Thursday, September 6, 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. Vascular medicine specialist, Dr. Heather Gornik answers your questions about PAD.
Peripheral Artery Disease (PAD) – Dr. Gornik’s advice for all patients
robertp: Is there specific advice you give to all your PAD patients?
Dr__Gornik: There's a lot I discuss with my patients. I think the two most important pieces of advice I give is that:
- Stable PAD can get worse, and patients can present almost with a "leg attack" or something called critical limb ischemia that is pain at rest, a non healing sore or severe color changes in the feet. If a patient with PAD develops worsening symptoms consistent with critical limb ischemia CLI, they need to see their vascular surgeon or other specialist right away as they may need to have a procedure to urgently restore blood flow and save their limb.
- My other key piece of advice for PAD patients is that blockages in the legs increase the likelihood for blockages in the arteries throughout the body. Patients with PAD have a significantly increased risk of having a heart attack or stroke. IT is really important that PAD patients receive aggressive modification of their atherosclerosis risk factors. That would include antiplatelet agents (blood thinners), cholesterol lowering medication (statin), blood pressure control, and blood sugar control. It is also critical that patients with PAD do not smoke!
china88: My husband has leg pain, from the top of his thighs down to his calfs. Sometimes he also has numbness in his legs. It hurts more when he walks alot. He has high cholesterol and blood pressure. Could this be PAD? His friend told him it is sciatica
Dr__Gornik: This definitely could be PAD especially if the leg pain comes on with exertion/walking and goes away within a short period of time (generally less than 10 minutes) after stopping to rest. Your husband should discuss his symptoms with his doctor. The first test (after a physical exam) would generally be an ankle-brachial index where blood pressures are measured in the legs at rest and after exercise. The test can be performed before and after exercise too (exercise ABI) to see if the leg symptoms are really due to blocked arteries. The first step though is for your husband to ask his doctor “Could this be PAD?”
rachelP: My mom has leg pain and she is scheduled for bypass surgery in a couple weeks. Are there any things other than pills that can help her pain until her surgery? It seems as though the pills are not working.
Dr__Gornik: It’s hard to say without more information about the symptoms she is having. Leg pain could be due to many things, including PAD (pain with exercise called claudication but also potentially pain at rest in the feet and legs in severe PAD), but also disease of the veins, nerves, arthritis, or muscular conditions. Please have your mom discuss her symptoms with her doctor and have a thorough physical exam.
waynerfreed: I have CHD (7 yrs) and for the last year I have had pain in both my feet. The doctor checked me for diabetes. I don't have it but they put me on gabapentin 300mg 3 times day. This helps a little but no one has told me what my problem is and how I can get rid of this terrible sensation in my toes. Should I see a specialist and if so what kind?
Dr__Gornik: Dear Waynerfreed. I am not sure what CHD refers to? Coronary heart disease? Your symptoms could be due to many things, including painful neuropathy. Vascular disease is also on the list of potential causes. I would recommend that you start with a neurologist. Your primary care physician or cardiologist could check you for peripheral artery disease/PAD with an ankle-brachial index ABI test. Good luck.
nutzy: leg pain generated by statin treatment could be confused with leg pain in PAD patients? It's going to be worse with the exertion and this is confusing.
Dr__Gornik: Dear Nutzy. I'm glad you asked this. Statin related pains are sometimes tricky, but usually they occur both with rest and with exertion and involve the large muscle groups of the legs/arms most commonly. PAD pain/claudication can be similar, but for most patients with PAD related leg pain, it worsens with a reproducible amount of activity and goes away very quickly with rest. My sense of statin related pain is that it does not resolve as quickly and often persists.
Medications for PAD
Duvid: I have had a catheterization in my left leg for PAD and I am taking Pletal. It has been nearly a year. Must I continue Pletal?
Dr__Gornik: Cilostzol/Pletal is a medication that can help with claudication pains in the leg. If this medication is helping you, it may be worthwhile continuing it, but it is not the same sort of medication as aspirin or clopidogrel after an angioplasy/stent which needs to be taken to keep a stent from developing a blood clot/thrombosis. I suggest you discuss this with your vascular doctor.
Lsmith: What medications are used to treat claudication?
Dr__Gornik: Unfortunately, we only have 2 drugs FDA approved in the United States for claudication as of now. 1 is not very effective --- it's called pentoxifylline (or Trental). The other agent is called cilostazol or Pletal. It has shown moderate effectiveness in improving the distance patients with PAD can walk without having leg pain and the total distance patients can walk. One of the other questions on this chat was also concerning cilostazol.
