Vascular Disease and Venous Thromboembolism

, Jay S. Giri2, Joseph M. Garasic3 and Joseph M. Garasic4



(1)
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA

(2)
Peripheral Intervention, Cardiology Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

(3)
Harvard Medical School, Boston, USA

(4)
Peripheral Vascular Intervention, Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

 



Introduction

Peripheral Artery Disease (PAD)

Prevalence

Presentation (Fig. )

Testing

Medical Management of PAD []

Interventional Therapy

Renovascular Disease

Atherosclerotic Renal Artery Stenosis

Fibromuscular Dysplasia (FMD)

Subclavian Artery Disease

Carotid Artery Disease

Mesenteric Vascular Disease

Deep Venous Thrombosis (DVT)

Incidence

Risk Factors

Presentation

Diagnosis (Table )

Treatment

Complications

Pulmonary Embolism (PE)

Incidence

Risk Factors Are Identical to DVT

Presentation

Diagnosis

Treatment

Massive PE: PE Associated with Hemodynamic Instability (Systolic BP <90 mmHg)

References


Abstract

Peripheral artery disease (PAD) is common and often unrecognized. Patients with PAD are at high-risk for adverse cardiovascular events. Management of lower extremity PAD has two components: aggressive treatment of cardiovascular risk factors as well as treatment of lower extremity symptoms. In some cases of carotid and renal artery disease, interventional treatment is performed in asymptomatic lesions with hopes of altering the natural disease history and reducing future events.

Venous thromboembolism is common and can present as deep venous thrombosis (DVT) or pulmonary embolism (PE). Both have high morbidity and present management challenges in a wide range of clinical circumstances.


Abbreviations


ABI

Ankle-brachial index

ACE

Angiotensin converting enzyme

ARB

Angiotensin II receptor blocker

ASA

Aspirin

CAS

Carotid artery stenting

CEA

Carotid endarterectomy

CLI

Critical limb ischemia

CTA

Computed tomographic angiography

CV

Cardiovascular

DVT

Deep venous thrombosis

FMD

Fibromuscular dysplasia

HTN

Hypertension

MI

Myocardial infarction

MRI

Magnetic resonance imaging

NSTEMI

Non-ST-elevation myocardial infarction

PAD

Peripheral artery disease

PE

Pulmonary emoblism

RBBB

Right bundle branch block

RVSP

Right ventricular systolic pressure



Introduction


Peripheral artery disease (PAD) is common and often unrecognized. Patients with PAD are at high-risk for adverse cardiovascular events. Management of lower extremity PAD has two components: aggressive treatment of cardiovascular risk factors as well as treatment of lower extremity symptoms. In some cases of carotid and renal artery disease, interventional treatment is performed in asymptomatic lesions with hopes of altering the natural disease history and reducing future events.

Venous thromboembolism is common and can present as deep venous thrombosis (DVT) or pulmonary embolism (PE). Both have high morbidity and present management challenges in a wide range of clinical circumstances.


Peripheral Artery Disease (PAD)



Prevalence






  • ∼4 % in patients over age 40



    • Increases with age and cardiovascular (CV) risk factors


    • ∼15–30 % in patients over age 70


  • CV Implications [1]



    • Roughly 50 % of PAD patients will have coronary artery disease (CAD)


    • CV events are more common than ischemic limb events


    • Ankle-brachial index (ABI)  <0.7  =  risk of myocardial infarction (MI) is 20 % at 5 years (double the highest-risk Framingham group)


    • ABI 0.7–.09  =  risk of MI is 10 % at 5 years


  • Patients at risk for PAD (All of the below risk groups have pre-test probabilities of over 15 % and should be screened for PAD) (Table 10-1)


    Table 10-1
    Groups with high PAD prevalence

















    Known atherosclerotic coronary, carotid, or renal artery disease

    Age  >70

    Age  >50 with DM or smoking

    Age  <50 with DM and an additional risk factor (smoking, hypertension, hyperlipidemia)

    Abnormal LE pulse examination

    Exertional leg symptoms


Presentation (Fig. 10-1)




A306999_1_En_10_Fig1_HTML.gif


FIGURE 10-1
Presentation of PAD





  • Symptoms



    • Typical claudication – cramping calf pain exacerbated by exertion and relieved by rest


    • Critical limb ischemia (CLI) – pain at rest in the foot, non healing ulcer, gangrene


  • Physical examination



    • Poor peripheral pulses (femoral, popliteal, pedal)


    • Femoral artery bruit on auscultation


    • Elevation pallor (foot develops pallor when raised)


