Peripheral Artery Disease (PAD)

/Peripheral Artery Disease (PAD)
Peripheral Artery Disease (PAD) 2017-07-13T09:35:59+00:00

The hardening of arterial walls is a sign of vascular disease, including myocardial infraction and stroke.

Peripheral Artery Disease (PAD), known also as Peripheral Vascular Disease is a fairly common condition that affects approximately 20% of the population over 65 years old in many developed countries across the globe. PAD presents as a complication of atherosclerosis (hardening of arterial walls) as result of high cholesterol levels that build up on arterial walls. This matter settles as plaque and the corresponding tissue does not receive enough blood in order to function normally. This is a serious condition and the loss of blood flow in the lower extremities due to partially or fully blogged arteries may cause significant pain while walking and may develop into gangrene and subsequent amputation.

Symptoms

  • The most common PAD symptoms are leg, calf and thigh cramps during walking or while engaging into physical exercise. Pain disappears when the person rests;
  • Numbness, tingling in the legs or feet;
  • Acute pain sensation in the legs, extreme during resting periods;
  • Muscle soreness sensation that does not pass (permanent sensation);
  • Cold legs or feet;
  • Variable skin color of legs or feet;
  • Loss of leg hair;
  • Pain in the legs or feet that prevent nocturnal rest.

Attention: Many senior citizens associate these symptoms with aging. These issues must be discussed with your doctors and are not associated with the process of growing old. An arterial Doppler examination is absolutely necessary in these circumstances so that the patient is prescribed medication in a timely fashion and more severe problems are avoided.

Affected population

  • In rural areas, PAD affects approximately 10% of the population, depending on lifestyle and diet;
  • PAD can affect any individual but is more prevalent in population over the age of 50.

Risk factors

  • Age over 50;
  • Smoking;
  • Diabetes;
  • Sedentariness;
  • Diet;
  • High blood pressure;
  • High cholesterol;
  • Family history.

Diagnosis

In order to establish a precise diagnosis, you will require the following examinations, indicated by a physician:

  • Doppler ultrasound to measure blow flow and degree of arterial blockage;
  • Ankle-arm index to compare arterial blood pressure in arms and ankles using a Doppler device. If the pressure in the ankles is lower that in the arms, the arteries in lower extremities are narrowed or blocked;
  • CT angiography (Computed Tomography) or MRI angiography (Magnetic Resonance Imaging) provide a very complex picture on thickening and thinning of arteries, blockages, aneurysms and/or calcifications.

Treatment

Lifestyle changes

If the disease is identified early, patients can be treated by making changes in their way of life. Smoking must be stopped and a daily physical activity program must be strictly enforced in order to alleviate symptoms and stop the progression of the disease.

Drugs

Drugs that lower cholesterol levels and control blood pressure can be prescribed. Other drugs can prevent the formation of blood clots or arterial plaque.

Endovascular

Angioplasty and stenting

Angioplasty and stenting are performed using imaging equipment for guidance. The physician inserts a catheter through the femoral artery in the inguinal region and lowers this catheter in the obstructed arterial segment (narrowed or blocked). In this area a balloon is inflated with the purpose of opening the blood flow in the obstructed segment. In some cases, a stent in the form of a small metal-wire cylinder is necessary. This procedure is minimally-invasive and does not require open surgery, only a small “buttonhole” the size of a pencil tip. Balloon angioplasty and stenting have replaced invasive surgery and are recommended as primary treatment option for Peripheral Artery Disease (PAD). Randomized studies performed on large samples in various centers around the world have shown that this method is as efficient as the classical surgery for many types of arterial obstructions, while having a lower recovery period (generally patients leave the clinic in 24h or less). Because of these multiple advantages, angioplasty and stenting are the first choice of treatment in PAD.

Atherectomy

In this treatment a small catheter is introduced through the artery and plaque can be grinded or cut and removed completely at the level of the blockage.

Stent-Graft

A braided metal stent in the form of a cylinder covered in synthetic material can be used in various arterial conditions with the purpose of reinforcing a weakened segment in the artery, known as aneurysm. Arterial pressure along with other parameters may inflate this weakened area and cause swelling and rupture. The stent-graft helps to reinforce and correctly seal this deteriorated arterial segment starting with the area under the aneurysm up to the one above it. This method allows blood to flow correctly in the fixed zone, without putting pressure on the arterial walls of the affected zone. Doctors use stent-grafts to cut aneurysms of the abdominal aorta (AAA), aneurysms of the thoracic aorta and rarely, other types of aneurysms.

Aneurysms frequently appear at the level of the aorta, the most important artery in the body. The diameter of the aorta is usually around 2cm and an aortic aneurysm is diagnosed if the diameter increases 1.5X in size.

Aortic aneurysms are serious medical conditions, a ruptured aorta causes massive internal bleeding and is fatal if rapid intervention by specialized physicians is not available. The endovascular stent-graft is performed in order to prevent aortic rupture. The term endovascularmeans that the procedure is done from inside the vessel. Endovascular procedures are done with technologies and instruments especially designed for this purpose. These procedures require a small artery incision. Through this incision, a vascular surgeon introduces a thin tube, called a catheter, which transports a device to the location of the aneurysm. This device is positioned in order to correctly align and reinforce the artery. Generally, the recovery period after endovascular treatment is shorter and patients leave the hospital earlier than for other types of procedures.

