Peripheral Artery Disease Interventions (Drs Shishehbor and Kelso 1 25 11)
Tuesday, January 25, 2011 - Noon
Rebecca Kelso, MD
Vascular Surgeon, Department of Vascular Surgery, Miller Family Heart & Vascular Institute
Mehdi Shishehbor, DO, MPH
Interventional Cardiologist, Department of Cardiovascular Medicine, Miller Family Heart & Vascular Institute
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. Take advantage of this rare opportunity to chat live about peripheral interventions with a interventional cardiologist and vascular surgeon in a secure online setting.
Cleveland_Clinic_Host: Welcome to our "Peripheral Interventions" online health chat with Mehdi Shishehbor, DO, MPH, and Rebecca Kelso, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us Dr. Shishehbor and Dr. Kelso, let's begin with the questions.
Dr__Mehdi_Shishehbor: Thank you for having me.
Dr__Rebecca_Kelso: It is good to be here today.
Carotid Artery Disease
Peppy: I was just told I have 50% blockage in both my carotids. Devastating news. They're going to monitor. How can I keep this plaque "calm" and even reduce it? I follow the Ornish diet-three years now.
Dr__Mehdi_Shishehbor: Good news as long as you do not have symptoms from a neurologic standpoint you do not need surgery or stenting at this time, however, you must continue with your diet, exercise, lipid control, and blood pressure control.
Dr__Rebecca_Kelso: Unfortunately you can never get rid of plaque but sometimes you can prevent them from getting worse.
John: After having carotid endarterectomy, how long is the recovery time before one can pursue strenuous activities and exercise?
Dr__Rebecca_Kelso: On average we recommend no heavy lifting (more than 25 pounds) for two weeks. In regards to exercise, it is ok to begin normal walking directly after surgery and slowly progressing to an exercise program over the next three weeks. Use common sense and not over do it.
Joe_Frost: Can you talk about the research studies that have compared carotid stenting with carotid endarterectomy.
Dr__Mehdi_Shishehbor: There has been a number of studies comparing carotid artery stenting to carotid endarterectomy—the most recent study was published in New England Journal of Medicine—the(CREST) trial. In general, the consensus is that carotid endarterectomy is more invasive (typically requires general anesthesia and a neck incision), which may result in complications, such as a cardiovascular event (myocardial infarction or heart attack) and cranial nerve damage. On the other hand, carotid artery stenting has been associated with higher stroke risk.
In my opinion both procedures are excellent when performed on appropriately selected patients and done by experienced physicians. Since carotid intervention (surgery or stenting) is an extremely risky and important procedure patients should be evaluated and the risks and benefits of each approach should be discussed in detail before a final decision is made. Since the complications of the procedures are physician and center specific, it would be extremely important to understand the complication rates of each procedure and the experience level of the physicians at the hospital where the procedure will be performed.
Dr__Rebecca_Kelso: I completely agree that there is no final decision based upon the research completed thus far of one approach being better than the other. For the right patient each can be performed very safely.
May Thurner Syndrome
cara: I have May Thurner Syndrome and had stents placed this past summer. I continue to have pain and swelling in my groin after sitting at work during the day. Is this normal?
Dr__Mehdi_Shishehbor: In general, if you are sitting or standing all day long it is not unusual to have some swelling. Typically for people that have May Thurner or some type of venous insufficiency, we prescribe compression stockings. This may be helpful in regards to your swelling and discomfort. However, you need to wear them appropriately—meaning from the time you wake up to the time you go to sleep—and there are specific instructions as to the management of the stockings. The best way to get them is to have them fitted appropriately by a provider.
Dr__Rebecca_Kelso: You also need to have continual follow up for your stents as more swelling or discomfort over time may mean that you need to have an ultrasound—so keep up with your doctor's recommended follow up.
Brian: My Mother just had a stent placed for May Thurner Syndrome. My parents are very private concerning all things medical, even with their 4 sons, so my interrogations fall short. I was wondering if MTS was hereditary, signs & symptoms, etc.. Thanks in advance for any information.
Dr__Rebecca_Kelso: May Thurners is not a hereditary disease but is an anatomic disease. It is caused by compression of the vein between the artery and the spine. Occasionally it does run in families but is not considered a genetic disease. Signs and symptoms would be swelling or clot within the left leg.
Peripheral Artery Disease
alpeery: What is the relationship of stress to the development of PAD?
Dr__Mehdi_Shishehbor: There is not a direct cause and effect of stress and PAD however overall it does affect your well being. There is some data that stress can heighten inflammation and we know that inflammation directly affects atherosclerosis. So in general I do consider stress as a risk factor for atherosclerosis both peripheral and coronary. However, unfortunately it is difficult to know how much stress is bad for you.
Eddy145: I have been having a lot of problems walking and my doctor did some tests and found I have a79% blockage in my leg artery and an 80% blockage in my neck. Can they stent both at the same time?
Dr__Rebecca_Kelso: When dealing with blockages in two areas, such as this, we do not recommend treating these at the same time as we need to monitor for different complications and we would like to make sure you are doing well before performing the next procedure.
