Clinician-to-Clinician Update Clinician-to-Clinician Update

Integrated Care Produces Successful Outcome in Patient with PAD

August 2016

Contributed by Abdi Jama, MD, and Alan T. Hirsch, MD

Many patients with complex vascular diseases require a broad-based approach to care to achieve best outcomes and an improved quality of life.1, 2 A step-wise approach that employs both medical and invasive strategies of care can help successfully manage arterial or venous diseases. Most patients with peripheral artery disease (PAD) or venous diseases can achieve excellent outcomes through medical care alone.

Treatment

A 55-year-old man presented with severe left calf claudication, which limited the distance he could walk pain-free to less than one-quarter of a mile. His history was significant for current smoking, and his primary care clinician was treating his hypertension, hypercholesterolemia, and type 2 diabetes. The patient was diagnosed with PAD, indicated by his left leg ankle-brachial index of 0.50. He underwent a Gardner-Skinner exercise ABI stress test to verify his functional status and to provide target goals for exercise training. A duplex ultrasound was also performed, which demonstrated a focal stenosis of the left superficial femoral artery. The patient agreed to join our Wellness and Exercise Program for Life (WEL) in order to participate in our supervised exercise training for patients with PAD. The program provided information and support that allowed him ultimately to achieve complete smoking cessation. After 3 months, his pain-free walking distance had doubled to one-half mile, and he indicated much greater self-confidence. The patient wanted to increase the distance he could comfortably walk. We therefore recommended and he agreed to endovascular left leg revascularization via paclitaxel-coated balloon angioplasty. Two weeks after this procedure, he reported that his claudication was “cured” and he can now walk 2 miles per day. Risk reduction goals have been fully met.

August-2016-Heart-Care-Case-Study-Article-Couple-Holding-Hands
— Participation in a supervised exercise program has been shown to improve the distance patients with PAD can comfortably walk. (Patient not pictured.) ©iStock

Discussion

Most patients with PAD and lifestyle-limiting claudication can markedly improve their walking distance via participation in the WEL PAD supervised-exercise program. Management of patients with PAD and intermittent claudication in a supervised exercise regimen has been shown to improve the distance patients can walk by 50% to 200% and is equal to or superior to all other claudication therapies.3 Participation in our PAD supervised exercise program also helps patients normalize their atherosclerosis risk factors, allowing them to stop smoking, lower blood pressure, and improve their lipids levels and glycemic control. Care plans can be individualized to combine exercise with cilostazol or with endovascular revascularization. This patient benefited from muscle re-conditioning, along with femoral artery revascularization via use of a paclitaxel-coated balloon. Use of a drug-coated balloon achieves a higher primary patency rate than does use of angioplasty alone (82% versus 52%; p<0.001), with an associated improvement in pain-free walking distance.4 New to the endovascular armamentarium, drug-coated balloons can potentially reduce the need for stenting in the superficial femoral artery, thus avoiding in-stent restenosis and stent fractures, inherent to stenting in this area.

References

  1. Olin JW, et al. Peripheral artery disease: evolving role of exercise, medical therapy, and endovascular options. J Am Coll Cardiol. 2016;67:1338-1357.
  2. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130:333-346.
  3. Lane R, et al. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2014;7:CD000990.
  4. Tepe G, et al. Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease: 12-month results from the IN.PACT SFA randomized trial. Circulation. 2015;131:495-502.
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