Monday, March 1st, 2010
Peripheral arterial disease (PAD) is arteries slowly become narrowed or blocked when plaque gradually forms inside the artery walls. There are many treatments for PAD such as lifestyle changes and medications, but more advanced PAD can be treated with interventional procedures to remove the blockage. Mehdi Shishehbor, DO, a Cleveland Clinic interventional cardiologist who is an expert in treating PAD answers your questions.
Mehdi Shishehbor, DO Interventional Cardiologist
Tomsich Family Department of Cardiovascular Medicine
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Mehdi Shishehbor. We are thrilled to have Dr. Shishehbor here today for this chat so thank for joining us. Let’s begin with the questions.
Speaker_-_Dr__Mehdi_Shishehbor: Thank you for having me today.
PAD and Cardiovascular Disease
MarkB: hello, 5 yrs ago was diagnosed with pad. Had an aorta bi femoral bypass done. Femorals blocked again 2 yrs. later. Had angioplasty and a stent put in left femoral. Nothing done to right. Dr. says now both are blocked again along with the aorta and cardio vascular. and carotids. he refuses to touch them again until something happens, ie heart attack, stroke or similar. he said my best bet would be a learning hospital such as Cleveland Clinic. I only have Medicare AB insurance. I feel I need a 2nd opinion. thank you
Speaker_-_Dr__Mehdi_Shishehbor: I would be happy to see you regarding the blockages of the arteries in your neck, heart and your legs. In general, everything has a risk and benefit. We must weigh the benefit of any kind of intervention in conjunction with the risk involved. Given the complexity of your prior operations, if you decide to come to Cleveland Clinic, please bring all imaging films and operative notes.
gg345: I am 30. I have Peripheral Artery Disease. I recently quit smoking I have had ongoing pain and heaviness in the left side of my chest for months. I have pain shooting into my left shoulder and sometimes I have numbness in my hands.
Speaker_-_Dr__Mehdi_Shishehbor: I suggest that you see a cardiologist familiar with coronary artery disease and peripheral arterial disease. Given your history, at age 30, one should consider the nontraditional risk factors for atherosclerosis. For example Lp(a), homocysteine, fibrinogen, hs-crp, and others. Furthermore, if your chest pain is angina, that would definitely require immediate attention.
Hiceski: My husband believes that if his GP did not refer him to a specialist that he doesn't need one. I am so concerned that this condition could lead to stroke or heart attack. Common sense tells me that if there is any pain in the back because of circulation it has to be affecting the heart. HIceski
Speaker_-_Dr__Mehdi_Shishehbor: I agree with your concern that atherosclerosis or circulation issues can affect all the vascular systems. i.e. the brain, carotids, heart, kidneys and the arteries of the legs. Therefore, in my opinion it is always a good idea to get a second opinion when it comes to your health.
Risk Factors for PAD
Hiceski: What makes an individual a risk for peripheral arterial deseade? HIceski
Speaker_-_Dr__Mehdi_Shishehbor: Same risk factors that apply to coronary artery disease are important for PAD. For example age, diabetes, family history of coronary artery disease or PAD, history of smoking, hypertension, hyperlididemia, kidney disease, obesity, stress. There are other non-traditional risk factors such as hs-crp, homocysteine, and lp(a). What is important is to realize that these risk factors affect all arterial beds as I described in the previous response.
Symptoms of Peripheral Arterial Disease
jamie: If I have a lot of pain in my legs with walking - is that vascular disease and are there treatments for this?
Speaker_-_Dr__Mehdi_Shishehbor: It is possible that the pain in your legs is due to vascular blockages or arterial blockages. This can be diagnosed by careful questioning and simple noninvasive tests such as ankle brachial index. Also, your cardiovascular risk factors are important in helping us determine whether your symptoms are related to vascular blockages.
Once we determine that your pain is related to arterial blockages, treatments would include risk factor modification, medication to help you walk, exercise rehabilitation, and eventually if needed, some form of intervention.
lopwise2: You mentioned numbness and tingling as symptoms of PAD. I have these symptoms, but was told it was associated with my diabetes. What are the symptoms of PAD that would require intervention?
