Peripheral Artery Disease (PAD) & Amputation Prevention - Drs Evans & Kirksey
Thursday , January 24, 2013 - Noon
Peripheral artery disease (PAD), also known as peripheral vascular disease, affects about 8 million Americans. It is estimated that 1 in 3 diabetics over the age of 50 are suffering from this condition. PAD is a disorder that occurs in the arteries of the circulatory system. Like the blood vessels of the heart (coronary arteries), your peripheral arteries (blood vessels outside your heart) also may develop atherosclerosis -- the build-up of fat and cholesterol deposits, called plaque -- on the inside walls. Over time, the arteries may become narrowed from plaque development and cause decreased blood to flow to the body’s tissues, restricting circulation to the limbs and organs. Without adequate blood flow, the kidneys, legs, arms and feet suffer damage. If left untreated, the tissue can die leading to gangrene which can become infected requiring emergency surgery and amputation.
Risk factors for PAD
BlueGreenJean: Can PAD be reversed by improving blood sugars? Is there a direct relationship between PAD and blood sugar?
Dr__Evans: People with diabetes are at high risk for PAD. In fact, it is one of the strongest risk factors for PAD. Improving blood sugars does not reverse PAD but it can help prevent bad outcomes such as amputation.
Symptoms of PAD
LynnK: I have a 60% blockage in leg. My doctor said it is not time for surgery. I have pain with walking. What should I do? Are there medications I should be on?
Dr__Evans: In patients with peripheral artery disease they typically should be on a cholesterol lowering medication, blood pressure control, diabetes treatment if applicable. And - if appropriate a medication called Cilostazol or Pletal, which can improve walking distance. Perhaps, most important in improving pain free walking distance is supervised walking. In some cases insurance does not cover this, so unsupervised walking programs are prescribed.
Dr__Kirskey: After introducing those non-operative strategies, re-evaluation of your condition would determine if a minimally invasive option is available for improving your circulation.
MargieM: I am experiencing a heaviness with pain and bad cramps in my left leg and numbness in my toes. I was told by family doc that it is probably circulation problem. What type of testing do I need? What type of treatment?
Dr__Kirskey: There are different types of "circulation problems". Some problems are related to arterial vessels and some related to the venous system. A thorough evaluation by a physician inquiring about the onset and factors related to the pain and cramps is important. That evaluation will lead to ordering the appropriate testing. It may lead to some type of an ankle brachial index (ABI) or venous ultrasound. Both of which are very simple, non-invasive tests to evaluate circulatory issues. Treatment depends on the results of your testing and evaluation.
keith5522: I have a long history of heart disease. Had a stent put in last year. I have recently been having calf pain. Wondering if it could be blockage in my leg or just cramps due to something else.
Dr__Evans: Patients with coronary artery disease are at high risk for PAD. You should have further evaluation by your physician to determine if this may be the case.
mistykl: I have been having a lot of pain and tingling in my legs, I have high cholesterol and blood pressure - both treated with medications. Is that PAD?
Dr__Evans: There are several causes of pain and tingling in the legs including spine disease, nerve problems and PAD. High cholesterol and high blood pressure are both risk factors for PAD. You should be evaluated by your physician to determine if you in fact have PAD.
paula22: My mother was diagnosed with Peripheral artery disease of the legs. her one foot is swollen and on another foot there are blood clots. Angiography was done but there was no blockage. what we should do now?
Dr__Evans: We need more information on the cause of the swelling. Swelling can make the symptoms of PAD worse. I would recommend your mother to be evaluated for the cause of the swelling. There are many causes of swelling.
Ulcers and Wounds
Theresa: My husband has acute pain due to vascular issues which are causing severe foot and ankle ulcers that will not heal. His condition has been ongoing now for almost 2 years and nothing is helping. From what I have read about Cleveland Clinic Vascular Treatment Center, I believe that he can be helped at your facility. The consistent level of pain he has endured for so long is intolerable; and, it is at the point now where in the last two months not a day has gone by where he has been pain free.
