Hello, I'm Christy Willocks again, and this is part two of our peripheral artery disease module. In this module, we're going to talk more about medical treatment and intervention for peripheral artery disease. These are my disclosures. So in this set of slides, I hope that we are able to learn more about goal-directed medical therapy. We're going to look at different patterns of disease and peripheral vascular disease. We're going to look at three different classifications of how to intervene. The first will be your claudication type patients. The other will be chronic ischemia and then acute limb ischemia, and then how best to evaluate for patients for ongoing risk factors beyond the point of their vascular intervention. Here are our reading materials if you really want to dig in. So the first thing we're going to talk about is for your patient with peripheral artery disease, what is goal-directed medical therapy? So I'll tell a funny on me. The very first time I saw GDMT in a chart, I had no clue what that meant. I was used to, I guess 20 years ago, we called it evidence-based medicine. So now we've moved to GDMT. I Googled it. I was able to become informed. So I'm comfortable with the term now. But more importantly, what does that mean for our patient? That means for peripheral artery disease patients that we want to put them in structured exercise programs. We want to have them modify their lifestyle to have a healthier lifestyle. We want to make them stop smoking. We want to treat their risk factors, including diabetes, hypertension, and cholesterol. And there's also some medications that we can give to these patients. So what does it mean to have a structured exercise program? And this was something that was defined by the ACC and AHA in the guidelines they published in 2016. These are programs that specifically take place in a hospital or outpatient facility. They are supervised programs, meaning you need to have a health care provider on site. This works best with cardiac rehabs, where you already have everything set up. Training is defined as a minimum of 30 to 45 minutes. You want them to be in training at least three times a week. And they do recommend about 12 weeks of exercise therapy. The goal with therapy is to have them walk, rest, walk, rest. You're trying to push through that claudication so the patients can get better and walk further. Now, there are tons of trials. You could do hours of talks on how well people do with exercise, but we all know that. Lots of trials in the PAD category show that 18 months all the way out to seven years have demonstrated long-term benefit for these patients that have been involved in exercise programs. CMS or Medicare will pay for this. You have to structure it just right for up to 36 sessions. And you can even re-up and try to get the patient enrolled a second time if you show that there has been improvement. So all of that sounds really great, but the reality of structured exercise programs is you cannot always get your patient to participate. They may not be willing to invest the time or effort to come. Where we are here locally, people drive an hour, hour and a half sometimes for their appointments, so they're certainly not going to do that three and four times a week. They may not be healthy enough to walk on the treadmill or to do any exercise. So in that situation, what we recommend are a home program. These are for sure less successful, but they're better than not doing anything at all. And the goal with your home program is to be sure you give your patients very specific plans and goals to achieve with walking. For example, if it's a primary sedentary patient, I will start out with something as simple as, I want you to do heel raises. I want you to do it three times a day after you eat a meal because you can remember that. So it can be as simple as that. Also have them get the exercise bands, and we do some pushing resistant exercises. And then you can also prescribe different distances of walking and just have them push beyond that claudication. So if you're going to do a home program, do ask him to come back in a few months and you can check back and say, hey, how are you doing? Are you sticking to it? Try to get the family involved. There's always a spouse or someone in the family that's willing to kind of get that patient motivated. Next up is smoking cessation, and this is where if we had a dollar for every patient we told to stop smoke, we could all retire very young, but we still have to try. You have to tell them every visit that smoking is something that you absolutely cannot do if you have peripheral heart disease. It is just like putting accelerant on an already burning disease. You want to involve the patient in the discussion of how best to help them stop. There's medications out there, Chantix, Welbutrin, nicotine replacement therapy. All those are fine things, but if the patient is truly, truly motivated, a lot of times they do better just stopping. You may want to refer them to assistance program. You want to ask them if people in their home might try to help them out and not smoke. Always review the health benefits of smoking cessation. Most of them know these things. They're just not willing to do it. And then tell them of all the nice things that they can own and buy if they weren't spending their money on cigarettes. Occasionally that'll work. But here again, reality