Peripheral Artery Disease (PAD) (Dr Evans 09 04 13)
Wednesday, September 04, 2013 - Noon
Peripheral artery disease (PAD) affects about eight million Americans. It is estimated that one in three 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. Dr. Natalie Evans answers your questions about PAD.
Peripheral Artery Disease (PAD)
alplaus130: I have peripheral neuropathy but am not diabetic. Also diagnosed with Graves Disease (lots of eye issues, double vision, etc., resulting in many eye muscle surgeries. Am medicated for high blood pressure. PAD issues with leg calf muscle pain when walking. I have had 2 procedures on left leg. First: knee area atherectomy and below knee angioplasty ( Oct. 22, 2012). Second: Aortagram, left superficial femoral artery artherectomy, balloon angioplasty, stent. One procedure on right leg: surgery in groin area to clean out blocked artery (Dec. 2012). I also had carotid artery (right side) surgery to clean out blockage (Dec. 21, 2009). What is my prognosis as a result of all this?
Natalie_Evans,_MD: It’s hard to say what your prognosis is without knowing the severity of your disease and your other risk factors for disease progression. In general, the greatest risk to patients with PAD is for having a heart attack or stroke. Up to 25% of patients with PAD will have a heart attack within 5 years. So it’s very important to control your risk factors: stop smoking, control your blood pressure and cholesterol, and take an aspirin or other platelet-blocking medication like clopidogrel (Plavix). It’s also very important to take good care of your feet and report any sores to your doctor.
WN: My paternal grandfather and my father had peripheral vascular disease resulting in bilateral leg amputations. Neither had diabetes and were not overweight. I am a 64 year old, non-smoking, normal weight female with medication/exercise controlled lipid levels. Am I am risk for PVD?
Natalie_Evans,_MD: Your age puts you at risk for PAD, but it sounds as though you have done a great job controlling the factors that most commonly cause PAD. The good news also is that the vast majority of patients with PAD never go on to amputation and can live good quality lives. The people at highest risk for amputation are those with very poorly controlled diabetes and who continue to smoke, and of course those with severe PAD.
pilatesgirl: Might you describe the mechanism of creating PAD?
Natalie_Evans,_MD: PAD is caused by atherosclerosis, which is the build up of cholesterol deposits in the walls of the artery. Sometimes, these cholesterol plaques can burst and cause complete blockage of an artery downstream.
gatorfrog: I have just recently been diagnosed with diabetes type 2 and I already have Microvascular Disease. I also have spinal stenosis and I am just wondering if all of this indicates that I likely will have PAD also. I have had 2 venous procedures on my legs already. Any information you can provide is highly appreciated. Thank you.
Natalie_Evans,_MD: Diabetes is one of the strongest risk factors for PAD, so it is essential that you try to get your blood sugars under good control. Spinal stenosis does not cause PAD, but the symptoms sometimes mimic those of PAD, which can make the diagnosis tricky. Because you have diabetes, it would be recommended that you be screened for PAD using a noninvasive test called the ankle brachial index.
Kellen512: I've been suffering from PAD For the last 5 years. Diagnosed at age 39. I was wondering if there are any new treatments such as PLX PAD that are being successfully utilized? Although my fem-pop helped, I wish to avoid another should I begin suffering restenosis.
Natalie_Evans,_MD: Novel treatments such as stem cell therapy are being explored for PAD, but all of them are being given only in research settings. You may wish to schedule an appointment here or go to www.clinicaltrials.gov to search for available trials.
Dontherock: I have seen the use of "smoke/smoking" as a causative factor. What about smokeless tobacco aka Chewing tobacco or snuff?
Natalie_Evans,_MD: The relationship is not as clear, although we do see many vascular diseases in patients who chew tobacco. I recommend totally stopping all products that contain nicotine.
Regis: As PVD progresses, what are the most notable physical effects?
