Peripheral Arterial Disease (PAD)

What is Peripheral Arterial Disease (PAD)?

Arteries carry blood rich in oxygen and nutrients from the heart to all parts of the body. When the arteries to the legs become blocked, the muscles are deprived of oxygen and cause significant symptoms. This condition is called Peripheral Arterial Disease or PAD.

What are the Risk Factors for Peripheral Arterial Disease (PAD)?

The risk factors for PAD are the same as those for all types of atherosclerosis:

• Smoking
• High Blood Pressure
• Diabetes
• High Cholesterol
• Family history of stroke, heart attack, or PAD
• Age (>65)
• Prior history of coronary heart disease or peripheral arterial disease (PAD)
• Obesity

What are the Symptoms of Peripheral Arterial Disease (PAD)?

In the early stages, patients with PAD may have no symptoms. The most common early symptom from PAD is intermittent claudication (IC). IC is characterized as pain in the buttocks or legs that occurs with walking and goes away with rest. It occurs more quickly with strenuous walking or walking up hills and stairs. Over time, the pain occurs at shorter and shorter distances. As the disease progresses, the legs do not get enough oxygen even at rest. This leads to pain in the legs even at rest. In severe PAD, called critical limb ischemia (CLI), ulcers and gangrene can develop, usually on the toes and feet.

How is Peripheral Arterial Disease Diagnosed?

First your doctor will ask questions to determine if you have symptoms consistent with PAD. On physical exam, your doctor will check your pulses and examine your feet and legs to determine if there are signs of PAD.An ankle-brachial index (ABI) is a test that compares the blood pressure in the legs to the blood pressure in the arms. This can give an early indication of PAD.

An arterial duplex ultrasound is the best initial test to diagnose the presence, location, and severity of PAD. The ultrasound images the arteries in the legs and measures blood flow in order to detect blockages. This exam is simple and painless, and is performed in the office of your vascular surgeon.

If the ultrasound is positive for PAD, the next test is usually an angiogram. This can be done using CT scan, MRI, or tradition catheterization through the groin arteries. Dye is injected into the arteries and precisely defines the degree and location of the blockage, and provides your surgeon with a road map to plan further intervention.

Is Peripheral Arterial Disease (PAD) Dangerous?

PAD in and of itself is dangerous in that it limits activity and can cause significant discomfort. People with PAD can become disabled and be unable to work. When it advances to a severe level, gangrene can occur and can lead to amputation. More importantly, however, is that PAD is a marker that the patient likely has blockages in the arteries in the heart and brain. This puts them at a significant risk for having a heart attack or a stroke.

Do I need treatment?

The decision as to whether you need treatment is determined by the severity of your symptoms. If no symptoms or mild symptoms are present, then only medical therapy is indicated. As your symptoms become more severe, and become lifestyle limiting, then minimally invasive techniques may be warranted. When critical limb ischemia occurs, as characterized by rest pain, ulcers, or gangrene, aggressive intervention is essential to prevent amputation.

How is Peripheral Arterial Disease (PAD) Treated?

Medical Therapy:

Medical therapy consists of lifestyle modifications, medications, and walking exercise.

Lifestyle Modifications:

• Quit smoking
• Control high blood pressure and diabetes
• Control high cholesterol
• Achieve and maintain a desirable weight

Medication:

• Aspirin is the most important medication, and should be taken every day. A baby aspirin is adequate, as no dose of aspirin has been proven to be superior.
• Plavix works in a similar fashion to aspirin, but is more powerful. It is often given in combination with aspirin in patients at especially high risk.
• Trental and Pletal are medications that can help improve blood flow to the peripheral blood vessels.

Walking Exercise:

Exercise and walking regularly, at least 30 continuous minutes three times per week, can help improve your symptoms by encouraging your body to form new, collateral blood vessels. With a structured walking program, many patients experience a dramatic increase in the distance they are able to walk without pain.

ENDOVASCULAR (Minimally invasive) THERAPY

In some cases, your doctor may recommend angioplasty and stenting. It is done in a specially equipped room, Specials Radiology, which is a combination X-ray room and operating room that is unique to Milford Hospital. The patient receives a local anesthetic and is awake for the procedure. Sometimes a light sedative is given. A blood vessel in the groin is accessed using a catheter, similar to the type used when you get an intravenous line. The catheter is guided through the arteries to the area of the blockage. Once in place, a special balloon (see picture at left), which is attached to the catheter, is inflated and deflated several times. The balloon pushes the plaque that makes up the blockage against the artery walls, widening the vessel. In some circumstances, the doctor may also place a mesh metal tube, called a stent, into the narrowed area to keep the blood vessel open (see pictures at right). The stent remains permanently in the artery.

A specialized stent graft that is lined with a non-stick plastic (Viabahn) can help keep the artery open long-term (see picture at left). Some of these are impregnated with a blood thinning medicine called Heparin.

It is not possible to predict which of these techniques will be used until the surgeon is well into the procedure, but it is important that he is familiar with and has access to all of these techniques. Both Dr. Esposito and Dr. Davis, who usually perform the procedures together, are expert in these techniques and have actually served as instructors to other physicians in the area.
There is no surgical incision, only a small pinhole in the groin. The procedure takes between 1 to 2 hours. The typical recovery involves an overnight stay in the hospital. Sometimes, if the procedure is straight-forward, same day discharge is possible. There is very little postoperative pain, and the patient is able to eat right away. After a few hours, the patient can get out of bed and ambulate. The patient is typically discharged home after breakfast the day after surgery, often less than 24 hours after the procedure. The patient can resume normal activities right away. The patient may experience some discomfort at the groin puncture site and some swelling of the leg from the increase in blood flow. These are normal occurrences and usually last only a few days. The patient’s symptoms usually improve dramatically within one week.
For more severe, longer blockages more advanced techniques may be used. An atherectomy catheter has a sharp blade that rotates very quickly and actually cuts and removes the plaque, like a roto-rooter.

After the procedure, the patient will continue with lifestyle modifications, aspirin and Plavix, and routine ultrasound surveillance at the Milford Vascular Institute.

SURGICAL THERAPY

Sometimes the blockages are so severe that surgery is the only option. The surgery, called a bypass, creates a detour for the blood around a narrowed or blocked section of a leg artery.

To create the bypass, the surgeon uses one of your own veins or a plastic blood vessel called a graft (see picture at right). The bypass is attached with stitches above and below the area of the blockage. This creates a new path for the blood to flow to the distal parts of the leg. This procedure is done in the operating room.

Depending on the severity of the blockage and the patient’s medical condition, general, spinal, or local anesthetics may be used. There are usually two separate incisions in the leg. If the patients own vein is being used, the incision will be longer in order to harvest the vein. The surgery usually last between 1 to 3 hours. The patient can expect to be in the hospital 3-5 days.

The recovery from surgery is longer, but bypass surgery is very durable, usually more durable than the other techniques described previously. Dr. Esposito is board certified in Vascular Surgery, and has performed hundreds of leg bypass surgeries with excellent results. After the surgery, the patient will continue with lifestyle modifications, aspirin and Plavix, and routine ultrasound surveillance at the Milford Vascular Institute.