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Peripheral Arterial Disease (P A D )

Peripheral Arterial Disease (P.A.D.)

September 26, 2011
12:00 p.m. – 1:00 p.m. (EST)

  • Mark Berman, MD – Interventional Radiologist, Florida Location
  • Mehdi Shishehbor, MD – Interventional Cardiologist, Ohio Location

P.A.D. or Peripheral Arterial Disease is when the arteries in the legs, or any other part of the body that carries blood out side of the heart, become narrowed or clogged with fatty deposits, or plaque. P.A.D. is a serious condition that can more than double your risk for heart attack or stroke, but often it can successfully treated by quitting tobacco, exercising and eating a healthy diet.

Cleveland_Clinic_Host: Today's Online Health Chat "Peripheral Arterial Disease" with Dr. Mark Berman and Dr. Mehdi H. Shishehbor, will begin in 5 minutes at 12:00pm (EST). Please submit your questions by typing in the box below and then click "Ask a question".

Cleveland_Clinic_Host: Welcome to our "Peripheral Arterial Disease" online health chat with Mark Berman, MD and Mehdi H. Shishehbor, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us, let's begin with the questions.

84yo: : I am an 84 year old male diagnosed with chronic Venus Insufficiency. Although I take Coumadin, Atenolol, and Cardizem to aid in the control of atrial fibrillation, I am in reasonably good health. I also medicate for control of hypertension. I walk, and exercise daily, and golf (9 holes) one or two times per week. What treatment is suggested for the Venus Insufficiency?

Mark_Berman_MD: It depends on how bad the venous insufficiency. If it just swelling I would recommend compression stockings 15 to 20 to be worn during the daytime from time you wake up in the morning until bedtime. If it is more severe case then obviously there are other options including more aggressive compression stockings or wrapping.

Mehdi_Shishehbor_MD: I am glad you are exercising and taking all your medications - controlling your blood pressure is extremely important.

Aonepop: After walking for 5 minutes the pain in my left calf is very severe. What can be done? I was told to walk more but it gets worse.


Anna01: Is it true that people who are not active now or have not been in their previous years are at an increased risk for PAD?

Mehdi_Shishehbor_MD: Yes. Obviously, physical activity could potentially slow or prevent arterial atherosclerosis including PAD.

BrendaP: I read in an article that the use of hormone replacement therapy can help protect postmenopausal women against developing PAD. What are your thoughts on this?

Mark_Berman_MD: It is absolutely true that estrogen is protective against atherosclerotic disease.

Mehdi_Shishehbor_MD: But it also has other side effects which may be detrimental to breast and gynecological pathology, so you would need to discuss this with your primary care doctor and weigh the benefits and risks.

Connor_440: Does smoking increase the risk of developing PAD?

Mark_Berman_MD: Absolutely. It is probably the greatest single risk factor for developing PAD.

Frank: For PAD, the insertion of a stent a better alternative than angioplasty?

Mark_Berman_MD: It depends on the specific artery that is being treated. Larger arteries above the groin are known to do better with stents. In the thigh, stents are better for complete occlusions.

Deborah1959: Why is it said that women have worse outcomes, more complications, and at a higher risk of death than men do after undergoing surgery for PAD?

Mehdi_Shishehbor_MD: We are not yet very clear as to why this is. It could be related to the co-morbidities and the fact that the studies have been limited by sample size. Also, severe PAD requiring surgery is more prevalent in socio-economically challenged individuals especially black females, which could further complicate the association between gender and outcomes.

GeorgeB: What is the best diagnostic test for peripheral artery disease?

Mark_Berman_MD: The first screening exam should be non-invasive testing with exercise. If that is abnormal, an additional non-invasive exams such CTA or MRA may be obtained to define exact location and severity of blockages.

Cleveland_Clinic_Host: For those just joining, we are chatting with Dr. Mark Berman and Dr. Mehdi H. Shishehbor about peripheral arterial disease. If you would like to review what already has been discussed, please click on the 'Transcript' button above. If you would like to submit a question, please type in the text box below and click 'Ask'.

HowardM: I am 55 years old with a family history of PAD. I am interested in knowing the things I can do to prevent PAD.

Mehdi_Shishehbor_MD: There are many things you can do including lifestyle modification (smoking cessation if you smoke, controlling cholesterol, diet, exercise, and if necessary blood pressure control).

