Peripheral Arterial Disease/ABI Screening

Peripheral arterial disease (PAD) is more commonly known as hardening of the arteries. Peripheral arterial disease screening is done by using the ankle-brachial index (ABI). This ABI screening is painless, quick, and non-invasive. It will identify most cases of peripheral arterial disease.

What you can learn

The ankle-brachial index measures the ratio between the pressure in your arms and that in your legs. This ratio indicates how well blood flows to the legs. A ratio of less than 0.90 indicates plaque buildup and possible peripheral arterial disease. A ratio of 0.90 or greater is considered normal.

The ABI screening is simple and painless. After removing your socks and shoes, you will have pressure cuffs placed around your upper arms and ankles. A small ultrasound device will then measure the systolic blood pressures in your limbs.

Read more

Symptoms and Diagnosis of PAD

The most common symptom of PAD is a painful muscle cramping in the hips, thighs or calves when walking, climbing stairs or exercising.

The pain of PAD usually goes away when you stop exercising, although this may take a few minutes. Working muscles need more blood flow. Resting muscles can get by with less. If there's a blood-flow blockage due to plaque buildup, the muscles won't get enough blood during exercise to meet the needs. The "crampy" pain (called "intermittent claudication"), when caused by PAD, is the muscles' way of warning the body that it isn't receiving enough blood during exercise to meet the increased demand.

Many people with PAD have no symptoms or mistake their symptoms for something else.

To see the symptoms of severe PAD, click here

Study Finds Differences in Care for Patients Beginning on Dialysis

A study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN)says that kidney disease patients
insured by some federally sponsored national health care organizations are more likely to undergo an important predialysis procedure than patients with other types of insurance.

The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis.

To read entire article, click here

Hunterdon Medical Center among first to use artery cleaning device

By: Hunterdon County Democrat

February 14, 2010, 11:06AM

Scott Collins, 45, of Lambertville visited Dr. Andrey Espinoza, interventional cardiologist at Hunterdon Medical Center, last summer in an act of desperation. After suffering from peripheral arterial disease for the past seven years, Collins had grown accustomed to the pain and numbness in his legs that prevented him from walking more than 50 yards without having to take a rest.
Once his legs reached 100% arterial blockage, Collins began to accept the idea that he would likely be a candidate for amputation.
Peripheral arterial disease occurs when plaque builds up on the inside walls of blood vessels, causing a blockage of blood flow to the extremities, and is often associated with high blood pressure, diabetes, heart disease, stroke and aging.
After a short visit with Espinoza, Collins learned that a new device, Pathway Medical Technologie’s Jetstream, could fix his problem. Interventional Cardiologists at Hunterdon Medical Center is now treating patients using a newly FDA cleared device that clears away and removes potentially deadly artery clogging plaque in leg arteries for those suffering from peripheral arterial disease, a chronic condition that affects nearly 12 million Americans.
Collins came back for his procedure and the moment they finished their work, he knew that they had changed his life.
“I was still lying on the table, but I knew the procedure had worked,” Collins said. “My leg began to itch. I hadn’t felt anything in that leg for years.”
Working from his three-story home as an antique reseller is enjoyable again, Collins said, adding he has found freedom in what he deems his “new legs.”
“This treatment represents an innovative and minimally invasive solution to clear blockages in the peripheral arteries, restoring blood flow and effectively treating the disease without surgery,” explained Espinoza, who is the first physician to treat a patient using the device at Hunterdon Medical Center.
The Jetstream Atherectomy System is the first on the market capable of treating an entire spectrum of disease found in the PAD patient, including hard and soft plaque, calcium, thrombus and fibrotic lesions with consistent clinical results. The Jetstream catheter is equipped with tiny rotating blades and a vacuum that cuts through accumulated plaque in the legs and then vacuums away the debris left behind.
This treatment has the potential to reduce procedure time and minimize vessel trauma, which can mean fewer complications for patients. Removing the plaque that has been cut loose also minimizes the potential for that plaque to travel back through the leg’s arteries and cause another blockage.
PAD usually affects adults from age 60 to 80, but patients can be younger. Further, while people with elevated cholesterol, smokers or those with a history of heart disease can develop PAD, many people do not realize they have blocked arteries. Unfortunately, despite the large number of sufferers, traditionally invasive treatments for PAD, such as bypass surgery, coupled with a lack of consumer education, means that PAD is responsible for more than 150,000 leg amputations each year and only about 400,000 patients receive the endovascular intervention they need. In addition, many patients are poor surgical candidates for whom surgery can be life threatening.
Jetstream is now in use at more than 100 centers across the country, including New York-Presbyterian Hospital in New York, St. John Hospital and Medical Center in Detroit, Cardiovascular Consultants of Washington in Seattle, Wellstar Kennestone Hospital in Atlanta and Leesburg Regional Hospital in Leesburg, Florida, and has been used to successfully treat more than 600 patients suffering from PAD to date.
Jetstream offers renewed hope for patients and the benefits of a minimally invasive treatment option, including faster recovery and decreased systemic complications.
For more information on cardiac services at Hunterdon Medical Center call Registered Nurse Nicole Camporeale, heart and vascular care coordinator at Hunterdon Medical Center, at 908-237-5440 or visit hunterdonhealthcare.org.

