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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана
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systemssuchasthePioneercatheter(Medtronic,Inc.,Minneapolis,MN)orOutbackLTDreentrycatheter
(CordisCorporation).
E. The Pioneer catheter is a device platform in which a curved needle is deployed under IVUS
guidance.IntimalpunctureisperformedunderdirectIVUSimaging,anddependingonthethicknessofthe
subintimalflap,theoperatorcouldadjustthedepthoftheneedlepuncture.Theneedletraversestheintima
andplaqueintothetruelumen,andawireisadvancedthroughthisneedletothetruelumen(Fig.9.1).
FIGURE9.1 Intravascularultrasound(IVUS)imagewithPioneercatheterinsubintimalspace.
F.ReentrywiththeOutbackcatheterisperformedbyfluoroscopy-guidedalignmentofmarkersonthe
catheterthatindicatesthelocationofthereentrycannula.“L”and“T”markersareusedtodefinewhen
the catheter was positioned in a perpendicular or inline plane of the needle, respectively. Through
imagingintwo orthogonalviews,theorientationisconfirmedtoensurethedeliverycatheter entersthe
truelumen.
G.InastudybyJacobsetal,requirementfor reentrydevices was morefrequent withiliac chronic
totalocclusions(CTOs),incomparisonwithfemoralCTOs(34%vs26%).However,therewasa100%
successrateinreentrywith the PioneerorOutback reentrycatheters.Therewerenocasesofbleeding
fromtheneedledeploymentsiteorotherreentry-relatedcomplications.
13
VIII.AngioplastyandStentPlacement
A.Stentingofiliacarterydiseaseiscurrentlystandardofpractice.However,iftreatmentwithballoon
angioplastyisundertakenforTASCAandBlesionsoftheexternaliliacartery,angiographyinmultiple
views must be performedtoexclude dissectionfollowing balloonangioplasty.Furthermore, aresidual
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hemodynamic gradient greater than 10 mm Hg at rest or following arterial vasodilator administration
warrantsstentplacement.
B.Severalstudieshaveexaminedtheresultsofprimarystentplacementversusselectivestentplacement
followingangioplastyiniliacdisease.
1. Inthe DutchIliac Stent Trial, 279 patientswith >50% iliac stenosis mostly due to TASC A andB
lesions were randomized to direct stent placement versus primary angioplasty with selective stent
placementincaseofaresidualgradient>10mmHg.
Almost43%ofpatientsingroup 2 underwent selective stentplacement. Theprimary endpoint, which
was clinical success defined by improvement in Fontaine category, was significantly better in the
selective stent group. (Hazard ratio, 0 0.8; 95% confidence limits: 0.6, 1.0.) However,long-term(58year)patencyratesweresimilarbetweenthesetwogroups.
14
2.ConsideringendovascularinterventionofTASCCandDiliac lesions, currentdataoverwhelmingly
support primary stenting.The Stents versusAngioplasty… of the Treatment of Iliac ArteryOcclusions
(STAG) trial randomized 112 patients to percutaneous transluminal angioplasty or primary stent
placement. Technical success was higherintheprimarystentgroup(98%vs 84%), andcomplications
werelessfrequent.(5%vs20%)
3.Ameta-analysisof16studieswithatotalof958patientswhounderwentendovasculartreatmentfor
TASCCorDaortoiliacdiseasefoundbetterpatencyratesforprimarystentingincomparisontoselective
stenting.
15
C.Endovascular Interventions for AIODUnfortunately most data on endovascular interventions for
AIOD are not analyzed according to the involved segment. From an anatomical and hemodynamic
standpointtheaortic,commoniliac,andexternaliliacsegmentsdiffersignificantly.Aorticandcommon
iliacarteriesarestraight,relativelyimmobile,large,andcalcified.Theexternaliliacarteryissmallerin
diameterandhasatortuouscourse.Itisalsoexposedtoexternalforcesduringthemovementofthehip
joint.
