Evaluation and Management of Intermittent Claudication and Chronic Limb Threatening Ischemia

During Monday morning’s session on Essentials of Endovascular Therapy, Dr. Jessica P. Simons of UMass Chan Medical School presented information on evaluating and managing intermittent claudication and chronic limb-threatening ischemia (CLTI). She began by providing an overview of peripheral arterial disease (PAD), which is estimated to affect over 200 million people globally. “The prevalence is increasing too,” she said, “due to both the aging population and the increase in diabetes, among other factors.”

Dr. Simons then outlined the differences between IC and CLTI. IC is a single-level disease, with a risk of limb loss < 1% per year and a 5-year mortality of 30%. The goal of therapy in IC is to improve quality of life and physical function. CLTI, on the other hand, is a multi-level disease, with a risk of limb loss >20% per year, and a 5-year mortality of 60%. The goal of CLTI therapy is limb preservation. “These differences dramatically influence patient counseling and treatment algorithms,” she said.

Dr. Simons then took a deeper dive into the symptoms, vascular risk factors, physical exam and testing, management, therapy options, and follow-up for IC and CLTI. Symptoms of IC are exertional and reproducible, and distribution of leg symptoms suggests level of disease (eg, buttocks, aortoiliac; thigh, iliofemoral; calf, femorpopliteal; and foot, tibial). Vascular risk factors of IC include smoking, hyperlipidemia, hypertension, coronary artery disease, diabetes, and a family history of premature coronary disease. Physical exam and testing include a complete pulse exam including insonation of doppler signals if nonpalpable, bedside ankle-brachial indices ABIs), and noninvasive testing (ABIs, segmental pressures, and pulse volume recordings). Management, exercise therapy, and follow-up were also discussed. “The gold standard is considered supervised exercise therapy,” she said. “But my experience has been that the quality of the counseling provided about ET largely dictates the success of unsupervised ET. Home-based exercise therapy offers several advantages for the patient. When this counseling is done well, a significant proportion of patients will have a positive outcome and avoid the need for procedure.”

The symptoms of CLTI include rest pain classically described as metatarsalgia, often at night when supine, or numbness; and ulceration and/or nonhealing wounds, where the location varies depending on concomitant problems. Vascular risk factors for CLTI are the same as for CI. Physical exam for CI patients includes a complete heart and lung exam, bilateral assessment for loss of normal skin appendages, a complete pulse exam including insonation of doppler signals if nonpalpable, and bedside ABIs. Testing includes bilateral lower extremity vein mapping and formal noninvasive testing (ABIs, segmental pressures, and pulse volume recordings). Patients must be informed that CLTI is a life-threatening problem, and it’s important to assess their preferences and social support.

In summary, Dr. Simons said that CI is not a limb-threatening problem, risk factor modification and smoking cessation are imperative, as are a 3-month period of exercise therapy. CI requires a lot of counseling to properly select patients who require and will benefit from revascularization. As for CLTI, it is limb-threatening problem, and risk factor modification and smoking cessation are imperative. Expeditious workup is needed to determine surgical candidacy and revascularization options, and Global Vascular Guidelines are an invaluable comprehensive resource for this complex disease.