    • Dependent rubor (foot slowly becomes red when returned to the ground)


    • Poor capillary refill (>3 s)


    • Ulcerations on the toes, intertriginous spaces, borders of the feet


Testing





$$ \text{ABI}=\frac{\text{Ankle}\text{systolic}\text{blood}\text{pressure}}{\text{Brachial}\text{artery}\text{systolic}\text{pressure}}$$




  • ABI Interpretation
























    1.40
    Uninterpretable/incompressible

    1.00–1.39
    Normal

    0.91–099
    Borderline

    0.71–0.90
    Mild PAD

    0.41–0.70
    Moderate PAD

    <0.40
    Severe PAD


  • Uninterpretable ABI due to incompressible vessels secondary to Mockenburg’s medial artery calcification.



    • This is more common in diabetic and elderly populations.


  • Toe brachial index <0.7 is sensitive for dx of PAD in settings of uninterpretable/incompressible ABI (Table 10-2).


    Table 10-2
    Diagnostic tests for PAD evaluation



































     
    Pros
    Cons

    ABI
    Non-invasive, fastest, office-based
    No clarity regarding level of disease

    Segmental pressures with pulse volume recordings
    Non-invasive, rapid, no contrast
    Does not clarify anatomic details

    Arterial ultrasound
    Non-invasive, no contrast
    Operator-dependent, may not be able to image suprainguinal and/or infrapopliteal vessels, time consuming

    CTA
    Non-invasive
    IV contrast, radiation, difficult to interpret in the setting of heavy vascular calcification

    MRA
    Non-invasive
    Gadolinium, expensive, may overestimate stenosis severity

    Digital subtraction angiography (DSA)
    Best quality anatomic information, option for concurrent therapeutic procedure
    Invasive, IV contrast, technical expertise necessary


Medical Management of PAD [2]






  • Treat DM to glycohemoglobin <7 %


  • Daily Foot Care and Regular Podiatry Appointments


  • Smoking Cessation


  • Lipid Lowering Therapies – Statins decrease CV events and may improve leg functioning (i.e.: pain-free walking distance)


  • Treatment of hypertension to guideline derived goals.



    • ACE-inhibitors may improve leg functioning


    • Beta-blockers are NOT harmful


  • Anti-platelet therapy



    • Aspirin or clopidogrel should be used in all patients



      • CAPRIE trial showed a 24 % decrease in CV outcomes for PAD patients treated with clopidogrel rather than aspirin [3]


      • CHARISMA study showed no decrease in CV outcomes from combining clopidogrel plus aspirin in patients with PAD [4]


  • Coumadin – Coumadin is not recommended in addition to anti-platelet therapy for PAD [5]


  • Symptomatic Medical Therapy



    • Supervised exercise rehabilitation improves pain-free walking distance.


    • Increased daily activity leads to decreased mortality


    • 3–6 months of cilostazol is recommended (contraindicated in patients with heart failure)


Interventional Therapy






  • Contraindications



    • Lack of symptoms


    • Lack of pressure gradient across an angiographic stenosis


  • Endovascular revascularization



    • Indicated if life or work-limiting symptoms exist after a trial of medical and exercise therapy


    • Primary stenting should not be performed in the femoropopliteal segments (i.e.: use stents for failure of angioplasty or atherectomy techniques)


  • Surgical revascularization



    • Indicated if life or work-limiting symptoms exist after a trial of medical and exercise therapy and if not a good anatomic candidate for endovascular approach


    • Autogenous vein grafts are preferred to prosthetic grafts for lower extremity bypass due to improved long-term patency


  • Special topic: Critical Limb Ischemia (CLI)



    • Revascularize suprainguinal segments first for treatment of CLI


    • If ulcer persists, consider revascularization of infrainguinal segments with the goal of establishing “straight-line” blood flow to the foot


    • Open repair and endovascular repair of the lower extremities had equivalent results in the BASIL trial [6]


  • Special topic: Acute Limb Ischemia (ALI)



    • Initiate parenteral anticoagulation


    • Seek consultation from an expert vascular interventionalist or surgeon


    • If ALI is less than 14 days, catheter-directed thrombolysis with or without adjunctive catheter-based mechanical therapies may be used to restore vessel patency


    • The decision between open surgical and endovascular treatment is influenced by the likelihood of the technical success and the rapidity of revascularization with each strategy.


Renovascular Disease



Atherosclerotic Renal Artery Stenosis




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Jul 13, 2016 | Posted by in CARDIOLOGY | Comments Off on Vascular Disease and Venous Thromboembolism

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