D.Lesions
1. As lesions of the infrarenal aorta and common iliac arteries are short and usually calcified,
balloon-expandablestentsareused.Theballoon-expandablestentsoftenmadefromstainlesssteelhave
adequate radial strength to hold a calcified lesion expanded. Ease of precise positioning during stent
deploymentaddsvaluetousingthesestentsintheaorticandcommoniliacpositions.
2. Lesions of the descending aorta are seldom isolated and more frequently involves the iliac
bifurcationandcommoniliacarteries.
3.Isolatedaorticlesionscanbetreatedwithunilateralfemoralaccess.Oncethelesioniscrossedwitha
low-profilehydrophilicwire andback-upcatheter,astiff 0.35 ″wire suchanAmplatzsuperstiff wire
(Boston Scientific) is advanced through the backup catheter. A 12-14 mm stent is used dependingon
patient characteristics.IVUSexaminationcouldbe undertakentoaid withsizingof the stentfollowing
whichballoon-expandablestentisrecommended.
4. Lesions of the aortic bifurcation or bilateral common iliac arteries require bilateral common
femoralaccess.Oncethelesionsarecrossed,balloondilatationcouldbeperformedwithalow-profile
4-5 mm compliant balloon. This would allow for the sheaths to be advanced across the iliac artery
lesions.Thisstepminimizestheriskofstentdislodgementwithinthecalcifiedvessel.Useofsheathswith
radiopaque markers at thetip suchas the Vista brite tip (Cordis) is advantageous. Next thestents are
advancedwithinthesheathacrossthelesionsbilaterally,andthesheathsareretractedwiththestentsheld
inplace.Simultaneousballoonexpansionisundertakenforsymmetricdeploymentofsimultaneouskissing
stents.Asignificantdisadvantageofplacingsimultaneouskissingstentsis theinabilitytoeasilyaccess
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the contralateral leg by crossover of the bifurcationfor future interventionsnecessitating anantegrade
commonfemoralorbrachialaccess.
5.Withisolatedostialiliaclesions,whicharelessthan5mmfromthebifurcation,simultaneouskissing
stentsshouldbeconsideredtominimizetheriskofcontralateraliliacocclusionowingtoplaqueshiftand
deformationofthearchitectureofthebifurcation.
6. When stent placement of proximal common iliac lesions more than 5 mm from the ostium is
undertaken, simultaneous low-pressure balloon expansion of the contralateral common iliac is
recommendedtoreducetheriskofembolizationanddisplacementofthebifurcation.
7. Aortoiliac lesions are more commonly associated with thrombus formation in comparison with
femoral disease. The operator wouldhavea reasonable suspicionof thrombotic occlusions,if a wire
crosses the lesion with ease. This could be managed in several ways. The intervention could be
completed following several hours ofcatheter-assisted thrombolysis. Covered stents can be placed to
minimizeembolization.
E.Occlusionsoftheexternaliliacarteryareroutinelystentedwithself-expandingnitinolstentsowingto
theexternalforcesduringhipjointmovement.Nitinolhasavaluablefeatureofthermalshapememoryand
superelasticity,duetowhichthestentreturnstotheoriginalshapeafterseveredeformation.Furthermore,
itsability toadapttothe tortuouspathofa vesselreducestheriskofdissectionandperforation inthe
externaliliacarteries.
IX.Patency
ExaminingtheTable9.1,itisshownthatiliacstentplacementhasa greaterthan95%successrateand
primarypatencyaround90%and85%at1-3years,respectively.
