Kuliah Vi Blok Hematologi 2009 Arterial Trombosis Pad

8/12/2019 Kuliah Vi Blok Hematologi 2009 Arterial Trombosis Pad

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Peripheral Arterial Disease Guidelines:Management of Patients with Lower Extremity PAD

A Collaboration of the American College of Cardiology, the American HeartAssociation, the American Association for Vascular Surgery/Society forVascular Surgery, Society for Cardiovascular Angiography and Interventions,Society of Interventional Radiology, Society for Vascular Medicine and

Biology, and the PAD Coalition.

The PAD CoalitionSVMB



Why A PAD Guideline?• To enhance the quality of patient care• Increasing recognition of the importance of

atherosclerotic lower extremity PAD: – High prevalence – High cardiovascular risk – Poor quality of life

• Improved ability to detect and treat renal artery

disease• Improved ability to detect and treat AAA• The evidence base has become increasingly robust,

so that a data-driven care guideline is now possible



Peripheral Arterial Disease Guideline:The Targ et A ud ien ces A re Diverse

• Primary care clinicians – Family practice – Internal medicine – PA, NP, nurse clinicians

• Cardiovascular/vascular medicine,vascular surgical, & interventional

radiology trainees and vascularspecialists

This w as not in tended to b e a pro cedural guid el ine;i t i s in tended to pro vide a guide to o pt im al l ife long PAD c are.



Defining a Population “At Risk”for Lower Extremity PAD

• Age less than 50 years with diabetes, and one additionalrisk factor (e.g., smoking, dyslipidemia, hypertension, orhyperhomocysteinemia)

• Age 50 to 69 years and history of smoking or diabetes• Age 70 years and older• Leg symptoms with exertion (suggestive of claudication)

or ischemic rest pain• Abnormal lower extremity pulse examination• Known atherosclerotic coronary, carotid, or renal artery

disease



The First Tool to Establish the PAD Diagnosis:The HPI, ROS, and Phy sic al Exam inat ion

• Individuals with asymptomatic PAD should beidentified in order to offer therapeuticinterventions known to diminish their increasedrisk of myocardial infarction, stroke, and death.

• A history of walking impairment, claudication,and ischemic rest pain is recommended as a

required component of a standard review ofsystems for adults >50 years who haveatherosclerosis risk factors, or for adults >70years.



The First Tool to Establish the PAD Diagnosis:The HPI, ROS, and Phy sic al Exam inat ion

• Pulse intensity should be assessed and should be recordednumerically as follows:

– 0, absent – 1, diminished – 2, normal – 3, bounding

Use of a standard examination shouldfacilitate clinical communication



Individuals with PAD Present in Clinical

Practice with Distinct Syndromes

A s y m p t o m a t i c : Without obvious symptomaticcomplaint (but usually with a functional impairment).

Class ic Claud icat ion : Lower extremity symptomsconfined to the muscles with a consistent (reproducible)onset with exercise and relief with rest.

“Atypical” leg pain : Lower extremity discomfort that isexertional, but that does not consistently resolve withrest, consistently limit exercise at a reproducibledistance, or meet all “Rose questionnaire” criteria.

This guideline recognizes that:



Individuals with PAD Present in Clinical Practicewith Distinct Syndromes

Cri t ical Lim b Isc hem ia: Ischemic rest pain, non-healing wound, or gangrene

Ac ute l im b i sch em ia: The five “P’s, defined by theclinical symptoms and signs that suggestpotential limb jeopardy:

Pain

PulselessnessPallorParesthesiasParalysis (& polar, as a sixth “p”).

This guideline recognizes that:



Hemodynamic Noninvasive Tests

• Resting Ankle-Brachial Index (ABI)

• Exercise ABI

• Segmental pressure examination

• Pulse volume recordings

These traditional tests continue to provide a simple, risk-free,and cost-effective approach to establishing the PAD diagnosis

as well as to follow PAD status after procedures.