of it is they'll usually kind of come back with I'm perfectly healthy. I've smoked all my life, just like this lady here. But again, best efforts at smoking cessation. What other risk factors do we want to focus on? One, we want to focus on glycemic control. If their A1C is less than seven, we've been shown that we make micro and macro events less. Remember where we're talking about the innermost layer of that artery and the damage that the high sugars and cholesterol can cause. That's all about prevention at this point. When we have better blood sugar control, we're less likely to lose limbs. We're less likely to get wounds. If we control their cholesterol, tons of studies out there. You've got the heart protection study. You have the regress study. All of these studies showed that statins and better cholesterol decrease the risk of vascular events and cause plaque regression. Even if they come back at you with, hey, my cholesterol is great. I don't know why you have me on this medication. It's all about keeping what you have stable, decreasing embolic events and different things like that, that the benefit of statins will gain that patient. We want to control their blood pressure. Several studies, including HOPE, showed some benefit to PAD patients with use of ACE inhibitors. We know there's different goals for patients with blood pressure with diabetes versus non-diabetes. How can we prevent a wound? A lot of this is education to the patient to try to help them not get the wound to begin with. Because a patient with peripheral heart disease, once they have that wound, sometimes it spirals. It's hard to kind of control. We want to ask the patients to look at their feet every day. If they have someone in their house that can look at the bottom of their foot, if they can't do that anymore, that's a good idea. We ask them not to walk barefoot. We want them to use good shoes. If they're diabetics, of course, prescriptions for diabetic shoes. I highly, highly encourage podiatrist care. A lot of our PAD patients have very thick nails that are very hard to take care of. And I have had more than two or three patients, primarily men. They'll get out their pocket knife and they'll decide to trim around their nail. And once they get in their tissue and get a wound, that's never a good thing. So I always say, hey, have you thought about a podiatrist instead of your pocket knife? Early recognition of wounds and cellulitis is imperative. You don't want to see the patient once the toe is black or they have active infection. You want to get a hold of that in advance if possible. So some medical therapies per guidelines. As you all probably know, Class I means that's the best classification you can get for treatment going on down to Class III. So for Class I treatment for antiplatelet, they recommend aspirin and or Plavix to decrease cardiovascular risk and PAD risk. The CAPRI trial showed that Plavix, if you're going to use monotherapy and you went with just Plavix, there was 24 percent risk reduction in Plavix versus aspirin alone. So if you're going to pick one pill over the other, there has been some shown benefit of choosing Plavix or Copretagril over just the aspirin. Now, if your patient is asymptomatic. And their ABI is less than point nine, it's still reasonable to give them some form of antiplatelet therapy. But if you move over to 2B, if they're asymptomatic and their ABIs really aren't that abnormal, not really sure aspirin or Plavix is indicated. And then the 2B over here is talking about dual antiplatelet therapy being able to reduce limb related events in patients with symptomatic PAD post-intervention. I would say that almost always if a patient has had an intervention within a certain time frame, the immediate time frame, we always use dual antiplatelet therapy in those patients to prevent restenosis. Some other medications, statins, we talked about cholesterol management, blood pressure medications, decreasing cardiovascular risk. Your ACE and ARB are kind of at the top of that blood pressure list. Oral anticoagulants, the use of these medications is felt to be class 2B. And that is in the situation of post-vascular bypass. Said it was uncertain if it helped. But again, a lot of our patients that have intervention, they'll either be on dual antiplatelet therapy or they'll be on oral anticoagulation. Oral anticoagulation happens more frequently if the patients have had return disease and return interventions. So at the top of this list here, this is more for symptomatic relief, is your Celastazole or Pletol. It's felt to be an effective therapy to improve symptoms, help them walk a little bit further. And I'll talk quite a bit more about that particular medication. Pitoxaline is also an option, but it gets a class 3 here and it's not felt to be effective for patients. Occasionally, we'll have some patients here that are desperate to try anything and they do not want invasive measures. So we will give them Trentol. I can't say it usually helps, but it's something to try. But this here documentation says it's really not that beneficial to patients. Occasionally, you'll have people that will ask you about chelation therapy. It's also not been found to be very beneficial. So let's talk a little bit more about Pletol. It is a phosphodiesterase inhibitor. You should always tell your patients that because they're going to want to know. But I always