PAD: Interventions and Surgery
cape28: I am a 55 year old female who had a doppler due to claudication and an angiogram which showed peripheral artery disease narrowing. The doctor also said I had some collateral circulation and that he is not sure he would do anything. I am having leg pain though. When do they decide to do interventions for PAD
Dr__Gornik: Great question. Whether or not a leg intervention is done for PAD depends on a number of factors, including the severity of your symptoms (just leg pain when walking long distances or at worst leg and foot pain at rest with non healing sores) as well as factors such as the location and extent of blockages (whether they can be fixed with angioplasty/stent or require surgery) and your general health (do you have kidney function, diabetes, other major health issues that post an immediate risk to your health). I think it would be important to try other treatments for PAD, like supervised exercise training or a home based walking program or cilostazol. I also think it is important to follow-up and let your doctor know whether things are (or are not) improving so that revascularization can be reconsidered.
kittykat78: I am a healthy 30 year old who is on BC pills. Recently I had to have a stent put in my leg for PAD. Do you think the BC pills caused the narrowing? Can I stay on them?
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Dr__Gornik: The fact that you are 30 years old and having a stent in the leg for PAD is very, very unusual. First, I would want to know if the stent was placed for an artery problem (PAD) or a vein problem such as a venous blockage or blood clot. It is very unusual for 30 year old woman to have atherosclerotic PAD, and I would be concerned about more unusual. Unfortunately, since I don’t have all of the important clinical information I need, I can’t make a recommendation in terms of the oral contraceptives.
JacksonF: I have blockage in my iliac arteries. The doctor put a stent in 2 years ago and now it is blocking again. What do they usually do in that case? Can they clean the blocked stent out with something? Do I need surgery now?
Dr__Gornik: Good question Jackson. It sounds like you have had restenosis of the stent (called “in stent restenosis”) in the medical literature. In most cases, this would be treated by another catheter based procedure and a balloon angioplasty to treat the narrowing. Sometimes another stent is needed. It would be less common to need a surgery initially. It would be very important for you to follow-up with the doctor who placed the stent.
cheryl4: I have bilateral renal disease and had an angioplasty six year ago but now have restenosis. What treatment options should I consider? I also have a renal aneurysm.
Dr__Gornik: Treatment options for restenosis would generally start with repeat angioplasty (sometimes repeating stenting is needed) and also open surgery. In your case, it sounds like you may have FMD, and with a renal aneurysm, surgical revascularization would also need to be considered depending on the size and location of the aneurysm.
anitasmay: When surgery is required is there an alternative to iodine dye for those with severe allergy?
Dr__Gornik: dear anitasmay. I am afraid you will have to discuss that in more detail with the surgeon who will be doing the procedure to discuss his/her approach. It will vary by surgeon and also the type of blockages.
PAD and Research
RichardTK25: Can you talk about stem cell trials or other types of research being done for patients with PAD?
Dr__Gornik: There are a number of ongoing research studies nationwide and abroad for new treatments for PAD. Most of the stem cell studies involve mobilizing early stem cells either from the bone marrow or peripheral blood and injecting them into the lower extremity. Most of these studies are enrolling patients with very advanced peripheral artery disease, known as critical limb ischemia, which includes patients with very poor circulation to the leg and pain at rest, non healing ulcers (sores), or even gangrene. All of the stem cell programs are investigational or research only at this time (i.e., there are no FDA approved stem cell therapies for PAD). To learn about clinical trials for PAD which may be in your area, you can always go to: www.clinicaltrials.gov and type in PAD or PERIPHERAL ARTERY DISEASE as key words.
PAD and Leg Ulcers
SamanthaR: My uncle has bad PAD and he has an ulcer that is not healing on his foot. He has been recommended treatment with hyperbaric chamber for his ulcer treatment. Can you tell me how that works? Should we pursue this? We would have to drive pretty far to get this treatment.
Dr__Gornik: Hyperbaric oxygen can help some patients with non healing wounds. However, I would also want to be sure your uncle’s PAD has been thoroughly evaluated and that he has been considered for revascularization procedures to improve blood flow to the limb to improve wound healing. If he has not been seen already by a vascular specialist, he should see one soon.
PAD and Limb Loss
enieman: Dr. Gornik, I have heard that PAD is associated with loss of limb. How concerned should I be?
Dr__Gornik: Good question. In general, all comers with PAD have an increased risk of an amputation, but this is not very high --- on the order of 5% or less at 5 years. That being said, there are certain groups who have very high risk of having an amputation, which would include patients who have critical limb ischemia, the most severe category of PAD where there is pain at rest in the leg or a non healing sore/ulcer. In critical limb ischemia, the amputation rate can be as high as 1 in 4 patients at 1 year, and for these patients, getting help from a vascular surgeon/specialist as soon as possible to try to salvage the limb is critical.
Cardiac Rehabilitation and PAD
will44: Can you talk about cardiac rehabilitation for PAD patients? What does it entail? Is it covered by insurance?