Lower extremity systolic pressureBrachial artery systolic pressureABI =

• The ankle-brachial index is 95% sensitive and 99% specific for PAD• Establishes the PAD diagnosis• Identifies a population at high risk of CV ischemic events• “Population at risk” can be clinically & epidemiologically defined:

The Ankle-Brachial Index

Exer t ional l eg s ym ptom s , non- healing w ou nd s, age > 70, age > 50years wi th a h i s to ry o f sm oking o rdiabetes.

• Toe-brachial index (TBI) useful inindividuals with non-compressible pedalpulses

Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34;

Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14



Exercise ABI

• Confirms the PAD diagnosis

• Assesses the functional severity ofclaudication

• May “unmask” PAD when resting the ABI

is normal



Arterial Duplex Ultrasound Testing•

Duplex ultrasound of the extremitiesis useful to diagnose anatomiclocation and degree of stenosis ofperipheral arterial disease.

• Duplex ultrasound is useful toprovide surveillance followingfemoral-popliteal bypass usingvenous conduit (but not prostheticgrafts).

• Duplex ultrasound of the extremitiescan be used to select candidates for:(a) endovascular intervention;(b) surgical bypass, and(c) to select the sites of surgical

anastomosis.

However, the data thatmight support use of

duplex ultrasound toassess long-termpatency of PTA is notrobust.



Noninvasive Imaging Tests

Duplex Ultrasound

Duplex ultrasound of the extremities is usefulto diagnose the anatomic location and degree

of stenosis of PAD.

Duplex ultrasound is recommended for routine

surveillance after femoral-popliteal or femoral-tibial-pedal bypass with a venous conduit.minimum surveillance intervals areapproximately 3,6, and 12 months, and thenyearly after graft placement.



MRA of the extremities is useful to diagnoseanatomic location and degree of stenosis ofPAD.

MRA of the extremities should be performedwith a gadolinium enhancement.

MRA of the extremities is useful in selectingpatients with lower extremity PAD as candidatesfor endovascular intervention.

Magnetic Resonance Angiography (MRA)





CTA of the extremities may be considered

to diagnose anatomic location andpresence of significant stenosis inpatients with lower extremity PAD.

CTA of the extremities may be consideredas a substitute for MRA for those patientswith contraindications to MRA.

Computed Tomographic Angiography (CTA)





Lipid Lowering and Antihypertensive Therapy

Treatment with an HMG coenzyme-A reductase inhibitor(statin) medication is indicated for all patients withperipheral arterial disease to achieve a target LDLcholesterol of less than 100 mg/dl.

Antihypertensive therapy should be administered tohypertensive patients with lower extremity PAD to a goalof less than 140/90 mmHg (non-diabetics) or less than

130/80 mm/Hg (diabetics and individuals with chronicrenal disease) to reduce the risk of myocardial infarction,stroke, congestive heart failure, and cardiovasculardeath.



Antiplatelet Therapy

Antiplatelet therapy is indicated to reduce the risk ofmyocardial infarction, stroke, or vascular death inindividuals with atherosclerotic lower extremity PAD.

Aspirin, in daily doses of 75 to 325 mg, is recommended

as safe and effective antiplatelet therapy to reduce therisk of myocardial infarction, stroke, or vascular death inindividuals with atherosclerotic lower extremity PAD.

Clopidogrel (75 mg per day) is recommended as an

effective alternative antiplatelet therapy to aspirin toreduce the risk of myocardial infarction, stroke, orvascular death in individuals with atherosclerotic lowerextremity PAD.



Supervised Exercise Rehabilitation

A program of supervised exercise training isrecommended as an initial treatmentmodality for patients with intermittent

claudication.

Supervised exercise training should beperformed for a minimum of 30 to 45minutes, in sessions performed at leastthree times per week for a minimum of 12weeks.