Vascular Screenings Check for Silent Problems

From: Keeping in Circulation

Most of us know something about heart disease, but many do not know that we need to take care of our arteries as well. These vessels create a "superhighway" of blood flow that takes oxygen-rich blood from the heart to every area of our bodies. It is the buildup of plaque (which is a combination of fat, cholesterol, calcium and other materials) in the arteries, which can lead to more serious health issues such as peripheral arterial disease (PAD), heart attack or stroke.

One way to monitor what is going on with your arteries is to have a vascular screening, which can aid in the early detection of vascular disease. This can be helpful, as many vascular diseases do not have noticeable symptoms as warning signs.

Vascular screenings check for a variety of issues related to the arteries, are painless, non-invasive and involve no radiation. The screenings typically check the:

Carotid arteries – This test uses Doppler ultrasound to check for plaque and assess the rate of blood flow in the arteries of the neck which bring blood to the brain.
Abdominal aorta – This test checks for an enlargement of the abdominal aorta, the largest artery in the body.
Peripheral arteries – This is a non-invasive blood pressure test called the ankle-brachial index (ABI) that looks at the systolic pressure (upper number of your blood pressure) in your arms and legs to check for diminished blood flow.
The screenings are most appropriate for those over age 50 with specific risk factors such as smoking, high blood pressure, high cholesterol, or a family history of heart attack, aortic aneurysm or stroke. If you have diabetes, you are at a particularly increased risk for PAD. The American Diabetes Association recommends that every person with diabetes age 50 and older have a screening for PAD.

Screenings are generally not offered as part of a regular physical examination and most health insurance companies will not cover the costs unless you have symptoms.

As the conditions for which these tests screen tend to be silent in the early stages, there can be benefits to screening when you are at risk. The good news is that there are hospitals and private companies that offer the screenings in the community at low cost and sometimes for free.

Look for a screening event provided in conjunction with your local hospital. Or, look for an event conducted by a private company that has a solid reputation and clearly explains the screenings offered and provides background information on its clinical team.

No screening for any disease is 100 percent accurate all the time. There is always a chance for a false finding. That is why it is important that you share your screening results with your health care provider, who can discuss the findings of the screening with you and make sure you have all of the follow-up that you need.

Rise in Endovascular Therapy for PAD Parallels Improved Outcomes

Key Points:
Endovascular treatment for PAD has waxed as surgery has waned
Contemporary PAD patients tend to be sicker
Nonetheless, decreases seen in major amputations, mortality

From: TCTMD - The Source for Interventional Cardiovascular News and Education
By Kim Dalton
Wednesday, January 13, 2010


Over the past decade, as angioplasty increasingly displaced surgery for revascularization of peripheral arterial disease (PAD), rates of major amputation as well as mortality and other complications declined. The shift occurred despite patients presenting with more comorbidities, according to a study published online January 4, 2010, ahead of print in the Journal of Vascular Surgery.
To evaluate the shift in treatment of lower-extremity PAD and the impact of this trend on different patient groups, investigators led by Roman Nowygrod, MD, of Columbia University Medical Center (New York, NY), analyzed data from the National Inpatient Sample as well as New York State inpatient and outpatient databases on patients at least 40 years old who underwent either surgical or endovascular lower leg procedures or major amputations from 1998 to 2007.
Comparing 2007 with 1998, hospitalizations for invasive treatment of lower-extremity PAD decreased slightly, from 192 to 183 per 100,000 people aged ≥ 40 years. However, the proportion of open vs. endovascular revascularizations changed substantially, with the former declining 67% while the latter almost doubled. Meanwhile, the per capita volume of major amputations decreased by 38%.
Although most procedures were performed for critical limb ischemia, the overall rate of lower-extremity revascularizations in this group declined by 20%, from 93 per 100,000 in 1998 to 75 per 100,000 in 2007. Likewise, the incidence of interventions (endovascular or open surgical) for other PAD diagnoses decreased slightly, from 78 to 70 per 100,000. On the other hand, after a stable period from 1998 to 2002, interventions for claudication increased by almost 50% from 2003 to 2007.
The rate of procedures for critical limb ischemia declined steeply for octogenarians (from 317 to 240 per 100,000) and more moderately for patients aged 65 to 79 years (199 to 160 per 100,000), while interventions for claudication increased for all age groups (≥ 40 years). Meanwhile, outpatient interventions increased for all PAD diagnoses in all age groups.
Differing Fortunes of Open vs. Endovascular Intervention

While the proportion of open procedures decreased, use of endovascular revascularization increased substantially, quadrupling for critical limb ischemia and doubling for claudication.

Over the same period, rates of major amputations declined from 42% to 30% for critical limb ischemia, from 0.9% to 0.3% for claudication, and from 18% to 14% for other PAD diagnoses. Importantly, the improvement in patients with critical limb ischemia occurred despite the fact that they were twice as likely to have diabetes and 3 times more likely to have renal disease as those with claudication. In fact, comparable reductions in major amputations were seen in both diabetics (27%) and nondiabetics (32%).
Complications Decline for Both Revascularization Strategies
Over the study period, even as the prevalence of comorbidities such as CAD, COPD, renal disease, and (among claudicants) diabetes increased, operative mortality rates decreased for both revascularization procedures, as did postoperative cardiac complications, bleeding, and stroke. In addition, the incidence of infection declined with endovascular revascularization.