Table9.1
PatencyRatesforAortoiliacStentinginTASCClassA–DLesions
Study Year No.ofPatients SuccessRate PrimaryPatency
Uher
2
2002 77 70%(3y)
Leville
3
2006 92 91% 76%(3y)
Kashyap
4
2008 86 100% 74%(3y)
Higashiura52009 216 93%(3y)
91%(5y)
Koizumi
6
2009 296 96% 88%(3y)
84%(5y)
Jaff
7
2010 151 91%(2y)
Ichihashi
8
2011 533 100% 90%(1y)
83%(5y)
Soga
9
2012 2601 98% 92.5%(1y)
83%(3y)
deDonato102013 147 100% 93%(1y)
88%(2y)
X.Complications
A.Ruptures
1. The most catastrophic complication of endovascular intervention of AIOD remains to be vessel
rupture.Suddencomplainsofsignificantpainandhemodynamiccompromisearestrongwarningsignsof
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rupture.Immediateinjectionisperformedtoidentifythesiteoftheperforation,andaballoonisexpanded
acrossthesite.Acoveredstentiscalledfor,andrapidresuscitationshouldbeundertaken.Ifthecurrent
sheathdoesnotallowfordeliveryofacoveredstent,contralateralfemoralaccessshouldbeobtainedand
a balloon advanced proximal to the perforation. While this balloon is inflated, the sheath can be
exchangedwithaviewtodeliverthecoveredstentthroughtheoriginalaccesssite.Althoughreversalof
anticoagulationisundertakeninthissituation,inourinstitutionwedonotroutinelyuseanticoagulationfor
nonthromboticaortoilicinterventions.
2.Ruptureisrelativelyrare inAIOD.Ina studyincluding657iliacinterventions,therateofrupture
was0.8%.
16
3. Factors predisposing to rupture include calcified vessels, occluded vessels, oversized balloons,
recentendarterectomy,chronicsteroidtherapy,diabetesmellitus,femalegender,andexternaliliacartery
lesions.
17
ClinicalPearl
Beforeundertakingsuch an intervention, each operator should ensure equipment for bail out is
availableontheshelf,asimmediateinterventionislifesavinginaortoiliacrupture.
B.ArterialDissectioncanalsooccurduringinterventioninAIOD.Asnotedabove,carefulevaluation
of final angiography in multiple views is undertaken to ensure a dissection flap is not missed. A
dissection could be treated by prolonged balloon inflation across the dissection or by stenting in the
settingofaflow-limitingdissection.
C. When significant distal embolization occurs maintaining anticoagulation, performing aspiration
thrombectomy with manual aspiration or mechanical aspiration such as the Angiojet device (Boston
Scientific,Marlborough,MA,USA)isthecornerstoneofmanagement.Inthesettingofalargethrombus,
burden delivery of focal thrombolysis (10 mg of intraarterial tissue plasminogen activator) could be
considered.Freshthromboticlesionsthatareresistanttoabovetherapymayrequireballoonangioplasty
oropenthrombectomy.
D.AcuteStentMisadventuresduringiliacinterventionincludestentdislodgementbeforedeployment,
embolizationandmigration,andcompressionofthecontralateraliliacartery.Advancingasheathbeyond
the lesion before advancing the stent could minimize stent dislodgement. Embolization and migration
occurinseverelycalcifiedlesionswiththestentsusuallymigratingawayfromcalcifiedsegments.Hence
understanding the lesion and applying gentle forward or backward pressure duringdeploymentonthe
stentshafttowardthecalcifiedareaofthelesionhelpstoreducethiscomplication.Intheeventofstent
embolization,retrievalcouldbeattemptedbysnaringthestent.
ClinicalPearl
Inanticipationofcompressionofthecontralateralartery,low-pressureballooninflationorkissing
stentdeploymentisnecessary.
E.Latecomplicationsincludestentthrombosisandpseudoaneurysmformation.
1.Stentthrombosisisduetoamechanicalreason,whichoftenisduetoanunrecognizededgedissection
or poor distal runoff. Treatment with overnight thrombolytic infusion and endovascular of the flow
limitation is the least complicated approach. However, if distal disease was not amenable to
endovasculartherapy,surgicalrevascularizationwouldbeundertaken.
2.Psuedoaneurysmformationisoftenduetoprogressionofadissectionatthetreatmentsite,whichwas
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notseenatthetimeoftheprocedure.Thiscouldbetreatedwithanendovascularstentgraftintheabsence
ofinfection.