Pharmacotherapy of Claudication

Cilostazol (100 mg orally two times perday) is indicated as an effective therapy

to improve symptoms and increasewalking distance in patients with lowerextremity PAD and intermittentclaudication (in the absence of heart

failure).



Endovascular procedures are indicated forindividuals with a vocational or lifestyle-limiting disability due to intermittentclaudication when clinical features

suggest a reasonable likelihood ofsymptomatic improvement withendovascular intervention an d …

a. Response to exercise or pharmacologictherapy is inadequate, and/or

b. there is a very favorable risk-benefit ratio(e.g. focal aortoiliac occlusive disease)

Endovascular Treatment for Claudication



Endovascular intervention is recommended asthe preferred revascularization technique forTASC type A iliac and femoropopliteal lesions.

TASC A:(PTA recommended)

Iliac Femoropopliteal

TASC B: (insufficient data to recommend)




Provisional stent placement is indicated foruse in iliac arteries as salvage therapy forsuboptimal or failed result from balloondilation (e.g. persistent gradient, residualdiameter stenosis >50%, or flow-limitingdissection).

Stenting is effective as primary therapy forcommon iliac artery stenosis andocclusions.

Stenting is effective as primary therapy inexternal iliac artery stenosis andocclusions.

Endovascular Treatment for Claudication:Il iac A rter ies



Endovascular intervention is not indicated ifthere is no significant pressure gradientacross a stenosis despite flowaugmentation with vasodilators.

Primary stent placement is notrecommended in the femoral, popliteal, ortibial arteries.

Endovascular intervention is not indicatedas prophylactic therapy in an asymptomaticpatient with lower extremity PAD.




Surgery for Critical Limb Ischemia

Patients who have significant necrosis of theweight-bearing portions of the foot, anuncorrectable flexion contracture, paresis of theextremity, refractory ischemic rest pain, sepsis,or a very limited life expectancy due to co-morbid conditions should be evaluated forprimary amputation.

Surgery is not indicated in patients with severedecrements in limb perfusion in the absence ofclinical symptoms of critical limb ischemia.




For individuals with combined inflow andoutflow disease with critical limb ischemia,inflow lesions should be addressed first.

When surgery is to be undertaken, an aorto-bifemoral bypass is recommended for patients

with symptomatic, hemodynamicallysignificant, aorto-bi-iliac disease requiringintervention.




Bypasses to the above-knee poplitealartery should be constructed with autogenoussaphenous vein when possible.

Bypasses to the below-knee popliteal arteryshould be constructed with autogenous veinwhen possible.

Prosthetic material can be used effectivelyfor bypasses to the below knee poplitealartery when no autogenous vein from ipsilateralor contralateral leg or arm is available.




Femoral-tibial artery bypasses should beconstructed with autogenous vein, includingipsilateral greater saphenous vein, or ifunavailable, other sources of vein from the legor arm.

Composite sequential femoropopliteal-tibialbypass, or bypass to an isolated poplitealarterial segment that has collateral outflow tothe foot, are acceptable methods ofrevascularization and should be consideredwhen no other form of bypass with adequateautogenous conduit is possible.



Acute Limb Ischemia (ALI)

Patients with ALI and a salvageableextremity should undergo an emergent

evaluation that defines the anatomic level ofocclusion, and that leads to promptendovascular or surgical intervention.

Patients with ALI and a non-viable extremityshould not undergo an evaluation to definevascular anatomy or efforts to attemptrevascularization.



• Population at risk is now defined by epidemiologiccriteria applied to practice.

ACC/AHA Guidelines for the Management of PAD:Major Con tr ibut ion s to Im pro ved Care Stand ards

•

Presentation-specific algorithms will expedite care (e.g.,asx, atypical leg pain, classic claudication, critical limbischemia, & acute arterial occlusion).

• Use of exercise, pharmacologic, endovascular, andsurgical interventions are emplaced in care asdefined by evidence.

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Kuliah Vi Blok Hematologi 2009 Arterial Trombosis Pad

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