Major bleeding occurred with 4. Patient characteristics associated with bleeding included age, female sex, heart failure, preprocedure Hb Major bleeding occurred in 4. The 4. Bleeding complications such as pseudoaneurysm requiring a secondary procedure potentially would have been excluded but are undoubtedly considered major complications by patients nonetheless.
These observations warrant consideration during treatment selection and counseling, especially for patients with claudication for whom PVI is not a must. It should also be noted that this incidence reflects in-hospital bleeding only, and therefore, may be conservatively biased by omission of patients who experience bleeding complications post-discharge. It is also important to check the temperature, color, and trophism of the foot.
Patients with claudication do not usually show a reduction in temperature or capillary filling.
Peripheral Artery Disease Treatment Program
The reduction in temperature, however, and paleness, with or without cyanosis or dangling erythrosis, are common in patients with critical ischemia. Finally, clinical examination of the upper limbs should not be forgotten as well as cervical auscultation due to the great prevalence of carotid lesions or supra-aortic trunk lesions, which in most cases are subclinical..
After the initial clinical and physical examination, patients with suspected occlusive arterial disease should be studied in a non-invasive vascular examination laboratory. This evaluation enables the degree of functional involvement to be quantified and the occlusive lesions to be localized. The basic study consists of recording the segmental pressures of the limb upper thigh, lower thigh, calf, and ankle by means of Doppler ultrasound to detect flow in the malleolar arteries anterior tibial, posterior tibial, and fibula.
Comparison between the systolic pressure obtained in the brachial artery and that obtained in the different segments of the leg permits the site of the lesion to be determined and provides information about the intensity of the hemodynamic involvement.. Recording the pulse wave volumes along the limb by plethysmography is particularly useful in patients in whom arterial calcification prevents a reliable recording of systolic pressures. Transmetatarsal or digital recording provides important information about the state of the vascularization in this zone, which is difficult to obtain with other techniques Figure Figure 1.
Study of segmental pressures and wave volume according to the affected sector. A: normal study: pulse wave volumes PWV with dicrotic wave. C: femoropopliteal occlusion: normal PWV and indices in proximal thigh. D: intense calcification: the vessels do not collapse despite the very high sleeve pressures falsely high ankle-arm index. Very pathologic PWV, transmetatarsal planes..
Finally, recording the velocimetric wave obtained by Doppler can also provide very useful information by means of evaluating the changes in the different components of the arterial velocimetric wave Figure Figure 2. Doppler velocimetric wave. A: normal study. Prominent systolic wave with dicrotism in the descending wave.
B: mildly pathologic study. Absence or reduction of the dicrotism in the descending wave. C: very pathologic study. Flattening of the systolic wave.. Some patients may have symptoms of typical claudication at mid-long distance, but with a study and ABI within normal ranges. In these cases it is convenient to carry out a claudicometry, which consists of the measurement of the ABI after walking on a treadmill. A normal physiological response consists of a rise in the pressure at the ankle in response to exercise. When an occlusive lesion is present that is not important at rest, this can be shown up by a reduction in the ABI with exercise.
This method enables the symptoms of the patients to be reproduced objectively and the claudication distance quantified. In the case of claudication of non-vascular origin, the ABI will not fall and the studies to be undertaken can then be adequately oriented..
Types of peripheral vascular disease
Imaging techniques are indicated if surgical or endovascular repair is contemplated after identification of a susceptible lesion. The clinical situation short or progressive claudication, pain at rest, or trophic lesions is the main factor to be evaluated regarding the indication for surgery. Angiography remains the reference study, but it involves certain risks, such as intense reactions to iodized contrast material, the possibility of worsening renal function, and other local complications, like dissection, atheroemboly, or problems related with the access site hemorrhage, pseudoaneurysm, or arteriovenous fistula..
Echo-Doppler is a less costly and safer technique. In expert hands, it can reliably show the main anatomic characteristics in order to undertake revascularization.
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Its main limitations concern the fact that it is excessively dependent on the operator, that it has a poor reliability in the evaluation of the infrapopliteal vessels and the time required to carry out a complete examination.. Both multislice computerized angiotomography and magnetic resonance angiography are being increasingly used for the diagnosis and surgical planning. Magnetic resonance angiography enables 3-dimensional images to be obtained safely of the whole abdomen, the pelvis, and the lower limbs at 1 single study. Its usefulness is limited by the presence of such devices as defibrillators, cochlear implants, or intracerebral stents, as well as by the fact that certain patients suffer claustrophobia.