Speaker_-_Dr__Mehdi_Shishehbor: The symptoms of PAD are typically pain, heaviness, or tiredness in the thigh and the calves with walking that is associated with walking and is relieved by resting. The typical patient complains of pain in the calf with ambulation that is relieved after 5 to 10 minutes of standing.
karawhite09: My dad's left leg has been going numb and having trouble walking on it and feels like he is going to fall. Could that be artery disease? what tests should be done?
Speaker_-_Dr__Mehdi_Shishehbor: Numbness by itself is a rare result of peripheral arterial disease (PAD). I would need to know your father's risk factors, more about his leg pain or numbness (i.e. does this happen with walking or just standing), and whether he has had any prior cardiac interventions.
A simple ankle brachial index would also be helpful. However, an abnormal ABI does not necessarily mean that arterial disease is causing his symptoms. Other causes such as diabetes, spinal stenosis, herniated disc, or neuropathy should be excluded.
Hiceski: Should I be seeing my cardiologist instead of my GP for my circulation problems. I have 3 stints and still have inactive clots in my leg. My circulation going down is good but is bad coming up. I get a pain between my shoulder blades when I exert myself, such as washing the car. I stop and rest and it goes away. My GP tells me it is because of my circulation.
Speaker_-_Dr__Mehdi_Shishehbor: In my opinion, you should see a vascular medicine doctor to address your circulation issues. For example, the section of vascular medicine here at the Cleveland Clinic offers physicians that are board specialized in cardiology and vascular medicine. These physicians should be able to address your cardiac and your circulation issues if any.
Diagnosis of PAD
Hiceski: What procedures would take place to correct my circulation issues with a vascular specialist? Hiceski
Speaker_-_Dr__Mehdi_Shishehbor: The most important procedure is your interaction with a vascular specialist in the clinic. She or he will have an opportunity to ask specific questions related to your circulation. This is extremely important since most vascular interventions are based on symptoms and not just on anatomic blockages. Furthermore, based on the expertise of the vascular specialist, noninvasive tests such as ankle brachial index or duplex ultrasonography can be performed. Collectively, vascular specialists spend their career dealing with circulation issues that affect the arterial and venous system
When to Treat PAD
coder1: what percentage of stenosis do you need to see before you would do an intervention?
Speaker_-_Dr__Mehdi_Shishehbor: We don' intervene solely based on degree of stenosis. Any kind of intervention should be in the context of the patient's clinical presentation including their symptoms. However, once a decision has been made that the symptoms warrant some type of intervention, a combination of angiographic stenosis and hemodynamic assessment is used as a criteria for intervention.
mickey_j: When the arteries in the leg are narrowed what can be done for it? And how much narrowing before it's done?
Speaker_-_Dr__Mehdi_Shishehbor: The degree of narrowing is not as important as are the symptoms of the individual. We focus on the individual rather than angiographic narrowing. For example, some people have totally occluded arteries but have good collaterals which are natural bypass arteries. These individuals may be completely asymptomatic despite having totally occluded arteries. Therefore, it is not the stenosis that matters but rather symptoms.
kk567: I am 75 years old. My doctor couldn't get a blood pressure reading in my arm so he put me through a series of tests and found I have a blockage in the artery in my arm causing weakness and tingling. What are treatment options for this? angioplasty and stent?
Speaker_-_Dr__Mehdi_Shishehbor: As mentioned before, we don't intervene in the arteries of the neck and arms unless the individual is symptomatic. If your symptoms are affecting your quality of life, meaning you are unable to use your arms due to tingling and numbness, or you are having other symptoms then you should be evaluated for a possible intervention with balloon and stents.
Interventional Procedures – Stenting and Angioplasty for PAD
sandra829: Are the stents that are used with peripheral arteries the same as with coronary arteries? Do they use medicated stents and bare medical stents? Do you need to be on plavix?
Speaker_-_Dr__Mehdi_Shishehbor: Good question. Currently, we do not have drug coated stents for the peripheral arteries. They have been evaluated in two trials for this purpose - however, to date they have not been as successful as those used in the coronaries.
