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Peripheral Vascular Disease ManagementAka: Claudication Management

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  1. See Also
    1. Claudication (Peripheral Arterial Disease)
  2. Background
    1. Claudication is very disabling
    2. Consider intensive management in all patients
  3. Protocol: Overall (See agents below)
    1. Ankle-Brachial Index < 0.3
      1. Treat as threatened limb
    2. Ankle-Brachial Index 0.3 to 1.0
      1. Step 1: Risk factor modification for 3 months
        1. See General measures below
        2. Aspirin 325 mg PO qd (or Plavix)
      2. Step 2: No change in 3 months after step 1
        1. Add Cilostazol (Pletal) to regimen for 3 months
          1. Avoid Pletal in Congestive Heart Failure
          2. Dose:
            1. Typical: Pletal 100 bid
            2. Calcium Channel Blocker use: Pletal 50 bid
      3. Step 3: No change in 3 months after step 2
        1. Evaluate for possible surgery (see below)
    3. Ankle-Brachial Index >1.0
      1. Consider alternative diagnosis
      2. See Leg Pain for differential diagnosis
    4. References
      1. (1996) Lancet 348:1329
  4. Protocol: Evaluation for surgical intervention
    1. Indications
      1. Significant limitations refractory to other measures
      2. Limb-threatening ischemia (usually ABI <0.3)
        1. Gangrene
        2. Non-healing ulcers
        3. Rest pain
    2. Non-invasive Testing
      1. Ankle-Brachial Index (Non-specific screening)
      2. Segmental Arterial Pressure (Defines occlusion site)
      3. Treadmill Testing
        1. Perform at 2 MPH at 12% grade
        2. Reassuring test: Patient walks >5 minutes
        3. Signs of significant occlusion
          1. Drop in ankle systolic BP with Exercise
          2. Claudication limits walking to <5 minutes
      4. Duplex arterial ultrasound
        1. Significant if occlusion >50%
        2. Excellent noninvasive confirmatory test
          1. Helps to define surgical candidates
          2. Assists to risk stratify for arteriography
  5. Management: General Measures for risk modification
    1. Cardiovascular Risk Reduction is critical
      1. Carries same risk as Coronary Artery Disease
    2. Tobacco Cessation is the most important intervention
      1. Increases walking time by 6.5 minutes on average
    3. Maximize Hyperlipidemia Management (LDL <100 mg/dl)
    4. Maximize Hypertension Management (<130/80 mmHg)
      1. ACE Inhibitors may be preferred agents in PVD
      2. Yusuf (2000) N Engl J Med 342:145
    5. Maximize Diabetes Mellitus management (Hgb A1C <7%)
    6. Exercise Program (see below)
  6. Management: Exercise
    1. Exercise Stress Test needed before vigorous activity
      1. Peripheral Arterial Disease is a marker for CAD
    2. Efficacy
      1. Walking improves Claudication distance
    3. Exercise types
      1. Walking (standard walking or on a treadmill)
      2. Stair stepping
    4. Time for Exercise
      1. Start: 3-5 times per week for 30 minutes per time
      2. Increase by 5 minutes until 50 minutes/session
      3. Continue program for at least 6 months
    5. Speed and grade selection
      1. Intensity that provokes Claudication at 3-5 minutes
      2. Continue to increase intensity as ability improves
        1. Claudication should occur at every session
    6. Intermittent walking technique
      1. Walk until moderate to near maximal Claudication pain
      2. Rest briefly at severe Claudication symptoms
      3. Rest in sitting or standing position
      4. Restart walking when Claudication symptoms tolerable
    7. References
      1. Stewart (2002) N Engl J Med 347:1941
  7. Management: Medications
    1. Antiplatelet Medications
      1. First-Line agents
        1. Aspirin 75 to 150 mg orally daily
      2. Second-Line (alternatives if Aspirin intollerant)
        1. Clopidogrel (Plavix)
        2. Ticlopidine (Ticlid)
    2. Phosphodiesterase inhibitor medications
      1. Cilostazol (Pletal)
        1. Significant benefits in Claudication distance
        2. Preferred agent over Pentoxifylline
        3. Higher frequency of adverse effects
        4. Contraindicated in Congestive Heart Failure
        5. Thompson (2002) Am J Cardiol 90:1314
      2. Pentoxifylline (Trental)
        1. Only small benefits in Claudication distance
        2. Consider 3 month trial before assessing benefits
  8. Management: Surgical
    1. Indications
      1. Failed maximal medical therapy (see above)
      2. Severe symptoms significantly reducing life quality
      3. Limb threatening ischemia
        1. Rest pain
        2. Non-healing wounds
        3. Gangrene
    2. Lesion localization
      1. Arterial duplex ultrasound
      2. Magnetic resonance anigiography
      3. Angiography
    3. Procedures
      1. Angioplasty (with or without stent placement)
        1. Higher risk of restenosis
          1. Brachytherapy reduces restenosis risk
        2. Significantly lower risk than arterial bypass
        3. High efficacy in aorto-illiac (90% at five years)
        4. Low efficacy femoral-popliteal (<60% at five years)
      2. Arterial Bypass
        1. High efficacy in aorto-illiac (90% at 5 years)
        2. Mod. efficacy femoral-popliteal (70-85% at 5 years)
        3. Higher rate of mortality (<3%)
      3. Intra-arterial Directed Thrombolysis
        1. Urokinase
  9. References
    1. Boccalon (1999) Drugs Aging 14:247
    2. Samuelson (March, 2000) Fed Pract, p. 34-50
    3. Carman (2000) Am Fam Physician 61(4):1027
    4. Gardner (1995) JAMA 274(12):975
    5. Gey (2004) Am Fam Physician 69:525
    6. Hirsch (2001) JAMA 286(11):1317
    7. Santilli (1999) Am Fam Physician 59(7):1899
    8. Santilli (1996) Am Fam Physician 53(4):1245
    9. (1999) Med Lett Drugs Ther 41:(1052):44

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