JerryK: I have been having some symptoms listed for PAD - At what point should I see a doctor to get tested?

Mark_Berman_MD: If the symptoms are lifestyle limiting and severe enough to warrant consideration of angiography and/or surgery, you should talk to your doctor about it.

Mehdi_Shishehbor_MD: Patients that have PAD are at significant risk of cardiovascular events. Therefore, exercise and activity is extremely critical in these individuals. In my opinion, if your PAD is preventing you from being active, then you should definitely consider therapy (medical and/or interventional).

MaryJo: What are the most common symptoms of PAD? Is it leg pain?

Mehdi_Shishehbor_MD: Typically PAD presents as a pain or a burning sensation involving the calf muscles after walking. It is relieved with rest.

LeslieCT: Is PAD like CAD? Can dieting and healthy eating habits contribute to treating PAD? What is the best diet for this?

Mark_Berman_MD: Dieting can lower cholesterol and it has actually been shown to reverse some plaque burden in the coronary arteries. Therefore, we recommend this for PAD as well.

Porchplant: My vascular doctor has talked with me about drug coated stents (?) that are currently only available in Europe, but he says will be available in US the first quarter of next year. Any hope of sooner? Do these somehow prevent scar tissue from occluding them? Are these to be used for PVD as well as CAD?

Mehdi_Shishehbor_MD: As you noted, drug coated stents are not currently available in the U.S., but hopefully early next year they will become available for PAD. These stents have shown a lower rate of re-blockage compared to the current non-drug-coated stents used for PAD. However, data regarding long term patency (staying open) is not available. The stents used for PAD are different than the ones used for CAD. Currently we do have drug coated stents for CAD. However, they are not typically used for PAD.

Raj_16: Can Angiogram be done for a person creatinine level is 2.0 and he is 71 years old?

Mark_Berman_MD: Yes, but contrast related kidney injury could occur. Preventive measures such as intravenous hydration and mucomyst may lessen chances of contrast related injury. Stable renal insufficiency is less likely to encounter contrast nephropathy than patients with actively worsening kidney function. You should talk to your doctor about your specific case.

Debbie1967: Have you ever had a patient (mid 40s, active), that only had symptoms of fatigue with periodic "waves" of energy loss (weak), that ultimately tested positive for PAD? And could a cardiopulmonary exercise SHAPE test give an incorrect reading of low blood oxygen just due to cold hands? PS. Patient has reduced capacity to exercise, when 8 months ago was playing competitive beach volleyball...

Mehdi_Shishehbor_MD: We need more information to answer this question. It is possible to get erroneous readings regarding oxygen measurements, but obviously we would need to know exactly what has been done. Also, it is unusual for a 40 year old competitive athlete to have significant PAD. There are other conditions that could affect the arterial blood supply to the legs causing pain or weakness in the legs. However, rarely do they cause generalized weakness. We are more than happy to evaluate you by online consultation or in person.

Porchplant: Is "magnetic" surgery available to PVD patients?

Mehdi_Shishehbor_MD: We are not aware of any magnetic surgery.

Porchplant: Endocrinologist wants me on Niaspan because he says, as evidenced in high above range LP(a) testing for hyperthyroidism, would slow the progress of arteriosclerosis from long term type 1 diabetes. Currently facing possibilty of amputation of lower right leg and already on a lot of meds that contribute to internal bleeding (Plavix, Pradaxa, Methimazole) and so afraid of adding another. Regular LDL testing shows me in range, but this LP(a) is not showing very well at all. At the crossroad of bleed internally without knowing it until too late or amputating leg. And by the way, would I still have to take blood thinners after amputation if disease was all in lower leg and amp was above knee?

Mehdi_Shishehbor_MD: It is difficult to answer all these questions via this web chat. It sounds like you have undergone a lot and are currently taking a number of medications. Your questions are appropriate. Niaspan has little to do with bleeding and is mainly used to treat high levels of triglycerides. The fact that you are on blood thinners is probably related to your PAD and the requirement for amputation. Unfortunately, it is hard for me to tell just by what you have described as to if you are on appropriate blood thinners or not. You need to be evaluated. We are happy to see you.

Milkmoney: Are there other health conditions that are associated with PAD?

Mark_Berman_MD: Yes. There is a strong association in PAD with coronary artery disease and carotid atherosclerosis. Risk factors for development of these three processes are similar.