XI.Follow-Up
A.Medical Therapy following intervention forAIOD usually includes aspirinfor life and a second
antiplateletsuchasclopidogrel,prasugrel,orticagrelorfor1month.Aggressiveriskfactormanagement
for cardiovascular disease is undertaken with treatment for diabetes mellitus, hypertension, and
dyslipidemia.Smokingcessationisstronglyencouraged,andwalkingprogramsareinitiated.
B.PatientswithAIODshouldbefollowedatregularintervals.Inourinstitution,weevaluatepatientsat
1-, 3-, 6-, and 12-month intervals by clinical and ultrasound evaluation. In the event of significant
restenosis being noted, revascularization is recommended, as revascularization during restenosis is
simplerthantreatingcompleteocclusion.
XII.Summary
AIODisreadilytreatablebyendovascularmethods,whichshouldbe consideredasfirst-linetreatment.
The success rates and patency are high. The complexity of the lesion may dictate access site and
equipment needed. Each operator should be well versed in possible complications and bail out
techniques in endovascular treatment of AIOD. Patients with aortoiliac disease are followed up to
evaluateforclinicalandultrasoundevidenceofrestenosisandaggressivetreatmentofriskfactors.
References
1.NorgrenL,HiattWR,DormandyJA,NehlerMR,HarrisKA,FowkesFG.Inter-societyconsensusforthemanagementofperipheral
arterialdisease(TASCII).JVascSurg.2007;45(supplS):S5-67.
2.UherP,NymanU,LindhM,LindbladB,IvancevK.Long-termresultsofstentingforchroniciliacarteryocclusion.JEndovascTher.
2002;9:67-75.
3.LevilleCD,KashyapVS,ClairDG,etal.Endovascularmanagementofiliacarteryocclusions:extendingtreatmenttoTransAtlanticInter-
SocietyConsensusclassCandDpatients.JVascSurg.2006;43:32-39.
4.KashyapVS,PavkovML,BenaJF,etal.Themanagementofsevereaortoiliacocclusivedisease:endovasculartherapyrivalsopen
reconstruction.JVascSurg.2008;48:1451-1457,7.e1-3.
5.HigashiuraW,KubotaY,SakaguchiS,etal.Prevalence,factors,andclinicalimpactofself-expandingstentfracturesfollowingiliac
arterystenting.JVascSurg.2009;49:645-652.
6.KoizumiA,KumakuraH,KanaiH,etal.Ten-yearpatencyandfactorscausingrestenosisafterendovasculartreatmentofiliacartery
lesions.CircJ.2009;73:860-866.
7.JaffMR,KatzenBT.Two-yearclinicalevaluationoftheZilvervascularstentforsymptomaticiliacarterydisease.JVascIntervRadiol.
2010;21:1489-1494.
8.IchihashiS,HigashiuraW,ItohH,SakaguchiS,NishimineK,KichikawaK.Long-termoutcomesforsystematicprimarystent
placementincomplexiliacarteryocclusivediseaseclassifiedaccordingtoTrans-AtlanticInter-SocietyConsensus(TASC)-II.JVasc
Surg.2011;53:992-999.
9.SogaY,IidaO,KawasakiD,etal.Contemporaryoutcomesafterendovasculartreatmentforaorto-iliacarterydisease.CircJ.
2012;76:2697-2704.
10.deDonatoG,BosiersM,SetacciF,etal.24-MonthdatafromtheBRAVISSIMO:alarge-scaleprospectiveregistryoniliacstentingfor
TASCA&BandTASCC&DLesions.AnnVascSurg.2015;29:738-750.
11.GolombBA,DangTT,CriquiMH.Peripheralarterialdisease:morbidityandmortalityimplications.Circulation.2006;114:688-699.
12.UbbinkDT,FidlerM,LegemateDA.Interobservervariabilityinaortoiliacandfemoropoplitealduplexscanning.JVascSurg.
2001;33:540-545.
