Peripheral arterial disease (PAD), also known as peripheral vascular disease (PVD), is a common condition that affects about 20% of the population over the age of 65 in many developed countries worldwide. Peripheral arterial disease occurs as a result of atherosclerosis, the hardening of arterial walls, as a result of cholesterol that builds up on the inside of arterial walls.

This material is deposited in the form of platelets, arterial plaque, and the tissue in question will no longer receive enough blood to function normally. This is a serious condition and the reduction in the amount of blood reaching the feet due to “partially or totally clogged” arteries can cause significant pain when walking, which can lead to gangrene and amputation of the leg.

What are the Peripheral Arterial Disease symptoms?

• The most common symptoms of peripheral arterial disease are cramps in the leg, calf and thigh muscles when walking or exercising.
• The pain disappears when the person stops exercising.
• Numbness, tingling in the leg and foot may signal peripheral arterial disease.
• Acute pain sensation in the leg, flashing during rest.
• Feeling of muscle fever in the leg that does not go away (permanent sensation)
• Cold foot, or cold paw, a sign that you may have peripheral arterial disease.
• Loss of hair on the legs.
• Change in the color of the skin of the foot or paw indicates peripheral arterial disease.
• Pain in the foot or foot sole that wakes you from sleep at night

Recommended article: Arterial Angioplasty with Endovascular stent graft

Warning: Very many elderly people associate Peripheral Arterial Disease with ageing.

These problems should be discussed with your Doctor, they have nothing to do with the ageing process but with peripheral arterial disease. An arterial Doppler examination in these circumstances is mandatory so that the patient could be treated during the early stages of the condition and does not end up with more serious problems.

Population affected by peripheral arterial disease:

From country to country, depending on lifestyle and dietary habits, peripheral arterial disease affects about 10% of the population. PAD can occur in anyone but occurs in high percentages in the population over the age of 50.

Risk factors in Peripheral Arterial Disease:

Those most affected by peripheral arterial disease are:

• People over 50
• Smokers
• Diabetics
• Sedentary
• Overweight
• Hypertensives or those with high cholesterol
• Those who have family members with the same condition.

How is the Peripheral Arterial Disease diagnosed?

In order to get  an accurate diagnosis you will need the following investigations, as indicated by
doctor:

• Echo-Doppler to measure blood flows and the degree of blockage of the arteries.
• Ankle-brachial index, which measures the blood pressure of both ankles in comparison with that of the hand with a doppler device. If the ankle blood pressure is lower than the
  hand, then the arteries in the foot are narrowed or blocked.
• CT (Computer Tomography) angiography or MRI (Magnetic Resonance Imaging) angiography
• Nuclear Resonance Imaging) gives a very complete picture of the thickening or narrowing of the arteries, their blockage, aneurysms, arterial calcification.

Talk to your doctor if you are experiencing symptoms of peripheral arterial disease. Early diagnosis can help you find ways to reduce your symptoms and increase the effectiveness of treatment. Click to enlarge.

Peripheral Arterial Disease complications

Complications arising from undiagnosed and untreated peripheral arterial disease can be serious and even life-threatening. Reduced blood flow from this condition can be a red flag for other diseases of the vascular system. Click to enlarge.

Peripheral Arterial Sisease, Arterial Ischemia – treatment

Peripheral arterial disease drug treatment

Medications that lower cholesterol and control blood pressure may be prescribed. Other drugs that prevent blood clots or arterial plaque formation can treat peripheral arterial disease.

Peripheral Arterial Disease treatment by Angioplasty and Stenting

Angioplasty and stenting is done using visualization equipment for guidance. The doctor inserts a catheter through the femoral artery in the groin area, and then uses this catheter to go down to the area of the blocked (narrowed or blocked) artery. A balloon is inflated in this area, the aim being to re-open the blocked area to blood flow. In some cases, it is necessary to place a stent, a small cylinder made of metal wires, in this area. This procedure is minimally invasive and does not require surgery, just a ‘buttonhole’ the size of a
pencil tip.

