If it happens within a few seconds versus if it takes, you know, a minute or two, um, to really kind of darken up, then that's the signing of more severe Ph. D. So that's kind of a poor man's Doppler, a poor man's eight that you can do in the office real quick because we do see, you know, people that develop this kind of rude bar color of their feet for other other reasons, most commonly Venus disease. But this kind of this foot elevation test kind of separates out some of that to kind of get a little bit more specific about Could I be dealing with arterial disease or Venus disease or something else? Um, it would not be a Ph. D. Talk in my clinic, and we didn't include some gross photos. Um, this is kind of what I look at for a lot of the day when I look a lot of feet. Um, and so these air kind of some examples I think these were mostly obvious examples that nobody's gonna miss. With this walks into your office, you're gonna know that something is wrong, but you can see kind of the cyanosis, um, wounds, etcetera of the feet. This is the lunch hour. So I put them or kind of PG photos first. Eso a squeamish stomach. You may not want to look at the next set, but these air, some of them or dramatic kind of wounds and ulcers that I see. Hmm, Mhm. And oftentimes again. I mean, you can see some of these photos are pretty dramatic with the tissue loss on the tissue damage that they've they've suffered, but for one reason or another, often because they also have diabetes with peripheral neuropathy and or because they have such severe ischemia of the foot that they get neuropathy. Ah, lot of these patients, despite the fact that they've got wounds in this last photo. They've got exposed tendons of the foot. They're completely pain free. Eso This is not painful for them in most cases. And so that's another kind of reason why a lot of times you don't find out about these things unless you really look because of the patient. You know, a lot of times of patients don't hurt. Um, they're not gonna really say much about it unless you ask. This is kind of a spectrum of PhD chart. Really? The only reason I say put this up is to look at the far right when you start seeing poor wound healing. Um, you can see that That's amore Severe advanced sign of P A. D. And I point that out because this really pertains to any wound. Meaning that a lot of times I see patients that are, you know, so far along the spectrum that they've had these severe wounds have not been healing for 89 10 months, and they've never had a vascular evaluation because over the wound was a diabetic wound or oh, the wound was a pressure ulcer or oh, the wound happened when I stubbed my toe on the table. And the truth be told is it doesn't really matter how the wound starts. The fact that it's not healing should be the thing. That's a tip off to say, Well, this isn't normal. Lots of people stubbed their toe. Lots of people do this or that, and the wound heals just fine. If the wound doesn't heal, then that should immediately kind of trigger vascular testing. Now immediately are sorry. Admittedly, not all non healing wounds or vascular in nature, but that should trigger vascular testing to kind of be sure. So how do we pick up on all of this? The biggest thing here is screening. So screening is something that the U. S. P S. T F does not recommend for or against kind of universal screening of P A D. At this stage, however, the American Heart Association and the A, C. C. The American College of Cardiology both have, um statements out there that air strongly and supportive of screening of patients. And their recommendations state that basically all patients over 65 should be screened within a B. Regardless, service factors all patients over the age of 50 that have any risk factors which includes hypertension, hyper live anemia, smoking, diabetes should be screened. And then any patients under the age of 50 that have diabetes and one additional risk factors should be screened. And again, I think the important thing to note here is that this is screening. So this is this is irrespective of symptoms or other co morbidity ease, except for the these risk factors that these patients should undergo screening. If you kind of look at the patients in this this threshold in a cardiology practice, that's that's probably, you know, the vast majority of what we're seeing, what we have patients that fall into these categories. And I think that that is something that all of us myself, including, despite the fact I have a big vascular practice, is we kind of lose sight of this. Sometimes you get focused on the coronary disease in the heart failure and caryatids, and this and that, and then you kind of forget, Oh, I haven't done any the eyes on this person, so just something to kind of be my glove so kind of quickly a b ice. For those that aren't aware, we basically measure the blood pressure in both arms and the blood pressure down in both feet, both with the door Sallis PDS artery and the post. Your tibial artery is calculated using the higher ankle pressure of the right leg with the highest arm pressure right or left, followed by the highest ankle pressure of the left leg and, um, the higher of the armed pressures either arm. And then you get a number, which you can see in this top right, which is a ratio. Basically, anything above 0.90 is normal. Anything below is abnormal numbers above zero point. We're sorry above 1.3, you're considered non compressible, which essentially just means it's inconclusive and you need further testing. If indicated. Additional information