The mean length of hospital stay also declined over the decade, from 9.5 days in 1998 to 7.6 days in 2007. In addition, 35% of patients were discharged within 1 to 2 days in 2007, compared to only about 16% in 1998.
“Our analysis of national inpatient and outpatient state data supports the trend toward increasing treatment of PAD by endovascular intervention,” the authors write, predicting that given the safety of the minimally invasive approach, the percentage of outpatient procedures is likely to continue to grow.
The investigators caution that “although the decline in amputation rates seems likely due in large part to the increased use of endovascular interventions, other variables are clearly operative, including improved endovascular technology, better diabetes management and foot care, and improving and more ubiquitous application of medical therapies.”
In addition, the study findings are based on administrative data and thus subject to certain limitations, the authors note. For example, the absence of anatomic characteristics and condition variables precluded a careful analysis of treatment groups. Also, the inability to track patients over time meant they could not distinguish primary from secondary interventions, readmission, or complications.
Endovascular Trend Justified
“This is a very important paper,” William A. Gray, MD, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview. “It both validates trends that we have perceived in the [vascular] community and justifies the increased use [of the endovascular approach] that it documents.”
“It’s not surprising that an easier, more accessible procedure is increasing,” Dr. Gray observed. “But that is nicely balanced by the fact that outcomes appear to be improving too—fewer mortalities, morbidities, shorter length of hospital stay. There are also fewer admissions for critical limb ischemia—likely because claudicants are being treated earlier. And treatment of claudicants may be leading to fewer patients with end-stage PAD.”
Though the study only reports hospitalization trends, “it speaks to the improvement in surveillance and care that these patients have been getting over the past decade, which is quite striking. This translates into a lot of saved limbs and lives,” Dr. Gray said, adding that it also reflects changes in the training of vascular surgeons, who are increasingly receiving instruction in endovascular techniques from fellow surgeons, as documented in a recent study in the Journal of Vascular Surgery.

Source:
Egorova NN, Guillerme S, Gelijns A, et al. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg. 2010;Epub ahead of print.

Disclosures:
Drs. Nowygrod and Gray report no relevant conflicts of interest.

Pathway Medical Technologies Receives FDA 510(k) Clearance For JETSTREAM G3™ Atherectomy System

From: Medical News Today

Pathway Medical Technologies, Inc., an innovator of endovascular treatments for peripheral vascular disease (PVD), announced that the U.S. Food & Drug Administration (FDA) has granted the company 510(k) clearance to market JETSTREAM G3™, its newest peripheral revascularization catheter for the treatment of PVD. With a new distal cutter and enhanced aspiration efficiency, JETSTREAM G3 offers a significant improvement in cutting and removing disease as compared to previous versions. JETSTREAM G3 is used for treating the entire spectrum of disease found in the PVD patient, including hard and soft plaque, calcium, thrombus and fibrotic lesions.

"JETSTREAM G3 is the next step in atherectomy treatment for peripheral vascular disease. These enhancements incorporate a new state-of-the-art cutter that will enable physicians to treat PVD more quickly, safely and effectively than any of the existing technologies," said Pathway Medical Technologies President and CEO Paul Buckman. "Over the past twelve months Pathway has made significant advances to our atherectomy system. We believe that JETSTREAM G3 now represents the definitive treatment for all lesion morphologies, including calcium and total occlusions. We are fully committed to the continued development of innovative medical devices for the treatment of vascular disease."

"The JETSTREAM device is a highly effective technology for the treatment of occlusive and thrombotic peripheral arterial disease," stated Tom Shimshak MD, an interventional cardiologist and Director of the Cardiovascular Laboratory and Medical Director of the Cardiovascular Institute, Wheaton Franciscan Healthcare, All Saints, Racine, Wisconsin. "The advances in the cutting tip and increased power in the JETSTREAM G3 device will be particularly desirable for long, diffusely diseased segments, including calcification, chronic total occlusions and traditional 'no-stent' zones."

JETSTREAM is a peripheral revascularization catheter designed to remove all kinds of artery-clogging plaque in the lower limbs of patients. This innovative and minimally invasive solution clears blockages in the peripheral vasculature, restores blood flow and effectively treats PVD. JETSTREAM consists of a sterile, single-use catheter and control pod and a reusable, compact console that mounts to a standard I.V. stand. The catheter has an expandable cutting tip that safely debulks and preemptively removes both hard and soft plaque, as well as calcium, thrombus and fibrotic lesions. Excised tissue and thrombus are continually aspirated from the peripheral treatment site through ports in the catheter tip to a collection bag located on the console. The distal portion of the catheter also possesses infusion ports that provide continuous infusion of sterile saline during the atherectomy procedure. Active aspiration is a safety feature that minimizes the risk of distal embolization.

With simple set up and an ergonomic design for easy operation by trained clinicians, JETSTREAM maximizes treatment effectiveness and offers renewed hope for non-surgical candidates and the benefits of a minimally invasive treatment option, including faster recovery and decreased systemic complications.

