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Peripheral Artery Disease
Peripheral Artery Disease
Edited By
Emile R. Mohler, MD, MSVM, FACC, FAHA
University of Pennsylvania, Philadelphia, PA, USA
Michael R. Jaff, DO, FACP, FACC, FAHA, MSVM
Newton-Wellesley Hospital, Newton, MA, USA
Second Edition
This second edition first published 2017 © 2017 by John Wiley & Sons Ltd.
Edition History
American College Of Physicians (1e, 2008)
All rights reserved. No part of this publication may be reproduced, stored in a retrie val system, or transmitted, in any form or by
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The right of Emile R. Mohler and Michael R. Jaff to be identified as the author of the editorial material in this work has been
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Library of Congress Cataloging-in-Publication Data
Names: Mohler, Emile R., III, editor.
Title: Peripheral artery disease / edited by Emile R. Mohler, Michael R. Jaff.
Other titles: Peripheral arterial disease (Mohler)
Description: Second edition. | Hoboken, NJ, USA ; Chichester, West Sussex :
John Wiley & Sons, Inc., 2017. | Preceded by: Peripheral arterial disease
/ edited by Emile R. Mohler III, Michael R. Jaff. Philadelphia : American
College of Physicians, c2008. | Includes bibliographical references and
index. |
Identifiers: LCCN 2017014491 (print) | LCCN 2017015849 (ebook) | ISBN
9781118776070 (pdf) | ISBN 9781118776087 (epub) | ISBN 9781118776094
(cloth)
Subjects: | MESH: Peripheral Arterial Disease--diagnosis | Peripheral
Arterial Disease--therapy
Classification: LCC RC694 (ebook) | LCC RC694 (print) | NLM WG 550 | DDC
616.1/31--dc23
LC record available at https://lccn.loc.gov/2017014491
Cover Design: Wiley
Cover Image: © Science Photo Library - SCIEPRO/Gettyimages
Set in 10/12pt Warnock by SPi Global, Chennai, India
10 9 8 7 6 5 4 3 2 1
v
Contributors xi
Preface xiii
1 Epidemiology of Peripheral Artery Disease 1
Wobo Bekwelem and Alan T. Hirsch
Definitions 1
PAD Clinical Syndromes 2
Prevalence andIncidence 3
Asymptomatic PAD 8
Claudication 10
Atypical Leg Pain 12
Critical Limb Ischemia 12
Acute Limb Ischemia 13
Risk Factors forDevelopment ofPAD 13
Tobacco Use 14
Diabetes Mellitus
15
Dyslipidemia 15
Hypertension 16
Homocysteinemia 16
C‐Reactive Protein andFibrinogen 17
Obesity 17
Other Risk Factors 18
Awareness ofPAD intheCommunity 20
Progression, Natural History, andOutcomes ofPAD 20
Progression 20
Natural History andOutcomes 22
Summary 24
References 26
Contents
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Contents
vi
2 Office Evaluation of Peripheral Artery Disease – History and
Physical Examination Strategies
37
Maen Nusair and Robert S. Dieter
Introduction 37
Identifying At-Risk Individuals 37
Regional Symptom Analysis 38
Neurologic Symptoms 38
Thoracic Symptoms 40
Abdominal Pain 41
Extremity Pain 42
Skin Manifestations 44
Physical Examination 46
General Appearance 46
Head andNeck Examination 46
Chest 48
Abdominal Examination 48
Lower Extremity Examination 49
Palpating forPulses 50
Auscultation 52
References 53
3 Vascular Laboratory Evaluation of Peripheral Artery Disease 57
Thomas Rooke
Introduction 57
Anatomic 57
Hemodynamic 57
Functional 58
Physiological Testing 58
Background/History 58
Physiological Invasive Testing 58
Physiological Non‐Invasive Testing 58
Vascular Laboratory 59
Doppler 59
Motion Detection 59
Waveform Analysis 60
Plethysmography 60
PVR Amplitude 61
PVR Contour 62
Ankle–Brachial Index (ABI) andSegmental Pressures 63
Tissue Perfusion 65
Transcutaneous Oximetry (TcPO
2
) 66
Duplex Scanning 67
Background/History 67
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Contents vii
Imaging (Anatomy) 67
Doppler (Hemodynamic) 68
Vascular Laboratory Accreditation 69
References 69
4 Magnetic Resonance, Computed Tomographic, and Angiographic Imaging
of Peripheral Artery Disease
73
