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FIGURE 157 Upper-extremity access. Selective left renal artery engagement
with multipurpose catheter.
On crossing the inguinal ligament, the EIA becomes
the CFA, which lies over the femoral head. When it reaches
the lower third of the femoral head, the CFA divides into the
SFA and profunda femoris, or DFA. The DFA runs posterolaterally along the femur. The SFA continues down the anteromedial thigh, and in its distal portion dives deeper to enter
Hunter's (adductor) canal and emerges as the popliteal
artery (
Fig. 15-10).
Below the knee, the popliteal artery bifurcates into the anterior
tibial (AT) artery and tibioperoneal trunk (TPT). The AT artery runs
laterally and anterior to the tibia toward the foot and continues onto
the foot as the dorsalis pedis (DP) artery. The TPT bifurcates into
the posterior tibial (PT) and peroneal arteries (
Fig. 15-11). The PT
artery courses posteriorly and medially in the calf, whereas the peroneal artery runs near the fibula between the AT and PT arteries. On
the dorsum of the foot, the DP artery has lateral and medial tarsal
branches. After the PT artery passes behind the medial malleus, it
divides into medial and lateral plantar arteries. The lateral plantar
and distal DP arteries join to form the plantar arch.
Vascular access for diagnostic aortoiliac and lower- extremity
angiography is obtained in the CFA, preferentially in the least
symptomatic extremity, although upper-extremity access (axillary,
brachial, or radial) may also be used. A 4 F to 6 F pigtail catheter is
positioned above the aortic bifurcation. The preferred technique is
to use DSA with a stepping table and a large (15- or 16-inch) format
image intensifier so that both legs are imaged together. A single
bolus of contrast is injected from the catheter at the aortic bifurcation at 8 to 12 mL/sec for 8 to 10 seconds, and sequential images
are obtained from the aorta to the feet.
Selective angiograms performed in angulated views of a particular artery or arterial segments are useful when clarification of
a potential stenosis is needed. One option is to place a diagnostic
catheter at different levels in the iliac, femoral, or popliteal artery
for a more detailed examination of a particular arterial segment.
If access has been obtained in the CFA and the arterial segment
in question is located in the contralateral extremity, a 4 F internal
mammary catheter is positioned at the level of the aortic bifurcation, with the tip of the catheter selectively engaged in the contralateral CIA (
Fig. 15-12). An angled guidewire is advanced to the
CFA, and the diagnostic catheter is advanced over the guidewire
to the area of interest.
Several angiographic views are important to mention because
they help clarify anatomical detail. In the AP view, there is often
overlapping of the origin of the external and internal iliac arteries,
and ostial stenoses in either or both vessels may be missed. The
contralateral oblique view (20°) with 20° of caudal angulation is
very useful to separate these vessels (
Fig. 15-13).
Overlap at the origin of the SFA and DFA arteries commonly
occurs in the AP projection and can be improved with a 20° to 30°
LAT oblique view.
9
Another common source of artifact may occur
when the tibial arteries overlie the relatively radiodense bony periosteum of the tibia or fibula. In that case, slight angulation will
move the artery in question off the bony density to allow better
visualization.
FIGURE 158 Selective superior mesenteric angiography in lateral
(LAT) projection, with internal mammary artery (IMA) catheter. Note
ostial stenosis (arrow).
Aortic Arch and Brachiocephalic Vessels
The aortic arch includes portions of the ascending, transverse, and
descending aorta (
brachiocephalic trunk in the proximal portion of the arch, the left
common carotid artery in the mid-portion, and the left subclavian
artery in the distal portion. In 10% to 20% of cases, the left common
carotid artery originates from the brachiocephalic trunk, an anatomical variation known as a bovine arch (
mon variations include the left vertebral artery originating directly
from the aortic arch, between the left common carotid artery and
left subclavian artery, and the right subclavian artery originating
from the aortic arch distal to the origin of the left subclavian artery.
