Clinical Evaluation of PAD After Prior Intervention

 

Introduction

 

Clinical surveillance of patients with PAD can be divided into two distinct categories:

  • Those who have asymptomatic PAD which is currently treated with medical therapy alone
  • Those with PAD who have undergone prior intervention (endovascular or surgical).

This is a critical distinction since early diagnosis and reintervention are important to ensuring long term durability of endovascular procedures.

 

Note

Background

There is no schedule for follow-up which has been shown to be ideal.  It depends upon the nature of the intervention, severity of underlying disease, and patient specific factors such as likelihood of compliance.

How I Do It

I generally see my patients back for check-up and ABI’s at 1 month, 6 months, and annually thereafter.

Clinical surveillance starts with a good comprehensive vascular examination and screening ABI’s

Patients who are symptomatic, or patients who are asymptomatic but demonstrate either abnormal or deteriorating ABI’s, or abnormal clinical exam, undergo additional non-invasive testing in preparation for secondary intervention.

Other forms of non-invasive imaging – usually Doppler US, but occasionally CTA or MRA – help to define the role of endovascular vs. surgical therapy, and to characterize the location and nature of any necessary endovascular re-intervention  which can drastically reduce contrast dye load and radiation exposure.

Patients who are asymptomatic and demonstrate normal or stable near-normal ABI’s are counseled in lifestyle modification and evaluated closely for arterial disease in other parts of the body.

I have a much lower threshold for secondary intervention than for primary intervention in PAD for several reasons:

  1. First, these patients have a high risk of developing recurrent disease
  2. They have already been symptomatic, so restenosis or reocclusion is likely to result in recurrent clinically significant manifestations for the patient.  This differs from patients with PAD in whom no prior intervention has been performed, because we don’t know if progression of disease in such a cohort will be well compensated or not.
  3. Treatment of a restenosis is technically easier than treatment of a reocclusion.
  4. Risk of  complications such as distal emboli, thrombosis or dissection is lower with treatment of a stenosis than with treatment of occlusion.

Conclusion

Close clinical surveillance with physical examination and screening ABI’s is essential to ensuring long term patency for vascular interventions in patients with PAD.  Asymptomatic recurrence is very likely to progress to symptomatic disease in previously treated patients.  Early recognition and re-intervention of recurrent disease is technically easier to perform, should result in reduced contrast dye and radiation exposures, is more likely to succeed and is safer than secondary intervention in advanced recurrent PAD.

 

References

  1. None

 

Author

Jason E. Himmel, MD

 

 

Disclaimer: The information above is not intended to represent a thorough or exhaustive reference of any topic.  There are nuances to every clinical situation which may render this information irrelevant, impractical or inappropriate. It is the sole responsibility of any practitioner to interpret the information provided on this website with utmost caution. There is simply no substitute for good clinical judgement.

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