Thomas Le, Masahiro Horikawa and John A. Kaufman
Introduction 73
Computed Tomography Angiography 73
Basics 73
Image Acquisition andInterpretation 74
Protocol 74
Advantages 76
Pitfalls 76
Calcification 76
Artifacts 76
Radiation Exposure 76
Contrast‐Induced Nephropathy 76
Anaphylaxis 77
Magnetic Resonance Angiography 77
Basics 77
Image Acquisition andInterpretation 77
Protocol 77
Non‐Contrast‐Enhanced MRA 77
Contrast‐Enhanced MRA (CE‐MRA) 78
Post‐Processing andInterpretation 78
Advantages 78
Pitfalls 80
Time 80
Nephrogenic Systemic Fibrosis 80
Bolus Timing 80
Artifacts 80
Other Pitfalls 80
Conventional Angiography 81
Basics 81
Image Acquisition andInterpretation 81
Pre‐Procedure Patient Care 81
Protocol 81
Advantages 82
Pitfalls 82
Contrast‐Induced Nephropathy andAnaphylaxis 82
Artifacts 84
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Contents
viii
Other Disadvantages 84
Intravascular Ultrasonography 84
Basics 84
Advantages 85
Pitfalls 85
Results 85
Aortoiliac 85
CTA 85
MRA 86
Runoff 86
CTA 86
MRA 86
Pedal 87
CTA 87
MRA 87
Conclusion 87
References 87
5 Non-atherosclerotic Peripheral Artery Disease 91
Mitchell D. Weinberg and Ido Weinberg
Introduction–Presentation ofPeripheral ArteryDisease 91
When Should Non-atherosclerotic Causes ofPAD BeSuspected? 92
Entities that Make upNon-atherosclerotic PAD 94
Popliteal Artery Entrapment Syndrome 94
External Iliac Artery Endofibrosis 98
Fibromuscular Dysplasia 99
Cystic Adventitial Disease 100
Vasculitis 101
Idiopathic Mid‐aortic Syndrome 102
Arterial Manifestations ofPseudoxanthoma Elasticum 102
Chronic Exertional Compartment Syndrome 103
Musculoskeletal Pathology 103
Diagnostic Evaluation ofPatients withLeg Pain withExertion 104
Treatment Considerations 105
Conclusions 105
References 105
6 Medical Therapy of Peripheral Artery Disease 111
Lee Joseph and Esther S. H. Kim
Introduction 111
Atherosclerotic Risk Factor Management 111
Hypertension 112
Diabetes Mellitus 113
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Contents ix
Hyperlipidemia 114
Tobacco Cessation 114
Antiplatelet Agents 116
Management ofClaudication 117
Claudication Pharmacotherapy 118
Cilostazol 118
Exercise Therapy 118
Claudication Management Strategies: AComparison 119
Lower Extremity Wound Care 120
Summary 121
References 121
7 Endovascular Treatment of Peripheral Artery Disease 129
Vikram Prasanna, Jay Giri and R. Kevin Rogers
Introduction 129
Clinical Background 129
Intermittent Claudication 129
Critical Limb Ischemia 131
Limb Prognosis/Overall Survival 131
Typical Anatomy inPatients withCLI 131
Patency Issues 131
Indications forEndovascular Therapy forCLI 131
Background forEndovascular Therapy 132
Anatomy 132
Technical Background 136
Preprocedural Imaging 136
Access 138
Anticoagulation 139
Antiplatelet Management 141
Radiation 143
Chronic Total Occlusions 143
Clinical Evidence forPeripheral Intervention 145
Aorto‐Iliac Interventions 145
Angioplasty vs. Stent 146
Polytetrafluoroethylene (PTFE)‐Covered versus Bare Metal Balloon‐
Expandable Stents 147
Femoropopliteal Interventions 147
Angioplasty versus Stenting 149
Drug‐Eluting Stents inFemoropopliteal Arteries 149
Drug‐Coated Balloon (DCB) Therapy inFemoropopliteal
Disease 150
Covered Stents inFemoropopliteal Disease 151
Atherectomy 152
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Contents
x
Specialty Balloons 153
Tibioperoneal andPedal Interventions 153
Post-procedural Care 155
Conclusion 155
References 156
8 Surgical Management of Peripheral Artery Disease 163
Julia Glaser and Scott M. Damrauer
When toRefer Patients withClaudication 163
When toRefer Patients withCLI 164
Revascularization Options andResults 166
Iliac Revascularizations 166
Femoropopliteal Disease 169
Tibioperoneal Disease 171
Complications ofRevascularization 173
Preoperative Evaluation andManagement 175
Conclusion 175
References 176
Index 179
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