Screening the Legs for a Serious Condition

January 8, 2010
Screening the Legs for a Serious Condition
Diane Fennell
From: www.diabetesselfmanagement.com/Blog/Diane-Fennell


Researchers in Canada are recommending that people over age 40 be screened for peripheral arterial disease, or PAD, a condition of the legs and feet that is associated with a higher risk of complications such as heart disease, stroke, and lower limb amputations. People with diabetes are more likely than those in the general population to develop PAD, which affects roughly 8–12 million Americans.

The condition, which is characterized by a narrowing of the arteries that supply blood to the legs, typically causes cramping, pain, or tiredness in the legs, particularly when walking or exercising; numbness, tingling, or coldness in the lower legs or feet; and infections in the legs or feet that heal slowly. In some people, however, symptoms are very mild, and in others there may be no symptoms at all.

Ross Tsuyuki, PharmD, MSc, and his colleagues at the University of Alberta looked at 362 people over age 50 who had visited pharmacies and doctors’ offices in Central and Northern Alberta. After extensive screening, 17 people, or 5% of the participants, were diagnosed with PAD. Significantly, 80% of those diagnosed had not previously been aware that they had the condition.

According Dr. Tsuyuki, “The pain some PAD patients experience is the lower limb equivalent of the chest pain from the heart. PAD is as serious as heart disease and its prevention and treatment is similar. It’s unique in that it manifests in the legs but is just as urgent.”

Screening for PAD is a painless and relatively simple procedure that involves comparing the blood pressure in the leg to that in the arm. The American Diabetes Association (ADA) recommends that people who are over 50 and have diabetes be screened for PAD even if they have no symptoms and that people under 50 who have risk factors such as smoking, high blood pressure, high cholesterol, or a history of diabetes longer than 10 years also receive screening.

To learn more about Dr. Tsuyuki’s research, read the article “Angina In The Legs? Time To Alert Patients And Physicians.” And for more information about PAD, see “When Your Legs Ache: Peripheral Arterial Disease and Diabetes.”

Doctors aim to increase awareness of peripheral arterial disease

Peripheral arterial disease is one of the most common types of cardiovascular disease - and also one of the least publicized, health officials say.

According to Dr. Robert Wilkins, a board-certified cardiovascular specialist with Southern Heart Center, a service of Hattiesburg Clinic, this lack of awareness could be deadly.

During September, which is "National P.A.D. Awareness Month," Wilkins and his colleagues Drs. Craig Thieling, Ben Rester and Randel Smith, are committed to increasing the public's knowledge of this disease.

P.A.D. affects about 10 million Americans and occurs when the arteries in the legs or other non-heart arteries become narrowed or clogged by fatty deposits or plaque. The buildup of plaque causes arteries to harden and narrow, a process called atherosclerosis. When leg arteries are hardened and clogged, blood flow to the legs and feet is reduced.

The most common type of P.A.D. is the extertional leg pain, burning or tightness known as "claudication."

When not diagnosed and treated early, this may lead to a severe decrease in leg blood flow, a condition known as "critical leg ischemia," a condition that can result in a possible amputation.

P.A.D. is a warning sign that other arteries in the body, including those in the heart and brain, may also be blocked.

This condition is associated with a high risk of heart attack, stroke and death.

Unfortunately, many people may not recognize their leg pain symptoms as P.A.D.

"People were not aware of the risk factors for this disease, the increased risk for heart attack and stroke associated with this disease, or simple diagnostic tests which can identify this disease," Wilkins said. "In addition, many people are not aware of the numerous non-surgical, minimally invasive treatment options for this disease."

Southern Heart Center has now developed a special P.A.D. treatment team including: cardiovascular medicine physicians and endovascular specialists, acute care nurse practitioners, physician assistants and nurses.

Southern Heart Center also has a number of events scheduled throughout September to increase public awareness of P.A.D.

These events include speaking to senior and civic organizations, presenting at Forrest General Hospital's Spirit of Women luncheon, and working with primary care providers in this region.

The center also will sponsor three vascular disease screening events. The screenings will be provided in Hattiesburg, Picayune and Magee.

"Our cardiovascular physicians have made themselves available to speak to any organization which wants to learn more about this very serious but often treatable disease" said Ken Smith, Southern Heart Center's administrator. "They are very passionate about the need to increase public awareness of the diagnosis and treatment of peripheral arterial disease."

For more information, visit www.hattiesburgclinic.com or call Southern Heart Center at 268-5800.

Shammi Kapoor speaks about his battle with the little-known disease

By: Hemal Ashar Date: 2009-08-06 Place: Mumbai




Celebrities are notorious for keeping their guard up, not letting the world see that their star (literally) has dimmed, that they are human after all. So former star Shammi Kapoor deserves a double yahoo for letting his defences down and giving the world a peek into his frailties.

The actor was at the Breach Candy hospital on Tuesday afternoon, along with a clutch of doctors to raise awareness about peripheral vascular disease. The relatively little known disease occurs when there is a blockage of blood flow from the artery to organs other than the heart.


In familiar territory

The SoBo hospital is familiar territory for the actor, (also a kidney patient) who takes regular dialysis at the hospital. Shammi is also a Chronic Obstructive Pulmonary Disorder (COPD) sufferer, where his lungs have been compromised. He arrived in a wheelchair; and ribbed the docs at the press conference, "Ah, you all are wearing ties today." He then asked in jest, "What do you want me to talk about? The last time I winked at a girl? Okay, okay, I will tell you about my experience with vascular disease."