Thoracic aortography is commonly performed to diagnose pathological entities such as stenoses of the origin of the great vessels,
aneurysms, aortic dissection, coarctation of the aorta, patent ductus arteriosus, and vascular rings, and to evaluate vascular injuries
caused by blunt or penetrating chest trauma.
most often obtained at the CFA, although the brachial or radial
approaches are also useful. A pigtail catheter is advanced into the
ascending aorta and positioned proximal to the brachiocephalic
trunk. Using a power injector, radiographic contrast material is
injected at 15 to 20 mL/sec for a total of 2 to 3 seconds. The LAO
Fig. 15-14). The thoracic aorta gives rise to the
Fig. 15-15). Other com-
10
Vascular access is
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FIGURE 159 Aortoiliac angiography.
Pigtail catheter contrast injection of 20 mL/sec
for a total of 30 mL.
FIGURE 1510 Common femoral arteries
(CFA) branching into deep femoral artery
(DFA) and superficial femoral artery (SFA).
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Popliteal
Anterior
Tibial
Tibioperoneal
Posterior
Tibial
FIGURE 1511 Left popliteal artery bifurcates into anterior tibial
(lateral) and tibioperoneal trunk, which then divides into posterior
tibial (medial) and peroneal arteries.
Peroneal
projection (30° to 60°) separates the ascending from the descending aorta and allows good visualization of the origin of the great
vessels (see
The brachiocephalic trunk, left common carotid artery, and subclavian arteries originate from the transverse thoracic aorta. The
brachiocephalic trunk or innominate artery divides into the right
common carotid artery and the right subclavian artery. The common carotid arteries run lateral to the vertebral bodies and bifurcate into the external and the internal carotid arteries at about the
level of the fourth cervical vertebra (
portion, the internal carotid artery has no branches. On entering the
skull, the internal carotid artery makes a sharp turn at the carotid
siphon and thereafter divides into the middle (MCA) and anterior
(ACA) cerebral arteries, from which the anterior communicating
artery forms the anterior portion of the circle of Willis (
Fig. 15-14).
Fig. 15-16). In its extracranial
Fig. 15-17).
Carotid Angiography
Selective carotid angiography is usually performed after obtaining
an aortic arch aortogram in the LAO view, which allows the operator to visualize the origin of the brachiocephalic trunk and left
common carotid artery. Using that same LAO angle, the brachiocephalic trunk is engaged with a diagnostic catheter (
Once the origin of the common carotid artery has been
engaged with a guidewire, the catheter is advanced into the common carotid artery over the wire. Care must be taken to clear the
catheters and manifold of air and debris before injecting into the
carotid artery. Carotid angiograms are obtained in the AP, oblique,
and LAT views.
Because of the dense bony structure of the skull, it is preferable
to use digital subtraction techniques for diagnostic images of the
intracranial vascular anatomy. A 12-inch or larger image intensifier
is optimal for intracranial angiography. It is important to emphasize
using DSA for the intracranial portion of the internal carotid artery
and its branches in the AP and LAT views. This enables assessment
of the circle of Willis and demonstrates the presence of any collateral circulation.
Fig. 15-18).
Subclavian Angiography
Important branches of the subclavian artery include the vertebral
(superior) and internal mammary (inferior) arteries (
vertebral artery, the first and usually largest branch of the subclavian
artery, arises from the superior and posterior surface of the subclavian. The AP view will disclose stenosis in the proximal subclavian
artery (the left subclavian artery is affected three to four times as
frequently as the right subclavian artery). In patients with a tortuous
proximal left subclavian artery, a steep right anterior oblique (RAO)
view with caudal angulation may help elucidate a proximal stenosis.
If the proximal portion of the right subclavian artery is suspected of
having a lesion, the AP view may not show the stenosis because of
overlap with the origin of the right common carotid artery. A steep
RAO caudal view (40°-60° RAO and 15°-20° caudal) will usually
separate the ostia of these two vessels (Fig. 15-20).
Fig. 15-19). The
FIGURE 1512 Drawing illustrating contralateral iliac access for
selective angiography.
Vertebral Angiography
The vertebral arteries are identified on the aortic arch aortogram. Often, a nonselective injection of contrast in the subclavian
artery near the origin of the vertebral artery is performed to view
ostial lesions. Cranial angulation (30°-40°) with shallow oblique
views (RAO or LAO), may be necessary to view the origin (see
Fig. 15-19). Nonselective angiography is preferred to avoid trauma
when engaging the ostium of the vertebral artery with an angled
catheter (Judkins right coronary, Berenstein, Cobra, or internal
mammary artery catheter). Typically the catheter is placed very
near the ostium, and hand injections of contrast are made to visualize the vertebral artery.
