Peripheral Artery Disease
Emile R. Mohler, Michael R. Jaff
John Wiley & Sons, 13-Jul-2017 - Medical - 208 pages
A comprehensive, quick-reference guide to the diagnosis and management of peripheral artery disease for non-specialists
With an aging population subject to an increasing number of health risks, peripheral artery disease (PAD) is on the rise throughout the world. Because of PAD's direct links to heart attack and stroke, it is critical that internists, surgeons, cardiologists, radiologists, gerontologists, GPs, and family practitioners know how to recognize it and make the best treatment recommendations for their patients. This book provides all the expert, practical information and guidance they need to do just that.
Edited by two thought leaders in PAD diagnosis and treatment, and comprising chapters written by subject matter experts, Peripheral Artery Disease, Second Edition provides clinicians with guidance on how to diagnose and treat one of the most under-diagnosed conditions affecting millions of patients. This updated and revised edition of the popular guide distills the complexities of PAD into clear, actionable advice for busy medical practitioners, providing them with the information they need—when they need it.
Provides clinicians with essential information for recognizing and treating this under-diagnosed condition that affects millions of patients
Distills the complexities of PAD, from diagnosis to traditional and emerging treatment options, into clear, actionable advice for clinicians
Covers PAD epidemiology, office examination, imaging, laboratory evaluation, medical therapy, surgical interventions, endovascular treatments, and much more
Reflects the latest PAD Guidelines and Performance Measures established by leading specialty societies
Features contributions from internists and surgeons, all recognized experts in PAD
Peripheral Artery Disease, Second Edition is an important working reference for internists, cardiologists, radiologists, and surgeons, as well as fellows and residents in those fields.
LOWER EXTREMITY MANIFESTATIONS OF PERIPHERAL ARTERY DISEASE: THE PATHOPHYSIOLOGIC AND FUNCTIONAL IMPLICATIONS OF LEG ISCHEMIA
Circ Res. Author manuscript; available in PMC 2016 Apr 24.Published in final edited form as:Circ Res. 2015 Apr 24; 116(9): 1540–1550. doi: 10.1161/CIRCRESAHA.114.303517
PMCID: PMC4410164NIHMSID: NIHMS676651PMID: 25908727
Mary McGrae McDermott, MD
Diagnosis and Treatment of Chronic Arterial Insufficiency of the Lower Extremities: A Critical Review
Jeffrey I. Weitz, John Byrne, G. Patrick Clagett, Michael E. Farkouh,
Originally published1 Dec 1996https://doi.org/10.1161/01.CIR.94.11.3026Circulation. 1996;94:3026–3049
https://www.ahajournals.org/doi/full/10.1161/01.cir.94.11.3026
What is critical limb ischemia?
Critical limb ischemia (CLI) is a severe blockage in the arteries of the lower extremities, which markedly reduces blood-flow. It is a serious form of peripheral arterial disease, or PAD, but less common than claudication. PAD is caused by atherosclerosis, the hardening and narrowing of the arteries over time due to the buildup of fatty deposits called plaque.
CLI is a chronic condition that results in severe pain in the feet or toes, even while resting. Complications of poor circulation can include sores and wounds that won't heal in the legs and feet. Left untreated, the complications of CLI will result in amputation of the affected limb.
Symptoms of critical limb ischemia
The most prominent features of critical limb ischemia are called ischemic rest pain — severe pain in the legs and feet while a person is not moving, or non-healing sores on the feet or legs. Other symptoms include:
Pain or numbness in the feet
Shiny, smooth, dry skin of the legs or feet
Thickening of the toenails
Absent or diminished pulse in the legs or feet
Open sores, skin infections or ulcers that will not heal
Dry gangrene (dry, black skin) of the legs or feet
Critical limb ischemia: current challenges and future prospects
Vasc Health Risk Manag. 2018; 14: 63–74. Published online 2018 Apr 26. doi: 10.2147/VHRM.S125065
PMCID: PMC5927064PMID: 29731636
Dyslipidemia
Total cholesterol, low-density lipoprotein cholesterol (LDL-C), triglycerides and lipoprotein(s) are risk factors for development and progression of PAD.24 The use of statins in PAD patients is recommended. It is well documented that low levels of LDL-C reduce cardiovascular events (myocardial infarction, cerebrovascular events), and the goal in all patients with PAD is LDL-C <70 mg/dL.
Hypertension
Guidelines suggest a close control of blood pressure with values <140/90 mmHg in all patients and <130/80 mmHg in diabetic patients or patients with proteinuria. All drugs that are effective in lowering blood pressure can be used: thiazide diuretics, angiotensin-converting enzymes (ACEs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs) and beta-adrenergic blockers. In diabetic patients, ACE and ARB are considered as the first-line treatment.
https://en.wikipedia.org/wiki/Chronic_limb_threatening_ischemia
Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence
European Heart Journal, Volume 36, Issue 15, 14 April 2015, Pages 932–938, https://doi.org/10.1093/eurheartj/ehv006
Lower limb ischaemia
EBM Guidelines
7.7.2020
Palpation for foot pulses
First-line examination. The arteries to palpate are the dorsalis pedis artery and the posterior tibial artery.