Dr__Gornik: I'm really glad you asked that. Supervised exercise training is a very, very effective treatment for PAD. It involves going to a facility (usually a cardiac rehab) 3 or more times per week with supervised training sessions on the treadmill of walking exercise and then rest. Exercise rehab can greatly improved the function and quality of life of PAD patients.
Unfortunately, most insurance payers do not cover exercise rehab for PAD in 2012... this is something that many of us in the field hope to remedy some day. In the meantime, if you have coronary artery disease, angina, or recent heart bypass or stent, you may qualify for coverage for rehab that can be tailored to PAD.
PAD and Risk Factors
nieman: What risk factors are associated with PAD?
Dr__Gornik: Another important question. The main risk factors for lower extremity PAD (plaque in the leg arteries leading to blockages) are smoking, diabetes, older age. High cholesterol, high blood pressure, kidney failure, and certain racial/ethnic groups also are associated with increased risk. Both men and women can have PAD.
Herbals and PAD
KathyKL: I keep reading on the internet to take cayenne pepper to help relieve symptoms of PAD? Have you heard of that?
Dr__Gornik: Sorry, but I have not read any scientific literature on cayenne pepper to help with PAD symptoms
Difference between PAD (Peripheral Arterial Disease) and PVD (Peripheral Vascular Disease)
enieman: Dr. Gornik - do you want to talk about the differences between PAD and PVD - I am confused by the differences in names
Dr__Gornik: Great question. There was a time when PVD used to mean PAD... let me explain. It's confusing! The American Heart Association put together a group to work on vascular nomenclature a few years ago. What they decided was that PVD or Peripheral Vascular Disease would refer to all vascular disorders outside the heart (arteries, veins, lymphatics). Peripheral artery disease is the term used for vascular disease of the extremities, and generally of the legs. This is blocked arteries in the legs that can cause claudication (or pain in the legs with walking that goes away with rest), non healing sores on the legs, or other kinds of leg pains.
Varicose Veins and Spider Veins
Shana65: What are other treatments for varicose and spider veins, besides Sclerotherapy? Is one option considered better than others? Is there anything new on the horizon?
Dr__Gornik: Dear Shana65, for others on the chat, you are asking about vein disease, spider and varicose veins. There are a lot of options to treat this, beginning with the most simple measure which is prescription strength graduated elastic compression stockings which can help with leg swelling, fatigue, and pain related to veins. Beyond this, there are many options, including sclerotherapy where a chemical (usually hypertonic saline or foam) is injected into the vein to cause it to regress/shrink. There are other procedures available for larger veins which include radiofrequency or endovenous laser ablation. Finally, there are surgical options for varicose veins, including ambulatory phlebectomy where small veins are removed through incisions in the skin or vein stripping procedures. Before moving to these invasive procedures, the first thing to try would always be compression therapy --- there are many strengths of compression, types of fabric, colors, etc. available to make this more palatable than the old fashioned “surgical hose”.
Fibromuscular Dysplasia (FMD)
scottie: I have FMD of the cervical and renal arteries and also subclavians. There is a possibility that I have coronary FMD also, as I have had some night-time squeezing chest pains-suggestive of Prinzmetal angina. My question is- would a coronary angiogram be more difficult in an FMD patient due to the possibility of radial or femoral arteries being affected and more stenosed/fragile? Would an MRA of the coronary arteries reveal FMD there? I do not have access to a specialist FMD hospital or clinic. Thanks for answering these questions.
Dr__Gornik: Dear Scottie. For others on the chat, your questions is about FMD or fibromuscular dysplasia which is an uncommon disorder of the arteries that affects the blood vessels to the kidneys and brain most commonly, but also can affect the leg arteries. It’s different than PAD, but also an important disease. FMD can cause coronary artery disease, but usually it presents very abruptly with a coronary artery dissection and chronic stable chest pain is very uncommonly caused by FMD. I think the best place to start to evaluate your chest pains would generally be a cardiologists evaluation and also a stress test. MRI does not effectively view the coronary arteries in most centers. Coronary CTA can be done in certain very specialized centers. I would generally recommend a heart cath only if the non invasive testing (i.e., the stress test) shows evidence of inadequate blood flow to the heart (or ischemia). Heart caths can be done on FMD patients, but need to be done with extra care given some potential for injury/dissection of the access arteries. I do think the best place to start for you would be to see a cardiologist who is familiar with FMD who can help you figure out if it requires additional testing or if it could be FMD related (though again, I think it is unlikely to be FMD related). Good luck!
pmace: hi Dr Gornik, Can you share with us how your FMD patients are being treated for tinnitus?
Dr__Gornik: Back to FMD! FMD patients can have a pulsatile sound in their ears (swooshing or wooshing). It can be very annoying and is related to blockages in the carotid arteries. We have been working with out Cleveland Clinic audiology/hearing specialists and they have some therapies available for pulsatile tinnitus, including some devices that help distract patients from the annoying sounds.
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