we typically get with our FBI's include segmental limb pressures and post volume recordings where you get tracings that looked like this. The one on the right side of the screen is a normal tracing where you can see kind of a try physic wave form throughout. The one on the left side is an abnormal tracing where you see by physic wave forms, uh, to the tibial vessels just below the knee, and then down in the paedo vessels down at the foot, you see a basic way, form and then finally, kind of ways of diagnosis. One is ultrasound duplex, which we commonly performed were actually physically look for signs of obstruction based on the ultrasound velocities of blood and then angiography and angiography has multiple modalities CT, Emery and Kath or invasive. There's pros and cons for each technique. C t, of course, uses radiation. In contrast, can be an issue with C. K. D. Emery. Likewise, the contrast can be initiative with advanced CKD. Um, the calf has the downside, of course, of this invasive and does use radiation. But invasive angiography also has the the highest spatial resolution way also have other contrast media that we can use, which was co two imaging that actually has no effect in CKD. So even in patients that have advanced ckd weaken do angiography safely without worrying of worsening renal disease with invasive angiography. Oh, so what do we do with patient once we know they've got it? The first is the important distinction of Is this gonna be clawed occassion? Or is this a critical limb ischemia? Because the management, you know, up front should be different if it's qualification you're really talking about. What do we need to do to improve symptoms if it's critical in ischemia? What we're talking about is what do we need to do to save the leg to do limb salvage? Um, in general, all things should be focused on lifestyle modifications, which include, you know, making sure that their high blood pressure cholesterol, diabetes and smoking or treated and address patients should have an exercise program if they could, which should be a 30 to 45 minutes of walking three times per week and then, of course, harping on smoking cessation. So this just shows, um, with an exercise training program, the distance of walking in the improvement on symptoms versus no walking program. And this actually shows, um, survival curves and P A d patients that air smoking or stop smoking. And so the PhD doesn't just slow the onset or worse, or slow the worsening progression of the disease. Continuing to smoke with active Ph. D. Actually increases your mortality. Um, assed faras medications go all patients with diagnosed PD should be on anti platelet regiments. Most commonly, this is aspirin. I only show this slide. Just to kind of think is that this is a kind of a pooled analysis of a meta analysis of 42 trials with about 20,000 patients of P A. D. And they compared aspirin versus Plavix. Or sorry, I should say, with just vascular disease compared aspirin versus Plavix. They did show a relative reduction in vascular events with Plavix when compared to aspirin alone. But if you look off to the right when you look at the individual, um, risk groups, you see, the P A. D actually had the most significant benefit from Plavix compared to aspirin. Now, these air subgroup analysis and you know, I know theoretically just kind of thought provoking and hypothesis generating. But something to kind of keep in mind is that the P 80 patients, for whatever reason, seemed to have maybe a little bit better effects of more potent platelet inhibition than just aspirin alone. So I use a lot of Plavix in my practice. Um, likewise, statins should be prescribed for all patients with PhDs. Uh, this shows that basically not only a reduction in cardiovascular events which we are well familiar with From the cardiovascular standpoint, the CED standpoint, but it also shows a reduction in the progression to communication. Um, and then importantly, also to consider is that once you know what patient s p a. D similar to some of our other diseases, like C A d heart failure, etcetera. It should trigger additional screening and additional testing, because once you're diagnosed with PH. D, that's automatically put you into a higher risk category s. So it makes sense to screen lipids. Make sure that you know they're reaching target goals. Yeah, the screen caryatids andan also cardiac screening, you know, probably also with an echo and maybe a stress test. And then a lot of these patients are gonna meet the criteria for screening of Triple A's based on age and smoking history. Um, so now the intervention standpoint. So again, uh, intervention would be indicated for any patient with critical limb ischemia and then any patient that has what's considered life limiting clouded cage. Now, what's life limiting? That's gonna be different for every patient. So the patient that you know, for lack of a better word or term that sits around and is not very active all day, um, is probably not gonna be limited by their P 80 symptoms as much. But that doesn't mean that somebody who's super active and can run, you know, five miles and says, Well, now I can only run three miles. I would say that that is a life limiting symptoms because they've had to alter their normal exercise routine to adjust for their symptoms. And if we can improve on that and get them back running five miles, I think everyone agree that's a better overall course of action for them. Long term, Um, now endovascular management of P A. D is now the kind of the first line treatment recommended by