tell patients that what Pletol is, is a blood slicker and a blood vessel dilator. And so it works by helping us push the blood, get the small areas of cells down into our collateral flow, down to our feet. And that works best if we take the medication and we walk with it. So that's the part that they kind of hold on to is, okay, I'm on a blood slicker. It's going to push those blood cells down to the bottom of my leg. And they can kind of comprehend that a little bit better than phosphodiesterase inhibitor. Initial studies showed that even though these patients may not have improvement in their ABI scores, they may have improvement in their quality of life and the distances that they're able to walk. A recent survey showed that at least 20% of patients discontinue due to side effects. I would say that that's completely correct. Most patients stop the medication because of, I would say, headaches, diarrhea, some irregular heartbeats. So it's not tolerated by everyone. The medication is given 100 milligrams twice a day, 30 minutes before you eat or two hours after you eat. If patients do have stomach side effects, I've found that going to 50 twice a day is enough to help some patients with claudication while not really upsetting their stomach. It is a medication that has lots of drug interactions. So you have to consider that. This medication is not indicated if the patient has active bleed, of course. And then you have to consider, do you already have the patient on dolanoplatelet therapy? And do they have to have that because they had a recent stent? So you kind of have to weigh which medication would be best for your patient. We do not give this in patients with heart failure. They tend to swell and not do well. We do not give it in patients that have rhythm issues and or if they have renal kidney disease or liver disease. So there's some indications where we just really want to avoid this particular medication. But it's always good to initially introduce it and try, see if you can get the patients to walk while they're taking this medication. I do usually tell people that if you're going to have some benefit of this medication, we want to give it about anywhere between three to six weeks. So don't expect that you take a pill and all of a sudden your symptoms are gone. So Xarelto or Rivoxaban are in the most recent guidelines for peripheral heart disease treatment. This can be taken twice a day with an aspirin and has been shown to reduce major adverse cardiovascular and limb related events in comparison to just taking aspirin alone. Now, common sense here, when you take a blood thinner, you're going to have some increased risk of bleeding. But if you're going to pick a drug, the Rivoxaban alone didn't help with major adverse effects of cardiovascular events, but it did help with major limb events. So if you have a patient that you're kind of scared to put them on two drugs for whatever the reason may be, both the Rivoxaban and aspirin, and you're looking mostly at leg stuff, then the Rivoxaban may give you more risk reduction overall. Another study that they did with Xarelto is Voyager, and this is in patients that have been revascularized already. They give the lower dose 2.5 BID, you give that with aspirin, and it has been shown to decrease risk of acute limb ischemia, major amputations, ischemic stroke, death than just aspirin alone. Again, your bleeding risk are going to go up, but you kind of have to weigh the risk benefit ratio of taking this medication. And I would say probably in the last several years, we're seeing more of this come into common place, especially in your post-procedure patients, and especially in patients that have issues with patency taking traditional dual antiplatelet therapy. So a couple other medications to talk about. One is Zontivity. It is a protease-activated receptor inhibitor. It is used in combination, however, with aspirin and Plavix. So test results or study results show that it does reduce hospitalizations for acute limb ischemia or the need for urgent revascularization. But you're putting a patient on triple therapy, Zontivity, aspirin, Plavix, and or another agent in order to get this benefit. So it's not something I would say is common. I think it's an additive layer of treatment for these high-risk patients. And then lastly on this list is Repatha. Great risk reduction with these type of medications. So even in your patients that have fairly well-controlled cholesterol, if you really want to push them further, 40% risk reductions in patients that took Repatha with peripheral vascular disease. So that's a great reduction there. So let's talk about disease patterns. So there's several classic patterns that these people can present with. The first is aorta iliac disease. That tends to happen more frequently in younger patients. They will have bilateral hip and buttocks pain. So think about, tell the patients your blockage is not going to hurt exactly where the blockage is, but it's where the muscles are that you're not getting the blood flow. So these patients will come in with hip and buttocks pain. They will have decreased femoral pulses. You should be able to hear bruise in a lot of patients. Now, a subset of these patients are those with Lorechi syndrome. That means they have occluded aorta. They present with claudication, impotency, and absence of pulses. So that's kind of a subset of this disease. These