Dr__Mehdi_Shishehbor: In general we do not treat blockages, we treat people so we treat their symptoms—so it would be extremely important to know what symptoms you are having from your neck blockage and what symptoms you are having from your leg.
LaurenT: What is normal recovery time for femoral bypass surgery? Does one have rehabilitation or Physical Therapy?
Dr__Rebecca_Kelso: The normal rehab time for a femoral to below knee bypass is 5-7 days in the hospital with 2-4 weeks of rehabilitation. Whether you need to go to a rehab center or physical therapy come to your house depends on your progress while in the hospital and your support at home.
Sandra56K: Do you use laser therapy to treat blocked arteries in the legs?
Dr__Mehdi_Shishehbor: Yes—we do use laser as a mean of atherectomy (removing plaque) to treat leg blockages.
DAniel: What is done for a blocked subclavian artery bypass surgery? What types of vessels are used for this surgery?
Dr__Rebecca_Kelso: I am not sure what you are asking but, if you have a subclavian artery blockage that has never had surgery before, the options include: endovascular (within the blood vessel) with balloon angioplasty and possible stenting; vs. open bypass. Open bypass if the blockage is a short length is often done with synthetic material made of polyester or gortex. If the blockage is long, the vessel would often be vein taken from the leg.
If you have already had a subclavian artery bypass. the next surgical option would depend on the type of bypass you had and may still include all the above options listed, depending on your situation.
MorelJane: I have bad PAD in my family. My sister has had bypass surgery in her leg and 2 stents placed in her heart. I have developed claudication—I am taking pills which has helped to dilate the blood vessels in my legs. I wonder if I should also be checked for heart disease?
Dr__Rebecca_Kelso: Yes. You should be checked for heart disease as not only do you have a family history, but you seem to be developing PAD as well. We know that having PAD of the legs is a marker for disease in other blood vessels including the heart. We recommend you talk to your primary care physician for further testing.
KFT: My mom had bypass surgery in her leg but her claudication has returned. Does that mean that the surgery did not take? Is there anyway to get rid of the claudication?
Dr__Rebecca_Kelso: It is important to know why your mom had the bypass surgery. As we often do not perform bypass surgery for claudication alone, instead we may be more concerned about ulcers or chronic pain in her leg.
If her claudication has returned and this is the reason that she had surgery, it is possible that the bypass has not been working as well as when it was placed or is blocked. It is important for your mom to have her bypass evaluated to see how it is working.
Sometimes, scar can develop within the bypass and this can be treated to get rid of symptoms.
Symptoms of Peripheral Artery Disease
MaryKemper: My husband has numbness in his legs and feet and complains of pain in his leg when he walks a lot. He has high blood pressure and high cholesterol.
Dr__Mehdi_Shishehbor: It is possible that this could be PAD however to give the diagnosis we would require more questioning and have a better understanding of his symptoms in general. And to perform some simple non-invasive tests, such as ankle brachial index which compares blood pressure in the arms and legs. Typically they should be equal however in people with PAD, typically the pressure in the legs is lower than in the arms. This test is non-invasive and does not require any radiation or contrast—and can be performed in the office.
Dr__Rebecca_Kelso: You should also make sure your husband gets his blood pressure and cholesterol well managed.
Dr__Mehdi_Shishehbor: The presence of PAD can be an indication of atherosclerosis in other areas of the body including the heart, therefore it would be important to identify if the symptoms are truly PAD related or due to another condition, such as back.
Jean: I recently went to my primary care physician w/left ankle severely swollen. I had a venous doppler done w/ the results that everything was OK. Then the swelling went down but returned. He scheduled an arterial doppler to be done. I am scheduled to have it done this Friday and I am going. But my ankle has returned to normal size again and has not swollen up. Could this be a sign of peripheral artery disease? I am a 62 year old female, with Diabetes type 2, Morbid Obesity, also have Multiple Sclerosis. I am unable do get much physical activity due to the MS and my inability to walk w/o assistance. I use 2 canes or a walker inside the house.
Dr__Mehdi_Shishehbor: It is unlikely that the swelling in your ankle is related to peripheral arterial disease (PAD). This is most likely to venous insufficiency and loss of muscle tone in your calf. My recommendation would be to wear compression stockings and to keep your legs above your heart as much as possible. The reason for waxing and waning of the swelling is most likely related to the position of your leg. So when you are sitting or standing for a long time, you most likely have swelling and when you are sleeping and have your legs elevated you most likely have less swelling. Compression stockings should be provided by your provider for proper fitting and instructions.
Medications and Peripheral Artery Disease
ccass: Had left carotid and fem/fem + fem/pop bypass early 2005. Have been on Plavix 75mg & asa 81mg qd since. What is your opinion regarding continuing either or both drugs?
Dr__Rebecca_Kelso: My recommendation would be to continue aspirin 81 mg for life. Continuing the plavix is a little more complicated and is related to how well your bypasses and the reason why your doctor started you on plavix.
ccass: In addition to exercise what drug treatment do you generally recommend for PAD?
