Monday, January 9, 2012 - Noon
Peripheral artery disease (PAD) affects about 8 million Americans. It is estimated that 1 in 3 diabetics over the age of 50 are suffering from this condition. If left untreated, PAD can lead to severe damage to the limbs and organs. Dr. Kirskey answers your questions about PAD, diagnostic testing and treatments.
Cleveland_Clinic_Host: Welcome to our "Peripheral Artery Disease Interventions and Surgery" online health chat with vascular surgeon Dr. Levester Kirksey. He will be answering a variety of questions on the topic. We are very excited to have them here today! Let's begin with the questions.
Peripheral Vascular Disease (Vein disease or PVD) and Varicose Veins
char98: I have been told that the valves in my vein in my right leg are shot. Can they be replaced? Can you replace a vein?
Dr__Kirksey: There are two types of veins in the lower extremity - superficial and deep. The treatments that are available depend on which system is affected. A vascular specialist can perform an ultrasound test to determine which system is affected and which treatment is appropriate, including valve replacement.
gatorfrog: I was in a store and all of a sudden I noticed (felt) something on my leg. It turned out to be blood (allot of it) coming down my leg from the varicose veins in the back portion of my upper thigh. We got it stopped and it hasn't happened since but should I be concerned and should I have it checked out? Thank you!
Dr__Kirksey: Yes. It is likely to reoccur. If it does, immediately sit down and elevate your leg and apply pressure. You should be evaluated for CVI, which may be easily treated with minimally invasive therapies.
gatorfrog: I just wanted to thank you for your answers to my questions. They were very helpful and I can take them to my doctor appointments this week. Thank you!
Dr__Kirksey: You are welcome.
Lola: Why are varicose veins so much more common in women? Are they related to heart disease?
Dr__Kirksey: Varicose veins are more common in women for multiple reasons including the hormonal changes that women experience monthly and during reproductive years; hormonal and anatomic changes that occur in child bearing and pregnancy. There also seems to be a poorly defined genetic predisposition in women of certain families. Varicose veins and heart disease have no clear relationship.
Peripheral Artery Disease (PAD) and Peripheral Vascular Disease (PVD)
RT: What is the difference between PVD and PAD? What are the causes?
Dr__Kirksey: PAD or peripheral arterial disease refers to blockages in the arteries outside the heart. PVD or peripheral vascular disease refers to disease within the arteries or veins in the body. The causes include high cholesterol, diabetes, hypertension, smoking and genetic predisposition.
Kimber: If you have PAD, does that increase your likelihood of having other arterial problems and vice-versa?
Dr__Kirksey: Yes PAD or blockage of the blood vessels outside of the heart is a systemic process. Fortunately identification of PAD often allows us to identify arterial blockages in other systems and aggressively treat them with either medications or interventions which prevent the complications of the disease.
KAREM: ON WHAT BASIS, CAN YOU DECIDE THIS PATIENT NEEDS MEDICAL OR SURGICAL TREATMENT
Dr__Kirksey: The need for medical or surgical treatment is dictated by the severity of symptoms and the risk factors for developing complications which include limb loss; stroke or heart attack. Your vascular specialist will determine which treatment is appropriate for your disease process.
mconiglio: What are you doing at Cleveland Clinic to help patients seek treatment for PAD?
Dr__Kirksey: Educational forums like this assist patients in acquiring the knowledge to take action for their disease process. Improving the availability of diagnostic testing through our health care system with same day appointments available throughout the region makes seeking treatment much more convenient.
Symptoms of PAD
Gatorfrog5: I have all the symptoms of PAD but I also have peripheral neuropathy. Lately, the achiness and tingling have gotten worse in my ankles and feet. When I saw my neurologist and told him, he just said that my peripheral neuropathy was probably worse. When he did the reflex text on my knees, my legs didn't even move, nor did my ankles. Do you think I should be tested for PAD? Thank you!
Dr__Kirksey: Yes. everyone with risk factors for PAD and symptoms should be tested. The screening test is simple and painless referred to as ankle brachial index.
JanieG: Is dropped foot caused by PAD and is there any treatment for this condition?
Dr__Kirksey: Dropped foot may be a symptom for PAD however in general; dropped foot suggests an underlying neurologic disorder. A simple screening test, ankle brachial index, can identify any underlying PAD.
F45687: What are the symptoms of PAD, what should be look out for?
Dr__Kirksey: Symptoms of peripheral arterial disease range from pain in the muscles with exertion; discoloration of the feet and toes; ulcer formation on the toes. If you have risk factors for peripheral artery disease a simple test is the ankle brachial index which can be performed by your primary care physician or a vascular specialist.
Paul49K: What exactly is Intermittent Claudication?
Dr__Kirksey: Intermittent claudication usually manifests as cramping in the muscles of the hip, calf or thigh with exertion. It is a manifestation of peripheral arterial disease and can be significantly lifestyle limiting. Diagnostic tests like the ankle brachial index can identify and measure the severity of peripheral arterial disease which presents as claudication.