The vertebral artery runs cranially through the foramina of the
transverse processes of the cervical vertebrae to the base of the skull
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FIGURE 1513 Selective left common
iliac angiography (20° left anterior oblique
[LAO] and 20° caudal view) demonstrating
origin of internal iliac artery (IIA) (ostial
stent present) and external iliac artery (EIA).
(Fig. 15-21). After penetrating the foramen of the atlas, it enters the
cranial cavity through the foramen magnum. The first branch of the
vertebral artery, located in its V4 segment, is the posterior inferior cerebellar artery (PICA). The vertebral artery joins with the contralateral vertebral artery to form the basilar artery (
Fig. 15-22).
Nonselective angiography is performed with hand injections,
using a coronary manifold with pressure monitoring, analogous to
selective coronary angiography. Anteroposterior and LAT views of
the extracranial and intracranial course of the vertebral and basilar arteries should be performed with a DSA technique. Similar to
views of the anterior cerebral circulation, it is important to determine the contribution of the posterior circulation to the circle of
Willis.
Complications of Peripheral Vascular
Angiography
Complications of peripheral vascular angiography may lead to
significant morbidity or even mortality.
thought of in three categories: (1) access site related, (2) systemic,
or (3) catheter induced.
11
The best strategy to minimize these com-
plications is to anticipate and avoid them.
5
Complications may be
Access Site–Related Complications
Vascular access site–related complications include hematoma formation, retroperitoneal hemorrhage, pseudoaneurysm formation, AVF
FIGURE 1514 Aortic arch and brachiocephalic vessels. Digital subtraction
angiogram injection of 15 mL per second of contrast material for 3 seconds, with
image obtained at 30° left anterior oblique (LAO). CCA, common carotid artery.
creation, and infection. Access site bleeding is the most frequent
complication following femoral arterial access.
note that femoral closure devices shorten time to ambulation but
also add cost without reducing complications.
access site bleeding depends on the severity and hemodynamic
12
It is important to
13
Management of
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FIGURE 1515 Bovine aortic arch
angiogram injection of 15 mL of contrast per
second for 3 seconds (total 45 mL contrast)
at 45° left anterior oblique (LAO). L.CCA, left
common carotid artery; R.ECA, right external
carotid artery; R.ICA, right internal carotid artery;
R.IMA, right internal mammary artery.
ACA
MCA
FIGURE 1516 Common carotid bifurcation. External carotid artery is
marked by presence of branch vessels.
FIGURE 1517 Intracranial carotid arteries (anteroposterior [AP] view).
Internal carotid artery branches into middle cerebral artery (MCA) and anterior
cerebral artery (ACA).
FIGURE 1518 Commonly used brachiocephalic and carotid
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angiographic catheters.
Vertebral Artery
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IMA
Subclavian
FIGURE 1519 Left subclavian angiogram showing vertebral artery
arising superiorly and internal mammary artery (IMA) arising inferiorly.
FIGURE 1521 Drawing of vertebral artery, divided into four
anatomical segments that course through cervical spine foramina.
consequences of bleeding. In general, access site bleeding may be
controlled by manual or mechanical compression and reversal of
anticoagulation. If bleeding continues despite these steps, more
aggressive therapies—including percutaneous intervention or surgical therapy—may be considered.
14
Signs and symptoms of retroperitoneal bleeding include hypotension, abdominal distention or fullness, and pain. Diagnosis
of retroperitoneal bleeding may be confirmed by computed
tomography (CT) or abdominal/pelvic ultrasound. If retroperitoneal bleeding is suspected, anticoagulation should be reversed
and discontinued. Volume resuscitation with crystalloid solutions and/or blood products should be administered if volume
depletion is clinically evident. If bleeding causes hemodynamic
embarrassment (hypotension), emergency angiography from the
contralateral femoral artery access site should be performed to
identify the bleeding site. Once the bleeding site has been identified, tamponade of bleeding with balloon occlusion will stabilize
FIGURE 1520 Proximal right subclavian stenosis (arrow),
seen best at 40° right anterior oblique (RAO) and 20° of caudal
angulation. IMA, interior mammary artery.
