Peripheral Artery Disease

A comprehensive, quick-reference guide to the diagnosis and management of peripheral artery disease for non-specialists

With an aging population subject to an increasing number of health risks, peripheral artery disease (PAD) is on the rise throughout the world. Because of PAD's direct links to heart attack and stroke, it is critical that internists, surgeons, cardiologists, radiologists, gerontologists, GPs, and family practitioners know how to recognize it and make the best treatment recommendations for their patients. This book provides all the expert, practical information and guidance they need to do just that. 

Edited by two thought leaders in PAD diagnosis and treatment, and comprising chapters written by subject matter experts, Peripheral Artery Disease, Second Edition provides clinicians with guidance on how to diagnose and treat one of the most under-diagnosed conditions affecting millions of patients. This updated and revised edition of the popular guide distills the complexities of PAD into clear, actionable advice for busy medical practitioners, providing them with the information they need—when they need it.

• Provides clinicians with essential information for recognizing and treating this under-diagnosed condition that affects millions of patients
• Distills the complexities of PAD, from diagnosis to traditional and emerging treatment options, into clear, actionable advice for clinicians
• Covers PAD epidemiology, office examination, imaging, laboratory evaluation, medical therapy, surgical interventions, endovascular treatments, and much more
• Reflects the latest PAD Guidelines and Performance Measures established by leading specialty societies
• Features contributions from internists and surgeons, all recognized experts in PAD

Peripheral Artery Disease, Second Edition is an important working reference for internists, cardiologists, radiologists, and surgeons, as well as fellows and residents in those fields.

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 1
Wobo 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 37
Maen 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 57
Thomas 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 73
Thomas 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 91
Mitchell 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 111
Lee 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 129
Vikram 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 163
Julia 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

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