SAVE LIMBS SAVE LIVES!
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1 SAVE LIMBS SAVE LIVES! PAD Awareness: The Key to Limb Preservation By Frank J Tursi, D.P.M., F.A.C.F.A.S.
2 Epidemiology Over 12 million people are afflicted with PAD 11 Million of these-dm 4 Million DFU in the US Wound Healing Perspectives, Volume 6 No
3 A PANDEMIC PROBLEM Approximately 34 Million Living with HIV (HIV was Considered Pandemic in 2011) Fowkes, et al. Noted in the Lancet that Peripheral Arterial Disease Affects >202 Million in 2010! From , HIV Mortality Rate Dipped to 15%. PAD Mortality 30% PAD is thus both More Prevalent and has a Higher Fatality Rate than HIV
4 KEY POINTS TO CONSIDER WITH PAD With Modifiable Risks Factors, PAD is Preventable. PAD is not only a Disease of the Aged The Belief that PAD is More Common in Men than Women is Untrue. As Communicable Diseases Decrease in Low-Middle Income Countries, PAD s Effect on these Populations Rises Exponentially!
5 PAD - Prevalence Meijer,A. (1998) Peripheral artery disease in the Elderly: The Rotterdam Study. Arteriosclerosis, Thrombosis and Vascular Biology.18: PARTNERS Hirsch, JAMA 2001;286:
6 PAD AT-RISK PATIENTS Diabetics >50 years of age Diabetics <50 with Hx of Hypertension/Hyperlipidemia Geriatrics > 65 Wound Care Patients Cardiac Impaired Chronic Renal Impaired Patients with Hx of MI, CVA Smokers
7 PHYSICAL EXAMINATION Decreased or Absent Pulses Presence of Bruits Muscle Atrophy Hair Loss Pallor or Cyanosis Cool Extremities Ulcers or Gangrene
8 PAD - Diagnosis Physical Exam - It is not unusual for patients with palpable pulses to have abnormal ABIs Ankle Brachial Index Stress ABI- >25% decrease in ABIs with exercise is diagnostic for PAD Duplex Ultrasound CT Angiogram MRA - magnetic resonance angiography Angiography gold standard for diagnosis & treatment
9 Grading of the ABI ABI Severity of PAD >1.3 Calcified, not compressible Normal Mild Moderate Severe <0.4 Critical Casserly, I. (2011) Practical Peripheral Vascular Intervention. Philadelphia: Wolters Kluwer.
10 an ABNORMAL ABI <.4 AND A FLAT PVR Critical Limb Ischemia! Emergently Refer to Your Vascular Colleague
11 PAD: Evolution of the Disease 1. Claudication or asymptomatic 2. Rest pain 3. Ulceration 4. Gangrene 5. Limb loss Adapted from Hirsch AT et al. Available at: Accessed March 22, 2006.
12 PAD - Prognosis Over 5 years: 27% PAD pts have worsening symptoms 4% have limb loss 20% sustain nonfatal MIs and CVAs 30% DIE Weitz Circulation 1996;94:
13 AMPUTATIONS* Patients with Rutherford Classification 4, 5, & 6 100% Require amputations after 12 months Without Revascularization ~ Wolfe, et al ,000 amputations/year USA/Europe 4-30% 30-day perioperative mortality! 8-37% 30-day perioperative morbidity! >20,000 amputations/month! 25-30% mortality within one year of diagnosis of CLI *Taken Directly from Costs of Bypass vs. PTA vs. Amputation by Davie Allie, MD at New Cardiovascular Horizons, Thursday, July 9, 2009.
14 Amputation Costs* Yearly professional nursing home costs (US) post amputation ~ $100,000 Yearly amputee home alterations costs vary - >$25,000 ~ ex. Wheel Chair ramps $3 billion/year could be saved with just a 25% reduction in amputations *Taken Directly from Costs of Bypass vs. PTA vs. Amputation by Davie Allie, MD at New Cardiovascular Horizons, Thursday, July 9, 2009.
15 Amputation Costs Are High, & Not Always Necessary* Shockingly primary amputations (PA) are still the most common CLI treatment More shockingly 50% PA are performed without angiography or a simple ABI! Yost quotes 50-75% of amputees have no angiogram despite the fact that an angiogram reduces the odds of amputation by 90% *David E. Allie, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment Unmasks the clinical and economic costs of CLI. EuroIntervention-Vol. 1, No. 1, May 2005 pgs 75-84
16 The Pathway to Amputation * 26% had cardiology consultation 21% had vascular surgery consultation Only 35% had ABI before PA! Only 16% had angiography before amputation < 50% had any vascular evaluation *David E. Allie, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment Unmasks the clinical and economic costs of CLI. EuroIntervention-Vol. 1, No. 1, May 2005 pgs 75-84
17 Thank You! 17
18 Closing Remarks / Thank You
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