Dr__Kirskey: Leg pain related to non healing ulcers and PAD Peripheral Arterial Disease can significantly alter one’s ability to perform daily activities and diminish ones quality of life. There are numerous causes including arterial and venous blockages which impair blood flow to the feet and legs. Identifying the exact cause is the first step towards initiating treatment which can relieve the pain. Often times a blood flow improving procedure is combined with the initiation of a wound care regimen, improving nutrition and controlling medical conditions like diabetes- and hypertension.
Dr__Evans: Please call Cleveland Clinic for an appointment - we would be happy to evaluate you.
JoanH23: I have Peripheral Artery Disease. I had a bypass a couple years ago in my left leg and since then I developed an ulcer on my foot. My doctor attempted an angioplasty but couldn’t do it. The ulcer has still not healed. I am not sure what I should do at this point. Can you advise?
Dr__Evans: We can provide you with a second opinion consultation.
Dr__Kirskey: There are many options for treatment beyond angioplasty such as atherectomy. It is always a good idea to get a second opinion when faced with a limb threatening condition. We would be happy to evaluate your husband.
NJbob: I have had a lot of swelling in my lower legs. A month ago I started an ulcer on my right foot. Worried that it is getting worse and not really sure what to do. I see a doctor but want to make sure he is giving me the right advice.
Dr__Evans: If you are not sure if you are getting the right advice, you can always get a second opinion.
Dr__Kirskey: There are a number of types of physicians who evaluated peripheral arterial disease and have specialized expertise including vascular medicine, cardiologists and vascular surgeons. Sometimes it is helpful to have one of these specialists evaluate your problem to determine if it is a result of circulation problems.
suzanne92: Does it really help to see a wound clinic for a sore that won't heal or can a doctor handle the care. I am trying to get my dad to go to a wound clinic but he just wants his PCP to treat him.
Dr__Kirskey: The benefit of a wound care clinic is the multi-disciplinary approach to wound evaluation and treatment which may not be available by a single doctor. For instance, at Cleveland Clinic our multidisciplinary approach includes vascular medicine specialists to evaluate the medical causes of wound development. The medical causes such as diabetes, hypercholesterolemia, and hypertension are very important aspects of wound healing. In addition, podiatrists can be helpful in caring for the wound and providing offloading mechanisms. A vascular surgeon may be able to improve the circulation on either the arterial side or the venous side. When these sub-specialists work in collaboration the chances in wound healing are increased significantly.
iron24: Can you talk about the use of hyperbaric chambers for the treatment of wounds.
Dr__Kirskey: Hyperbaric oxygen treatment involves the placement of the patient in an oxygen rich environment such as a hyperbaric chamber. This option is sometimes used as an adjunct to wound treatment. However, there are a number of other preliminary steps in optimizing wound healing which should be undertaken first. These include: eliminating infection; optimizing the wound care circulation including the treatment of arterial and venous problems. As well as the control of edema around the wound area. With these preliminary steps, most wounds will heal up without hyperbaric oxygen therapy. Most of our research confirms this and in most cases, hyperbaric oxygen should be reserved as a second line treatment for the most difficult to treat wounds.
Types of Arterial and Venous Disease
lauren-s: I have 70 - 80% blockages in the Celiac and mesenteric arteries as well as aorta narrowing. 80% stenosis in the renal arteries. Do you have any medical treatments or research studies that help patients with this type of disease.
Dr__Evans: Regarding medical treatment, control of risk factors for progression of atherosclerosis is critical. This includes lowering cholesterol and blood pressure and controlling diabetes. However, you may need further evaluation for whether an invasive procedure is required to treat your disease.
Dr__Kirskey: These are severe blockages that can impair circulation to critical organs. We do, at Cleveland Clinic, have access to minimally invasive techniques for treating these problems - Problems which were previously only able to be treated with large, invasive operations in the past.
MaryAnn: Need a differential diagnosis for Reynaud’s disease vs. Kienbock's disease. symptoms include: bilateral discoloration of fingers, swelling, numbness and tingling (with protection on 50 degree and below weather).
Dr__Evans: Reynaud’s Phenomenon describes symptoms in the hands, and sometimes the feet that are caused by spasm of the small arteries. This can include discoloration of the fingers and pain usually with exposure to cold weather and sometimes emotional triggers. We usually diagnose this in the vascular lab, measuring doppler wave forms in the finger tips with temperature maneuvers.
