Friday, January 31, 2014 - Noon
Peripheral arterial disease (PAD) -- also known as peripheral vascular disease, atherosclerosis or hardening of the arteries -- is a disorder that occurs in the arteries of the circulatory system. PAD affects between 8 and 12 million Americans. If left untreated, PAD can lead to severe damage of the limbs and organs. Dr. Kirsksey and Dr. Evans answer your questions about PAD.
Nadia K: I have a throbbing feeling constantly in my leg. Could that be a blockage or blood clot?
Natalie_Evans,_MD: It is always a possibility, but it is a good idea to first get checked out by your primary doctor. The most common symptoms of blood clots in the veins are swelling of the leg, pain and tenderness to the touch, along with redness. Blockages in the arteries classically cause pain in the leg with walking that improves with rest. Again, it is a good idea to get your leg symptoms checked out.
virginia-blue: This past week I felt pain and throbbing in my one side of my neck where my carotid artery would be. Is that carotid artery disease? Or what can it be?
Natalie_Evans,_MD: Typically atherosclerotic carotid artery disease does not cause pain and throbbing in the neck. Very uncommonly, patients can have a tear in the carotid artery that can cause severe pain in the neck. Sometimes this is accompanied by neurologic symptoms. It is important if you have severe neck pain that does not go away on its own after a couple of days to be evaluated.
bethP: ,em> My husband’s legs are very swollen. He has had an angiogram and went to a vascular specialist. It showed no blockage but he needs to wear special stockings. He continues to have swelling even above the stockings and the doctors said they cannot do anything more. He may not have good drainage in his legs. Are there treatments for this?
Lee_Kirksey,_MD: Leg swelling can have a number of etiologies. Common etiologies include chronic venous insufficiency; acute venous thromboses (blood clots); or lymphedema. We usually begin this evaluation by performing an ultrasound to determine if the veins are a cause. In many instances we are able to identify abnormalities in the venous anatomy which can be corrected by minimally invasive ultrasound guided treatments. One of these treatments is endovenous laser ablation, another is sclerotherapy. I would suggest seeing your vascular specialist or we would be happy to see your husband at Cleveland Clinic for the various causes of leg swelling.
there4jsweetie: I have a diagnosed idiopathic neuropathy related to numbness in my legs and feet. I have had numerous nerve tests with nothing conclusive. Could this be due to PAD?
Natalie_Evans,_MD: In general, PAD has to be pretty severe to cause severe neuropathy, however, research has shown that many PAD patients may have some degree of neurologic dysfunction on nerve function studies. In your case, I would imagine that PAD may have been ruled out already but it is a good conversation to have with your doctor. We typically test for PAD by performing the ankle brachial index which involves measuring the blood pressure in the arms and at the ankles. We may additionally test the pressure at other levels in the legs. Other tests that may be used to diagnose PAD include arterial ultrasound and CT and MRI scans.
firstname.lastname@example.org: I have MVD and am very interested in finding out about any research being conducted to find a solution/cure that will dissolve the plaque in the small vessels that are untreatable with angioplasty, stents, etc. For example, are you aware of any drug companies developing a drug that will dissolve plaque? Thank you!
Natalie_Evans,_MD: Great question. I’m not aware of any drugs to dissolve plaque that are in development. However, there may be other therapies available to you. If your microvascular disease is in the legs, I would recommend consultation with a vascular specialist such as a vascular surgeon, vascular internist, or cardiologist who specializes in peripheral vascular diseases to look into this further. If your disease is in the heart arteries, then a visit with a cardiologist would be the way to proceed.
Cardiovascular Disease and PAD
clara: I have had eight stents in all major arteries in the heart, but I do not have PAD. It amazes me that the my legs do not have a problem. Would you explain this to me?
Lee_Kirksey,_MD: Roughly 50 percent of people with symptomatic cardiovascular disease will have symptomatic lower extremity occlusive disease. Fortunately it sounds like you are in the group that does not have infra-inguinal atherosclerosis. Hopefully with continued risk factor modification you can reduce your risk of developing lower extremity vascular disease or cerebrovascular disease.
Chronic Venous Insufficiency
ElmiraNY55: I was diagnosed with chronic venous insufficiency and my doctor said I need surgery. I don't really understand what that is or the surgery to treat it. Can you explain. Also - is this genetic as my mom also had several vascular problems too.
Natalie_Evans,_MD: In Chronic Venous insufficiency, the valves in the veins may not work as well as they used to which can cause swelling, discomfort, and in severe cases, ulcer. It is hard to explain the particular surgery your doctor has in mind without knowing more about your case. In general, the surgical options for venous insufficiency include endovenous laser ablation (which is a catheter based procedure in which the offending vein is destroyed), sclerotherapy (involves injecting a material into the vein to destroy it), and phlebectomy (commonly known as vein stripping). We don't totally understand the genetics of Chronic Venous disease, but it is clear that it does run in some families.
Lifestyle Changes and PAD (diet and exercise)
email@example.com: Are there dietary approaches to treat and/or reverse PAD?
