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Winter 2009

Managing Claudication: Double Threat of PAD and CVD

"Claudication is sometimes the first sign that an individual has cardiovascular disease (CVD), on top of their peripheral artery disease (PAD)," says Michael S. Conte, M.D., chief of Vascular and Endovascular Surgery at UCSF Medical Center. "It's as though they're getting angina in their leg."

Most clinicians recognize that claudication demands treatment and careful monitoring, but Conte warns that patients' fears about limb loss can cause a fixation on addressing leg pain to the detriment of managing all cardiovascular risk factors. It's important, therefore, to reassure patients that claudication does not mean imminent loss of limb. Nearly 70 percent of patients with claudication never progress to critical limb ischemia, much less require an amputation.

Nevertheless, because individual disease progression is unpredictable, a cardiovascular specialist should follow these patients closely. "Most research indicates that up to half of patients with PAD and claudication are not having their cardiovascular risk factors fully managed, or if they are, the targets are too modest," says Conte.

"Global management of cardiovascular risk factors is essential for patients with claudication," says cardiovascular specialist Yerem Yeghiazarians, M.D. That type of management begins with a comprehensive evaluation of risk factors and continues with optimized management of those factors, which includes the most effective medications, where appropriate, for cholesterol level, hypertension and diabetes, as well as lifestyle modification including smoking cessation, a healthy diet and daily exercise that features a progressive walking program.

With this type of management, most patients with claudication can slow the progression of symptoms and improve walking ability. If, however, comprehensive management fails and the patient experiences persistent and worsening disability that limits lifestyle or occupation, then it is important to refer to a center that offers the full range of options for opening the arteries and enabling these patients to walk without pain.

Lack of Guidelines Complicates Treatment Choice

"Though treatment options for underlying arterial occlusion have increased, the choice — especially in the absence of any firmly established guidelines — depends on the location, length, burden of the disease and expertise of the operator," says Yeghiazarians.

Angioplasty represents a less invasive therapeutic option and is often considered as a possible first option; open bypass surgery represents another set of options. Lasers and atherectomies are also choices in select cases, although typically as a precursor to either angioplasty or open surgery.

"To avoid a bias for what's available and known, a team approach is especially important," says Conte. "The correct choice is the key to a quality outcome."

At UCSF Medical Center, where there is access to the full range of potential treatments, an interdisciplinary conference is held monthly in which vascular specialists and cardiologists look at each individual patient's case and decide on a treatment strategy after weighing all the applicable factors.

"We believe these conferences are very important for a systemic disease process that affects every artery from head to toe," says Yeghiazarians.

Finally, says Conte, both before and after any procedure "these patients need to be followed closely because they're at continued risk for the rest of their lives and because the course can be so unpredictable. But if PAD is treated correctly, we can improve quality of life and prevent morbid endpoints."

To contact Michael S. Conte, M.D., call (415) 353-4366.

To contact Yerem Yeghiazarians, M.D., call (415) 353-3815.

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