Lost toes

The flamboyant Kapoor was afflicted with the disease last year. He said, "I lost a toe on each of my feet to vascular disease. I was saved from losing my limbs by timely medical treatment." He then revealed how he heard the doctors who were operating on him in the operation theatre. "I was given local anaesthesia, so I could hear the docs speaking: "Here I found it, hey milaa vein, oh artery.

The pain was so bad, I started shrieking, an anaesthetist clamped my mouth shut." He said gesticulating wildly to laughter by the docs. The docs admitted that Shammi started bleeding while the operation was on and his thigh had swelled to twice the size, underlining the gravity of this disease.

Finally, Shammi when urged to give a message to mark Vascular Awareness Day on August 6, told people to take timely medical help, with the same flourish he delivered lines like Chahe koi mujhe jungli kahe on screen.

What is peripheral vascular disease?

Peripheral artery disease (PAD) is a heart condition similar to that of coronary artery disease and carotid artery disease. In PAD, the fatty deposits build up in the inner linings of the artery walls. These blockages restrict the blood flow circulation, mainly in arteries leading to the kidneys, stomach, arms, legs and feet.
In its early stages, a common symptom is cramping, or fatigue in the legs and buttocks during activity. Such cramping subsides when the person stands still. This is called “intermittent claudication.” People with PAD often have fatty buildup in the arteries of the heart and brain. Because of this association, most people with PAD have a higher risk of death from heart attack and stroke.
There are two types of these circulation disorders:
Functional peripheral vascular diseases don’t have an organic cause. They don’t involve defects in blood vessels’ structure. They’re usually short-term effects related to “spasm” that may come and go. Raynaud’s disease is an example. It can be triggered by cold temperatures, emotional stress, working with vibrating machinery or smoking.
Organic peripheral vascular diseases are caused by structural changes in the blood vessels, such as inflammation and tissue damage. Peripheral artery disease is an example. It’s caused by fatty buildups in arteries that block normal blood flow.
How is peripheral artery disease diagnosed and treated?
Techniques used to diagnose PAD include a medical history, physical exam, ultrasound, X-ray angiography and magnetic resonance imaging angiography (MRA).
Most people with PAD can be treated with lifestyle changes, medications or both. Lifestyle changes to lower your risk include stopping smoking, diabetes control and blood pressure. Become physically active; eat a low-saturated-fat, low-cholesterol diet.
PAD may require drug treatment, too. Drugs include medicines to help improve walking distance, antiplatelet agents and cholesterol-lowering agents (statins).

Peripheral Arterial Disease (PAD)

Peripheral Arterial Disease (PAD) is also known as atherosclerosis, poor circulation, or hardening of the arteries. PAD progresses over time at variable rates in each individual depending on the area of circulation effected and one's health and family history. The signs and symptoms of PAD may not arise until later in life. For many, the outward indications will not appear until the artery has narrowed by 60 percent or more.

One method the body uses to adapt to the narrowed arteries is the development of smaller peripheral arteries that allow blood flow around the narrowed area. This process is known as collateral circulation and may help explain why many can have PAD without feeling any symptoms.

When a piece of cholesterol, calcium or blood clot abruptly breaks from the lining of the artery or a narrowed artery blocks off completely, blood flow will be totally obstructed and the organ supplied by that artery will suffer damage. The organs in PAD most commonly affected and researched are the legs.

What happens if the disease worsens?

The severity of PAD depends on when it is detected and any pre-existing health factors; especially smoking, high cholesterol, heart disease or diabetes. In the later stages, leg circulation may be so poor that pain occurs in the toes and feet during periods of inactivity or rest. This is especially true at night. This is known as rest pain, which usually worsens when the legs are elevated and is often relieved by lowering the legs (due to the effects of gravity on the blood flow).

Critical Limb Ischemia

The most advanced stages of PAD can lead to Critical Limb Ischemia (CLI) . Here the legs and feet have such severe blockage that they do not receive the oxygen rich blood required for growth and repair of painful sores and even gangrene (dead tissue). This condition, if left untreated, may require amputation.

PAD | Are You at Risk for Peripheral Arterial Disease?

PAD | Are You at Risk for Peripheral Arterial Disease?
Tuesday, July 21, 2009
From: thebpmonitor.com

