Peripheral Vascular Disease (PVD): Management

00:01 Medical therapy is incredibly important in patients with peripheral arterial occlusive disease.

00:06 Here, we’ll take a look at a few pharmacologic and lifestyle change options.

00:11 Pharmacologically, we can put the patient on antiplatelet therapy, whether it's aspirin or Plavix.

00:18 Next, statins.

00:20 As you recall, statins have the (inaudible 0:22) properties.

00:24 And as a result of chronic biomechanical stresses on the arterial walls, hypertension or antihypertensive medications can be helpful in these disease processes.

00:34 Unfortunately, these usually limit the propagation and doesn't actually treat the stenosis.

00:42 Lifestyle changes are quite important.

00:44 And oftentimes, it's very easy for us to recommend.

00:47 Unfortunately, it’s more difficult for the patients to follow the programs.

00:51 Smoking cessation, as you know, smoking is a risk factor for all vascular disease.

00:57 Cessation of smoking is one of the most important things to do.

01:02 Exercise, particularly in patients with claudication, exercise is the first line therapy, not surgery.

01:09 So, remember, if a clinical scenario is presented to you, the next step of management is a regimen of exercise, smoking cessation.

01:17 And lastly, some patients are put on a peripheral arterial dilator called cilostazol.

01:22 Now, let's focus a little bit more on the peripheral arterial occlusive disease management.

01:27 Remember, the most common location for arterial occlusion is in the superficial femoral artery.

01:34 This leads to calf claudication symptoms.

01:38 It's fairly easy to figure out what level of occlusion there is.

01:41 Usually, the symptoms occur one joint space below the area of the occlusion.

01:49 For aortoiliac disease, typically, the symptoms are in the upper thigh or buttocks.

01:58 Now, let's describe Poiseuille’s law.

02:02 Remember, when I described how there is a pressure differential in a stenotic region, this is the premise behind an ankle brachial index.

02:11 On the left side of the screen, you notice a normal-sized vessel.

02:16 As it progresses to a stenotic region, the pressure drop is proportional – directly proportional to the flow.

02:24 However, it's indirectly proportional to the fourth power of the radius.

02:29 Therefore, when your radius completely drops, the pressure gradient is actually decreased to the fourth power by the radius.

02:38 This is, again, the premise behind why there's a pressure difference between the ankle and the arm.

02:47 Let me ask you a question.

02:48 So, what’s so concerning about peripheral arterial occlusive disease.

02:52 I’ll give you a second to think about this.

02:56 The answer is risk of limb loss.

02:59 Thankfully, the vast majority of patients with particularly claudication symptoms do not lose their extremities.

03:06 This is due to adherence to medical and lifestyle changes, as well as a very aggressive exercise regimen.

03:14 However, sometimes patients have tissue loss and a deterioration of their clinical arterial disease and amputation is unavoidable.

03:25 The most important determinant of risk for limb loss in peripheral arterial occlusive disease is diabetes, age and, again, continued smoking.

03:36 Remember, vascular societies recommend, if the patient is already bedridden and not mobile, there's no need to revascularize the patient.

03:45 Amputation is perhaps the best approach.

03:50 Let’s start with another question.

03:52 As you know, patients can develop ulcers, but sometimes ulcers are due to arterial disease and other times due to venous disease.

04:00 What is the difference between an arterial versus venous ulcer? I’ll give you a second to think about this.

04:09 Venous ulcers typically occur on the medial ankle or malleolus.

04:13 They are associated with pigmentation, typically bilaterally.

04:18 And usually unless it's infected, the patient is painless.

04:22 This is a little different than arterial ulcers, which normally occur in the heels and toes, can be painful and have a punched-out appearance due to the ischemic regions.

04:32 Now, let's discuss what indications for surgeries are.

04:35 Rest pain, necrosis, non-healing infection.

04:40 Remember, claudication that does not respond to medical therapy and affects quality of life significantly – take a look at this list of indications for surgery.

04:50 These have one thing in common.

04:52 They’re all end stages of peripheral arterial occlusive disease.

04:56 Your job and my job, as a physician, is to try to halt the progression to end stage diseases that require bypass surgery.

05:06 Nevertheless, some patients will require surgery.

05:10 For example, this patient has gangrene of the foot.

05:13 This patient – a gangrene and ulcer will not heal unless there is adequate inflow.