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Ethan Korngold, MD @ekgpdx
, 10 tweets, 7 min read Read on Twitter
1️⃣#FITSurvivalGuide on Peripheral Artery Disease. #PAD treatment is multidisciplinary, highly creative, and constantly evolving! You can have a huge difference in these patients’ lives. 1/3 of your patients with CAD will also have PAD. Most PAD patients die of MI or stroke.
2️⃣Claudication is the stable angina of the lower extremities. Described as tightness, cramping, heaviness in the legs or buttocks with exertion that improves with rest. Some patients will have atypical or no symptoms. Ask your patients!
3️⃣Critical Limb Ischemia is defined as ischemic rest pain, ulcers, or non-healing wounds. Clinical findings: dependent rubor, elevation pallor, and punched out ulcerations. Urgent angiogram and revascularization is usually indicated to prevent amputation. #CLIFighters
4️⃣Diagnosis starts with Ankle-Brachial Index (ABI)—the EKG of the legs. Noncompressible (>1.4) is abnormal/nondiagnostic; toe pressures can help. If nl ABI but suspicious, consider exercise ABI or a duplex ultrasound—you wouldn’t stop with a normal EKG!
5️⃣Medical therapy saves lives in PAD, and PAD patients are undertreated. Smoking cessation, ASA, maybe clopidogrel, ACE-i, statin. Rivaroxaban may have a role per the COMPASS trial.
6️⃣Exercise therapy works! Tell your patients that walking cannot hurt their legs, and to push through the pain if possible (very unlike CAD). This is a revelation for many. Cilostazol can help in some cases, but is contraindicated in CHF.
7️⃣Indications for intervention: CLI or lifestyle limiting claudication refractory to exercise therapy. Generally useful to have additional imaging such as duplex ultrasound, segemental pressures, or even CTA/MRA prior to angio, but practices vary. From @ACCinTouch
8️⃣Iliac arteries: stents have high technical success and very low restenosis rates. No clear difference outcomes between balloon expanding and self expanding. Covered stents may be useful in complex lesions (COBEST trial).
9️⃣SFA: Many options, little comparative data. Modern therapy includes drug coated balloons, atherectomy (directional, orbital, rotational), and stents (nitinol, interwoven, or drug-coated). Tailor to patient and anatomy.
🔟Below the knee intervention (usually reserved for CLI): Angioplasty and/or atherectomy. Coronary DES useful in focal disease or bailout. The role of drug coated balloons is unclear…Lutonix-BTK trial is pending. Tibiopedal access has revolutionized CTO crossing and treatment.
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