Femoral Artery Disease
FrankM552: My tests results came back and showed that I have a narrowed femoral artery. I am meeting with my doc this week to talk about stents vs. surgery bypass. How do they make the choice of bypass vs. stent? what is the recovery time? What is the length of time these work?
Dr__Kirksey: The choice of the appropriate therapy is dictated by the type of blockage and features including the length and severity of the narrowing. Additionally, patient factors and ability to tolerate an operation determines whether angioplasty or bypass is appropriate. After diagnostic tests are performed, a vascular specialist will discuss which option is appropriate for you.
Treatment of Peripheral Artery Disease (PAD)
stitchesandink: I have peripheral Artery Disease...diagnosed about 18 years ago. I have had a bk amputation of right leg due to no circulation to foot. I now have problems with my left leg....non-healing ulcer on big toe for about 2 years now. I had an angiogram done about 18 months ago & doctor couldn't open the blockage. It is in my ankle area. Is there another way to open a blockage?
Dr__Kirksey: Technology to treat vascular blockages improved rapidly and so I would suggest another evaluation to see if these blockages can either be opened with minimally invasive treatments or bypassed with surgery. This can potentially save your limb. See your vascular specialist immediately. I would be happy to see you at Cleveland Clinic for a second opinion consultation.
Limb Salvage – Amputation Prevention - PAD
LAJoe28: My dad had a couple toes amputated. He is a Type 1 diabetic. His doctor seems to think that this did not take care of everything. They are waiting to see how he does but if he does not do better, he may lose his foot. Can you talk about vascular surgery to improve circulation to his feet so he does not need another amputation?
Dr__Kirksey: Patients at risk for limb loss need aggressive management to prevent further amputation. The evaluation begins with diagnostic studies to determine what blood vessels are involved. Options for treatment include minimally invasive therapies like angioplasty and stenting or arterial bypass and other circumstances. The key is early intervention.
Cleveland_Clinic_Host: Dr. Kirksey, we know you have an interest in treating patients for peripheral arterial disease, especially in advanced limb threatening disorders. How has the treatment changed over the last few years?
Dr__Kirksey: Over the last decade we have seen a significant improvement in our ability to treat vascular disease both with medications and with procedural interventions. We now have very good minimally invasive procedures which provide immediate relief to patients; provide durable results and allow patients to resume their normal activities immediately.
Prevention and Screening
RachelK: My dad has had terrible vascular disease; he has had both carotid surgery and a left leg below the knee amputation. He is diabetic. My mom has high blood pressure and high cholesterol. She has had a couple stents in her heart. I am very worried. I am 28 years old and diabetic. I eat right and exercise but what else can I do? What tests should I have to make sure everything is ok?
Dr__Kirksey: The most important factor is controlling your diabetes which is a major risk factor for heart attack, stroke and limb loss. Significant advances have been made in the diagnostic genetic testing, which can guide your vascular specialist in preventing vascular disease from progressing. I recommend that you see a vascular specialist for genetic testing.
nutzy: I had an arteriography 10 years ago; It was ok but I’m worry because I have valvular and cardiac rhythm problems .Do you recommend to repeat it after 10 years?
Dr__Kirksey: The need to repeat additional diagnostic studies would be dictated by whether the symptoms that the initial study was performed for have recurred. Many studies have potential risks associated and we are careful to evaluate the need for diagnostic evaluations. Check with your vascular specialist.
mconiglio: Does Cleveland Clinic have a peripheral vascular screening (self pay) program? If yes, what tests are included and how much does it cost?
Dr__Kirksey: For people who have risk factors and symptoms suggested above for PAD, insurance usually covers the indicated testing. I encourage you to seek out the appropriate screening test because early intervention and management is important.
mconiglio: could you explain how genetic testing for vascular disease is done and what would be done with the genetic test results?
Dr__Kirksey: Genetic testing is performed through blood work evaluation. The testing can identify if risk factors like high cholesterol needs to be treated more aggressively. In some patients the cholesterol may be normal on regular cholesterol panel; however genetic testing will identify high risk factors.
meed2k: Is there an increase in heart attack with PAD?
Dr__Kirksey: The risk of heart attack in a patient with PAD is twice the normal risk for an unaffected patient. PAD represents an opportunity to identify silent heart disease and also to prevent stroke. All patients with PAD should be evaluated for heart disease and stroke risk factors.
kigue: What are screening programs, and what does that entail? What should I look for? Are they any good – it seems like a good deal to get screened – but how accurate are the tests?
Dr__Kirksey: In general screening programs will commonly include an ankle brachial index to identify peripheral artery disease, a carotid ultrasound to identify carotid stenosis, a risk factor for stroke and some may include ultrasound screening for abdominal aneurysm. The accuracy of the test is a function of the technicians and interpreting clinicians’ skill.
juliap: is there a correlation between PAD and hypercholesteremia?
