VA Special: Peripheral Vascular Disease

So your patient can’t walk to the mailbox anymore.  “Doc, I have to stop once I get there, and rest 5 minutes before I can move on back to the house.”
You check, and sure enough ABIs are <1 on both sides.
So you’ve made the diagnosis, now what? How can you improve your patient’s quality of life, and prevent loss of life and limb?
  • Lose your Kools: Get him to quit smoking.  It may not improve his walk distance, but it will prevent him from losing that leg and having the heart attack that’s coming.
  • Watch the numbers: These patients are a CV risk equivalent, so treat them that way. BP and Lipid goals are the same as they would be for someone with known CAD.
  • Stop the clot:  Take an aspirin. See above- mostly for prevention of CAD and CVD.  There has been a study (CAPRIE) to compare aspirin with Plavix, and Plavix may actually be more effective at preventing limb ischemia, however comes with higher risk. 
  • Make them feel better (oh yeah, that):  A few things that might improve their walk distance and quality of life:
    • Move it or Lose it.  There is a lot of evidence that exercise helps, but hard to operationalize, like most behavioral interventions.  But, certainly worth talking to your patient about a paced exercise program.  Simple- walk until it hurts, rest, walk some more.  Keep doing this- you will be able to walk farther each time.  
    • Cilostazol: inhibits platelet aggregation, vascular smooth muscle proliferation, and causes dilatation.  Improves walking distance, quality of life, and maybe even improves ABIs.
  • Warm up the OR:  Time for surgery if his function declines despite the above measures, or if he develops ulcer or other sign of limb ischemia.  

Here’s an article for more: Peripheral Vascular Disease NEJM 2007

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s