Balloon angioplasty and stenting has generally replaced invasive surgery as the leading treatment recommendation for Peripheral Artery Disease (PAD). Randomized studies done on a very large number of subjects in different centers around the world have shown it to be as effective as the surgical method for many types of arterial blockages. Recovery after surgery is much quicker (generally you leave the clinic in less than 24 hours). Because of these multiple advantages angioplasty and stenting are the first recommended treatment for peripheral arterial disease.

Peripheral Arterial Disease treatment by Atherectomy

With this treatment a small catheter is inserted into the artery and at the level of the blockage a “sanding” or “cutting” of the deposited plaque can be done and removed completely.

Peripheral Arterial Disease treatment by Stent-Graft

A stent made of a metal material that looks like a metal braid that takes the shape of a tube and is covered with synthetic material. It can be used in various arterial conditions to reinforce a weakened portion of the artery, called an aneurysm. Arterial pressure together with other parameters can cause this weakened portion to swell like a balloon, which over time can grow and rupture.

The stent-graft helps this damaged arterial area to be properly reinforced and sealed, starting from the portion below the aneurysm and ending with the portion above the aneurysm. This method allows blood to flow correctly through the repaired area without putting pressure on the arterial walls of the damaged area. Doctors commonly use stent-grafting to treat abdominal aortic aneurysms (AAA), thoracic aortic aneurysms (TAA) and less commonly other types of aneurysms.

Aneurysms frequently occur in the aortic artery, the most important artery in the body. Its diameter is usually 2 cm and an aortic aneurysm is considered to be formed if its diameter increases by 1.5 x more than its normal diameter.

Aortic aneurysms are very serious health problems, a ruptured aorta causes massive internal bleeding and is fatal if not treated quickly by a specialized medical team. Hardening of the artery walls is a sign of vascular disease, which includes heart attack and stroke. Often patients, if the disease is identified early, can be treated by changing their lifestyle. Smoking should be stopped, and a strictly enforced daily exercise program can remove symptoms and stop the disease from spreading.

The endovascular stent-graft is made in such a way as to prevent the rupture of the aorta. The term endovascular means that it is applied from inside the blood vessel. Endovascular procedures are performed with specially designed technologies and instruments. These procedures require a small incision in the artery. Through this incision a vascular surgeon inserts a thin tube, called a catheter, which carries inside it the device to be placed at the site of the aneurysm. The device is then positioned so that it correctly repositions, realigns and strengthens the artery.

In general, after endovascular treatment the recovery time is shorter, and you leave hospital more quickly than with other types of procedures. The risks are also lower than with conventional surgery because the incisions are also smaller. However, in some cases the correct indication for surgery is conventional surgery if the shape of the aneurysm or its placement is not favorable for an endovascular approach.

How to prepare for Stent-Graft treatment

Your doctor will ask you about your medical history and do a complete examination. In addition, he or she may ask for some investigations, which include an electrocardiogram, stress test, and an Angio scan (MRI or CT) that will determine the configuration and placement of the aneurysm and decide if endovascular technique is recommended. If the decision is positive for stent-graft treatment, the doctor may ask for further investigations:

• Spiral CT scan: this involves a rapid series of X-rays taken in a spiral shape, after which a three-dimensional computer image of the blood vessels is reconstructed.
• Angiography: a catheter is inserted into the artery, after which a contrast substance is injected through the catheter and photographs are taken using X-rays.

Am I eligible for endovascular Stent Graft?

You may be eligible for endovascular stent grafting if the aortic aneurysm is large enough (>5 centimeters in thickness) and there are long enough segments of normal  artery above and below the aneurysm so that the stent graft can be safely attached.

