Part 3: Management.

BACK

1) Pharmocotherapy

Although controlled trials on drugs like pentoxyfylline, naftidrofuryl and cilostazol have shown some benefit in walking distance, this benefit is small. There is little data to support the routine use of these agents in all claudicants.

2) Exercise

This is becoming increasingly important as a treatment modality. It can increase initial walking distance by 180% and maximum walking distance by 100%. Supervised programmes are better than unsupervised home walking. The programme should take place for one hour, three times a week for 3 -6 months. The most suitable patients are those with mild to moderate claudication. It can be used for patients with incapacitating claudication if they are not suitable or surgery. Exercise can be adapted to patient mobility but clearly a level of mobility is needed to derive benefit from the exercise programme.

3) Intervention treatment - Surgical and endovascular

These are used for patients with incapacitating claudication or critical ischaemia. With one of these is chosen is determined by the anatomical location and type of atherosclerotic lesion.

a) Aortic - iliac disease

For stenoses < 3 cm long, angioplasty should be used. Stenting is not routinely recommended unless the stenosing plaque is extremely difficult to dilate or the angioplasty result is unsatisfactory or causes a dissection in the artery. For long or multiple stenoses or occlusions, surgery is the better option - usually an aorto-femoral graft. For very high risk patients, a graft is taken from the axillary artery and tunneled under the skin to the groin - an axillo-bifemoral graft. Endovascular techniques have largely taken over from surgery for aorto-iliac disease.

b) Femoro-popliteal disease

Angioplasty gives better results for stenosis or occlusions < 3 cm long and in patients with claudication rather that critical ischaemia. Stenting below the inguinal ligament gives poor results. For multiple stenosis or long occlusions (> 5 cm), the standard femoro-popliteal bypass graft using a synthetic graft or vein (if the distal anastomosis is below the knee) is still the procedure of choice. There is now also an endoluminal femoro-popliteal bypass where by the atherosclerotic plaque is cored out of the superficial femoral artery. This artery is then lined by a synthetic graft which is passed down the inside of the artery and then inflated with a balloon to take the shape of the inside of the artery. This is done through a single groin incision.

c) Proximal and distal disease

For a patient with an iliac artery stenosis and superficial artery occlusion, the current approach would be an angioplasty of the iliac artery lesion and a femoro-popliteal bypass - open or endoluminal. The author's practice is to do this in theatre as a single procedure.

d) Infracrural / infrapopliteal disease.

These are usually the patients who present with critical ischaemia and frequently have disease in the femero-popliteal or even the aorto-iliac segments as well. The commonest method of treatment is by way of a femoro-distal bypass where a vein graft is taken from the common femoral artery to the infrapopliteal artery with the best run-off to the foot - usually the anterior or posterior tibial artery. Angioplasty does have a role at this level of disease mainly for localised disease at the origins of the anterior tibial artery or tibio-perineal trunk.

Summary

The management of PAD is changing considerably, Risk factor management is a very important aspect of management at primary care level. All patients with PAD should be on antiplatelet agents and I think in time will also be on a statin. Supervised exercise programmes are becoming the method of choice for those with mild to moderate claudication. Intervention should be reserved for patients with incapacitating claudication or critical ischaemia. Endovascular intervention is being increasingly used, especially in the aorto-iliac segment.