Peripheral arterial disease effects approximately 20% of adults over the age of 55 with an estimated prevalence of about 27 million people in North America. The risk of peripheral arterial disease increases 2-3 fold for every 10 year increasing age after 40 years old. Unfortunately number of cases due to severity of disease, anatomic location and lack of acceptable targets for revascularization or bypass medical management is the only option available for the patient. Medical management includes correction of modifiable risk factors, walking specific therapy, and other therapeutic interventions.
When the patient is determined to have nonsurgical peripheral arterial disease aggressive risk factor modification , a dressing modifiable risk factors such as smoking control of underlying comorbidities such as diabetes, hypertension and hyperlipidemia are of the utmost importance.
Baseline management of modifiable and manageable medical conditions such as diabetes targeting hemoglobin A1c between 6.5-7.5%. Blood pressure control, maintenance of serum LDL to less than 70 mg/dL, management of triglycerides, and secondary target of non-HDL reduction should also be considered.
Conservative interventions
Smoking cessation:
Smoking and of itself presents at 3 times greater relative risk for development of intermittent claudication and peripheral arterial disease encounter parts, any dose-dependent fashion. Tobacco cessation strategies early and repeatedly through medical management help to decrease the ongoing insult presented by tobacco use. Therapeutic options including cognitive behavioral therapy, nicotine supplementation, and newer novel oral options should be considered and discussed with the patient. Smoking cessation reduces severity of claudication and the risk of developing rest pain.
Exercise therapy:
Exercise improves maximum walking time and overall walking ability in patients with claudication, improved his gait pattern and nonsurgical patient’s, in leads 2 improvement in quality of life similar to OB experience with surgical management. Ideal exercise programs are delivered under supervised hospital-based vascular rehabilitation setting and efficacy is most commonly seen after 2 months of this particular treatment
Medication management
Antiplatelet agents:
The goal of an antiplatelet agent is to delay the rate of progression of peripheral arterial disease, reduce the need for intervention and reduce rate of graft failure following revascularization procedures. Study such as the CAPRIE (Clopridigrel versus aspirin in patients at risk of ischemic events), demonstrate a decrease in relative risk for MI stroke and cardiovascular death in patients treated with 75 mg of clopidogrel.
Lipid lowering therapy:
Statin therapy is considered standard of care in management of the patient with peripheral arterial disease and has been reported to decrease the risk of new onset intermittent claudication and improve pain-free walking distances. Current goal is an LDL less than 70. Statins in conjunction with dietary modification, and treatment to secondary targets of triglycerides and non-HDL are also considered effective in the medical management of lipids in the PAD patient
Antihypertensives:
Hypertension goals specific to peripheral arterial disease is a blood pressure less than 140/90, or less than 130/80 if concomitant diabetes or renal insufficiency. No specific antihypertensives are felt to improve PAD, or claudication in terms of improvement walking distances. Management of hypertension in general helps reduce cardiovascular comorbidities.
Cilostazol:
Cilostazol therapy 100 mg twice a day in the peripheral arterial disease patient is demonstrated to have antiplatelet, antithrombotic, vasodilatory and Anna mitogenic properties. Cilostazol versus placebo as compared in a Cochran Peripheral Vascular Disease Group confirm its efficacy in the claudicating patient with improvements in quality of life scores based on walking impairment questionnaires. The treatment is contraindicated in patients with congestive heart failure and bleeding disorders.
Pentoxifylline:
Pentoxifylline has effect to lower blood viscosity and improve erythrocyte flexibility. It is associated with modest increases in walking distance although overall efficacy is unclear and no longer recommended for use and peripheral arterial disease patients.
Therapeutic interventions
Pneumatic compression therapy:
In patients with symptomatic peripheral arterial disease and critical limb ischemia experiencing claudication, rest pain, ischemic ulcerations there is data to show that conservative management with pneumatic compression in the form of arterial pump therapy is ineffective option which is been demonstrated in clinical trials to increase pain-free walking distance, symptomatology and systolic blood pressure measurements in the lower extremity. Typical regimens for the use of external pneumatic compression typically recommend a 45 minute to one hour treatment twice a day. Short bursts of high pressure in the range of 85- 220 mmHg to the calf is the usual recommended treatment pressure. With improvements being seen typically after. Approximately 16 weeks of therapy. These devices are not related with complications which allow for them to be used for long-term therapy and could be an ideal modality for nonsurgical candidates. The biggest limitations of these devices is currently poor coverage by insurance, currently not covered service by Medicare.
Leave a Reply