Non-Invasive Evaluation of Peripheral Vascular Disease 27 th Annual Heart & Vascular Conference Cardiovascular Care for Primary Care Christopher DeMaioribus MD Vascular Program Director Medical Director, Non-Invasive Vascular Laboratory Essential East Health System Objectives Develop a general framework for the clinical and non-invasive evaluation of peripheral vascular disease This framework can be applied, with some differences, to all of the peripheral circulatory beds affected by systemic atherosclerosis Introduction Atherosclerosis is a systemic chronic disease Clinical and non-invasive vascular laboratory evidence of vascular disease should lead to initiation of risk factor modification the only way to affect the cardiovascular morbidity and mortality of systemic atherosclerosis
Risk Factors for Systemic Atherosclerosis Smoking Age Diabetes Hypertension Genetic Hematologic Factors Hyperlipidemia Hyperhomocysteinemia Hypercoagulability Coexistence of risk factors Non-Invasive Evaluation of Lower Extremity Arterial Occlusive Disease Essentia East Non-Invasive Vascular Laboratory Full-time laboratory dedicated to peripheral vascular evaluation (4 sonographers, ongoing quality assurance; approx. 4000 studies/year) Accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) for peripheral arterial, extracranial cerebrovascular, renal and visceral, and venous examinations. SMDC vascular laboratory can be reached at 218-786-8318 Indications for Non-Invasive Evaluation Clinical history and natural history Intermittent claudication Limb-threatening ischemia Other Physical examination Predictive role of ankle-brachial index
Claudication: Natural History 5-year outcomes Limb-Threatening ischemia: Natural History True natural history not known (role of revascularization) For patients with non-reconstructable disease, within 6 months of presentation: 40% limb loss 20% mortality Longer term limb loss and mortality Methods of Peripheral Arterial Evaluation Physiologic vs. Anatomic Imaging Non-Invasive Physiologic Examination Ankle-brachial indices with toe pressures/waveforms Segmental pressures, pulse volume recordings (PVRs), and Doppler velocity waveform analysis (DVWs) -- Lower extremity arterial studies Mainstay of initial non-invasive evaluation Limitations Duplex scanning Microcirculatory tests: tcpo 2 Non-Invasive Anatomic Examination CT or MR angiography Limitations Invasive Arterial Imaging Catheter angiography (diagnostic vs. therapeutic) Limitations
Pulse Volume Recordings and Doppler Velocity waveforms Pulse volume recordings Normal Severe Doppler velocity waveforms Normal Physiologic Arterial Study Pulse volume recordings Normal Physiologic Arterial Study Segmental pressures/ Doppler velocity waveforms
Normal Anatomic Imaging CT angiogram (reconstruction) Inflow (Aortoiliac) Disease Physiologic Study Pulse volume recordings Inflow (Aortoiliac) Disease Physiologic Study Segmental Pressures/ Doppler velocity waveforms
Inflow (Aortoiliac) Disease Anatomic Imaging CT angiogram (reconstruction) Outflow (Femoral-Popliteal-Tibial) Disease Physiologic Study Pulse volume recordings Outflow (Femoral-Popliteal-Tibial) Disease Physiologic Study Segmental pressures/ Doppler velocity waveforms
Outflow (Femoral-Popliteal-Tibial) Disease Anatomic Study CT angiogram (reconstruction) Other Physiologic Studies Digital Photoplethysmography (PPG) More accurate representation of digital perfusion Useful in individuals with medial calcinosis (e.g. diabetes, renal failure) Useful in evaluation of peripheral embolization Other Physiologic Studies Post-Exercise Ankle Pressures Most useful with clinical history of claudication and normal resting pulse exam/resting physiologic studies Pressure drop with exercise
Other Specialized Physiologic Studies Duplex Scanning Lower extremity graft surveillance Surveillance of lower extremity percutaneous revascularizations Revascularization planning Evaluation of possible embolic sources or aneurysms Recommendations for Evaluation of Intermittent claudication Moderate Symptoms + Severe Symptoms Recommendations for Evaluation of Limb-threatening ischemia +
Non-Invasive Physiologic Imaging in Other Vascular Beds Extracranial cerebrovascular Renal Mesenteric Upper Extremity Venous