It is a very good interventional option if the risk of conventional surgery is increased due to other diseases you have. However, if your life expectancy is high, if you have a low risk of complications, or if the shape of the aneurysm is not conducive to an endovascular stent-graft, conventional surgery will be recommended. General surgery is a particularly important section of the VenArt clinic. Surgeries are performed by highly experienced physicians, specialized in renowned clinics in Europe, USA and Israel.

The physical characteristics of an aneurysm will help your doctor determine if you are a good candidate for endovascular stent grafting. In the case of AAA if the positioning is good and the aorta does not have very curved anatomical variants you are eligible. Also, the blood vessels must be wide enough to allow the stent graft to pass through them to its destination and the device must be able to mold to the configuration of the aorta.

The stent graft is not limited to the aorta, it is an option for arterial aneurysms in other regions of the body. Your vascular surgeon will be able to tell you precisely if you are eligible for this procedure.

Are there risks of complications?

If you have chronic renal failure, complications may be caused by the contrast material, which can in some cases damage the kidneys. If you have an unfavorable form of aneurysm associated with arterial occlusive disease or have already had an AAA repaired, then the risks are increased. Some of these risks can be addressed so that they can be minimized during the procedure where conventional surgery carries much greater risks. Your vascular surgeon will discuss all these details with you and recommend the best approach, depending on your situation.

How does the endovascular Stent-Graft process work?

Before starting the procedure you will be sedated and given a local-regional anesthesia, or a general anesthesia, depending on your particular case. The skin will be cleaned and disinfected at the point of entry so that the risk of infection is minimized. A small incision will be made in the skin in the region of the femoral artery. Through this “buttonhole” the guidewire is inserted into the femoral artery and advanced to the level of the aneurysm.

As there are no nerve endings in the arterial wall you will not feel the catheter moving inside the artery. You may feel a slight pull from time to time during insertion of the guidewire.

Under visual guidance, the vascular surgeon inserts the catheter through the guide followed by positioning the stent in the required location. During this process an angiogram will be taken to confirm the correct positioning of the endovascular stent-graft. You may feel a sensation of slight warmth due to the release of contrast at this time. Next, a compressed form of the graft is inserted through a larger catheter called a sheath.

When the graft reaches the desired site the sheath is withdrawn, leaving the graft in place, the graft expands and sticks to the arterial wall, the bond is perfect. Often additional components of the graft are similarly placed through incisions in the groin area, on both sides, to address areas of the arteries feeding both legs.

What can I expect after Stent Graft implantation?

You will normally stay in hospital for about 2-3 days. On the first day of recovery, you will be able to eat and start walking. After leaving the hospital you are not allowed to drive until your doctor allows it. You will be allowed to wash the area around the incisions with a sponge, but you must not wet the incision areas in the groin region until it has healed completely. You will probably be advised not to lift weights heavier than a few pounds for up to 6 weeks.

The doctor will give you all the necessary recommendations when you leave the hospital and at the first check-up will check the healing of the incision and assess your health. In the first months after the procedure, you will have an imaging control to reconfirm the normal function of the stent. After the first year after the stenting, you will have an imaging check of the aneurysm in which its size will be measured and compared. More frequent imaging tests may be requested if you suspect problems that need to be monitored.

Are there any post-surgery complications?

Potential endovascular stent-graft problems can be:

• Endoleaks leaking blood around the graft.
• Infections
• Movement of the graft from the desired site
• Graft fracture
• Blockage of blood flow through the graft
• Sometimes fever and increased white blood cell count may occur. May last
  2 to 10 days and is treated with aspirin and ibuprofen. Other complications are
  rare but serious, they include arterial rupture, kidney damage, paralysis, blockage of blood flow blood flow to the abdomen or below and rupture of the aortic aneurysm.
• Stent-grafts can sometimes leak blood into the graft components, or allow blood to flow back into the aneurysm. These types of leaks are called endoleaks. They can occur years after surgery and can be dangerous if the size of the aneurysm increases. This is why your doctor will advise you to have a CT scan periodically for the rest of your life so that if any problems occur, they will can be treated early before they become fatal.