13.JacobsDL,MotaganahalliRL,CoxDE,WittgenCM,PetersonGJ.Truelumenre-entrydevicesfacilitatesubintimalangioplastyand
stentingoftotalchronicocclusions:Initialreport.JVascSurg.2006;43:1291-1296.
14.KleinWM,vanderGraafY,SeegersJ,etal.Dutchiliacstenttrial:long-termresultsinpatientsrandomizedforprimaryorselective
stentplacement.Radiology.2006;238:734-744.
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15.GoodeSD,ClevelandTJ,GainesPA.Randomizedclinicaltrialofstentsversusangioplastyforthetreatmentofiliacarteryocclusions
(STAGtrial).BrJSurg.2013;100:1148-1153.
16.BallardJL,SparksSR,TaylorFC,etal.Complicationsofiliacarterystentdeployment.JVascSurg.1996;24:545-553;discussion53–5.
17.AllaireE,MelliereD,PoussierB,KobeiterH,DesgrangesP,BecqueminJP.Iliacarteryruptureduringballoondilatation:what
treatment?AnnVascSurg.2003;17:306-314.
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C H A P T E R 1 0
EndovascularInterventionsinSuperficial
FemoralArteryDisease
Qurat-ul-AiniJelaniMD
SasankaJayasuriyaMBBS,FACC,FASE,RPVI,FSCAI
CarlosMenaMD,FACC,FSCAI
I.Introduction
II.ClinicalAssessmentofPeripheralArterialDiseaseinPatientsWithSuperficialFemoralArteryDisease
A.PatientsatRiskforPeripheralArterialDisease
B.Examination
C.RevascularizationConsiderations
III.MedicalTherapyforPatientsWithPeripheralArterialDisease
A.ExercisePrograms
B.Pharmacotherapy
C.SmokingCessation
IV.InterventionsforPatientsWithPeripheralArterialDisease
A.PrinciplesofCatheter-BasedInterventions
B.OverviewofGuidelines
C.VascularAccess
D.LesionCrossing
E.PercutaneousTransluminalAngioplastyforSuperficialFemoralArteryDisease
F.PercutaneousTransluminalAngioplastyforSuperficialFemoralArteryDiseaseWithDrug-CoatedBalloons
G.TrialsComparingtheUseofDrug-CoatedBalloonWithPercutaneousTransluminalAngioplastyinSuperficialFemoral
Artery/FemoropoplitealDisease
V.StentinginSuperficialFemoralArtery
A.BareMetalStents
B.BareMetalStentStudiesandTrials
C.Polytetrafluoroethylene(PTFE)-CoveredStents
D.Drug-ElutingStentStudiesandTrials
VI.ClinicalTrialUpdateinSuperficialFemoralArteryDisease
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A.Follow-Up
B.ACC/AHARecommendations
VII.Summary
KeyPoints
■Asaresultofmultipledynamicstressors,theSFAisthemostcommonsiteofinvolvement
ofatheroscleroticarterialdiseaseinpatientswithPAD.
■Patientspresentingwithintermittentclaudicationshouldbetreatedwithoptimalmedical
therapy,interventionforsmokingcessation,andasupervisedexercisewalkingprogram.
■Patientswithongoingsymptomsinspiteofabovetherapyandpatientspresentingwith
criticallimbischemiaareofferedendovascularoropensurgicalrevascularization.
■Percutaneoustransluminalangioplastywithplainordrug-coatedballoonsandstentingwith
baremetalstents,drug-elutingstents,orstentgraftsareendovasculartreatmentoptionsin
patientswithfemoropoplitealdisease.
I.Introduction
Thesuperficialfemoralartery(SFA)isthemostcommonsiteofinvolvementofatheroscleroticarterial
disease resulting in claudication in patients with peripheral arterial disease (PAD). The SFA and the
contiguous popliteal artery constitute the femoropopliteal (FP) segment which is extremely long and
exposed to external compression. The SFA is exposed to multiple anatomic and dynamic challenges.