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PCA
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Basilar
AICA
artery
PICA
FIGURE 1522 Proximal vertebral artery segment visualized with
subclavian angiography. AICA, anterior inferior cerebellar artery; PCA,
posterior cerebral artery; PICA, posterior inferior cerebellar artery.
the patient. If prolonged balloon inflation is not effective in stopping blood loss, consideration may be given to placing a covered
stent to seal the leak. Open surgical repair may also be an option
to consider.
A pseudoaneurysm occurs when a hematoma communicates
with the arterial lumen. Low arterial punctures (SFA or profunda
femoris artery entry) are associated with pseudoaneurysm formation. Other risk factors include female sex, age older than 70 years,
diabetes mellitus, and obesity.
Patients with pseudoaneurysms often present with pain at the
access site several days following the intervention. On physical
examination, a pulsatile hematoma may be present with a systolic
bruit. Management of a femoral pseudoaneurysm is dependent
on its size, severity of symptoms, and need for continued anticoagulation. A small pseudoaneurysm (<
often will resolve spontaneously. Larger pseudoaneurysms may be
treated with ultrasound-guided compression, percutaneous offlabel thrombin injection, endovascular coil insertion, or covered
stents. Surgical repair of pseudoaneurysms is usually reserved for
failure of less invasive approaches.
An AVF complicates vascular access when the needle punctures the femoral artery and nearby vein, creating a fistulous
communication when the sheath is removed. The risk of creating an AVF is increased by either a high or low femoral puncture, multiple puncture attempts, or prolonged clotting times.
Fistulae may not be clinically evident for several days following the procedure. An AVF is characterized by a continuous toand-fro murmur over the access site. In some cases, there may
be a swollen and tender extremity due to venous dilation, and
in severe circumstances, arterial insufficiency (steal syndrome)
may occur. Diagnosis of an AVF can be confirmed by color flow
Doppler ultrasound.
Most AVFs following femoral access are small, not hemodynamically significant, and close spontaneously. Symptomatic
AVFs require closure to prevent increased shunting and distal
swelling and tenderness.
14
2 cm) may be observed and
14
15
Surgical repair, traditional therapy
for closure of catheterization-related AVFs when necessary, has
been replaced by percutaneous methods in most circumstances.
Surgical correction is reserved for those patients who fail a less
invasive approach.
Vascular access closure devices are designed to facilitate
hemostasis, reduce time to ambulation, and decrease length
of hospital stay. All devices currently approved by the U.S.
Food and Drug Administration (FDA) have shown favorable
results. However, these devices are prone to specific complications and have not been demonstrated to reduce access site
complications.
16
Systemic Complications
Systemic complications relate to allergic and anaphylactic reactions, as well as nephrotoxicity caused by iodinated contrast
agents. Allergic or anaphylactic reactions occur in fewer than 3%
of cases, and fewer than 1% require hospitalization.
Nonoliguric creatinine elevation, which peaks within 2 to
3 days and returns to baseline by 7 days, is the usual clinical
scenario of contrast-induced nephrotoxicity. Patients at risk for
contrast-induced nephropathy are those with baseline chronic
renal insufficiency, diabetes mellitus, multiple myeloma, and
those who are receiving other nephrotoxic drugs (e.g., aminoglycosides). All patients in general, but those at risk to develop
contrast-induced nephropathy in particular, should be well
hydrated before and after the procedure, and the amount of contrast volume should be minimized. One randomized trial reported
that in patients with renal insufficiency, Iodopaque (iso-osmolar,
nonionic) is less nephrotoxic than Omnipaque (low osmolar,
nonionic) contrast, but there are conflicting studies.17 Mucomyst
(N-acetylcysteine) has shown mixed results in preventing contrast
nephropathy.
18,19
The Acetylcysteine for the Prevention of ContrastInduced Nephropathy (ACT) trial, a pragmatic multicenter randomized trial that evaluated acetylcysteine in patients undergoing
coronary and vascular angiography was the largest randomized
trial conducted to date. However, it demonstrated that acetylcysteine was ineffective in preventing contrast-induced nephropathy.
20
Diuretics do not protect against contrast-induced nephrotoxicity. Hydration with half-normal saline for 12 hours before and
after the procedure provides better protection against creatinine
rise than the combination of hydration and diuretics. Two prospective trials have demonstrated that mannitol does not reduce
contrast nephropathy.