Natalie_Evans,_MD: In my practice, I recommend a diet that’s low in animal fats (saturated fats, including dairy) and things that are white—sugar, flour, rice, pasta—and high in fruits, vegetables, and whole grains. There’s no diet that has been definitively shown to reverse PAD, but the diet I recommend, in combination with weight control, exercise, and a good medication regimen, may help prevent artery disease from getting worse.
ds1939: Can you be more specific about "good medication regime"? Are you referring to cholesterol lowering ones?
Natalie_Evans,_MD: A good medication regimen includes a medication to block platelets, usually aspirin or plavix; a cholesterol lowering medication; and medications to control the blood pressure. If you have diabetes, it is critical to control your blood sugar. These medications can lower your risk for heart attack and stroke, which are the greatest risks for people with PAD.
sky321: I currently walk and do resistance exercises. Are there any specific resistance exercises that are good for PAD?
Natalie_Evans,_MD: Not that I am aware of. Everyone as they get older loses muscle mass, so resistance training can be beneficial in that regard. Walking exercise is an important strategy in improving function in PAD. We usually recommend that if a patient cannot get into a supervised walking-exercise program, that they walk on their own for a minimum of 30 min, 3 times a week, walking until they get pain, stopping to rest and then continuing to walk.
Rosemary4438: I am a 56 year old female with peripheral artery occlusive disease and have also been diagnosed with some coronary artery and renal disease - I am wondering what can be done to slow progression of these conditions.
Natalie_Evans,_MD: As we alluded to before, the key to preventing progression of atherosclerotic vascular disease is a combination of lifestyle changes and medications (including aspirin or other anti-platelet medication, cholesterol lowering medications, blood pressure lowering medications, and diabetes medications if you have diabetes). Lifestyle includes healthy diet and exercise and controlling your weight.
Irish: I have heard from Dr. Esselstyn that endothelial damage is the initiator of atherosclerosis. He claims studies show that any type of oil, fish, and caffeine destroy these endothelial cells. Olive oil and fish are the staples of the Mediterranean diet which many physicians at Cleveland Clinic support. Do you know of any evidence that supports olive oil, fish, and caffeine destroying endothelial cells. I enjoy my three cups of coffee a day, and would like to switch from plant-based diet to more Mediterranean but I am worried doing these is hurting my overall heart health. My father died from heart attack at 50, and was found to have 75% blockage in his "widow maker" artery. Can you clarify these conceptions for me?
Natalie_Evans,_MD: The results of studies of diet are highly variable and so it is difficult to say with certainty what the best diet is. Some studies would say caffeine is bad - some would say it is good. The important thing to remember with regard to caffeine is moderation. Tune in on Feb. 27th with Dr. Cho and Dr. Gillinov as they discuss heart and vascular health for your question regarding Dr. Esselstyn's diet.
Chris: I developed a superficial blood clot while on a car trip in a three hour traffic jam....later I learned that being dehydrated contributes to these clots but in a traffic jam, you are not likely to be drinking a lot when you can't get off the highway....it caused my leg to swell and turn red and a red line was further up the leg by the next day....a quick trip to emergency confirmed it was only superficial thank goodness... Is dehydration related to blood clots?
Natalie_Evans,_MD: Dehydration in theory can cause the blood to be more concentrated, but whether it’s truly a cause of blood clots remains open to question. More likely it’s prolonged sitting in a confined space that leads to clots.
Cheryl: Can you please explain post-thrombotic syndrome?
Natalie_Evans,_MD: Yes, Cheryl, I’d be glad to. The post-thrombotic is, unfortunately, a very common complication of deep vein thrombosis, or blood clots in the deep veins of the legs. The PTS is characterized by long-term signs and symptoms such as pain, swelling, and skin changes. It is most likely to develop in patients who have extensive clots in the legs and those who have a recurrence of blood clot in the same leg. Other risk factors include obesity, older age, and for those on warfarin (Coumadin), an INR that is below the therapeutic range during the first three months of treatment of DVT.
linda34: I have an area where it looks like a vein popped in my leg and now the area is reddish in color and slightly warm to touch. It is painful too. Do you know what that could be?
Lee_Kirksey,_MD: When varicose veins, dilated veins, develop in the leg they can sometimes develop small, superficial blood clots. This is termed thrombophlebitis. The area may be warm to touch and painful. I would suggest being evaluated by a vascular specialist who could do the appropriate testing to determine if this is a superficial blood clot.
External Iliac Artery Endofibrosis
Rachel-MN: My sister is a big bike rider - rides in races that are like 100 miles. She is very healthy but started having problems with her leg - pain and cramps. Her doctor said she needs surgery and this is common in people who ride bikes a lot. Have you heard of this and do you think she needs another opinion? Sounds crazy that this exercise could cause her to need surgery - and then after surgery will she be able to ride again?
Natalie_Evans,_MD: I wonder whether your sister has been diagnosed with external iliac artery endofibrosis, a rare cause of leg pain with exercise that occurs in long-distance cyclists and, less commonly, long-distance runners. It’s thought (but not known for sure) that irritation of the artery from frequent deep flexion at the hip causes the artery to thicken. If this is your sister’s diagnosis, surgery may be indicated, but without more information about her case it’s tough for me to answer the question more specifically.
