04-Peripheral-Artery-Disease-Robert-Hinchliffe-online.pptx

pvd , diagnosis and management

1. Robert Hinchliffe Rachael Forsythe Jan Apelqvist Ed Boyko Robert Fitridge Joon Pio Hong Konstantinos Katsanos Joseph Mills Sigrid Nikol Jim Reekers Maarit Venermo Eugene Zierler Nicolaas Schaper www.iwgdfguidelines.org

2. Peripheral artery disease Any atherosclerotic arterial occlusive disease below the inguinal ligament, resulting in a reduction in blood flow to the lower extremity Diagnosis Prognosis Treatment Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

3. Focus of PAD guidelines Patients with ulceration (highest risk) P atient I ntervention C omparator O utcome Recommendation Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

4. Do we need specific PAD guidelines in people with diabetes? Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

5. Common in DFU (50%) Poor prognosis (wound, limb, patient) Managed by non-vascular specialists (variation) PAD is a spectrum of disease Weak evidence to underpin clinical practice (No RCTs) PAD vascular guidelines – no diabetes focus Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

6. Fundamental questions PAD? Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

7. Fundamental questions PAD? Who revascularise? Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

8. Fundamental questions PAD? Who revascularise? When? Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

9. Fundamental questions PAD? Who revascularise? When? How? Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

10. Guidelines for clinical practice Relevant to generalist and specialist Variation in severity / mode of presentation Variation in distribution of PAD Variation in fitness of patients Revascularisation is beneficial & potentially harmful Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

11. Guidelines for clinical practice Diagnosis (1-3) Clinical exam Non-invasive tests Prognosis (4-9) Non-invasive tests Classification Decision making Treatment (10-17) Vascular imaging Revasc technique Organisation General principles Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

12. Diagnosis (excluding PAD) Clinical examination unreliable Pedal Doppler waveforms + ankle pressure / ABI or toe pressure / TBI measurement. No single modality / threshold optimal Triphasic pedal Doppler waveforms Toe brachial index ≥0.75. ABI 0.9-1.3 (Strong; Low) Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

13. Prognosis (classification) Use the WIfI classification system - Wound - Ischaemia - foot Infection stratify amputation risk revascularisation benefit (Strong; Moderate) Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

14. Prognosis ( be prepared to change strategy) Despite optimal wound and medical care Ulcer not healing in 4-6 weeks → vascular imaging (Strong; Low) PAD + no healing in 4-6 weeks → revascularise (Strong; Low) Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

15. Treatment Aim - direct blood flow to ≥1 foot arteries preferably to anatomical region of ulcer post procedure → objective measurement of perfusion. (Strong; Low) Revascularisation technique based on individual factors. (Strong; Low) Patient access to expertise and facilities d iagnosis PAD revascularisation (endovascular and bypass surgery). (Strong; Low) Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

16. Future research priorities Improve identificaiton of those who benefit from revascularisation Role of novel methods of perfusion assessment? Earlier revascularisation? Angiosome concept Venous arterialisation Novel medical therapies Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

17. Conclusions Clinical examination is unreliable Bedside tests helpful – limitations Optimise other aspects of care Revascularisation decisions complex (heal spontaneously) Be prepared to change strategy if no improvement Slides courtesy IWGDF; available at: www.iwgdfguidelines.org