Catheter Related Complications
Catheters may disrupt atherosclerotic plaque and cause atheroemboli (also see Chapter 47). When catheters are manipulated in
the aorta or brachiocephalic vessels during a thoracic aortogram,
stroke is a rare but potentially devastating complication.
In general, asymptomatic patients have a lower risk, whereas
patients who undergo angiography in the setting of transient ischemic events have a slightly higher complication rate. Patients who
develop a neurological complication should have an immediate
neurological assessment, and angiography of the culprit vessel
should be obtained prior to an emergency CT scan. If an embolic
stroke has occurred, one option is to perform catheter-directed
thrombolysis and/or angioplasty. In the presence of intracerebral
hemorrhage, anticoagulants and antiplatelet agents should be
reversed.
Atheroembolism is another cause of renal insufficiency following angiography. Unlike contrast-induced nephropathy, renal
dysfunction after atheroembolization usually develops slowly
(weeks to months) and some of these patients progress to renal
failure. Diagnosis is confirmed by tissue examination (biopsy),
and treatment is supportive. Systemic manifestations of atheroembolism include livedo reticularis, abdominal or foot pain,
and purple toes associated with systemic eosinophilia (blue toe
syndrome).
5,21,22
REFERENCES
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
1. Spinosa D, Angle J, Hagspiel K, et al: Feasibility of gadodiamide compared with dilute
iodinated contrast material for imaging of the abdominal aorta and renal arteries, J Vasc
Interv Radiol 11:733, 2000.
2. Diaz L, Pabon I, Garcia J, et al: Assessment of CO2 arteriography in arterial occlusive disease
of the lower extremities, J Vasc Interv Radiol 11:163, 2000.
3. Huber PR, Leimbach ME, Lewis WL, et al: CO2 angiography, Catheter Cardiovasc Interv
55:398–403, 2002.
4. Ledneva E, Karie S, Launay-Vacher V, et al: Renal safety of gadolinium-based contrast media
in patients with chronic renal insufficiency, Radiology 250:618–628, 2009.
5. Armstrong P, Han D, Baxter J, et al: Complication rates of percutaneous brachial artery
access in peripheral vascular angiography, Ann Vasc Surg 17:107, 2003.
6. Fitts J, Ver Lee P, Hofmaster P, et al, for the Northern New England Cardiovascular Study
G: fluoroscopy-guided femoral artery puncture reduces the risk of PCI-related vascular
complications, J Interv Cardiol 21:273–278, 2008.
7. Abu-Fadel MS, Sparling JM, Zacharias SJ, et al: Fluoroscopy vs. traditional guided femoral
arterial access and the use of closure devices: a randomized controlled trial, Catheter
Cardiovasc Interv 74:533–539, 2009.
8. Dotter CT, Judkins MP: Transluminal treatment of arteriosclerotic obstruction: description
of a new technic and a preliminary report of its application, Circulation 30:654, 1964.
9. Beales J, Adcock F, Frawley J, et al: The radiological assessment of disease of the profunda
femoris artery, Br J Radiol 44:854, 1971.
10. Schainfield R, Jaff M: Angiography of the aorta and peripheral arteries. In Baim D, Grossman
W, editors: Grossman's cardiac catheterization, angiography and intervention, Philadelphia,
2000, Lippincott Williams & Wilkins, pp 293.
11. Singh H, Cardella J, Cole P, et al: Quality improvement guidelines for diagnostic
arteriography, J Vasc Interv Radiol 13:1, 2002.
12. Jolly SS, Amlani S, Hamon M, et al: Radial versus femoral access for coronary angiography
or intervention and the impact on major bleeding and ischemic events: a systematic
review and meta-analysis of randomized trials, Am Heart J 157(1):132–140, 2009.
13. Arora N, Matheny ME, Sepke C, et al: A propensity analysis of the risk of vascular
complications after cardiac catheterization procedures with the use of vascular closure
devices, Am Heart J 153(4):606–611, 2007.
14. Samal AK, White CJ: Percutaneous management of access site complications, Catheter
Cardiovasc Interv 57:12, 2002.
1 5. Waigand J, Uhlich F, Gross C, et al: Percutaneous treatment of pseudoaneurysms and
atriovenous fistulas after invasive vascular procedures, Catheter Cardiovasc Interv 47:157, 1999.