patients can be treated with a surgery, which is aortic biofem biograph, or they can be treated with stenting. And both do very well with treatment for a really long period of time. The next is aorta iliac and femoral palpateal disease. So we didn't really leave a whole lot out. If you have disease at the top portion here, your aorta iliac, and then you have disease down here, the only thing you have left is this part right here. But when these patients come to you, they're usually very, very symptomatic, almost, if not to the point of critical lemischemia, because they have so much disease in different segments of the artery. They typically have all of your risk factors, and they are more at risk for developing critical lemischemia if they're not already there. So in picture A, this is a thing of beauty. When you work in peripheral vascular disease, you never really get to see a beautiful aorta iliac. Everything there just looks great. Everybody looks more like B. Can you see the calcification on the arteries? You see the occlusions? And then here you see this person's already had a bypass. So this is a more common pattern for patients with critical lemischemia, is that they'll have multiple segments of disease. Isolated femoral popliteal disease. These patients will present with calf claudication. So think about this is the segment that they don't have blood flow. They're going to tend to hurt down here in the calf muscle. They will typically be a little bit older. You can feel their femoral pulses just fine, but this person should not have a really good right distal pulses. Your patients with isolated SFA disease are less likely to develop limb loss or ischemia, especially if they have a patent profunda. And the profunda, as you remember from the first video, it's their lifeline that lives up here, comes around, and it's trying to reconnect. So we get some blood to that lower part of that blood vessel. These patients do respond well to exercise therapy, pleat tall, because we can strengthen that collateral flow. If that doesn't work, they also make good candidates for stenting and or surgical options with a bypass. We always still want to talk to these patients about the type of disease that they have and the procedure that they'll end up having and the length of time that that procedure may help them. Femoral popliteal disease, which we usually just call that disease below the knee. These are the patients that are highest risk for limb loss over time. The reason that they're at highest risk is because there's not a whole lot of options. By the time we get to the arteries below our knees, they're very small. These patients tend to be diabetic patients too, which means the vessels are uniformly diseased. These tend to be your older patients. They don't make good targets for bypass. And when you're trying to do intervention with balloons and stents, it's a long way from your access point in a really, really small vessel. So even if you do balloons and things like that, the likelihood of that intervention lasting a really long time are not great. It's something you do in order to treat a wound, and then you kind of move on to the next thing. So what are the tools that we have for intervention? And this slide is not to say, gosh, you need to know what all these things are if you're not gonna do peripheral vascular disease, but it's just to say, remember how many medications we had, just a handful. The market for things that we have available to treat peripheral artery disease, venous disease has completely exploded in the last 10 years. There's four or more different types of balloons, compliant, non-compliant, cutting, drug-coated, stents. Remember how excited everybody got when we had coronary drug-coated stents? We were equally excited when we got drug-coated peripheral stents. We've got stent graphs. We've got tools that are obvious, which is an ultrasound for inside of the artery that we can use that will tell us about blockages, atherectomy and mechanical thrombolysis. These are devices that we use to help break up the disease and remove that plaque to return the flow to normal. And then of course you have some bypass graphs there too. So lots of options for interventional tools that we didn't have 15, 20 years ago for sure. So we're gonna now go into when did we revascularize patient in which segments? So if the patient has claudication, we wanna follow one set of guidelines or train of thought versus critical versus acute. So let's first start talk about patients that have just claudication. If a patient comes to you with claudication, there's only a 10 to 15% chance that they will progress to critical limb ischemia if we treat them right. So the first thing you don't wanna do is scare them to death and make them think their leg's gonna fall off because that's not always what happens. But if you are encouraging them to walk and stop smoking, you might wanna say, hey, your risk is higher than the average person to kind of help you with that. If a patient has claudication, you wanna treat them with goal-directed medical therapy first. You might wanna try them on some medication. You wanna ask them to walk. You wanna make sure their cholesterol is treated, give them aspirin or Plavix. You wanna do all of these things. Now, also from an insurance standpoint, some insurances more than others are not gonna want you to rush this patient off