Peripheral Artery

Disease (PAD)
Dian Paramita, dr., Sp.JP
WHAT IS PAD?

An atherosclerotic disease that

characterized by occlusion (blockage)
or stenosis (narrowing) of the
lumen of peripheral arteries, which
leads to a reduction in blood flow to the
limbs

Potential causes are artery disease

progression, cardiac embolization, graft
thrombosis, hypercoagulable states
 WHY SHOULD
WE AWARE?

Ø 3–10% of the general population,

increasing to 15–24% in people aged
70 years or older
Ø Prevalence of PAD: 11 Million, compared
to stroke: 4.4 Million, and MI: 7 Million
o 23% will die within 5 years from cardiac,
cerebral, or other vascular events.
PATO P H YSI O LO GY
Krishna, S.M.; Moxon, J.V.; Golledge, J. A Review of the Pathophysiology and Potential Biomarkers for Peripheral
Artery Disease. Int. J. Mol. Sci. 2015, 16, 11294-11322. https://doi.org/10.3390/ijms160511294
 WHO’S AT RISK?

Older age (> 40 years)

Male gender

Smoking

Diabetes mellitus

Hyperlipidemia

Hypertension

Hyperhomocysteinemia

G U I D E L I N E S F RO M T H E T R A N S -
AT L A N T I C I N T E R - S O C I E T Y
C O N S E N S U S ( TA S C ) D E F I N E
I N C R E A S E D R I S K F O R PA D A S
THE PRESENCE OF ONE OF THE
F O L L OW I N G :
• Age <50 years with diabetes and one
additional risk factor (smoking, dyslipidemia,
hypertension, or homocysteinemia)
• Age 50 to 69 years with history of smoking
or diabetes
• Age ≥70 years
• Abnormal lower extremity pulses
• Leg symptoms with exertion or ischemic
rest pain
• Known coronary, carotid, or renal
atherosclerosis
 SPECTRUM OF
PERIPHERAL ARTERIAL DISEASE

Claudication Limb-Threatening Ischemia

Poor Impending
Fatigue, wound or overt
"Normal” Heaviness Mild Moderate- Severe Rest pain healing gangrene
½ ½ ½ ½ ½ ½ ½ ½

Worsening flow limitation

 CLINICAL SPECTRUM PAD

• Asymptomatic
• Atypical Leg Pain
• Claudication
• Acute limb ischemia
• Chronic limb threatening ischemia
 PRIMARY SITES OF
INVOLVEMENT

Femoral & Popliteal arteries: 80-90%

Tibial & Peroneal arteries: 40-50%
Aorta & Iliac arteries: 30%

Harrison’s Principles of Int Med

HOW TO
DIAGNOSE ?
HISTORY TAKING

History taking
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
 ADDITIONAL
EXAMINATION

• The ABI test compares the blood

pressure measured at ankle with the
blood pressure measured at arm.
• A low ankle-brachial index number can
indicate narrowing or blockage of the
arteries in your legs.
 Diagnostic Testing for Suspected PAD
Diagnostic Testing for
Suspected PAD

History and physical examination

suggestive of PAD without rest pain, Suspect CLI Colors correspond to Class of
nonhealing wound, or gangrene (Figure 2) Recommendation in Table 1.
(Table 4)
ABI indicates ankle-brachial index; CLI,
critical limb ischemia; CTA, computed
ABI with or without tomography angiography; GDMT,
segmental limb pressures
guideline-directed management and
and waveforms
(Class I)
therapy; MRA, magnetic resonance
angiography; PAD, peripheral artery
disease; and TBI, toe-brachial index.
Noncompressible
Noncompressible arteries
arteries Normal
Normal ABI:
ABI: 1.00–1.40
1.00–1.40 Abnormal
Abnormal ABI:
ABI:
ABI:
ABI: >1.40
>1.40 Borderline
Borderline ABI:
ABI: 0.91–0.99
0.91–0.99 ≤0.90
≤0.90

TBI Exertional
Exertional non–joint
non–joint
(Class I) related
related leg
leg symptoms
symptoms
Exercise ABI
Normal Abnormal (Class IIa)
Yes No
(>0.70) (≤0.70)
Exercise ABI
(Class I) Search for
alternative
Abnormal Normal
diagnosis
Search for (Table 5)
Lifestyle-limiting claudication
alternative
despite GDMT,
diagnosis
revascularization considered
(Table 5)

Continue GDMT Do not perform invasive

Yes No
(Class I) or noninvasive anatomic
Options assessments for
asymptomatic patients
Anatomic assessment: (Class III: Harm)
Anatomic assessment:
• Duplex ultrasound
• Invasive angiography
• CTA or MRA
(Class IIa)
(Class I)
 DUS (Ultrasound)C N. B.
DUPLEX Ultrasound (DUS)
……?.

Useful to diagnose anatomic location and degree of

stenosis of peripheral arterial disease.

Must be combined with ABI measurement.

85–90% sensitivity and >95% specificity to detect

stenosis >50%.

Operator dependent.

choice for routine follow-up after revascularization.