16. Toursarkissian B, Mejia A, Smilanich R, et al: Changing patterns of access site complications
with the use of percutaneous closure devices, Vasc Surg 35:203, 2001.
17. Aspelin P, Aubry P, Fransson S, et al: Nephrotoxic effects in high-risk patients undergoing
angiography, N Engl J Med 348:491, 2003.
18. Chow W, Chan T, Lo S, et al: Acetylcysteine for prevention of acute deterioration of renal
function following elective coronary angiography and intervention: a randomized
controlled trial, JAMA 289:553, 2003.
19. Ferrario F, Barone MT, Landoni G, et al: Acetylcysteine and non-ionic isoosmolar contrastinduced nephropathy: a randomized controlled study, Nephrol Dial Transplant 24:3103–3107,
2009.
20. Berwanger O, for the ACT Investigators: Acetylcysteine for the prevention of contrastinduced nephropathy (ACT) trial: a pragmatic multicenter randomized trial to evaluate
the efficacy of acetylcysteine for the prevention of renal outcomes in patients undergoing
coronary and vascular angiography, Circulation 122:2219, 2010.
21. Willinsky R, Taylor S, Terbrugge K, et al: Neurologic complications of cerebral angiography:
prospective analysis of 2,899 procedures and review of the literature, Radiology 227:522, 2003.
22. Fayed A, White C, Ramee S, et al: Carotid and cerebral angiography performed by
cardiologists: cerebrovascular complications, Catheter Cardiovasc Interv 55:277, 2002.
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PA RT IV
PERIPHERAL ARTERY DISEASE
CHAPTER
16 The Epidemiology of Peripheral
Artery Disease
Michael H. Criqui
Peripheral artery disease (PAD) is generally defined as partial or complete obstruction of one or more peripheral arteries due to atherosclerosis. Although the term PAD is sometimes inclusive of all peripheral
arteries, in this chapter PAD refers to atherosclerotic occlusive disease
of the lower extremities. Peripheral artery disease is associated with
many of the same risk factors as atherosclerotic cardiovascular and
cerebrovascular diseases, and is very common among the elderly.
Peripheral artery disease that exhibits typical symptomatology, usually
in the form of leg pain brought about by walking, has been conservatively estimated to reduce quality of life in at least 2 million Americans,
and in some cases leads to a need for surgical revascularization or
amputation.1 Six million more Americans have measurable asymptomatic disease or disease with atypical symptoms.
and asymptomatic PAD have been shown to be associated with a
sharply elevated risk of mortality due to coronary and cerebrovascular
3
disease.
Symptoms and Measures of Peripheral
Artery Disease in Epidemiology
It was recognized as long ago as the 18th century that insufficient
blood supply to the legs could cause pain and dysfunction in the
same way deficient coronary circulation could lead to angina.
This type of pain is known as intermittent claudication and is characterized as leg pain or discomfort associated with walking and
relieved by rest. Intermittent claudication is generally indicative of
exercise-induced ischemic leg pain, primarily in the calf, caused
by PAD.
Early studies of PAD focused primarily on claudication as the
chief symptomatic manifestation of PAD. A number of patient
questionnaires have been developed to uniformly identify claudication and distinguish it from other types of leg pain. The first
of these was the Rose questionnaire, also referred to as the World
Health Organization questionnaire.
Questionnaire (SDCQ) is a modification of the Rose questionnaire that additionally captures information on the laterality of
symptoms.
revision of the SDCQ that is shown in Table 16-1.
5
Recently we completed an evidence-based shortened
Ankle-Brachial Index
Although intermittent claudication is an important manifestation of PAD, it is not pathognomonic. Atherosclerosis may have
been developing for many years before claudication begins, and
the extent to which it occurs is influenced by factors other than
disease per se, such as the patient's level of activity.6 Furthermore,
the definitional distinctions used to separate claudication from
other leg pain make claudication more specific to arterial disease
but less sensitive to other types of pain that may in some cases
be related to arterial disease. Spinal stenosis can cause leg pain
similar to claudication during exercise.