Lee_Kirksey,_MD: The surgery necessary is dependent upon whether the reduced blood flow results because of scarring within the blood vessel or elongation and kinking of the blood vessel. Preoperatively, specialized imaging is taken of the blood vessel to determine the surgical option that is most appropriate.
Howard-A1934: I had a blockage in my right leg several years ago and had a bypass. Now I have a blockage in the left leg and the doc was unable to go through it with a catheter. But he also said that the vessels in my legs are not good enough to use as bypass. What are the options?
Lee_Kirksey,_MD: We see many patients at Cleveland Clinic who have failed therapies or interventions at other institutions. We would evaluate you by performing a detailed vascular imaging. Many times there are alternative catheter based interventions to improve blood flow. If minimally invasive catheter based interventions are not possible, depending upon your symptoms we would determine if conventional open surgery is appropriate. Depending upon your symptoms, whether you have leg pain with exertion or pain at rest, we have a high success rate for improving circulation with minimally invasive interventions. Please contact us if you would like a second opinion.
georgeFL: My friend's friend had surgery at Cleveland Clinic that helped his dropped foot - can you tell me what that surgery was and if there is surgery that can actually help that? My doctor said there is nothing that can be done.
Lee_Kirksey,_MD: A dropped foot is most commonly related to a nerve compromise like spinal cord stenosis. This is a neurologic disorder - you may wish to begin your evaluation with a neurologist. However, I know that it is possible to sometimes reverse or improve the symptom of foot drop with surgical intervention.
Marcus: Looking for treatment for my 80 year old dad who has peripheral vascular disease, which is causing pain. He can barely walk. Last month he developed an infection on his foot and is taking antibiotics. Several years ago the doctors did an angioplasty to open up the vessels in his leg and now the doctors say he is too high risk for a procedure. He is also diabetic. They have discussed amputation to treat the poor circulation in the lower leg and foot that has the infection. Any hope or thoughts?
Lee_Kirksey,_MD: A very important aspect of treating the patients with severe, advanced peripheral arterial disease is understanding their global risk profile. That is this group of patients often suffer from cardiovascular disease, hypertension, and diabetes. Here at Cleveland Clinic we use our multidisciplinary approach to risk stratify the patient. Many times we are able to get patients with severe cardiovascular disease treated by using minimally invasive interventions to improve the lower extremity circulation. I would suggest scheduling a consultation with our vascular surgery department to evaluate your father. We frequently see patients who have been deemed high risk at other institutions and find creative ways to preserve their limb function in our advanced limb salvage program.
FrankM52: I have bad kidneys and need dialysis. A vascular surgeon put in the fistula and then he said I need to limit my activities - I cannot play golf. Why would that be? Is there a problem with activity or arm movements if you get a fistula?
Lee_Kirksey,_MD: In general, I do not restrict physical activity after performing a dialysis access procedure. Unless there are some unusual circumstances there should be no reason to limit activity.
Research – Angiogenesis and Stem Cell Research
Donald22: Do you have any research trials going on where you can grow blood vessels for people with severe PAD?
Natalie_Evans,_MD: Good question for Dr. Kirksey. I’m not aware of any currently running trials on growing blood vessels in the Section of Vascular Medicine.
Lee_Kirksey,_MD: Historically trials for angiogenesis, the growth of new blood vessels, have focused on using an agent VEGf - vascular endothelial growth factor. Although this agent showed some benefit in animal models human clinical trials have been disappointing. We currently have a new trial using stem cells to create new blood vessels in patients who are not candidates for bypass of the leg vessels because of advanced atherosclerosis or lack of a vein conduit. The bone marrow of the patient is harvested for mononuclear cells which are precursors to native blood vessels. These stem cells are then injected into the area of the leg which has ischemia. The Biomet trial is currently enrolling and you may contact our phone line 866.289.6911 or chat with a nurse from our website. Dr. Rebecca Kelso is the primary investigator and I am a co-investigator in the Department of Vascular Surgery.
JoanneH: Any new information on stem cell research? I understand there was a study at Cleveland Clinic and wonder if there is any information to see if it helped patients with PAD.
Lee_Kirksey,_MD: In an earlier answer, I referred to the Biomet Trial at Cleveland Clinic which is trialing stem cell as a angiogenic factor for severe peripheral arterial disease. The human bone marrow has monocytes which are endothelial precursor cells for human blood vessels. The trial is not finished at this point but the clinical results have been promising. Please contact us if you want to see if you are a candidate for this trial.
Miscellaneous Questions about PAD
Irish: Can you still atherosclerosis with a 0 calcium score?
Natalie_Evans,_MD: We are having several chats in February with Dr. Nissen and Dr. Cho - who could answer this question. Please visit chat.clevelandclinic.org for a list of these upcoming chats!
Irish: What is the highest risk factor for atherosclerosis? Genetics, diet, lifestyle, inflammatory diseases such as arthritis and psoriasis?
Natalie_Evans,_MD: The problem with atherosclerosis is that there is no one particular culprit at which we can point the finger - atherosclerosis is truly a multi-factorial disease which means that all of these things come together to play a role.