You walk a block, then clutch your leg with what feels like a charley horse. You stop, and the pain does too. The discomfort may be a warning of a common yet serious condition called peripheral arterial disease (PAD).
In PAD, the same fatty material that can clog heart arteries builds up in the arteries of the legs, blocking blood flow. The risk for death from heart attack or stroke is six to seven times greater in people with PAD is equivalent to the risk of someone who has had a heart attack or stroke. Without prompt treatment, one in four people with the condition will suffer a heart attack, stroke or amputation or die within five years.
PAD is most often recognized when it causes claudication and fatigue, cramps, tiredness or pain in the leg or buttock muscles that goes away when you stop walking. Less frequently, it can cause ulcers or slow-healing wounds on the feet or toes, or pain in the feet or toes that disturbs sleep. However, as many as half to two thirds of those with the condition have no symptoms.
As with coronary heart disease, key risk factors for PAD are having diabetes, smoking or having smoked, and being over age 50. “If you have no other risk factors, age alone will increase risk and yet risk rapidly increases even in younger people who smoke or have diabetes,” says Alan T. Hirsch, M.D., professor of epidemiology at the University of Minnesota School of Public Health in Minneapolis. “We want people to recognize that if you are over 50 and have any other risk factor, you have a one in four chance of having this disease.”
Also at risk are African Americans and anyone with chronic kidney disease, high blood pressure, high blood cholesterol or a personal or family history of vascular disease, heart attack or stroke. An estimated 8 to 12 million people in this country have PAD.
If you have risk factors, talk to your doctor, whether or not you have symptoms. The PAD Coalition, a consortium of health organizations and government agencies, recommends that those at risk get a quick, painless, accurate and inexpensive diagnostic test called an ABI (ankle-brachial index).
The good news: PAD is both preventable and is very treatable. “PAD is a common and serious disease, which merits immediate and lifelong attention,” says Dr. Hirsch. “Become informed and take actions to protect your health.” Arms for Legs While exercise is helpful for people with PAD, walking is a typical workout for sufferers but can also be painful. Diane Treat-Jacobson, R.N., Ph.D., assistant professor at the University of Minnesota in Minneapolis, has done studies on the effects of exercise on people with this disease.
She recently discovered that supervised training using aerobic arm exercise was as beneficial as treadmill walking in improving walking distance. Treat-Jacobson notes that while results are preliminary, arm exercise might be a pain-free option that can “help break the cycle of disability or enable patients to start exercising sooner after a surgical procedure.”
Remember that peripheral arterial disease is both preventable and very treatable, but it is a a common and serious disease which merits your attention if you have any of the symptoms addressed in this article.
It is up to you to become informed about this disease and take active action to protect your health.

Saving limbs with drug-eluting stents

July 16, 2009
Saving limbs with drug-eluting stents
Filed under: Uncategorized — reducedapmiami @ 1:55 pm

Attempts to explore deprecatory limb ischemia in peripheral arterial disorder (PAD) patients with unworthy of-the-knee angioplasty are still thwarted by restenosis (the re-narrowing of the artery at the situate of angioplasty or stenting), the extremity due to the fact that replay treatments and the continued progression of atherosclerotic complaint, leading to tissue death (gangrene) and amputation.

Interventional radiologists have been studying a potential solution - the use of drug-eluting stents - and have found that these types of stents lessened the rate of repeat procedures to open these small arteries, according to results presented at the Society of Interventional Radiology’s 34th Annual Scientific Meeting.

“This is encouraging news for PAD patients with critical limb ischemia. The smaller blood vessels below the knee are more difficult to treat due to their size (3 millimeters) and are more prone to reclog than larger vessels. The use of drug-eluting stents in the tiny infrapopliteal arteries of the leg may significantly impact their care,” said Dimitris Karnabatidis, M.D., assistant professor of interventional radiology at Patras University Hospital in Rion, Greece. “Drug-eluting (or drug-coated) stents have emerged as a potential solution to the limitations of endovascular treatment of PAD patients with critical limb ischemia,” he added. An interventional radiologist performs a balloon angioplasty to open a clogged blood vessel and then places a drug-eluting stent in that artery. The stent acts as scaffolding to hold the narrowed artery open. Drug-eluting stents slowly release a drug for several weeks to block cell proliferation or regrowth, thus inhibiting restenosis.

Researchers from a single center studied 103 patients in a double-arm prospective registry who had critical limb ischemia and who underwent infrapopliteal revascularization with angioplasty and placement of either a drug-eluting stent (with sirolimus, an immunosuppressant drug) or a bare-metal stent (without a drug coating). The patients had regular follow-ups up to three years, and researchers studied how they did by stent type. In the first group, 41 patients (75.6 percent diabetics) were treated with bare-metal stents, and in the second group 62 patients (87.1 percent diabetics) were treated with drug-eluting stents.

At three years, those patients with drug-eluting stents had “significantly higher patency” (length of time the blood vessels stayed open and moved blood flow efficiently); reduced restenosis of the vessels; and consequently less clinical recurrence requiring repeat angioplasty, said Karnabatidis. “In the drug-eluting stent group, an estimated 60 percent of the treated arteries remained open at three years. This is significantly longer than the bare-metal stent group, where the arteries remained open only approximately 10 percent at 3 years,” said Karnabatidis. “This corresponds to a more than 5 times increased risk of vessel reclogging when bare metal stents were used,” he added. “Because of the reduced vessel restenosis, repeat angioplasties were necessary in only 15 percent of the patients in the drug-eluting stent group versus almost 35 percent in the bare-metal stent group up to 3 years - this being the equivalent to an almost 2.5-fold risk of repeat procedures in the case of bare metal stents,” noted Karnabatidis. “These statistical results are based on three-year adjusted survival analysis after application of a Cox model for multivariable analysis,” he explained.

If a person has critical limb ischemia, it means he or she is at great risk for tissue death due to lack of blood flow, which carries oxygen and nutrients to the cells. The severely restricted blood flow results in severe pain in the feet or toes, even while resting, and sores and wounds that will not heal. Tissue death (gangrene) and amputation are imminent at this advanced stage of PAD, which is caused by atherosclerosis, the hardening and narrowing of the arteries over time due to the buildup of fatty deposits called plaque.