Dr__Kirksey: Yes. Hypercholesterolemia is a significant risk factor for the development of peripheral arterial disease. Early identification of high cholesterol and aggressive reduction of high cholesterol can reduce the risk of peripheral arterial disease and its associated complications.
wednesday: is there a website with info about exiting treatments/preventative measures that are available?
Dr__Kirksey: Our website www.my.clevelandclinic.org/heart has information as well as the Vascular Disease Foundation - www.vdf.org
Chronic Venous Insufficiency
Ann: is it possible to have superficial CVI without the symptom of varicose veins but having other symptoms?
Dr__Kirksey: Yes CVI can be asymptomatic or symptom-less. Or it may be accompanied by leg pain, fatigue with standing or varicose veins.
Barb: My friend is suffering from CVI. She is on Coumadin for thinning her blood. She is in her late 30's. She keeps getting her period because of the blood thinner and usually has it for about 21 out of 30 days. She is in severe pain. Her hematologist says she can only take Tylenol OTC. Her gynecologist says she cannot take hormones to regulate her period because they interfere with the Coumadin. She is crying almost all the time because of her pain and her hormones. I feel her doctors are giving her the run around. Should she seek another opinion or are there other treatments or at least pain meds she can take to relieve her of the stress? She called me everyday this weekend, crying and not knowing what to do. She is trying to finish her MA and this is all making it more stressful. She exercise and keeps her weight down; she takes hot baths to relax her but she cannot sleep through the night because of either pain or stress. I am concerned for her mental health. What do you suggest? We live in Houston with one of the largest medical centers in the world and I suggested new doctors. Should she see a vein specialist as compared to a hematologist? Any suggestions would be appreciated.
Dr__Kirksey: The treatments for chronic venous insufficiency CVI - include laser or radiofrequency ablation of the abnormal vein. In general anticoagulation including blood thinners is not a treatment for CVI. Instead they may treat some of the problems that have led to the CVI. She should see a vein specialist.
Thoracic Outlet Syndrome
kk247: I have noticed just last week that my veins on my arms have become more prominent and if I am sitting at my computer for very long my hand becomes cold and tingling. Is something going on with the circulation in my arms? When I put my hands down after some point, they become warmer with time.
Dr__Kirksey: Your symptoms may suggest some type of exertion related venous stenosis or venous narrowing, like thoracic outlet syndrome. The diagnostic tests are quite simple as is the treatment. You should see a vascular specialist.
Barb_S: My daughter was in a car accident last year. She began experiencing tingling pain and numbing in her right arm. Her doctor said that she could possibly be having thoracic outlet syndrome and that she will be undergoing tests. I want to make sure she has the right tests to diagnose this and also can you talk about the right treatment for thoracic outlet syndrome?
Dr__Kirksey: Appropriate diagnostic tests include CT, MRI and EMG. The appropriate treatment depends upon precise excision or removal of the structure causing the obstruction which may be cartilage or bone.
Carotid Artery Disease
Charlotte_C: I want to know if the atherectomy can be done on the carotid arteries, as I have found out through testing that I have the carotids of an 86 year old and I am 65. What can be done for this?
Dr__Kirksey: Atherectomy is not performed in the carotid blood vessels. The minimally invasive method of treating the carotid vessels is angioplasty and stenting. This has shown results comparable to the gold standard of carotid endarterectomy. Ask your vascular specialist is best for your carotid problems.
Cleveland_Clinic_Host: Any other words of wisdom that you would like to offer?
Dr__Kirksey: In my experience the largest challenge for us as clinicians is identifying vascular disease early in the process. When vascular disease is identified early, medical options can significantly improve outcomes over time. As vascular disease advances in severity medical options are less likely to be completely sufficient. Fortunately our ability to diagnoses vascular disease with minimally invasive painless tests is very good at this point. Our challenge is to increase awareness about the signs and symptoms of vascular disease so that patients are empowered to seek treatment.
Newbiy: My husband has serious blood clots in his legs what are some things I could do to help him feel some what better?
Dr__Kirksey: The symptoms of lower extremity venous clots can vary from generalized leg swelling to leg pain and even ulceration. Various modalities like compression stockings of medical grade and compression pumps can significantly reduce patients' symptoms and improve quality of life. I would encourage you to visit a vascular specialist who will determine the most appropriate treatment for your husband.
Meril67: My father is 65 years old and had a test last week that said he has severe aorta atherosclerosis. What do they do for that? Does he need a specialist?
Dr__Kirksey: Yes he does need a specialist. Severe aortic atherosclerosis can significantly diminish ones quality of life and lead to complications such as limb loss if it is not treated. Treatments range from minimally invasive options which allow one to resume their normal activities immediately to other treatments like arterial bypass. A vascular specialist can evaluate your father to determine what treatment is appropriate for his disease.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.