A new area that in my opinion is extremely promising is the drug coated balloons. These devices have the advantage of delivering the medications without needing to leave stents behind. The stents used in the peripheral arteries are typically made out of nitinol, which is a special metal with memory. The stent is manufactured and designed for the specific shape of interest. Once it is released in the body, due to heat generated from the body, it expands to the shape that it has previously been designed.
susieq: what are the possible complications after an angioplasty on the leg? what is the recovery? how fast should you see results?
Speaker_-_Dr__Mehdi_Shishehbor: This procedure is usually safe with minimal complications. Patients are usually discharged home on the same day after a 3 to 4 hour bedrest. However, like any interventional procedure, there is a risk of infection or bleeding. Furthermore, if care is not taken there is always a risk of dissection (tear in the artery) or embolization (debris going down stream). Most complications can be managed conservatively in the lab. In rare cases, surgical repair may be necessary
danny3: Are there interventional procedures that are used to treat claudication?
Speaker_-_Dr__Mehdi_Shishehbor: Yes - we have a number of procedures that we can offer patients with claudication. Obviously, risk factor modification and exercise are the most important interventions. If these are not enough, then we have balloons, stents, and other devices that can remove plaque and open up arteries.
For example, we have devices that can remove the plaques from the arteries allowing us to place stents. Of note, we have had significant advances with the stents that we use in regards to flexibility and strength. These features prevent the stent from fracturing or reblocking.
0815jen: If you have blockage in your legs, what are the options for stenting and balloons?
Speaker_-_Dr__Mehdi_Shishehbor: Because the blockages in the arteries in the leg are typically long and since we use our legs continuously on a daily basis, we tend to prefer balloon angioplasty over stenting if possible. An area that is extremely exciting is the concept of drug coated balloons. These balloons can open up the arteries but also can deliver medications to prevent reblockage. The advantage would be that stenting would no longer be needed. There are other devices that we can use to debulk the arteries from plaque. This could also be helpful when balloon angioplasty alone is preferred.
teerr7: I have a 100% blockage in my leg, what procedure can be done for that?
Speaker_-_Dr__Mehdi_Shishehbor: Depending on the location and the length of the stenosis a percutaneous approach would be the first option. With advances in endovascular interventions, we are able to traverse completely occluded arteries up to 20 cm. Additionally, we have devices that guide us through these totally occluded arteries.
Cold Laser Surgery and Peripheral Arterial Disease (PAD)
kenR: what is cold laser surgery for peripheral artery disease? I have heard this is the way to go for leg blockages. Do you offer that at the Clinic?
Speaker_-_Dr__Mehdi_Shishehbor: Yes - we do offer laser atherectomy when indicated. However, to my knowledge this approach has not been shown to be superior compared to less invasive therapies, such as balloon angioplasty or stenting. Laser is typically used to burn some of the plaque in order to facilitate angioplasty or a stenting.
Surgery vs. Angioplasty for PAD
smith: When do they decide on surgery vs. angioplasty for a blocked leg artery?
Speaker_-_Dr__Mehdi_Shishehbor: The standard of care these days is to consider percutaneous (angioplasty, stenting) approach first if feasible. If not feasible, then obviously surgery would be the first option. The reason for this is that percutaneous intervention is typically less invasive and does not exclude future surgeries.
butterflygirl00: How long does a stent block after angioplasty and stent of your leg? How does this compare to bypass surgery?
Speaker_-_Dr__Mehdi_Shishehbor: The patency of the stent depends on a number of factors. These include how well the individual is addressing the risk factors (i.e. smoking cessation, cholesterol control, blood pressure control, and exercising). It also depends on the length of the stent used and the location. The benefit of stenting is that if a blockage occurs, it could be retreated with angioplasty. In comparison to bypass surgery, stenting is a little inferior with the advantage of being less invasive. Of note, stenting does not eliminate the option of bypass if reocclusion becomes a problem.
Research and Peripheral Artery Disease
Cleveland_Clinic_Host: Dr. Shishehbor, can you please talk about the upcoming research in this field? Is there anything that we can look out for?