The study is not affected by the presence of parietal calcium nor by nitinol stents, although stainless steel stents can provoke artifacts.. Multislice computerized tomography can also provide excellent 3-dimensional images and give information about the characteristics of the plaque, and all during a very quick study. However, the important doses of iodized contrast material required may be affected by the presence of calcium and the patient is exposed to radiation.. Medical Treatment of Peripheral Artery Disease. Medical treatment of patients with PAD has 2 objectives.
Types of peripheral vascular disease
One, to improve the functional situation of the limb, and 2, to prevent events secondary to the multifocal distribution of the disease. Patients with symptomatic PAD are known to have a very poor long-term prognosis, with an increase in year mortality 15 times higher than patients without PAD. For patients who smoke, quitting is probably a more effective factor than any pharmacologic therapy to reduce morbidity and late cardiovascular mortality.
These programs also affect quality of life indices, risk factors, endothelial function, and hemorrheologic markers. The drugs used in PAD can be directed at specific treatment of the claudication, in an attempt to achieve increased walking distance, or at the secondary prevention of cardiovascular events, thus achieving a better vital prognosis for these patients.. Secondary Prevention of Cardiovascular Events.
Acetylsalicylic acid. This study, and other similar studies, 27,28 determined that the best therapeutic dose with the lowest digestive risk profile was mg per day. Acetylsalicylic acid, therefore, should be used in all patients with PAD in order to reduce cardiovascular death.
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Importantly, acetylsalicylic acid has not been shown to improve claudication distance or symptoms of PAD Table Clopidogrel is an anti-platelet agent that has been shown to be more potent than aspirin for the reduction of secondary cardiovascular events. The CAPRIE 29 study found that the group in which clopidogrel was more effective at reducing major secondary events ictus, acute myocardial infarction, death was the group of patients with PAD. Whereas the overall reduction of secondary events in the whole series was 8. The combination of clopidogrel and acetylsalicylic acid might be better than monotherapy alone.
Whilst this association has been contrasted in patients with coronary disease, it has not been verified in patients with PAD. As occurs with acetylsalicylic acid, no scientific proof exists that clopidogrel improves the symptoms of intermittent claudication.. The Heart Protection Study 30 compared placebo with simvastatin and found that, in the group of patients who received placebo, the greater number of major secondary events was seen in the subgroup of patients who had PAD.
Peripheral vascular disease: Causes, symptoms, and treatment
The best evidence for the beneficial effect of statins in PAD comes from the more potent drugs simvastatin and atorvastatin. Control of statin toxicity should include the measurement of creatine kinase and the transaminases.. Angiotensin-converting enzyme inhibitors. Specific Treatment of the Intermittent Claudication. This was the first drug approved specifically for intermittent claudication. Its mechanism of action is based mainly on increasing the deformity of the red blood cells, although it also reduces blood viscosity, inhibits platelet aggregation, and reduces fibrinogen levels.
However, the true benefit of this drug is controversial and it has been questioned in different studies. Two meta-analyses have confirmed the discordance of the results and concluded that the benefit of pentoxifylline in intermittent claudication is really small. Cilostazol not available in Spain. This is a phosphodiesterase inhibitor that increases cAMP concentrations inside platelets, and blood cells, inhibiting platelet aggregation. Increased concentrations of HDL-C and reduced levels of triglycerides have also been reported. In these studies the patients who took cilostazol showed an increased claudication distance of m versus the patients treated with placebo.
Pentoxifylline and cilostazol are currently the only 2 drugs authorized by the Food and Drug Administration specifically for intermittent claudication.. Some randomized trials have shown that the patients who received statins experienced an improvement in claudication distance. Specific Treatment for Critical Ischemia. Their mechanism of action is based on inhibition of platelet aggregation and leukocyte activation, with an important vasodilator effect. A recent meta-analysis 4 reported that the patients who received the treatment had a greater survival and a higher rate of limb salvation.
Other recent studies, however, have failed to find that these drugs reduce the risk of amputation. Anticoagulants, hyperbaric oxygen, spinal stimulation, etc, are other alternatives that have been used for critical ischemia. However, only marginal benefit has been obtained with these measures.