“Multicenter randomized trials are necessary to support these promising results and build on the level of clinical evidence supporting the integral value of infrapopliteal drug-eluting stents in critical limb ischemia treatment,” he added. In the United States, drug-eluting stents are FDA-approved for the coronary arteries but not for infrapopliteal arteries. In Europe, drug-eluting stents have CE Mark approval for below-the-knee use.

http://www.sirweb.org/

Critical Limb Ischemia

From Woundresearch.com

Critical Limb Ischemia
PUBLICATION DATE: Aug 01 2008
Issue:
8

author:
Laura Bolton, PhD, FAPWCA

Dear Readers:
Critical limb ischemia (CLI), the most severe stage of peripheral arterial disease, affects 250,000 new patients annually in the United States with an estimated 40% requiring amputation within 12 months of a CLI episode, in addition to an annual mortality rate of more than 20%.1,2 Distal bypass surgery prompts healing of lower extremity ulcers associated with CLI if resulting arterial patency supports skin perfusion pressure of at least 35 mmHg.3 Surgical bypass of the occluded arterial segment improves3,4 and extends primary arterial patency, though there is insufficient evidence to support improved amputation rates or mortality compared to most other modalities.4 What options are available to the individual for whom bypass surgery is no longer feasible? This month’s Evidence Corner reviews two studies evaluating efficacy of modalities for treating CLI in patients without further vascular surgery options, as the search for an effective treatment of CLI continues.
Critical Limb Ischemia
Reference: Kavros SJ, Delis KT, Turner NS, et al. Improving limb salvage in critical ischemia with intermittent pneumatic compression: a controlled study with 18-month follow-up. J Vasc Surg. 2008;47(3):543–549.
Rationale: Intermittent pneumatic compression (IPC) is a noninvasive method of increasing arterial circulation and ameliorating intermittent claudication in patients with peripheral arterial disease (PAD).
Objective: Evaluate clinical efficacy of IPC in patients with chronic CLI, nonhealing foot ulcers, and minor toe or transmetatarsal amputation after further options for arterial revascularization had been exhausted.
Methods: This retrospective cohort study compared two similar groups, each consisting of 24 consecutive patients, for whom further surgical bypass was not an option, and were cared for in a multidisciplinary community clinic from 1998–2004. Resting ankle-to-brachial ratios of systolic blood pressure (ABI), sitting transcutaneous oximetry (TcPO2) duplex graft surveillance, and foot radiography confirmed vascular status. Both groups received weekly debridement and biologic dressings for tissue loss and nonhealing amputation wounds of the foot due to CLI. Intermittent pneumatic compression allocation was based solely on a patient’s willingness to use it. The IPC inflation pressure was 85 mmHg to 95 mmHg and was applied for 2 seconds with a 0.2-second rise, 3 cycles per minute, for three 2-hour daily sessions. Adherence was monitored closely. Healing outcomes were “favorable” if complete healing with limb salvage occurred during 18 months. Outcomes were considered “adverse” if nonhealing caused below-knee amputation during that time.
Results: Groups were comparable at baseline on all arterial and wound parameters; prior amputation and comorbid factors were assessed. Four patients (17%) in the control group and 14 IPC (58%) patients healed (P < 0.01). The likelihood of limb loss in the control group was 7 times that of IPC subjects who also increased in TcPO2 (P = 0.0038).
Authors’ Conclusions: When used within a protocol of standard wound care, IPC significantly improves clinical healing and below-knee amputation outcomes of patients with inoperable CLI. This research sets the stage for rigorous prospective, multicenter, randomized, controlled trials (RCTs) of IPC to establish its role in healing while clarifying its indications for use.
FGF-1 Gene Therapy Decreases Amputation Rates in Patients With CLI
Reference: Nikol S, Baumgartner I, Van Belle E, et al. Therapeutic angiogenesis with intramuscular NV1FGF improves amputation-free survival in patients with critical limb ischemia. Mol Ther. 2008;16(5):972–978.
Rationale: Although controversial, with its long-term effects under scrutiny, angiogenic growth factor therapy has been proposed for treatment of critical limb ischemia in end-stage PAD. Acidic fibroblast growth factor (FGF-1) is a potent mitogen for vascular endothelial cells, inducing blood vessel formation in vitro and in vivo. A plasmid-based gene transfer delivery system for FGF-1, NV1FGF with “Conditional Origin of Replication” (pCOR), reduces the potential for propagation in the host environment while sustaining local FGF-1 production permitting less frequent treatment.
Objective: A Phase 2b, double blind, randomized, placebo-controlled clinical trial investigated the efficacy and safety of intramuscular NV1FGF versus placebo in subjects with CLI at high risk of amputation.
Methods: A European multicenter trial screened 125 patients with CLI ineligible for revascularization as confirmed by a vascular surgeon. Each patient had at least 1 nonhealing ulcer, a TcPO2 £ 20 mmHg, ankle pressure
£ 70 mmHg, and toe pressure £ 50 mmHg. Patients were randomly assigned to receive 8 intramuscular injections of 2.5 mL NV1FGF in a 0.2 mg/mL solution (n = 59) or similar placebo injections (n = 56) on study days 1, 15, 30, and 45. Percent of patients with at least 1 ulcer completely healed at week 26 was the primary outcome. Secondary outcomes TcPO2, ABI, amputation, and death were evaluated at week 52.
Results: Among 107 subjects evaluated for healing, 19.4% of NV1FGF-treated and 14.3% of control patients healed during 26 weeks (P = 0.514; not significant). Likelihood of amputation or of major amputation was reduced in the NV1FGF group (P = 0.011), which also experienced improvement in time to death or major amputation. No other secondary outcomes were statistically significant. Adverse events were comparable in both groups, supporting the safety of NV1FGF.
Authors’ Conclusions: This was the first double blind, prospective RCT in patients ineligible for bypass surgery. Despite the fact that no improvement in wound healing was seen it showed the potential for NV1FGF to significantly reduce amputation risk, potentially lowering mortality rates in these high-risk patients.