Janice: My husband suffers from PAD. His left leg from knee to foot is completely calcified. He has had several procedures over the years to keep as much blood flowing to his left foot, but recently has displayed some complications during the procedures, i.e. exaggerated dementia, bleeding from bladder, larger prostate. He has hypertension, high blood pressure, some heart disease and suffered a small stroke about 20 years ago. We live in Detroit and his cardiologist who performs all of his vascular procedures is considered one of the best in Michigan. We are being told by friends and family that we should get a second opinion from Cleveland Clinic. Do you believe making an appointment with Cleveland in this case would be helpful? With what type of Dr would we start?
Dr__Kirskey: A second opinion is often helpful to identify other modalities that may improve a patient’s condition. Our limb salvage program provides a multidisciplinary, holistic approach to circulation and limb loss by using the latest advances in technology and medicine. We recognize that multiple factors must be addressed to successfully improve and maintain good circulation. We have recently enrolled one of the first patients nationally in an investigational trial that uses drug eluting stents-the identical technology to that used within the cardiac circulation. I encourage you to give us a call and bring your information for review.
janekic: I went to the ER about a month ago with pains I’d been having in my leg for a few weeks, we found had a large blood clot in my upper thigh, I believe it's called the femoral vein??? I am on lovonox injections 2x and 5mg coumadin daily. They told me it can break off and go to my lungs. I am scared. Is this the right treatment? Still having pain in leg. Is there anything else I should be doing?
Dr__Evans: Lovenox and coumadin are appropriate treatment for DVT. Although it is true that blood clots can break off and travel to the lungs, once you are on treatment, this becomes very unlikely. Leg pain due to a new blood clot may last for several months. However, some people with blood clots go on to develop chronic symptoms. It is important for you to be measured and fitted for a proper strength compression stocking to help controls symptoms and try to prevent long term complications.
DanOH: My wife has a Greenfield Filter due to DVT and PE. She also has been told she has Venous Insufficiency. She has been having swelling in both her legs. Her vascular doc does not seem to think there is more that can be done but wonder what you think.
Dr__Kirskey: Post thrombotic syndrome, or leg swelling following DVT, is unfortunately fairly common. Sometimes appropriate therapy is limited to compression stockings. The initial evaluation begins with venous ultrasound to determine what veins are responsible for leg swelling. Sometimes, treatment of the responsible veins is possible and can relieve the leg swelling.
Dr__Evans: Exercise focusing on strengthening the calf muscles may theoretically be beneficial in the post thrombotic syndrome. Unfortunately, there are not a lot of effective treatments for this syndrome but this is an area of ongoing research.
DarrylTX: Hi. I have pain in my toe and the podiatrist said I have an infection and blood clot. He put me on an antibiotic and I currently take aspirin. I am just wondering if I should take something stronger. How long will it take to go away? I usually exercise but I am not doing anything because of pain in my toe. Can I ride a bike or shouldn't I do any exercise? I have an appointment with my PCP on Friday.
Dr__Evans: It depends on the location of the blood clot and if it is in the veins or the arteries.
Dolly: Can laser varicose vein treatment encourage, or result in necrosis?
Dr__Kirskey: One intended goal of varicose vein ablation is injury to the vein wall which results in clotting within a localized portion of the vein and ultimately scarring within the vein. This procedure is commonly performed for symptomatic varicose veins or chronic venous insufficiency. The symptoms of varicose veins can range from unsightly painful varicosities to leg pain and swelling or fatigue with standing and walking.
Dr__Evans: Other varicose vein treatments include sclerotherapy, which is the injection of a medication that obliterates the vein. Most commonly we initially treat varicose veins with conservative therapy which includes compression stockings, elevation of the leg, exercise, and weight loss.
Roberta_9510: My husband is 65 years old. He has leg sores that won't heal and has lymphedema, his legs are very swollen. I have been told to do dressing changes every day - and the dressings are very weepy by the time I change them. We are frustrated and not sure he is getting the right treatment.
