NCVH. Why Every Interventionist Must Understand PAD. Craig M. Walker, MD, FACC, FACP. New Cardiovascular Horizons

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1 Why Every Interventionist Must Understand PAD NCVH New Cardiovascular Horizons KNOW YOUR OPTIONS Craig M. Walker, MD, FACC, FACP Clinical Professor of Medicine Tulane University School of Medicine New Orleans, LA Clinical Professor of Medicine LSU School of Medicine New Orleans, LA Founder, President, and Medical Director Cardiovascular InsAtute of the South Houma, LA

2 DISCLOSURES Consultant/Medical/Scientific Boards Abbott Boston Scientific Cardiva Cook Medical CR Bard Lake Regional Medical Medtronic Spectranetics PVD Training Abbott Bard Boston Scientific Spectranetics TriReme Medical Stockholders CardioProlific Cardiva Spectrane5cs Vasamed Speaker s Bureau Abbo= Bard Boehringer- ingelheim Bristol- Myers- Squibb/Sanofi Cardiva Cook Medical Cordis DSI/Lilly Gore ACHL/Merck Spectrane5cs

3 There is an epidemic of PVD Mary Yost of the Sage Group estimates up to 20 million Americans have PVD. In 2006 between 1 million and 2.5 million people in the U.S. had CLI. (Estimated this will grow to 2.8 million by 2020). PAD is a marker for death with 1 year mortality or major CV event rates of 20%. The Majority of patients with PAD or either asymptomatic or ascribe their symptoms to etiologies other than PAD. THE OVERWHELMING MAJORITY OF PATIENTS WITH PAD ARE UNDIAGNOSED.

4 Prevalence of PAD in High-Risk Patients (PARTNER S Trial) 29%$of$pa)ents$were$diagnosed$ with$pad$defined$as$ankle: brachial$index$<0.9$ N= 6,979 Age > 70 years or years + diabetes or smoking 29% 44% 56% PAD only PAD and CAD Hirsch AT et al. JAMA. 2001;286:

5 Symptomatic And Asymptomatic PAD (PARTNER s Trial) Prior Diagnosed PAD (n=366) Newly Diagnosed PAD (n=457) No Symptoms Nonspecific Symptoms Claudica5on Hirsch AT et al. JAMA. 2001;286:

6 Patient Survival by Ankle-Brachial Index in Cardiovascular Health Study 1$ 0.9$ 0.8$ 0.7$ ABI>1.0$ ABI:$0.9$2$1.0$ ABI:$ $ ABI<0.8$ 0.6$ 0$ 1$ 2$ 3$ 4$ 5$ 6$ Newman et al ATVB 1999;19:

7 Five year mortality rates - PVD versus Cancer Five%Year%Mortality%Rates% Lung#Cancer## Colon/Rectal# PAD# Breast#cancer# 0%# 20%# 40%# 60%# 80%# 100%# *Criqui M. Presenta5on: Vascular Medicine of the Lower Extremi5es at the American Diabetes Associa5on s Scien5fic Sessions June 1999

8 Prognosis in Patients with Intermittent Claudication PopulaEon >55 yr IntermiNent ClaudicaEon Peripheral Vascular Outcomes Other Cardiovascular Morbidity/Total Mortality Worsening ClaudicaEon 16% Lower Extremity Bypass Surgery 7% Major AmputaEon 4% 4% vs Nonfatal Cardiovascular Event (MI/Stroke, 5- year Rate) 20% 42.5% 5- yr Mortality 30% Cardiovascular Cause 75% Adapted from Weitz JI et al. CirculaAon. 1996;94:

9 Ongoing Fibrin Formation and Degradation as a Function of ABI Trend for both: p<0.001 D-Dimer (ng/ml)! 2000" 1500" 1000" 500" 0" >1.1" 0.9)1.1" 0.7)0.9" 0.5)0.7" <0.5" CAD"(+)" CAD"())" Ankle-Brachial Index! McDermo= et al. Am J Cardiol 2003; 92:

10 Spontaneous Platelet Aggregation in Non-Coronary Vascular Disease Platelet AggregaEon (%) p< CONTROL CEA AAA PAD

11 A diminished foot pulse is often the only clue that a patient has advanced cardiovascular disease. One can not rely on symptoms to guide diagnosis and therapy.

12 Amputation - the far end of the spectrum BKA 5 8% perioperative mortality AKA 8 12% perioperative mortality Many require contralateral amputation within 1 yr Only 50% develop mobility post BKA Only 25% develop mobility post AKA 40% Amputees dead within 2 yrs We need aggressive limb salvage

13 Patient History 48 year old female s/p CABG 6 months prior Angiogram repeated x2 and reported normal Anterolateral defect on nuclear Worsening angina BP R arm 130/80 L arm 80/60 mm Hg.

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18 Patient History 45 year old male referred for CABG from outside hospital. Known high grade brachiocephalic and lec subclavian stenosis and occluded lec common caro5d. High grade bilateral iliacs. Pt. developed crushing chest pain, diaphoresis, and dyspnea. Nurse called fran5c BP 50. I advised she give NTG she refused. I explained the BP was not representa5ve she s5ll refused. I arrived quickly and gave NTG, sx resolved

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25 Patient History 51- year- old male with severe coronary artery disease requiring CABG, PVD with claudica5on and impotence CV surgeon wanted to operate stat CT angiography demonstrated occlusion of the bilateral iliac systems with unique collateral filling of the distal vessels

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43 Craig Walker, MD Houma, LA

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45 Conclusions Diminished foot pulses may be the only clue of advanced ASCVD. Patients with PAD must be assessed globally PAD is associated with poor long term survival. PAD affects treatment. Patients with PAD must have longitudinal follow up. AMPUTATION SHOULD ALWAYS BE A LAST NOT FIRST RESORT

46 Closing Remarks / Thank You