Clinical Perspective
Both publications aim to improve the lot of patients with serious vascular impairment, using either biochemical or physical modalities. Plasmid gene transfer of NV1FGF administered once every 2–3 weeks for the first 7.5 weeks of care appears to save limbs, though its effect on ischemic ulcer healing remains uncertain. Other plasmid growth factors either lack healing and amputation effects5 or heal wounds without reducing amputation.6 The capacity to save limbs in high-risk patients for whom surgery is no longer an option is equally compelling for NV1FGF and IPC. Limb salvage plus the healing benefits of properly applied IPC are unprecedented, although it was a small retrospective study and was potentially biased by selection of IPC-willing patients. Larger prospective RCTs on patients with CLI, perhaps comparing IPC with and without NV1FGF, would seem necessary. As a physical modality, IPC may be compatible with gene or biochemical therapy. These studies open potential care options for patients with CLI who are faced with possible amputation.

References:
1. Dormandy J, Heeck L, Vig S. The fate of patients with critical leg ischemia. Semin Vasc Surg. 1999;12(2):142–147.
2. Dormandy J, Mahir M, Ascady G, et al. Fate of the patient with chronic leg ischaemia: A review article. J Cardiovasc Surg. 1989;30(1):50–57.
3. Tsuji Y, Hiroto T, Kitano I, Tahara S, Sugiyama D. Importance of skin perfusion pressure in treatment of critical limb ischemia. WOUNDS. 2008;20(4):95–100.
4. Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD002000.
5. Powell RJ, Simons M, Mendelsohn FO, et al. Results of a double-blind, placebo-controlled study to assess the safety of intramuscular injection of hepatocyte growth factor plasmid to improve limb perfusion in patients with critical limb ischemia. Circulation. 2008;118(1):58–65.
6. Kusumanto YH, van Weel V, Mulder NH, et al. Treatment with intramuscular vascular endothelial growth factor gene compared with placebo for patients with diabetes mellitus and critical limb ischemia: a double-blind randomized trial. Hum Gene Ther. 2006;17(6):683–691.

PVD Study

Objective: We studied the effectiveness of a screening program for peripheral vascular disease (PVD) carried out by trained renal nurses in patients with and without diabetes on continuous ambulatory peritoneal dialysis (CAPD).

Patients and Methods: We recruited 30 stable diabetic and 30 stable non diabetic CAPD patients into this cross-sectional study. Trained renal nurses measured the patients' ankle-to-brachial systolic pressure index (ABI) using a Doppler ultrasound machine and their foot vibration perception (VPT) using a biothesiometer, and administered a questionnaire on foot symptoms. An ABI < 1.0 was regarded as abnormal and suggestive of the presence of PVD. An ABI < 0.7 or > 1.3 was regarded as severely abnormal. Findings for VPT were classified as normal or abnormal. Patients were then followed for 1 year for any overt development of clinical PVD, leg complications, and other vascular complications and for clinical outcome.

Results: The mean age of the patients was 63 ± 9 years, and the ratio of men to women was 1:1.3. An abnormal ABI was seen in 22 patients (37%). The questionnaire detected clinical PVD symptoms in 3 patients. Abnormal ABI and VPT findings were more frequent in diabetic patients. After 12 months of follow-up, patients with an abnormal ABI (and particularly those with a severely abnormal ABI) were more likely to develop leg complications and any type of cardiovascular disease than were patients with a normal ABI. Foot vibration perception had no predictive value on subsequent development of leg complications. When risk factors including age, ABI, and VPT were analyzed by logistic regression, only ABI was a significant independent predictor of subsequent lower-limb vascular complications [odds ratio (OR): 21.0; 95% confidence interval (CI): 2.35 to 187.0; p = 0.00064]. The OR for moderately abnormal ABI was 13.0 (95% CI: 1.015 to 166.3); for severely abnormal ABI, it was 27.4 (95% CI: 2.35 to 187.0, p = 0.0045).

Conclusions: Measurement of ABI by Doppler ultrasound is a useful and effective screening test for PVD in CAPD patients. In this study, VPT was not shown to be predicative of future leg complications, indicating that peripheral neuropathy plays a less important role in the development of such complications. Our results proved that trained renal nurses can play an active role in detecting foot problems in renal patients by ABI measurement.

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