to an intervention. They want you to think about what medical options you can put in place before you jump there. You want to choose patients that have decreased quality of life and limiting symptoms because of their peripheral artery disease. I can't walk and do my job. I can't play with my grandkids. That is the number one reason why you should consider intervention. If a patient is on the couch and they only go to the kitchen or something like that, or the bathroom, it doesn't mean that they are not worthy of treatment, but if they don't hurt when they do those things, you're not likely to make them a whole lot better by doing an intervention. You should still put those patients on goal-directed treatment. You wanna select a patient that has the most favorable risk-benefit ratio, meaning you don't wanna eliminate people with severe renal disease, but you don't wanna do a procedure involving contrast or die with a creatinine of three and cause another problem. You don't wanna choose a patient that has a hemoglobin of six or seven that's gonna need to be on blood thinner. So you have to kind of weigh out, even sometimes before you make a referral, hey, do I really feel that this patient will benefit from intervention? You wanna talk to them about the long-term efficacy of the procedure that they're gonna have performed. So aorta iliac disease, as we talked about before, those people do great for a really long time. SFA disease, when we intervene on those, that disease can return, especially if patients aren't active and they're not taking their medications. And then below-the-knee disease, again, a very short relief period with some of these. You want to figure out which patients would be best for referral, whether it be endovascular or surgical intervention. But really, if you feel like the patient has lifestyle-limiting symptoms, that's a good go point for your referral if you think they're a good candidate. So the second class of patients are your critical limb ischemia patients. Critical limb ischemia, again, defined at ABI less than 0.5, 0.4 some institutions. But these are the patients that come in usually with rest pain. They may have even developed some neuropathy related to the lack of flow. What you wanna do in these patients is restore some flow back to their foot, and or especially if they come to you with a wound. Your goal is to get at least single-line blood flow back down to the foot. You want to always, and I would ask that no matter what line of work you're in, if you have a patient that you're in contact with and they're talking about amputation, always consider preferred disease before you consider the amputation. And that's why it's important to know the providers in your area, who does what, who's good at what, because you want to be able to say, hey, we did everything we could for this patient before they had that amputation. And it may be that treating their artery would preserve a limb, then that's a victory for everybody. So let's talk about a case study in a patient with chronic limb ischemia. This fella is 84 years old. Risk factors include high blood pressure, cholesterol, diabetes for 20 years. He's got a creatinine of 2.0. He used to be a smoker. We got one to quit, victory. Three to six month history of increasing pain in his ankle and foot with walking. He developed a wound at the dorsum of his foot from an injury with expansion despite wound care. His APIs were non-compressible, which means that's not very helpful. We know he has atherosclerosis, but we do not know what his flow is. So we go down to the TBI or the Toe Brachial Indexes and they were at 0.2. We got arterial duplex on that patient that showed distal vessel disease because of the creatinine of two, we want to avoid CTAs and MRAs. So this is actually this patient's wound. Sorry to those of you that just ate lunch, but it's kind of a mixed pattern wound and he had been in aggressive wound care and we weren't getting anywhere quick. So these are his pictures. The first picture you see the very top portion of his SFA. Remember the SFA is the artery that goes from your groin to your knee. This is a beautiful, nice artery here. On this is the distal part of that artery. Again, a little bit of blockage right in here, but overall it's big, it's beautiful, it's nice. And it's not what is causing the problem. The next set of pictures here were below the knee, below the level of the popliteal. And this is where you see your tibial peroneal trunk and that branches off to three vessels. But you can see in this little film here that he had an occlusion of the anterior tibial, the peroneal, all of his vessels had some area of blockage. So when you go over here to look at what he was getting to his foot, it's a little wispy, but it's not a whole lot. Now to kind of back up a little bit, this particular patient did not get that CT or MRA because of the creatinine. So critical limb ischemia, sometimes you may skip a step, especially if there's an urgency of that wound. So this is a little snippet of his intervention. The first thing that was treated was the anterior tibial. And then we have a little video here of how his flow is improving to his foot from that view. And you can already see over here after the stent intervention here, how you can see a little bit more flow beyond the knee there. Final picture here of a posterior view, you see that the patient at least