CHICAGO, Ill. - As many as 10 million Americans have peripheral artery disease (PAD), but despite the prevalence of the disease, current standards of care for diagnosis and management of PAD are poorly defined, and may be contributing to the overuse of invasive procedures.
The Society for Vascular Surgery has just released much-needed recommendations for the treatment of asymptomatic PAD and intermittent claudication (IC), its most common symptom. The treatment recommendations are evidence-based, patient-oriented and considered best practices by the SVS Lower Extremity Practice Guidelines Committee, a diverse group of eminent vascular surgeons.
The guidelines were published online in the Journal of Vascular Surgery just one day before a story in the New York Times about the over-use of stents in peripheral vessels and exorbitant Medicare payments that have been made to individual physicians as a result.
Though more patients than ever are receiving interventions for PAD, patients without symptoms or with mild-moderate IC seldom need stents or invasive procedures, note Drs. Michael Conte and Frank Pomposelli, who co-chaired the committee. In fact, they stressed, the majority of such patients should be treated with a variety of non-interventional treatments and regular case management by a vascular professional.
Among the recommendations developed by the committee for patients with asymptomatic PAD and claudication were:
- Patient education. A diagnosis of PAD establishes that the patient is at risk for cardiovascular events such as heart attack and stroke, and may be the first sign of atherosclerosis. A careful cardiovascular evaluation, in addition to modification of risk factors such as diet and lifestyle, is a first priority. Patients with asymptomatic PAD or IC are at a low risk for amputation and can be reassured, while being educated about the cardinal signs and symptoms of disease progression.
- Smoking cessation. While Americans tend to know that smoking can cause lung cancer, they may not realize it also affects their circulation. Because the elderly often have multiple health issues, such as diabetes, those with PAD, “shouldn’t smoke,” said Dr. Conte. “That’s like lighting a match at a gas station.”
- Exercise and limb function. Exercise is an effective, non-invasive and inexpensive way to improve leg circulation for many patients with mild-moderate IC. Patients with PAD should begin a walking regimen if they are able to do so and those whose program is managed by a physical therapist or coach are most likely to have the best outcomes. Unfortunately, said Dr. Pomposelli, most insurance companies don’t reimburse patients for those costs. “Our feeling is that most patients should be offered exercise therapy but a lot of the time that’s not being done. People who really get into walking can do remarkably well.”
- Medications for dyslipidemia. Treatment of dyslipidemia, or high cholesterol, with statins reduces the likelihood of adverse cardiovascular events in patients with atherosclerosis. Patients with PAD were designated as high or very high risk for adverse cardiovascular events by the National Cholesterol Educational Program Adult Treatment Panel #3 and are advised to undergo treatment to lower LDL to <100 mg/dL or to <70 mg/dL in very high-risk individuals.
- Selective interventions for IC. Invasive procedures (e.g., angioplasty, stent, or bypass surgery) for more severe claudication are used selectively to reduce disability. Catheter-based approaches and surgical treatments for IC can be effective when properly applied. The committee recommended that such procedures should be considered only in cases where it is more than 50 percent likely that it will be effective for at least two years. The quality of evidence available is unfortunately limited. Shared decision-making is recommended to insure that patients fully understand the risk-benefit tradeoffs for these elective procedures. In no case should asymptomatic patients undergo prophylactic interventions for PAD.
- Case management. PAD patients should receive ongoing case management by a vascular specialist who can evaluate their vascular health over time. PAD should never be treated by a specialist who performs a procedure and then never sees the patient again.
Furthermore, patients need to truly understand the possible benefits and health to be gained from any procedure before they agree to it, Dr. Conte added. “Just because an artery is blocked, that does not justify a procedure if there are no or minimal symptoms.”
Dr. Pomposelli has seen numerous patients who have had more than a half-dozen interventions for leg pain in just a few years. When the stents fail, the failures increase complications and the danger of amputation.
“Some have lost their limbs,” Dr. Pomposelli said. “Patients with walking pain from PAD have a low risk of amputation. When those patients consequently have invasive treatment that results in amputation, that’s never acceptable. That should never happen. Having good treatment guidelines are so important.”
“If you did an ultrasound on every 70- to 80-year-old, you would find that more than 20 percent of them have blockages in their leg arteries,” Dr. Conte said. “But less than 10 percent of those diagnosed with PAD should be offered an aggressive treatment option on the first visit. Unfortunately, some patients are led to think that if they don’t act right away, something terrible is going to happen. They meet with a specialist who tells them there’s no risk to put in a stent, or to undergo removal of the plaque (atherectomy), and it can be done as an outpatient procedure, so why not try it?
“’Why not?’ is not the question,” Dr. Conte said. “The questions should be, ‘Why? How much will this procedure help me, and for how long?’”
“Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs,” New York Times, Jan. 29, 2015.
The Society for Vascular Surgery advances the care and knowledge about vascular disease, which affects the veins and arteries of the body, to improve lives everywhere. It counts more than 5,000 medical professionals worldwide as members, including surgeons, physicians and nurses. For more information about vascular health and the society, please visit the society's website, www.vascularweb.org.