Dr__Evans: Lymphedema is very challenging to treat. Your husband should have further evaluation to determine if there are other problems contributing to the swelling and weeping.
Dr__Evans: We would be happy to see him here with our lymphedema specialists in vascular medicine.
gm3: Are there any new Endoleak II Repair Procedures that relate to an Aorta Abdominal Aneurysms? Also, what is the average number of years a Stent like the Gore Excluder will perform after placement in an AAA?
Dr__Kirskey:The durability of stent graft systems are dependent upon a number of complex variables including the complexity of the aneurysm anatomy and thus the environment that a given graft was implanted into. Factors such as the length and diameter of the aortic neck, clot or thrombus within the aortic and the overall quality of the aortic neck are major predictors of fixation over time.
Endo leaks, or blood flow into the aneurysm from aortic branch vessels such as the lumbar, hypogastric or mesenteric arteries, occur in up to 30% of patients undergoing aortic stent graft placement. The indications for the treatment of these vessels is somewhat controversial however after carefully reviewing the mid and long term consequences of untreated endoleaks over time—our department has adopted a very active approach towards their management.
Various combinations of metallic coils and liquid glue substances are used to treat endoleaks. In addition, at Cleveland Clinic we have a broad experience in open surgical explantation of stent graft devices with surgical reconstruction of the aorta for those type II endoleaks which are not amenable to endovascular treatments. It is not uncommon that explantation will be the best option available to a large group of patients.
Shawna: My mom has PAD. She had a femoral bypass. She was on metropolol a beta blocker for years that slows her heart rate down. Could that have contributed to low circulation and blockage.
Dr__Evans: In the past, metoprolol was thought to be potentially harmful to patients with PAD. We now know that is not the case and in fact it may be a life-saving medication for patients with PAD who have had a prior heart attack. Metropolol would not have caused her PAD.
Jordon1948: Have pad and diabetes. having two toes amputated in 2 weeks. what should I expect. problem with walking? what is recovery time?
Dr__Kirskey: Diabetes is a common risk factor for the development of PAD. An unfortunate consequence may be wound development requiring amputation. It is very important to be evaluated for adequate circulation to minimize the chance of losing additional toes.
If your circulation is normal, then one would expect that your amputation site will heal within 6 - 8 weeks. One very important factor for patients that suffer from diabetes and have undergone toe amputation is the proper fitting of shoe ware that prevents recurrence of ulceration and allows for normal walking. Occupational Therapy or Podiatry can help you with fitting shoes appropriately.
CharlesVa: My wife had a blood clot in her right iliac artery that traveled down her leg. She may need to have her toes amputated. How do they make the decision?
Dr__Kirskey: Toe amputation is in general performed for gangrene which is "dead toes." When the toes are non-viable they pose a risk for further infection and thus must be amputated. It is important that her circulation be adequately evaluated so that the chances of wound healing are improved.
Cleveland_Clinic_Host: Dr. Kirksey, you are very passionate about amputation prevention. Can you talk about the program at Cleveland Clinic?
Dr__Kirskey: There are multiple components of our amputation prevention program.
One critical component is to increase awareness about the early signs of PAD, which may include the development of early stage wounds. This early state represents the best way to identify the causative factors and correct those factors in a timely way which can alter the course of wound healing.
We really focus on the multiple factors that cause wounds. Not only performing a procedure to improve circulation but equally important, controlling the medical problems that led to the limb threatening condition including blood pressure, diabetes and cholesterol issues.
We frequently see patients who have been told by other providers that no options exist for preventing amputation and because of our collaborative expertise; we are able to develop a strategy to save the limb. Having said that, I would encourage any patient who has been told that no options exist for limb salvage to seek a second opinion.
Dr__Evans: We have talked a lot today about controlling blood pressure, diabetes and cholesterol but we haven't talked about smoking which is the number one risk factor for PAD and can put people at risk. Quitting smoking is essential at preventing amputation.
Dr__Kirskey: There was a study that came out this week about the benefits of quitting smoking - that you can gain 4 - 10 years of life by quitting. We have a smoking cessation program at Cleveland Clinic to help patients quit.
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