almost all the invasive societies. Of course, there are certain anatomical or patient factors that might lead you more to do of more of a traditional open or bypass operation. However, um, the accepted standard first line treatment at this stage is endovascular for just about all patients within a vaster. We have multiple options which you know where angioplasty, both with just plain balloons or drug coated balloons. Stent placement with both bare metal stents, drug eluting stents we have after ectomy devices for stand alone after ectomy, a swell as ah, newer technique in the last year or so, which is intravascular little trip See, which has yet to make it to the coronary world. But it's probably coming soon versus the open surgical techniques, which have been mostly the endarterectomy using bypass procedures. So a couple of cases to kind of go through here quickly. I know we're moving fast, but just to kind of give some examples of of kind of things and incorporate some of these things we talked about. So the first patients, a 75 year old man complaining of bilateral leg weakness again because most of these patients, uh, don't really complain of pain, what they complain much more often about his weakness, numbness, fatigue, the complaint of bilateral leg weakness with walking 50 ft or we're doing any prolonged standing. So with standing and making dinner standing in washing dishes after some time, he's got to sit down and rest before you can finish the job. Past medical history is common for a lot of these patients as coronary disease, hypertension, Hyperloop demand, diabetes. All the risk factors also has extensive smoking history. He's already on kind of the appropriate medical therapy with an aspirin and Staten physical exam. I'll just point out that he had intact radio ephemeral pulses, but his pedal pulses were absent bilaterally on both d p s and P. T s. He underwent a B ice, actually prior to even see me. And I point out here that his a b I on the right is actually completely normal is a be on the left would be considered, uh, non compressible. But when we looked at the pressure volume recordings and wave forms, which kinda adds that extra bit of information, you see that the way forms air diffuse li mon aphasic throughout, suggesting severe inflow disease. So because of his symptoms and lifestyle limiting, you underwent angiography. So for those not used to seeing these kind of the heads at the top, the feeder at the bottom, I'm injecting from above, coming from the wrist and you can kind of see this is his aorta. And this is his bifurcation of his iliac around his belly button to go down each leg. And you kind of focus on these areas right where the bifurcation happens, you can see the severe stenosis and the narrowing of these vessels which explains the Monta physical reforms throughout. Oh, this is us just lining up stents, inflating stands. And then this is after the stent placement. You seem much better flow without residual stenosis. This is kind of a before and after eso and follow up, of course, has complete resolution of the symptoms. You're now able to do everything he wants without any trouble, including the dishes and dinner and walking much further. So this case eyes a little bit of a curveball compared to what we talked about. But it's just kind of a reminder that P. A. D doesn't just apply to the legs. Um, it can be the upper extremities. Aziz. Well, so this is a 67 year old man complaining of right upper extremity weakness. He frequently dropped items that he's carrying or has to move them to the to the left arm to carry. Because the right arm becomes weak and painful. He cannot work overhead, so if he's trying to screw in a lightbulb, you can't do it with his right arm because it just goes numb on DSO. He kind of presents. For that. We get a right upper extremity ultrasound of the artery. I'm sorry of the arteries and you can see here that thes air velocities of blood flow that there's elevated velocities within the axillary artery, followed by a steep drop off in the radio on older arteries. So he undergoes noninvasive or sorry, invasive testing with angiography. So again, heads at the top, Peter at the bottom. This is actually coming down the right arm. Mhm. That will play again. So kind of turn your attention here and you can see this kind of large area avoid. Essentially, there's no flow here. And then you see a kind of reconstitute, and this is actually inclusion of the axillary artery. So likewise, we put a stent here and then this is post and you can kind of see that area is now completely Peyton before and after. And he had a resolution of his symptoms. Actually, when he came back to the office to follow up, he put a quarter on the ground, reached down and picked it up to prove to me that was kind of fine Motor control and strengthen the owner was was much improved. Now this last cases is kind of a highlight of of wounds and critical limb ischemia. So this is a 52 year old female presents with longstanding lower Sermanni pain that's been progressive. She could only walk about 15 ft before feet go, completely numb at night. She also often has to dangle her feet off the bed for relief. So that's similar to that dependent rube. Our physical exam findings we spoke of earlier. She has multiple slow healing wounds. She has all the risk factors, including smoking is actually already on Plavix as well as cumin. And because of our other risk factors on exam again, we see the dependent rhubarb with foot elevation leading to pallor. Interesting enough when we elevate