There is 13% shortening of the SFA between supine and fetal positions.1 Additionally there are
60degreesofSFAtorsionproducedbysimultaneouskneeandhipflexion.1While thesecharacteristics
makeitchallengingtotreatFPdisease,FPinvolvementoccursin20%-40%ofpatientswithcriticallimb
ischemia(CLI)andremainsthemostcommonlocationofdiseaseinpatientspresentingwithclaudication.
2
TheseverityofsymptomsfromSFAdiseasevaryconsiderably,basedontheextentofcollateralization
from the profundal femoral artery. The optimal treatment of SFA disease in patients with intermittent
claudicationremainsamatterofcontinuingdebate.Inthelastdecade,endovasculartreatment(EVT)of
infrainguinal disease has been readilyadopted as an alternative to openbypass surgery. Percutaneous
transluminalangioplasty(PTA)andstentingarethemostcommonlyusedEVToptionsforTASC(TransAtlanticInter-SocietyConsensus)typeAandBlesions.
3,4
Withtheadventofadvancedtechniquessuchas
subintimalangioplasty,advanceddevicessuch asthoseenablingreentry,availabilityofmechanicaland
laseratherectomy,eventypeCandDlesionsarebeingsuccessfullytreated.5Inmostcases,endovascular
procedures are also well tolerated, requiring short hospital stays, and result inrapid recovery.6 The
revised Trans-Atlantic Intersociety Consensus document3 and the American Heart Association
7
guidelinesrecommendtheuseofEVTasfirst-linetreatmentforpatientswithfocalandmoderatedisease.
Open bypass is recommendedfor diffusedisease or long segment total occlusions.After failure of an
exerciseprogramandoptimizationofmedicaltherapy,EVTmaybeconsidered.Asthedataforthelongterm efficacy of EVT versus open surgical bypass are limited, treatment approach should be
individualizedandshouldtakeintoaccountbothpatientandproceduralrisks.
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II.ClinicalAssessmentofPeripheralArterialDiseasein
PatientsWithSuperficialFemoralArteryDisease
8
A.PatientsatRiskforPeripheralArterialDisease
1.PatientsatincreasedriskofPADincludingSFAdiseaseincludeindividuals>65yearsofage,patient
betweenage50and64yearswithriskfactorsforPAD(ie,diabetesmellitus[DM],historyofsmoking,
hyperlipidemia, and hypertension [HTN]), individuals with known atherosclerotic disease in another
vascularterritory(eg,coronary,carotid,subclavian,renaletc).
2.Claudication
a. ThemajorityofpatientswithconfirmedPADdonothavetypicalclaudicationandmayeitherhave
non–joint-relatedsymptoms(atypicalsymptoms)orareasymptomatic.
9,10
b. Claudication isaclassicmanifestationofPADandis definedasfatigue,discomfort,cramping,or
pain of vascular origin in the muscles of the lower extremities that is consistently induced by
exerciseandconsistentlyrelievedbyrest(within10min).
3.CriticalLimbIschemia
MoreadvancedPADmaymanifestascriticallimbischemia(CLI)whichisdefinedaschronic(>2wk)
ischemicrestpainwithnonhealingwounds/ulcersorgangreneinoneorbothlegs.
B.Examination
1. Examination of patients with PAD include pulse palpation, auscultation for femoral bruits, and
inspectionofthelowerextremitiesincludingfeet.
2. Abnormal physical examinationfindings may includediminished pulses, vascular bruit,nonhealing
wounds/gangrene,andsoforth.