Oedema will hamper the palpation.
The examiner’s own capillary pulse may interfere with the palpation.
If both the dorsalis pedis artery and the posterior tibial artery can definitely be palpated, significant arterial stenosis is improbable. An inconclusive finding is always an indication for a Doppler study.
The efficacy of pentoxiphylline has not been established. The clinical response is either of short duration, slight or insignificant.
A selective beta-blocker may usually be used with no adverse effects, unless the patient has critical ischaemia. A beta-blocker may be indicated for the treatment of coronary heart disease or hypertension.
https://www.ebm-guidelines.com/ebmg/ltk.free?p_artikkeli=ebm00101
EXERCISE REHABILITATION FOR PERIPHERAL ARTERY DISEASE: A REVIEW
Mary M. McDermott, MD
J Cardiopulm Rehabil Prev. Author manuscript; available in PMC 2019 Mar 1.Published in final edited form as:J Cardiopulm Rehabil Prev. 2018 Mar; 38(2): 63–69. doi: 10.1097/HCR.0000000000000343
PMCID: PMC5831500NIHMSID: NIHMS932613PMID: 29465495
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831500/
Google search "walking exercise peripheral arterial disease"
Low-Intensity vs High-Intensity Walking Exercise and Walk Distance in Patients With Peripheral Artery Disease
Original Investigation, April 6, 2021
Effect of Low-Intensity vs High-Intensity Home-Based Walking Exercise on Walk Distance in Patients With Peripheral Artery Disease
The LITE Randomized Clinical Trial
Mary M. McDermott, et al.
JAMA. 2021;325(13):1266-1276. doi:10.1001/jama.2021.2536
Key Points
Question Does a low-intensity (does not induce ischemic leg symptoms) home-based walking exercise intervention improve 6-minute walk distance more than a high-intensity (induces ischemic leg symptoms) home-based walking exercise intervention and does the low-intensity intervention improve 6-minute walk distance more than a nonexercise control (weekly health educational sessions only) among patients with lower-extremity peripheral artery disease (PAD)?
Findings Low-intensity exercise, high-intensity exercise, and nonexercise control resulted in a mean 12-month change in 6-minute walk distance of −6.4 m, 34.5 m, and −15.1 m, respectively. Low-intensity exercise was significantly less effective than high-intensity exercise and was not significantly different from the nonexercise control.
Meaning These findings do not support the use of low-intensity walking exercise for patients with PAD.
Design, Setting, and Participants Multicenter randomized clinical trial conducted at 4 US centers and including 305 participants. Enrollment occurred between September 25, 2015, and December 11, 2019; final follow-up was October 7, 2020.
Interventions Participants with PAD were randomized to low-intensity walking exercise (n = 116), high-intensity walking exercise (n = 124), or nonexercise control (n = 65) for 12 months. Both exercise groups were asked to walk for exercise in an unsupervised setting 5 times per week for up to 50 minutes per session wearing an accelerometer to document exercise intensity and time. The low-intensity group walked at a pace without ischemic leg symptoms. The high-intensity group walked at a pace eliciting moderate to severe ischemic leg symptoms. Accelerometer data were viewable to a coach who telephoned participants weekly for 12 months and helped them adhere to their prescribed exercise. The nonexercise control group received weekly educational telephone calls for 12 months.
Results
Among 305 randomized patients (mean age, 69.3 [SD, 9.5] years, 146 [47.9%] women, 181 [59.3%] Black patients), 250 (82%) completed 12-month follow-up.
The 6-minute walk distance changed from 332.1 m at baseline to 327.5 m at 12-month follow-up in the low-intensity exercise group (within-group mean change, −6.4 m [95% CI, −21.5 to 8.8 m]; P = .34)
From 338.1 m to 371.2 m in the high-intensity exercise group (within-group mean change, 34.5 m [95% CI, 20.1 to 48.9 m]; P < .001) and the mean change for the between-group comparison was −40.9 m (97.5% CI, −61.7 to −20.0 m; P < .001).
The 6-minute walk distance changed from 328.1 m at baseline to 317.5 m at 12-month follow-up in the nonexercise control group (within-group mean change, −15.1 m [95% CI, −35.8 to 5.7 m]; P = .10), which was not significantly different from the change in the low-intensity exercise group (between-group mean change, 8.7 m [97.5% CI, −17.0 to 34.4 m]; P = .44).
Editorial
April 12, 2022
Home-Based Walking Exercise for Peripheral Artery Disease
Mary M. McDermott, MD1,2
Author Affiliations
JAMA. 2022;327(14):1339-1340. doi:10.1001/jama.2022.2457
Pentoxifylline for vascular health: a brief review of the literature
Mark F McCarty1, James H O'Keefe2 and James J DiNicolantonio2
https://openheart.bmj.com/content/3/1/e000365
Us. 19.10.2022
Pub. 17.9.2022