has single vessel runoff to that foot in order to try to help heal that wound that he had. So what are our goals for these patients that have ulcers? You wanna help them with their pain, you wanna improve their wound healing, you wanna get them up and walking. And the number one thing is we wanna prevent amputation. If the patient has a large wound like that that doesn't heal, we know that will result in amputation. And if you have amputation, then that increases the patient's risk of mortality. With patients with critical limb ischemia, in the short term, the mortality risk go up by 10% and their amputation risk is increased by at least 12%. These are the group of patients that revascularization or getting that patient to the endovascular or vascular surgeon is the first line treatment for these patients because we want them to get blood flow to that wound to try to heal the wound. Now, that's not the only thing you wanna do, you wanna make sure their blood sugars are controlled, go back through all the other things that you would do for every other patient, but getting these patients a little bit quicker to the cath lab or surgical suite is what you wanna do. After this patient's revascularized, you wanna make sure they stay in wound care. Peripheral vascular disease is rarely ever a one and done kind of thing. So every couple months or every few months, you wanna see how are our ABIs doing? How is the wound doing? So we're gonna move on to acute limb ischemia. So this is one of those things where we don't ever wanna miss it. Remember the slide with the purple leg, you wanna remember your five Ps of ischemia. Even if you can only remember two or three, if they come in with a purple, pulseless leg with extreme pain, you know that this patient has acute ischemia. The definition of acute ischemia means that they have had pain for less than two weeks. These are patients that you want them seen by a specialist quick. You don't wanna call for a consult in the office three months later. It's too late for that. These are usually treated as emergency and just like heart. How many studies and times have we talked about, you know, time is muscle, similar situation where if a patient has a complete and total occlusion of an artery, you only have four to six hours before tissue death starts. The timing intervention depends on the immediate threat to the patient. The most common interventions for this particular type of patient is often a catheter directed thrombolysis. I'll talk a little bit more about that in our example versus surgical thrombectomy. And that's where they do a cut down of the vessel and go in and try to get the clot out. The longer the patient is ischemic, increases the risk of amputation. Of course, that's just common sense. But once you've kind of gone through the acute phase with this patient, it's your job to figure out what happened. Have they had a recent intervention? That's what we see most frequently. They had a recent intervention and that has occluded. But it also can happen in patients that have AFib. Do they have a shunt? Do they have a vegetation? Do they have a hypercoagulable state that's not been diagnosed? Do they have a cancer, which puts them in the hypercoagulable category? You want to really look to see why this person had an acute emergency, because it's not something that should happen. This is a chart that kind of tells us where we are on the spectrum of preserving that limb function. We start out, of course, as viable. You see the patient, they're in pain, you have some discoloration, but you still have a little capillary refill, meaning you squeeze that big toe and you see what happens. You can still move the foot. They can still feel your touch. You may get a signal, both arterial and venous signal. If you go all the way down to irreversible, the patient will not have capillary refill. They will develop literally rigor where they are not able to move their toes or the front part of their foot. They won't be able to feel your touch and you will not get any Doppler signal. Usually by the time you get down to the bottom of this chart, the patient's not gonna be helped by any kind of intervention and those are gonna be your amputation patients. So a case study for acute limb ischemia. 82-year-old female, no history of coronary disease. Risk factors include high cholesterol, high blood pressure, still smoking. She's not a diabetic. Kidney function is normal. She presented with worsening claudication. ABIs were less than 0.4. The patient was treated surgically with a left femoral to popliteal bypass two weeks prior to her most recent admission. She presented after eight hours of worsening left foot pain and discoloration. Her sensation and movement were intact, but she was noted to have coolness in modeling. Patient was not really sure she took her dual antiplatelet therapy, which is usually a good indication she was not probably taking her medication. So this is a little trick play here. The actual patient had left foot, but I like the picture of this right foot better because I think it adequately represents what this particular person would come in with. You see where the discoloration starts at the toe and it kind of works its way up. And you can just imagine that's not gonna be a warm foot. You can begin to see again where they'll lose the mobility of their toes, which you can't see that in the picture and the