8
a. Abnormalphysicalfindingsshouldbeconfirmedwithdiagnostictesting.
b. Anklebrachialindex(ABI)isgenerallytheinitialtestofchoice.
i. TherestingABI is a simple, noninvasive test thatis usually obtainedbymeasuring systolic
bloodpressureatthebrachialarteries,dorsalispedis(DP),andposteriortibial(PT)arteriesin
the supine position. ABIis calculatedfor both legsbydividing the higher of the DP or PT
pressurebythehigheroftherightorleftarmbloodpressure.
ii. Segmental lowerextremity bloodpressuresandpulsevolumerecordingsare oftenperformed
alongwithABIswhichmaybeusedtolocalizeanatomicsegmentsofdisease.
iii. AnormalABIisbetween1.00and1.40.11AnABI0.90demonstrates90%sensitivityand95%
specificityforPADandistheacceptedthresholdfordiagnosis.Valuesbetween0.91and1.00
areconsidered borderline;however,thecardiovasculareventrateforanABIinthisrangeis
increasedby10%-20%.
iv. Atlevels>1.40,theidentificationofPADisnot accuratebecause of the presenceofarterial
calcificationandnoncompressibilityofthebloodvessels.
v. DependingonrestingABIvalues, additionalphysiologictesting may be consideredincluding
exercise treadmill ABI testing, measurement of toe brachial index (TBI), and perfusion
assessmentbytranscutaneousoxygenpressure(TcPO2)orskinperfusionpressure(SPP).
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vi. TBI is used to establish diagnosis of PAD in the setting of noncompressible arteries (ABI
>1.40)andmaybeusedinpatientswithsuspectedCLI.
vii. An abnormalABI is consistently relatedwith the presence ofcoronaryandcerebrovascular
disease.
12–14
In addition, it remains a predictor of cardiovascular mortality and morbidity
independent of clinical risk prediction scores such as the Framingham risk score, coronary
calciumscore,andcarotidarteryintimalmedialthickness.
15
C.RevascularizationConsiderations
Inpatientsinwhomrevascularizationisbeingconsidered,anatomicimagingmaybeperformedincluding
duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography.
16
Duplex ultrasonography is easily accessible, inexpensive, and especiallyuseful inpatients with renal
failure;however,ithaslimitedsensitivityformultilevelstenosisandincalcifiedvessels.CTAandMRA
bothallow rapid acquisitionofa high-resolution,three-dimensionalroadmapofthe peripheral arterial
tree.However,theuseofCTAis limitedbyexposuretobothiodinatedcontrastandionizingradiation.
MRA is associated with increased risk of nephrogenic systemic sclerosis in patients with advanced
diseasereceivinggadolinium.
III.MedicalTherapyforPatientsWithPeripheralArterial
Disease
A.ExercisePrograms
AllpatientswithPADshouldreceiveguideline-directedmedicaltherapyincludingastructuredexercise
program. Treatment should be aimed at limb-related outcomes including improving claudication
symptomsandpreventingCLIandamputation.Oneofthegoalsofmedicaltreatmentistopreventmajor
adverse cardiovascular events includingmyocardial infarction(MI), stroke, and cardiovascular death.
PatientswithPADcontinuetobeundertreated
17,18
despitethebenefitsofmultifactorialriskreductionin
thispatientpopulation.
19
B.Pharmacotherapy
Pharmacotherapy for patients with PAD includes antiplatelets and statins and is further tailored to
individual risk factors. Exercise training has beena mainstay of treatment for symptomatic PAD,
20,21
modifying several pathophysiological mechanisms including improved skeletal muscle metabolism,
endothelial function, and gaitabnormalities.22A 12-weekinterventionofsupervisedexercise program
improvesexerciseprogramandqualityoflifeinPAD.20Intrialswithfollow-uprangingfrom18months
to7years,
23–25
apersistentbenefitofsupervised exercise hasbeendemonstrated.Supervised exercise
programhasanexcellentsafetyprofileinpatientsscreenedforabsolutecontraindicationtoexercisesuch
asexercise-limitingcardiovasculardisease,amputationorwheelchairconfinement.
26–28
C.SmokingCessation
Smoking remains a major risk factor for the developmentandprogressionof PAD.In a study of 739
patients undergoing lower extremity angiography, 28% were active smokers. Those who quit and
continuedtoabstainhadasignificantlylower5-yearmortalityandimprovedamputation-freesurvival.
29
Discontinuationofsmokingisthemostimportantlifestylemodificationinpreventingamputation,CLI,and
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