January - April 2008 Issue
Leg Pain May Indicate Blocked or Narrowed Arteries
Gary Seabrook, MDMedical College of Wisconsin Vascular Surgeon
Chief, Vascular Surgery
Named one of the “Best Doctors in America®” 2007 by Best Doctors, Inc.
When the blood vessels outside the heart (peripheral arteries) become narrowed or blocked, the condition is called peripheral vascular disease or PVD. This disease is usually caused by a buildup of cholesterol and plaque in the peripheral arteries. Dr. Gary Seabrook discusses the risks associated with PVD and treatment options.
Q. What is peripheral vascular disease (PVD)?The arteries that take oxygen-rich blood from the heart to the arms, legs and other body parts are called the peripheral vessels. When a buildup of plaque and cholesterol in these blood vessels restricts the flow of blood, the condition is called peripheral vascular disease.
Q. Who is at risk for PVD?People at greater risk for PVD include smokers, those with diabetes, and people with high cholesterol, high blood pressure and a family history of vascular disease. Aging is another risk factor, even among people who have no other risk factors for PVD.
Q. What are the signs and symptoms of PVD?The main symptom is leg pain when walking, which is called claudication. This pain typically subsides with rest. The pain is worse when climbing stairs or walking at a faster pace. A symptom of severe PVD is that the leg pain persists, even at rest, or there may be a blister, cut or other wound on the foot or leg that does not heal.
PVD affects the legs far more often than the arms. Arterial blockages in the legs most commonly occur in the iliac arteries (located in the lower abdomen) and the femoral artery (located in the thigh). People with kidney failure or diabetes are at higher risk than the rest of the population for PVD in their legs.
Q. What are the risks associated with having PVD?There is a risk for limb loss if PVD is severe and is not treated. In addition, people with PVD could also have atherosclerosis in other arteries, such as the coronary arteries or the carotid artery that leads to the brain, placing them at risk for heart attack or stroke.
Q. How is PVD diagnosed?To screen for PVD in the legs, we do an ankle-brachial index (ABI) which is a simple blood pressure test. This involves placing a blood pressure monitor at the ankle and the arm while a patient is at rest. The test can also be performed after walking on a treadmill to reproduce painful symptoms associated with walking (claudication). The ABI is calculated by dividing the ankle pressure by the brachial (arm) pressure. An ABI as high as 1.10 is normal; abnormal values are those less than 0.95. Most patients who have pain when walking have ABIs ranging from 0.3 to 0.75.
If a person has leg pain and an abnormal ABI, PVD is diagnosed, and we need to consider treatment options. If someone has other major medical problems, treating PVD may not be a priority.
If treatment is being considered, we frequently recommend a computed tomography (CT) angiogram to look at blood flow in the major blood vessels throughout the body. A contrast dye is given intravenously to the patient, and CT produces detailed 3-D images of the vessels. This test provides a high resolution road map of the arteries. Another test called a duplex ultrasound may be done to determine the location and the degree of arterial blockage.
Q. What treatment options are available for PVD?Froedtert & the Medical College of Wisconsin have the expertise of vascular surgeons and interventional radiologists to offer the full range of treatments for PVD. If the disease is considered treatable, a number of procedures may be considered. Different risks are associated with treating different levels of disease, and we compare the risk and benefits of various treatments for each patient to provide the most appropriate therapy.
For some patients, medication and exercise may be the only therapy needed. That’s because of a process called collateralization, in which smaller arteries enlarge to create a bypass around a blocked major artery, providing an alternate pathway for blood to flow. It’s like when the freeway is clogged with traffic, motorists take the side streets. Exercise can help to stimulate the growth of the smaller arteries. This may be considered the best long-term solution for PVD.
Another treatment option is a minimally invasive procedure that uses a balloon catheter and a stent to prop open a blocked artery. Stents have a particularly good track record for treating PVD in the iliac arteries.
If medication, exercise and stents are not appropriate for a particular patient, a third option is a surgical procedure. The operation may involve removing a vein from the leg and using it to replace the blocked artery. If a suitable vein is not available, a synthetic vessel may be used.
Q. What are the short- and long-term outcomes for people treated for PVD?Patients who have a bypass graft with their own veins can expect a long-term (5-year) patency, which refers to the artery remaining open or unblocked, greater than 85 percent. Patients who receive a synthetic artery may have a patency of 40 percent to 70 percent.
Patients who receive an iliac artery stent can expect a long-term patency of 95 percent or higher, while femoral artery stents have not proven to have such a good track record.
Q. Can I minimize my risk for getting PVD?The risk factors for PVD are the same as those for heart disease. To reduce the risk of PVD, people should not smoke, and they should control their cholesterol, blood pressure and weight.
Source: Every Day
Date: Jan - April 2008 Issue