Nowadays, BAP treatment interventions consist of endovascular treatment methods (70%) and laparoscopic and conventional treatment (30%).
Peripheral arterial disease (PAD) is a common disease, most frequently caused by atherosclerosis (deposit of fatty substances in the lining of the artery wall, narrowing the arteries and blocking the blood flow within that area).
PAD most commonly affects arteries in the legs rather than arteries in the upper extremities. Left untreated, the lesions progress, and in time these might produce important damage to the tissue that receives blood through the affected vessel, damage which sometimes might be irreversible. Peripheral arterial disease (PAD) includes vascular disease in the extremities, in the neck (carotid artery disease), renal artery diseases and arteries that supply the gastrointestinal tract.
Statistics show that persons who suffer from this disease have an increased risk of heart attack and stroke, together with other conditions that may require aggressive treatments which can result in amputations. 30% of patients with coronary artery disease have peripheral diseases, and 30% of patients with PAD also suffer from coronary artery disease.
Risk factors for peripheral arterial disease
- High blood pressure;
- Age over 50 years;
- History of heart disease, heart attack or stroke.
The disease could be asymptomatic in an initial stage. However, if the disease is in an advanced stage you could experience:
- Pain during walking;
- Pain in the calf, discomfort in the muscles, cramps while doing effort (climbing stairs), paresthesia (numbness), weakness;
- Temperature differences between limbs (commonly the affected limb is colder), pulse differences
- Sores on the legs or toes that will not heal (ulcers);
- A change in the color of your skin, this may have a shiny aspect, hair loss in certain areas.
The examination will highlight particular aspects of the disease (the 5 P’s):
- Pulse (its absence);
The steps that need to be followed:
- Arterial Doppler ultrasound (legs, carotid, renal). If a patient is suspected to suffer from PAD, it is important to undertake a complete Doppler ultrasound to get an early diagnosis;
- If the physician requires this, additional investigations will be carried: CT angiography, MR angiography, angiography – depending on the area of interest.
The optimal treatment is determined based on the severity of the disease, and other related pathologies (which might increase risk for surgery). These procedures aim to restore the axis and the normal blood flow. The procedures may include surgery, laparoscopy or interventions.
The interventional treatment consists of dilating the affected area with a balloon and inserting a stent (metal tube of different sizes) which will keep the artery open. This does not require a surgical incision, and consequently you will have a fast recovery, and a short hospital stay.
- Moderate or severe (advanced) disease – it can relieve symptoms, stop disease progression and sometimes prevent the leg from aggressive treatments (e.g. amputation);
- High-risk surgical patients (local anesthesia performed);
- Claudication which may impact the quality of life, which might not respond to medical or physical treatment (specific physical exercises);
- Pain that occurs at rest;
- Ischemic skin changes (e.g. ulcers).
The procedure is performed under local anesthesia.
After anesthesia, the surgeon will make a small inguinal incision to visualize the femoral artery where a sheath will be introduced (a plastic tube that allows the physician to handle the equipment required for the intervention).
Following this, heparin is administered (a medicine that prevents blood clotting during the intervention). A guide wire (a thin wire) is inserted on the sheath to cover the stenosis, and after that a new catheter will be inserted. There will be periodical angiographies performed to check the location of the catheters. Subsequently, the stenosis will be dilated with a balloon that is inflated with diluted contrast agent, followed by insertion of the stent in order to preserve the normal diameter of the vessel. Finally, the stent position and any residual stenosis will be checked using arteriography. Sometimes it is possible to dilate the stent after it has been inserted. After finalizing the procedure, all catheters will be removed. The sheath may be left in place for several hours longer.
The procedure is not painful. Patient may experience a little discomfort.
The procedure usually lasts between 1 and 2 hours, and it is usually performed in the CAT-lab (room equipped with tools used for catheterization). A simple catheterization (up to 2 stents) usually lasts for an hour, and a more complex one (up to 5 stents) lasts for about 2 hours.
Complications are rare and the risk of complications is rare given the training of the personnel and the constant surveillance of the patient:
- Allergic reactions to the administered substances or to the metal in the stents;
- Reactions to anesthetics;
- Arteriovenous fistula at the vascular puncture site;
- Small bleedings at the vascular puncture site;
- Headache, migraine;
- Air embolism;
- Injury of the aortic wall (penetrating within the artery);
- Rupture or dissection of the aorta;
- Stent migration (migration of the stent from the initial place, after a certain period);
The examination before surgery will establish whether the stenosis is suitable for interventional or surgical treatment. Therefore, the imagistic investigations previously mentioned are necessary (the gold standard is angiography).
A series of tests will be required and you will have a short discussion via telephone with an anesthetist. There is no contraindication to perform the angiography/angioplasty, but this should be avoided for persons who cannot follow an appropriate treatment after intervention (aspirin antiplatelet medicine and plavix). People with severe renal insufficiency require additional measures to protect the kidney.
In some cases, if there is a certain time interval between the initial examination and the moment when the procedure will be performed, your physician may recommend you to take antiplatelet medicines before the intervention (aspirin and plavix). In addition, blood tests will be performed to check the blood coagulation, the hemoglobin level, and the renal function. Additional tests may be required according to the type of pathology. Hospitalization takes place one day before the intervention and in the morning of the procedure the patient should not eat.
The recovery after the intervention is usually quick.
After the intervention the patient will be monitored in the intensive care unit, and later in their room. It is necessary to rest in bed for 12-24 hours (avoid bending the leg to prevent complications at the puncture area). Most of the patients can leave the hospital after one day and continue their normal activities (it is recommended to avoid effort for a while). You will receive indications regarding your recovery and the treatment you need to follow after the intervention (treatment with aspirin and Plavix for period of time). Moreover, it is necessary to control for other risk factors.
At home, you will have to pay attention to the following symptoms:
- Fever of chills;
- Bleeding, hematoma – blood build up;
- A small bruising is normal;
- Any changes in the affected leg (color, temperature or sensitivity changes), together with other neurological signs.
Peripheral arterial disease is a common disease that can be asymptomatic for a long time. Symptoms may appear when there are severe lesions. Left untreated, this disease might lead to severe measures (e.g. amputation). This is why we recommend early treatment of the lesion, which will subsequently stop the disease progression and will improve symptoms.