4
The San Diego Claudication
2
Both symptomatic
For these reasons, another method of diagnosing PAD was
needed. Low blood pressure at the ankle was proposed as a test for
PAD as early as 1950
called the ankle-brachial index (ABI). The ABI is the ratio of the systolic blood pressure at the ankle to that in the arm. An abnormally
low ABI is indicative of atherosclerosis of the lower extremities. The
ABI has been shown to have good receiver operating curve characteristics as a test for PAD. Although there is no definitive cut point
above which disease is always absent and below which disease
is always present, an ABI of 0.9 or less is commonly used in both
clinical practice and epidemiological research to diagnose PAD.
The ABI is also sometimes referred to as the
index (ABPI)8 and the ankle-arm index (AAI).
As a test for ABI-based PAD, claudication has been shown to
have very high specificity but very low sensitivity. For example, in
the Rotterdam Study, 99.4% of subjects with ABI 0.9 or greater did
not have claudication, but only 6.3% of subjects with ABI of less
than 0.9 had claudication.
United States, the percentages were 93.3% and 18.3%, respectively.
Peripheral artery disease based on ABI criteria is much more common than claudication in the general population, and large numbers of patients without claudication can be shown to have either
atypical or no symptoms in the presence of PAD based on ABI.
To validate the ABI and the huge burden of previously unrecognized asymptomatic disease it implied, early studies compared
the ABI-based diagnosis with angiography, which was considered
the gold standard for visualizing atherosclerosis in the legs. Two
such studies often cited reported the sensitivity and specificity of
the ABI in the 97% to 100% range.
phy presents some risk to patients, it was not ethical to perform
angiography on patients not suspected to have PAD, so these
studies involved comparisons of patients with angiographically
confirmed PAD with young healthy patients assumed not to have
PAD. The sensitivities and specificities calculated are therefore
based on the ability of the ABI to discriminate between extremes
of disease and wellness. If measured among patients seen in routine clinical practice or the population in general, the specificity of
the ABI remains in the 97% + range, but the sensitivity is somewhat
less—closer to 80%
peripheral arteries and false-negative ABIs.
The ABI has been demonstrated to have strong associations with cardiovascular disease risk factors and disease outcomes. In the Cardiovascular Health Study (CHS) cohort, a
dose-response relationship was demonstrated between ABI and
cardiovascular disease risk factors, as well as both clinical and
subclinical cardiovascular disease.15 In a study in Edinburgh,
asymptomatic patients with an ABI of less than 0.9 were shown
to have a higher risk of developing claudication and higher
mortality.
0.9 who did not have exertional leg pain were shown to have
poorer lower-extremity functioning even after adjustment for
16
In a clinical study, patients with an ABI of less than
7
and led to development of a simple measure
ankle-brachial pressure
9
10
In a study of elderly women in the
11,12
However, because angiogra-
13
—in part due to some PAD patients with stiff
14
6
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TABLE 16-1 San Diego Claudication Questionnaire (Brief Version)
Circle Answer
1. Do you get pain or discomfort in either leg on walking? (If no, stop.) Right leg Yes No
2. Does this pain ever begin when you are standing still or sitting? Right leg Yes No
CH
16
3. Does this pain include your calf/calves? Right leg Yes No
4. Do you get it when you walk at an ordinary pace on the level? Right leg Yes No
5. What do you do if you get it when you are walking? Right leg Stop or slow down
6. What happens to it if you stand still? Right leg Lessened or relieved
Determine pain category separately for each leg as follows:
1. No pain: 1 = no
2. Pain at rest: 1 = yes and 2 = yes
3. Non-calf: 1 = yes and 2 = no and 3 = no
4. Classic: 1 = yes and 2 = no and 3 = yes and 4 = yes and 5 = stop or slow down and 6 = lessened or relieved
5. Atypical calf: 1 = yes and 2 = no and 3 = yes and not classic
Left leg Yes No
Left leg Yes No
Left leg Yes No
Left leg Yes No
Continue on
Left leg Stop or slow down
Continue on
Unchanged
Left leg Lessened or relieved
Unchanged
traditional risk factors and comorbidities.17 The ABI correlates
with ability to exercise as measured on an accelerometer,
an ABI of less than 0.6 is related to development of walking
impairment.
19
Thus, even aside from its association with clau-
18
and
dication, the ABI is related to the types of functional outcomes,
risk factors, and associated diseases that one would expect of
a measure of PAD. The ABI has also been shown to have high
intra- and inter-rater reliability.