Porchplant: Would laser revascularization be an option for severe lower leg PVD with current fempop and tissue occluded stents?

Mehdi_Shishehbor_MD: Yes. We use laser therapy when necessary to treat severe PAD. Given the complexity of your anatomy you would need to be evaluated in order to determine if laser or any other therapy would be helpful.

Whothewho: What is the difference between peripheral artery disease and peripheral vascular disease?

Mark_Berman_MD: They are the same. There are just different ways of saying the same thing.

Porchplant: Are self-expanding stents used for PVD of leg?

Mehdi_Shishehbor_MD: Yes. As a matter of fact they are commonly used to treat the majority of the arteries of the lower extremities. There are 14 self expanding stents currently available and used to treat lower extremity PAD< only 2 have FDA indication.

MarkKep: I am uncertain if I have peripheral arterial disease. I walk at least 5 days per week. I can walk for over an hour without any leg pain. Per my physician, I have a good pulse at the knees, but almost none at the ankles and I have night cramps in the calf areas. I am 79 years old, have never smoked, do not have Diabetes or high blood pressure.

Mark_Berman_MD: Your symptoms are atypical of PAD, but could easily be evaluated through a non-invasive arterial examination, such as a Pulse Volume Recording and ABI and doppler wave form analysis. This can be performed in a vascular laboratory.

Cleveland_Clinic_Host: For those just joining, we are chatting with Dr. Mark Berman and Dr. Mehdi H. Shishehbor about peripheral arterial disease. If you would like to review what already has been discussed, please click on the 'Transcript' button above. If you would like to submit a question, please type in the text box below and click 'Ask'.

William: My doctor has recommended I get an ABI. What is that?

Mehdi_Shishehbor_MD: ABI stands for ankle brachial index which compares the blood pressure in the arms and the legs. Typically the pressure in the ankles should be a little higher than the arms. This test is performed for people who have signs or symptoms of PAD. There are physicians that recommend this test as a screening tool in patients with diabetes or those who are smokers or are over the age of 65 years old. The test if abnormal, indicates that the individual is at risk of cardiovascular disease and should be managed aggressively with risk factor modification including diet, exercise and possibly medications.

AllyB98: My doctor has recommended I get an ABI. What is that?

Mark_Berman_MD: Daily walking may extend the distance you walk before first developing pain. If that is not enough to support your lifestyle evaluation for endovascular or surgical treatment may be necessary.

Mehdi_Shishehbor_MD: I also agree that taking pain medication long term to relieve symptoms of PAD would not be appropriate given that there are options to correct the problem.

KellerG: Recently my mother has been having hot flashes in her feet, sometimes in one foot, sometimes the other. Could this be a sign of vascular disease? It seems to occur after she has been sitting for a while and then starts to walk around.

Mehdi_Shishehbor_MD: This would be unlikely to be PAD. It may be actually be more related to venous insufficiency. Obviously, she would need to be evaluated by physical exam to truly determine the cause of her symptoms.

Sllys: What is restless leg syndrome (RLS)? Is this related to PAD?

Mehdi_Shishehbor_MD: It is likely not related to PAD. It has been associated to sleep apnea, but in general the etiology is unknown. There are medications that can be given to help this condition.

Cleveland_Clinic_Host: We are reaching the end of our chat. Would like to add any important information to our chat viewers?

Mark_Berman_MD: Patients may help themselves prevent PAD with smoking cessation; healthy diet and or healthy diet to lower cholesterol levels; control of blood sugar in diabetics; aggressive control of hypertension; and regular exercise are all important. The best treatment for PAD is to avoid developing it.

Mehdi_Shishehbor_MD: I agree with Dr. Berman. I also want to emphasize the fact that PAD is under diagnosed and under treated. If you have been diagnosed with PAD and are suffering from pain or claudication, you should definitely seek help. This is important because individuals who are diagnosed with PAD are at significant risk of having a heart attack or a stroke. Therefore, a global approach that deals with all the risk factors and also addresses the issue of exercise should be initiated. Simply, you should not become a couch potato because you have PAD and pain. If you have PAD and pain, you need to seek help and get treatment for the pain (which may include medication and or endovascular/surgical therapy) and initiate a healthy active lifestyle to prevent further progression of your PAD.

Cleveland_Clinic_Host: I am sorry to say that our time is now over. Thank you again for taking the time to answer our questions about peripheral arterial disease.

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