Risks are also lower than in classical surgical procedures because the incisions are smaller. Nevertheless, some cases require classic surgery if the shape or localization of the aneurysm is not favorable for an endovascular approach.

Frequently Asked Questions

How to prepare?

Your physician will ask you about your medical history and perform a complete checkup. Additional examinations may be required, such as EKG, stress test, angiography (CT or MRI) to determine the structure and location of the aneurysm and to aid in establishing whether endovascular techniques are recommended. If the decision is to use stent-graft treatment, the physician may demand the following examinations:

  • Helical CAT scan: implies a series of rapid X-rays captured in a spiraled form, after which a 3D image of blood vessels is constructed;
  • Angiography: a catheter is inserted in the artery and a contrast agent is delivered while capturing X-ray images.

Am I eligible for stent-graft endovascular treatment?

You may be eligible for endovascular stent-grafting if the aortic aneurysm is large enough (>5cm in diameter) and sufficiently long areas of normal (healthy) artery exists above and below the aneurysm so that the stent-graft can be placed safely. This represents a good treatment option in case the risk of classic intervention is high dues to existing comorbidities. Nevertheless, if the life-expectancy is high, the low risk of complications or the shape of the aneurysm is not favorable for an endovascular stent-graft, classic surgery is recommended.

The physical characteristics of the aneurysm will help your physician determine whether you are a good candidate for endovascular stent-grafting. In the case of AAA, if the positioning is good and the aorta has no anatomical abnormalities or curves, you are eligible. Also, blood vessels need to be large enough to allow the stent-graft to pass through then all the way to the aneurysm and the device must be molded into the shape of the aorta. The stent-graft is not limited to the aorta; other regions of the body are also suitable. Your vascular surgeon can tell you exactly whether you are eligible or not for this procedure.

Is there a risk of complications?

If you have chronic renal failure, complications can be prompted by the contrast agent that can affect the kidneys. If the shape of the aneurysm is unfavorable and is associated with Occlusive Arterial Disease or you have had a previous AAA repaired, the risks are much higher. A part of these risks can be addressed in order to minimize the time of the procedure, when the classic intervention poses much higher risks. The vascular surgeon will discuss all these details with you and will recommend the best approach, according to your individual needs.

How does the endovascular stent-graft process take place?

Before starting the procedure, you will be sedated and a general/loco-regional anesthesia will be performed. A small incision will be made in the skin in the femoral artery region. Through this “button hole”, a guide is inserted in the femoral artery and it is advanced until it reaches the aneurysms. Because no nerve endings exist in inside arteries, you will feel no pain. It is possible to experience a pinching sensation from time to time during guide kit insertion.

Under visual guidance, the vascular surgeon then inserts the catheter through the guide, and positions the stent in the required location. During this process, an angiography will be performed in order to confirm the correct positioning of the endovascular stent-graft. You may experience a slight warm sensation due to the contrast agent that is being released during that moment. A compressed version of the graft is inserted through a larger catheter (sheath). When the graft reaches the desired location, the sheath is extracted, leaving the graft in place to expand and stick to the arterial wall, perfectly sealing the gaps. Sometimes, additional components of the grafts are placed similarly through bilateral inguinal area incisions, in order to approach arteries that provide blood flow to the lower extremities.

What should I expect after stent-graft implant?

Normally, you will be hospitalized between 2-3 days. In the first day of recovery you will be able to eat and walk. After leaving the hospital driving a vehicle is prohibited pending approval from your physician. You will be allowed to wash the area around the incisions with a sponge, but inguinal regions must remain dry until full healing of incisions. Heavy weight lifting is not recommended in the first 6 weeks after the intervention. Your physician will provide you the necessary information at hospital discharge and will check the healing of the incisions and evaluate your health during the first checkup.

In the first months after the procedure you will require an imaging follow-up in order to confirm normal stent functioning. After the first year, you will perform another imaging checkup in order to establish and compare the size of the stent. Additional imaging examinations may be ordered if problems that require monitoring are identified.

Are there any post-intervention complications?

Possible endovascular stent-graft issues include:

  • Endoleaks: blood leakage around grafts;
  • Infections;
  • Graft displacement;
  • Graft fractures;
  • Blood flow blockage through the graft.

Sometimes, fever and a high white blood cell count may arise. This may last between 2-10 days and is treated using aspirin and ibuprofen. Other complications are rare but serious and include arterial ruptures, renal conditions, paralysis, blockage of blood flow to the abdomen or lower and aortic aneurysm ruptures.

Stent-grafts sometimes leak at their joints or allow blood to accumulate in the aneurysm. These issues may appear even years after the intervention and they can be dangerous if the size of the aneurysm increases. Because of this, your doctor will recommend performing a CT scan periodically for the rest of your life in order to identify problems before they become fatal.