 Imaging
CT Angiography
Advantages:
- Short scanning time
- Low operator dependency
- Widespread availability
Disadvantages:
- radiation exposure
- Contrast nephrotoxicity
- Reduced accuracy in
calcified vessels
MR Angiography
Advantages:
- Good contrast safety profile
- Optimal delineation of vessel
wall
- Dynamic flow information
Disadvantages:
- technical challenging
- Contraindication in px with
metallic implants
- Tendency to overestimate
stenosis severity
 Recommendations on
imaging in patients with
lower extremity artery
disease
Classification of PAD
 Critical Limb
Ischemia

Rutherford 4
Ischemic rest pain

Rutherford 6
Major tissue loss

Resting ischemic pain

Rutherford 5 PAD with
Minor tissue loss
skin breakdown,
Nonhealing ulcers,
Gangrene
 Treatment
Managementof
of PAD
PAD
Therapies Based Upon Symptoms

Intermittent Claudication Critical limb ischemia

• Exercise Therapy • Wound care
• Drugs • Antibiotics
• Revascularization • Revascularization
• Severe disability • Endovascular
• Surgery
Goal to provide relief of symptoms !! Goal to promote limb survival !!
 CARDIOVASCULAR RISK REDUCTION

• Smoking cessation
• Healthy diet and Physical Activity
• Diabetes control (FBG 80-120 mg/dl, PPG < 180 mg/dl, HbA1c < 7%)
• Dyslipidemia management (LDL < 55 mg/dl) Statin are
Recommended
• Hypertension control (BP < 140/90 mmHg). ACE-I / ARB are
Recommended
• Antiplatelet and antihtrombotic drugs
LEAD Long-term SAPT is recommended in :
1. Symptomatic patients.
2. All patients who have undergone revascularization.
3. After infra-inguinal bypass surgery.
4. In patients requiring antiplatelet therapy, clopidogrel may be preferred over aspirin.

DAPT with aspirin and clopidogrel :

1. for at least one month should be considered after infra-inguinal stent implantation.
2. considered in below-knee bypass with prosthetic graft.

• VKA may be considered after autologous vein infrainguinal bypass.

 ANTICOAGULANT

In patients with PADs and AF, oral anticoagulation:

à Is recommended when CHA2DS2-VASc > 2

In patients with PADs indication for OAC (AF or

mechanical prosthetic valve), à OAC alone

After endovascular revascularization, aspirin or

clopidogrel should be considered in addition to
OAC for at least 1 month à if the bleeding risk is
low compared to the risk of stent/graft occlusion.

OAC alone should be considered à if the bleeding

risk is high compared to the risk of stent occlusion.

OAC and SAPT may be considered beyond one

month in high ischaemic risk patients or when
there is another firm indication for long-term SAPT.
Management Exercise of PAD
CLAUDIC ATIO
ACUTE LIMB ISCHEMIA
 Diagnosis and Management of ALI
Diagnosis and Management
of ALI

Acutely cold, painful leg Colors correspond to Class of

Recommendation in Table 1.
Suspected ALI
ALI indicates acute limb ischemia.

Clinical evaluation, including: symptoms,

motor and sensory assessment, arterial
and venous Doppler signals
(Class I)

Audible arterial Inaudible arterial Inaudible arterial

Audible venous Audible venous Inaudible venous

Revascularization (urgent) Category I: Category III:

AND Viable limb Motor function Irreversible Primary
anticoagulation, Normal motor function assessment Complete loss of motor function amputation
unless contraindicated No sensory loss Complete sensory loss (Class I)
(Class I) Intact capillary refill Absent capillary refill

Intact Impaired

Category IIa: Category IIb:

Marginally threatened Immediately threatened
Slow-to-intact capillary refill Slow-to-absent capillary refill
Sensory loss limited to toes if present Sensory loss more than toes and with rest pain
No muscle weakness Mild or moderate muscle weakness

Salvageable if Salvageable if
treated promptly treated emergently

Revascularization (emergency) Revascularization (emergency)

AND AND
Anticoagulation, unless contraindicated Anticoagulation, unless contraindicated
(Class I) (Class I)
ALI
CLTI
Recommendation on
the Management of
Chronic Limb-
Threatening Ischemia
 Diagnostic Testing for Suspected CLI
Diagnostic Testing for
Suspected CLI

History and physical examination

suggestive of PAD with rest pain,
nonhealing wound, or gangrene
(Table 4)
Colors correspond to Class of
Search for alternative diagnosis Recommendation in Table 1.
Yes No
(Tables 5 and 6)
*Order based on expert consensus.
ABI †TBI with waveforms, if not already
(Class I) performed.

ABI indicates ankle-brachial index; CLI,

critical limb ischemia; CTA, computed
Non-compressible
Non-compressible arteries
arteries Normal
Normal ABI:
ABI: 1.00–1.40
1.00–1.40 tomography angiography; MRA, magnetic
Abnormal
Abnormal ABI:
ABI: ≤0.90
≤0.90
ABI:
ABI: >1.40
>1.40 Borderline
Borderline ABI:
ABI: 0.91–0.99
0.91–0.99 resonance angiography; TcPO2,
transcutaneous oxygen pressure; and TBI,
toe-brachial index.
TBI Nonhealing
Nonhealing wound
wound Additional perfusion
(Class I) or
or gangrene
gangrene assessment, particularly
if ABI >0.70:
Normal Abnormal
Yes No • TBI with waveforms
(>0.70) (≤0.70)
• TcPO2*
• Skin perfusion pressure*
Perfusion assessment: (Class IIa)
Search for
• TBI with waveforms†
alternative
• TcPO2* Normal Abnormal
diagnosis
• Skin perfusion pressure*
(Table 5)
(Class IIa)
Anatomic assessment:
Search for • Duplex ultrasound
alternative Normal Abnormal • CTA or MRA
diagnosis (Table 6) • Invasive angiography
(Class I)
surgical Endovascular

Endovascular à Balloon, stent, CDT, Thrombus Aspiration

Surgical à Embolectomy, Thrombectomy, Bypass, Amputation