SAVE LIMBS SAVE LIVES! PAD Awareness: The Key to Limb Preservation By Frank J Tursi, D.P.M., F.A.C.F.A.S.
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. 2. 2 009
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 2005-2010, HIV Mortality Rate Dipped to 15%. PAD Mortality 30% PAD is thus both More Prevalent and has a Higher Fatality Rate than HIV
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!
PAD - Prevalence Meijer,A. (1998) Peripheral artery disease in the Elderly: The Rotterdam Study. Arteriosclerosis, Thrombosis and Vascular Biology.18:185-192 PARTNERS Hirsch, JAMA 2001;286:1317-1324
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
PHYSICAL EXAMINATION Decreased or Absent Pulses Presence of Bruits Muscle Atrophy Hair Loss Pallor or Cyanosis Cool Extremities Ulcers or Gangrene
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
Grading of the ABI ABI Severity of PAD >1.3 Calcified, not compressible 0.9-1.2 Normal 0.8-0.9 Mild 0.6-0.8 Moderate 0.4-0.6 Severe <0.4 Critical Casserly, I. (2011) Practical Peripheral Vascular Intervention. Philadelphia: Wolters Kluwer.
an ABNORMAL ABI <.4 AND A FLAT PVR Critical Limb Ischemia! Emergently Refer to Your Vascular Colleague
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: http://www.acc.org/clinical/guidelines/pad/summary.pdf Accessed March 22, 2006.
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;94:3026-3049
AMPUTATIONS* Patients with Rutherford Classification 4, 5, & 6 100% Require amputations after 12 months Without Revascularization ~ Wolfe, et al. 220-240,000 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.
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.
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
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
Thank You! 17
Closing Remarks / Thank You