20
In practice, the ABI is measured using a blood pressure cuff, a
standard sphygmomanometer, and a Doppler instrument to detect
pulses. Pressure measurements are made with the patient at rest in
a supine position for 5 minutes prior to measurement. Ankle pressure is measured in both legs at the dorsalis pedis and posterior
tibial arteries. The higher pressure measurement in each ankle has
traditionally been used as the numerator of the ABI for that ankle.
Using the lower or average pressure can substantially change estimates of PAD prevalence; one study reported 47% prevalence
based on the higher pressure versus 59% based on the lower.
20
Results of two recent studies support the use of the average of
dorsalis pedis and posterior tibial pressures as the ankle pressure
for each leg, based on superior reproducibility in repeated tests
and closer statistical association with leg function.
20,21
However,
the relative predictive value of the higher versus the average (or
perhaps the lower) of the two ankle pressures for clinical events
has not yet been evaluated. Practice also differs as to the brachial
pressure used as the denominator of the ABI; the same brachial
pressure is usually used for both left and right ABIs in the same
patient, but that pressure may be the right arm, the average of
both arms, or the highest of both arms. A recent study supports
use of the average of the left and right arms, based on superior
reproducibility,21 but another study shows a strong correlation
between PAD and subclavian stenosis, suggesting the highest arm
pressure should be used in the ABI calculation.
22
Another issue is
that the first arm pressure measured is typically higher because of
the “white coat” effect, and a repeat of the first arm pressure after
the other pressures are complete will often give a more accurate
reading. Based on the numerators and denominators described,
separate ABIs are calculated for the left and right legs of each
subject. In epidemiological analyses, the unit of analysis is either
the leg, with appropriate statistical adjustments for intrasubject
correlation, or the subject, with disease status classified based on
the “worst” limb (i.e., the limb with the lowest ABI).
The ABI has several limitations as a measure of PAD. Occlusive
disease distal to the ankle is not detected by the ABI; other
measures, such as pressure ratios using pressures measured in the
toe, are required for detecting such distal disease. The ABI is also
sensitive to the height of the patient, with taller patients having
slightly higher ABIs; it is unlikely these differences are related to
real differences in PAD.
studies that the ABI of the left leg tends to be slightly lower on
average than the ABI of the right leg.
ment that ABIs in normal subjects, on average, are slightly lower in
women and African Americans.
23,24
Similarly, it has been noted in several
23,24
Recent data also docu-
25
Arterial calcification (medial calcinosis) can make the arteries
of the ankle incompressible and lead to artificially high ABI values.
This is particularly common in patients with diabetes.
brachial index values above 1.5 are often excluded in epidemiological analyses and should be viewed with suspicion clinically.
In two large population-based studies in the United States, the proportion of patients with such elevated values was around 0.5%.
Some investigators use the more conservative cut point of 1.3. New
evidence suggests 1.4 may be a good compromise.
31,32
Incidence and Prevalence of Peripheral
Artery Disease
Although uncommon among younger people, the prevalence of
PAD rises sharply with age to include a substantial proportion of
the elderly population.
mates of PAD prevalence by age from six large studies.
In four of the studies, the standard ABI of less than 0.9 criterion
was used; in the Limburg Study, PAD was diagnosed based on two
ABI measurements of less than 0.95,
Bernardo Study, a combination of a conservative ABI cut point
of 0.8 and other noninvasive tests was used.
vary, prevalence appears to be well under 5% before age 50,
around 10% by age 65 and in excess of 25% in patients 80 years
of age or older. All studies show this stronger-than-linear relationship of prevalence to age, although there is some variability in
the age at which prevalence begins to increase most dramatically.
Estimates of PAD incidence are reported somewhat less frequently in the literature, with more data based on claudication
incidence than on ABI. With respect to claudication, data from
the Framingham Study show claudication in men rising from less
than 0.4 per 1000 per year in men aged 35 to 45 years to more than
6 per 1000 per year in men aged 65 years and older.37 Incidence
among women ranged from 40% to 60% lower by age, although
Figure 16-1 shows some ABI-based esti-
35
whereas in the Rancho
33
Although estimates
26,27
Ankle-
6,15,28–30
15,30
10,15,33–36
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