modeling will kind of start going up the leg. So this is a foot that you really wanna be concerned about and for sure don't send it out of your urgent care, your ER without further evaluation. Now, if the foot comes in looking like this, our goal is to prevent this. These are patients that have come in after a really long time. Sometimes we'll see this in patients that are in nursing homes or things like that. They'll come in with this and there's not a whole lot that you can do with that particular foot. Again, sorry if that makes you sick. So in this particular little lady, we took her to the cath lab. And what we saw is what we suspected was that she had acute occlusion of her left femoral to popliteal graft. So you can see the little area kind of where things were supposed to be and they were not. You go over here and what treatment was chosen for her was an ECOS catheter. That is an infusion catheter where we put TPA into the area where the blockage is. The ECOS actually is ultrasound that kind of helps get that TPA into where that clot is. The downfall for the patient is they have to be in bed for about 24 to 36 hours before we do a rebook angiogram. In that time period, we're doing PTs, we're looking at their fibrinogen, their HNH. So it's kind of a long process for the patient. But again, it's effective. So we go over here to where we can see now how pretty that is. That bypass graft is back. She's got three vessel runoff almost. So we ran into a little bit of issue down here at the level of her ankle. And we decided to get fancy and try to get that section opened up too. You can kind of see a little bit better right there. And then we got a little bit further and there was another little blip in the road. And that's where we use aspiration thrombectomy technique again, trying to get all of that clot that's broke loose from that acute occlusion, get all of that out there so you can get blood flow to the foot. So again, you can see where it kind of stopped there. Another device to keep that blood, trying to get it all the way down to the toes. And then this is the final picture. SFA or bypass graft, three vessel runoff. We don't have any stop marks in the ankle or the foot. And we've got that blood all the way down to the toe. So that is a good success for that patient. But it doesn't stop there because you have to teach the patient that you need to take the medication. So for a patient that's had peripheral artery disease, what kind of things do we need to do? This is going to vary quite a bit based on what procedure they had done and who the interventionalist is, when you want to follow up. Sometimes it depends on how they presented. Are they a patient with claudication versus acute limb ischemia? Usually for surgical revascularization, you want to look at ABIs at least in three months with an ultrasound. And then usually every six months after that. Stenting patients, somewhere between the three to six months, you're going to look at ABI testing, talk to them about, are you walking? Are you taking your cholesterol medication? Are you taking your joint and platelet therapy? Just because they've had their disease treated, they need to understand you're not done. Again, PAD is not a one and done. So all the things that got them there, the smoking, genetics, they can't do a whole lot about. They really need to work on those things. If they were not exercising before, I always stress, you've got to move because our body depends on demand. So if you're moving your legs, you've got a new stent or you've got a new surgical graft in there. If you move, the need for that graft is increased. So you're more likely to have a better long-term outcome. The patient will need likely some kind of dual endoplatelet therapy. Again, depending on your proceduralist and depending on what they had done. We do try to avoid triple therapy in these patients. If you do use triple therapy, meaning if you do Aspirin, Plavix, Eloquus, or whatever combination, you want to do that as brief as possible because our goal is not to get these patients back with bleeding. Patients with peripheral artery disease are always at risk for restenosis and progression. Again, where we're telling people that they have to try to change the way that they live in order for these vessels to stay open. So in conclusion, peripheral artery disease has a very set structured base of treatments that you want to try for everyone with peripheral artery disease. The timing of intervention, again, is classified by different types of, are they only having claudication? Are they in the critical limb ischemia bracket or are they in the acute limb ischemia? And how you treat those patients will be how they fall on that continuum. Our treatment goals are based on trying to prevent worsening wounds and amputation. And please, please, please always get a team involved before we take somebody's limb. When we see a patient with limb ischemia, acute limb ischemia, we have to interact very early to help that patient do well in the longterm. That concludes module two on peripheral artery disease. If you have any additional needs to look at references, here are our references. And if you have any questions, please email academy at medaxiom.com.

peripheral artery disease

structured exercise programs

smoking cessation

medications

blood pressure control

revascularization

acute limb ischemia

complications