her foot, she actually starts to develop pain, too, because of ischemia, and then has multiple small wounds of bilateral feed in various stages of healing. So these were images of her right leg again, our heads at the top, feeder at the bottom. This is actually her right ephemeral area. So this is her right hip. This is a common Fillmore artery, and these were all before pictures. Now I know if you're not used to seeing these, you don't really know what you're looking at. But this is actually the profundity artery coming off year. And yes, FAA The superficial femur artery that should be coming down is completely included in absent. So coming further down the leg, it's a little more clear. This is her knee. There's actually no named vessels on that air showing here. All of these vessels were just collateral flow until you get down below the knee here, which these air where the tibial vessels kind of come back into the picture. So extensive long segment inclusion resulting in basically severe resting pain as well as critical limb ischemia. Non feeling waas. So we're able to open all these up on these. There are gonna be our after pictures. I'm sorry. This is actually the next picture below the knees showing the post your tibial artery reconstituting with flow all the way down to the foot. So then these air are after pictures. And so now this is up by the common ephemeral in the hip area, and once again, you can kind of see this flow. Before we saw the profundity much more clearly because it was the only vessel. Now that we've opened the S F A you can see much more brisk flow down the S F A, which wasn't seen before. There's actually more sluggish flow down the profundity now because the majority of the flows is headed down the normal pathways. So we're going down a little bit lower. This is the knee. You can kind of see the new joint coming in there, these air subtraction images so that not is clear for the bones. But now you can see that before where we had no named vessels and it was all collaterals. You can see the S F A clearly coming down into the popular teal and then connecting down to those TVO vessels which we saw before then kind of Cem side by side images before and after just to kind of make things a little bit more clear Over here, you see the profundity you see, a clearing filling much more, uh, widely, but basically because it was the only flow of the leg. But now, once we've opened the S f A. That's providing the predominant flow down the leg and the profound a less so likewise here, nothing but collateral flow, no named vessels. Now you see in line flow all the way to the tibial vessels down to the foot. And one thing I want to kind of point out, which is somewhat I won't say, uh, overly unique, but something that I think is interesting that that we can offers, you know, through our practice. Um, we do a lot of this is all obviously endovascular, but not just to know vascular, but I do a lot of kind of small vessel work on pedal access. So this last patient, we did all of this from a combination of her wrists and foot eso. This is basically everything is done through these two sheath access points. There's no ephemeral access, which is a little bit lower risk. Obviously, in terms of bleeding and complications, it's much easier on the patient, meaning that they don't have to lay flat for 4 to 6 hours after the case. The recovery times much faster. Patients are basically sitting up immediately after the procedure, and they're able to eat etcetera. So kind of in summary. Uh, Ph. D is a very common disorder that's often undiagnosed or are under recognized mostly due to atypical or completely absent symptoms. It's associate with a six fold increase in the risk of death from cardiovascular disease. The biggest thing about all this is screening, because most of these patients raise symptomatic, and so far not screaming, screaming, We're not gonna pick up on it. And also, once you screen, then I think you get a little bit more aggressive about asking about symptoms. And then you start to find things that you didn't realize before but also, of course, affect your medical management. You start getting more aggressive about things like cholesterol lipids and screening for other diseases. The kind of stall front or the main treatments for these, in terms of the conservative therapy is exercise. Stop smoking medications with anti platelet agents and status. When it gets to the point that that's not enough for the patient is critical. In ischemia, we proceed with revascularization. The first line of this should be endovascular. Um, many of us, with our practices were able to offer minimally invasive, not just know of, ask about minimally invasive meaning peter or radial access to avoid femoral access, which is easier on the patients with lower bleeding and vascular uh, adverse events associated with Kath and then three other thing to plant a seed is that with angiography, we actually have non metro toxic contrast agents with CO two imaging. So renal function should not be, ah, prohibitive factor for patients undergoing angiography or being referred for angiography because that could be managed safely. So thanks everyone for kind of logging in and listening. We kind of move quick. That was a lot of slides, but didn't want to go past the lunch hour too much. Um, this is my contact info. Feel free to call all text, whatever with any questions. Concerns. I get lots of pictures of feet. Um, lots of pictures of toes and everything else throughout the week. Toe weigh in on. So feel free. Yeah, yeah.