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Peripheral Arterial Disease MedicalContinuing Education CLINICAL PODIATRY Goals and Objectives After reading this article, the pod- PeripheralPeripheral ArterialArterial iatrist should be able to: 1) Verbalize a definition of periph- Disease:Disease: DiagnosticDiagnostic eral arterial disease 2) Understand the risk factors asso- EvaluationEvaluation andand ciated with peripheral arterial disease 3) Identify the objective methods used to confirm the diagnosis of pe- CurrentCurrent TherapeuticTherapeutic ripheral arterial disease 4) Appreciate the importance of OptionsOptions risk factor intervention as primary therapy of peripheral arterial disease 5) Develop a strategy for treat- NewNew treatmentstreatments offeroffer anan improvedimproved ment of peripheral arterial disease prognosisprognosis forfor PAD.PAD. using medical, endovascular, and surgical modalities. Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin- uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (you save $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred- its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 190. Other than those entities cur- rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podia- try Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 190).—Editor By Michael R. Jaff, DO grene. Prompt recognition of this Given the inaccuracy of physical ex- disorder is critical to avoid progres- amination, using pulse examination eripheral arterial disease (PAD) sive deterioration in physical func- as the sole criterion will grossly over- is defined as occlusive arterial tion, limb loss, and premature death estimate the true prevalence. In con- Pdisease of the lower extremities from myocardial infarction or stroke. trast, an historical query for the pres- that reduces arterial flow during ex- The podiatrist plays an important ence of intermittent claudication un- ercise or, in advanced stages, at rest. role in this process, and must under- derestimates the prevalence of PAD. The presentation of PAD is varied, stand the prevalence and natural his- Epidemiological studies have wide- and may appear as asymptomatic ar- tory, presenting symptoms and ranging prevalence rates from 1.6% terial disease with abnormal non-in- signs, objective diagnostic tests, im- to 12%, while other studies using ob- vasive tests; symptomatic disease portance of risk factor intervention, jective disease detection with non-in- presenting as either classic or atypi- and therapeutic alternatives. vasive tests have prevalence rates var- cal intermittent claudication (IC); ing from 3.8% to 33%.(1) Non-inva- and critical limb ischemia (CLI), Epidemiology sive methods for disease definition in manifesting as ischemic rest pain, The prevalence of PAD depends epidemiological surveys have usually non-healing ischemic ulcers, or gan- on how one defines the disease. Continued on page 182 www.podiatrym.com AUGUST 2004 • PODIATRY MANAGEMENT 181 PAD... The first objective test which The higher of the two ankle pres- must be performed in patients either sures (either the dorsalis pedis or Continuingincluded statistically validated at risk for PAD, or with symptoms posterior tibial artery) is used as the claudication questionnaires. The and physical findings of PAD is the numerator of the ABI calculation. Medical Education Edinburgh Claudication Question- ankle-brachial index (ABI). The ABI is The process is repeated on the naire (a modification of the World a safe, simple, highly accurate, and contralateral limb. Health Organization/Rose claudica- reproducible method of determining A normal ABI is defined as a rest- tion questionnaire), when compared * The presence and severity of PAD * ing measurement > 0.90. Any value < with the independent assessment by The cardiovascular risk of myocardial 0.90 represents the presence of PAD. two physicians of 300 patients over infarction, stroke, and vascular death. Obviously, the lower the ABI, the age 55, demonstrated a sensitivity of This test is easily performed in the more severe the PAD. Patients with 91% and specificity of 99% for the di- podiatric specialist’s office. It requires ABI values > 0.70 may be asymp- agnosis of intermittent claudication.1 * Routine sphygmomanometer tomatic, or have very mild symptoms The ankle-brachial index (ABI), * Hand held, continuous wave of intermittent claudication. ABI val- which is a comparison of the systolic Doppler ues between 0.40 and 0.70 represent blood pressure in the dorsalis pedis * Acoustic Gel. patients with mild to moderate inter- and posterior tibial arteries of the In patients with symptoms sug- mittent claudication. Values < 0.40 limb to the brachial artery of the arm gestive of PAD, physical findings in- suggest the most advanced stages of using a hand-held Doppler, has been creasing the likelihood of PAD, or in PAD, with ischemic rest pain, non- validated against angiographically patients at high risk for PAD, the ABI healing ulcerations, and gangrene oc- confirmed PAD and found to be 95% is the ideal office-based objective curring with frequency. sensitive and almost 100% specific.2 evaluation. The ABI provides information In clinical practice, this is the most A sphygmomanometer is placed about the presence or absence of simple, inexpensive, reliable and re- on the upper arm, and the systolic PAD, along with the severity and risk producible method of identifying of co-morbid atherosclerotic patients with PAD. events. If the clinician, however, The age-adjusted prevalence desires more detailed information of PAD, as defined by an ankle- concerning the location of arterial brachial index < 0.9 is 12%1. PAD occlusive disease, whether disease prevalence rates defined by non- is represented by stenoses or oc- invasive testing are reported to be clusions, the length of atheroscle- 2.5% at age 40 to 59 years, 8.3% rotic disease, and the status of the at age 60 to 69 years, and 18.8% ‘run-off’ arteries, other diagnostic at age 70 to 79 years.3 tests such as segmental limb pres- sures, pulse volume recordings, Diagnosis of Peripheral Doppler segmental waveforms, Arterial Disease and arterial duplex ultrasonogra- Classic (“Rose”) intermittent phy should be considered. claudication, the most common pressure is measured using a hand- The ABI is a highly accurate symptom of PAD, is characterized by held Doppler device. This process is method of determining the presence exertional discomfort in a major repeated on the contralateral upper of PAD and its severity. However, if muscle group in a limb, which devel- arm. The higher of the two pressures the ankle vessel is calcified, com- ops with exercise and is promptly re- is used as the denominator of the monly seen in patients with diabetes lieved with rest. A significant propor- ABI calculation. Following this, the mellitus or end-stage renal disease, tion of patients with symptomatic sphygmomanometer is placed on an accurate ankle pressure cannot be PAD will not describe classic symp- the lower leg, just above the ankle. obtained. The pressure in these calci- toms, making the diagnosis more Again utilizing the hand-held fied arteries is often > 200-250 difficult. More than 50 percent of pa- Doppler, an arterial Doppler signal is mmHg. If not recognized as artifac- tients with PAD are either asymp- obtained in the dorsalis pedis artery, tually high, the physician may false- tomatic or have atypical symptoms, the cuff inflated until the arterial ly conclude that arterial circulation one-third have classic symptoms of Doppler signal disappears, and then is adequate, or even normal, in these intermittent claudication, and 10 the cuff is gradually deflated. When patients. In this scenario, other tests percent of patients develop critical the arterial Doppler signal returns, available in the vascular diagnostic limb ischemia.4 The spectrum of PAD this represents the arterial pressure in laboratory are necessary, including is not a continuum. Patients com- the dorsalis pedis artery. The photoplethysmography, digital pres- monly present with CLI without Doppler device is then positioned sures, arterial duplex ultrasonogra- having experienced prior symptoms posterior to the medial malleolus, phy, and even assessments of wound (the classic example is the patient and the
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