Speaker_-_Dr__Mehdi_Shishehbor: There are a number of trials and observational studies that we are currently conducting to address issues related to carotid artery stenosis, renal artery stenosis, and peripheral arterial disease. These studies include an assessment of the safety and efficacy of various devices such as stents, balloons, and atherectomy. In the area of carotid stenosis, we are currently enrolling patients who have asymptomatic or symptomatic carotid disease. The studies compare carotid artery stenting with carotid endarterectomy.
In the area of peripheral artery disease, we are currently conducting studies that compare the safety and efficacy of various stents in the iliac arteries. Furthermore, we are studying the role of endovascular intervention for critical limb ischemia.
In addition to these, we are also interested in primary prevention to help individuals at risk of peripheral arterial disease. For example, we recently submitted a NHLBI grant to examine the role of screening ankle brachial index at high risk of peripheral arterial disease.
marta: I have a blocked Vertebral Artery also a both right and left Subclavian steal syndrome have had open heart surgery, experiencing high blood pressure could this be the problem would like to find out more regarding procedures to correct this problem
Speaker_-_Dr__Mehdi_Shishehbor: In general, we do not tend to treat vertebral artery stenosis or subclavian steal syndrome if patients are asymptomatic. Therefore it would be important to know if you are experiencing signs of dizziness, light headedness, or history of stroke or TIA.
carolle: what is subclavian steal syndrome and have what was your treatment?
Speaker_-_Dr__Mehdi_Shishehbor: Subclavian steal syndrome is a condition where the subclavian artery is stenosed or occluded and the blood supply to the arm is typically provided by the vertebral artery. In general, this is not symptomatic however, if individuals have signs of dizziness, syncope, or lightheadedness with movement of the arm, an intervention can be considered.
Renal Artery Disease
rose212: I am a 45 year old female who recently had a renal scan and my doctor said I have renal artery stenosis. He wants to do an angiogram. If they have blockage, can you do angioplasty? What does that involve?
Speaker_-_Dr__Mehdi_Shishehbor: Renal artery stenting should be reserved only for individuals who have uncontrolled hypertension on four medications. I do not recommend renal artery angiography, angioplasty, or a stenting unless you meet these criteria. Uncontrolled hypertension is defined as a systolic blood pressure of greater than 140 mm Hg despite four medications.
ted_utlg: I read online that angioplasty of the kidney artery is not that successful and medications should be considered first. I have a blocked kidney artery and not sure what to do - can you shed any light?
Speaker_-_Dr__Mehdi_Shishehbor: In general, we don't intervene on renal arteries unless there is evidence of uncontrolled hypertension with at least four blood pressure medications on board. I would highly recommend you consider seeing a vascular specialist before any kind of intervention to your kidney arteries. Renal artery intervention is a serious procedure and has been reported to be associated with death.
Multiple Sclerosis (MS) and Vascular Disease
MollyC: Can you talk about the relationship between MS and vascular disease?
Speaker_-_Dr__Mehdi_Shishehbor: I am not a specifically familiar with an association between MS and vascular diseases. That being said vascular disease is an inflammatory process and any condition that is associated with inflammation such as MS or rheumatoid arthritis may have an association with vascular disease.
jonathan: can you tell me about intracranial stenting and when is it used? My dad had a stroke due to blockage and I wonder if it would help him?
Speaker_-_Dr__Mehdi_Shishehbor: We typically prefer not to place stents intracranially. However, if an individual is symptomatic - ie having a stroke, or signs of a stroke, an intracranial intervention with a stent may be necessary. Once a stroke has happened, intervention to these arteries is typically more dangerous than helpful. These decisions need to be made in conjunction with a neuro - interventionalist who has access to imaging studies and can question the patient directly.
robyn51: I have been told I have vascular disease in my legs - can chelation therapy help with this?
Speaker_-_Dr__Mehdi_Shishehbor: I am sorry - I am not familiar with this treatment.
Hiceski: We are in Jacksonville, FL. Where is the nearest location for Cleveland Clinic Vascular Dept.? Hiceski
Speaker_-_Dr__Mehdi_Shishehbor: We would be happy to see you in Cleveland, Ohio
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Mehdi Shishehbor is now over. Thank you for joining us and thank you again Dr. Shishehbor for taking the time to answer our questions about interventional treatments of PAD.
Speaker_-_Dr__Mehdi_Shishehbor: Thank you for having me today.
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