Dr__Rebecca_Kelso: The exercise component for treating PAD when you have cramping in your calves is very important. It is important that the exercise be a focused and dedicated part of your day. We recommend walking until you develop cramping in your legs 5 out of the 7 days of the week. The next week we recommend increasing this walking distance to develop more pathways around the blockages in your legs. This can often take several months to build and so patience and persistence is important.
Dr__Mehdi_Shishehbor: Routine risk factor modification with statins, blood pressure control, and aspirin or plavix would be necessary. In addition obviously smoking cessation is recommended. These interventions may help stabilize PAD or reduce its associated morbidity and mortality, however they have not been shown to improve walking distance. The only medication that has been shown to improve walking distance in patients with PAD is pletal. This medication has side effects such as headache, diarrhea and flushing, and muscle cramps. I may benefit in about 30 - 35% of the patients.
Renal Artery Disease
JGI825967: My dad's doctor said he has a totally occluded left renal artery but said that he has other smaller blood vessels that are helping to get blood flow to the area. What do you suggest? Bypass? Are there catheters that can open a 100% blocked artery—or are the small blood vessels enough?
Dr__Rebecca_Kelso: A completely blocked renal artery is often very difficult to fix and it depends on your dad's underlying kidney function. We are born with two kidneys however can function well with just one—so his other kidney may be sufficient. This information is important before recommending any procedure for the left kidney as we would not want to put him through unnecessary procedure.
There are catheters that can open up a 100% blocked arteries however the anatomy of the kidney artery and the length of the blockage may make this difficult, which is why information about the function of the kidney is key.
Dr__Mehdi_Shishehbor: When people have 100% blocked artery, the kidney becomes small and non-functional so even if you are able to open it—it may not provide you with more benefit.
Sammy_LIT: My dad has renal artery blockage and his doctor suggested a stent. He has a history of coronary disease and diabetes. Can you talk about renal artery stenting in a diabetic? Are there any things special he should consider?
Dr__Mehdi_Shishehbor: In general we reserve renal artery stenting for 2 indications: 1) Uncontrolled hypertension on 4 medications that are maxed out, one of them being a diuretic or 2)in rare cases to preserve renal function in those that have bilateral renal artery stenosis.
So, just having stenosis by itself in the renal arteries is not an indication for intervention.
In regards to the presence of diabetes and stenting—diabetics are at greater risk for restenosis or reblockage after a stenting, however the procedure itself should not be that different for those without diabetes.
JonesTori: I have uncontrolled high blood pressure and my doctor wants to do a renal perfusion scan. What is that?
Dr__Rebecca_Kelso: A renal perfusion scan is a nuclear study and evaluates the function of each kidney and the upper and lower portions of each kidney. This is sometimes useful in determining if there is a component of high blood pressure that is due to the kidney. However this is usually not the first study that is used to evaluate whether the kidneys play a role in high blood pressure. We usually start with an ultrasound as this does not require contrast and does provide a great deal of information.
Molly: How long do stents to the renal arteries last? What do they do if they block up again?
Dr__Mehdi_Shishehbor: It depends on the size of the artery and other risk factors such as diabetes and smoking. In general, because the size of the renal artery is relatively big, restenosis (reblockage) is around 10%. If reblockage occurs typically re-intervention (from inside the blood vessel) with balloon angioplasty or other modalities can be performed.
Connie_Lai: My husband has a blocked leg artery and his leg is swollen and painful. Especially when standing a lot. The doctors are concerned about doing angiography because he only has one kidney -
Dr__Rebecca_Kelso: To start with, it is unusual for someone who has a blocked leg artery to have swelling as that is usually reserved for vein problems—unless there is an infection. It is important to insure that he does not have an infection or a vein problem. When doing angiography we are concerned that contrast can affect the kidneys however that is often related to the underlying kidney function and with proper kidney protection and use of other contrast such as carbon dioxide, we can often perform angiogram safely.
Kelly: Have you heard of atherogenesis treatments for PAD?
Dr__Mehdi_Shishehbor: Yes—there are studies looking at various modalities including gene therapy and stem cells in promoting angiogenesis. You can go to www.clinicaltrials.gov to learn more. We do offer some of these trials at Cleveland Clinic. Please remember these are still undergoing investigation and long-term success is unknown.
Fred: I have been diagnosed with subclavian steel. My doctor made an appointment with a surgeon to discuss this—what exactly does this mean and what is the treatment?
Dr__Mehdi_Shishehbor: Subclavian steal usually describes a condition where there is narrowing of the subclavian artery and instead of the blood going in the usual fashion to the arm, it gets there through the vertebral arteries, which come from the brain. The process of the blood coming down from the brain to the arm is called "steal phenomenon." Generally, people are asymptomatic from this condition however typical symptoms could include loss of consciousness, dizziness, light-headedness when exerting the affected arm, which could make the steal worse. The treatment usually involves correcting the subclavian blockage which can be done endovascularly (through stents) or by surgery.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Shishehbor and Dr. Kelso is now over. Thank you again for taking the time to answer our questions about peripheral interventions.
Dr__Mehdi_Shishehbor: At Cleveland Clinic both cardiac interventionalists and vascular surgeons work closely together to provide the best care for our patients. Thank you for having me today.
Dr__Rebecca_Kelso: Thank you as well.
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