Natalie_Evans,_MD: Classically, the most common symptom of PAD was described as intermittent claudication, the pain in the muscles of the legs that develops with walking and goes away with rest. However, we now know that only about 10% of patients with PAD have classic intermittent claudication. They may have a whole range of leg symptoms or they may be entirely asymptomatic.
In more advanced PAD, we may see skin changes, hair loss on the legs and in severe cases, ulcer or gangrene. The most concerning changes related to PAD are in the risk for heart attack an stroke. Up to 25% of PAD patients will have a heart attack in the next 5 years.
alplaus130: I have never smoked and am taking blood pressure medication and whole aspirin and plavix. I also see a cardiologist a couple of times a year. I have issues with my feet, very dry skin that tends to crack but I try to keep this under control. I also have peripheral neuropathy that makes foot and hand issues worse. What other things can I do?
Natalie_Evans,_MD: It is very important to take meticulous care of your feet - you should use a moisturizing lotion daily after you wash them. It is absolutely critical that you look at your feet every single day, including the soles, especially because you have peripheral neuropathy. Patients with neuropathy are at risk for developing non-healing sores or ulcers.
Blockages – Legs
marion12: How is PAD related to blocked leg arteries? And should each be treated as a different disease? I am not overweight, not a diabetic, but both these problems run on the female side of my family. I have had 2 stents put in one leg and developed blood clots 6 mo. after having the stents put in. The ultra sound shows that the arteries are again blocked and my PAD is worse. This has caused me to limit my exercises because it is so painful. I was hoping that there was an herb that I could take to ease some of the pain (something that would not interfere with 75 mg. Plavix) so that I could go back to exercising and should I wear support stockings with PAD and blocked arteries?
Natalie_Evans,_MD: PAD—peripheral artery disease—refers to poor arterial circulation in the legs due to atherosclerosis, or buildup of cholesterol-rich plaque in the artery wall. PAD causes partial or complete blockage of arteries. We recommend that most patients with PAD perform walking exercise (especially supervised exercise in a rehab program, if your insurance covers it), as this helps the body create new pathways around blocked arteries. There is one medication on the market called cilostazol (Pletal) that may help some patients walk farther before pain starts, but it’s important to talk to your doctor about whether you are a candidate for it, because it has some important side effects and contraindications.
Katrina224: My mom has a blocked artery in the right leg. The doctor put her on meds to start and told her if this doesn't work after 6 months they will check her for a stent. Is this the usual course? Is this a hereditary problem? Should my sister and I be concerned?
Natalie_Evans,_MD: It depends on the cause of the blockage. In older patients, PAD is the most common cause. When I first see patients with PAD, I recommend management of risk factors for heart attack and stroke, including blood pressure control; cholesterol medication; aspirin; and treatment if diabetes if applicable. I also recommend walking exercise as the first line of treatment. If walking does not improve symptoms after 12 weeks, then we talk about treatments like stents or surgery. Some of the risk factors for PAD may be inherited so it is good to get control of them.
donnaKD: My husband has clogged arteries in both legs. They want to do a stent. Is that what you would do for this? He has no family history and his cholesterol tests have been normal. I am nervous it can reclog again if we don't know why this happened to him. His family history is of high blood pressure and stroke. He has high sugars but they are in control right now.
Natalie_Evans,_MD: It depends on your husband's particular situation. As I have mentioned, I usually exercise first. If you are unsure about how you want to proceed, it would be reasonable to get a second opinion. I would be happy to see him at Cleveland Clinic.
PAD can develop in patients who have no family history and normal cholesterol. It sounds though that he has diabetes which is one of the strongest risk factors for PAD. Controlling his diabetes is essential.
PAD and DVT
miamickey: Are PAD and DVT (or venous insufficiency) often diagnosed in same patient? I have total cholesterol over 500, ASD, had one bypass, ASD closure, and AFIB maze procedure at age 55. With constant leg pain, especially when I'm lying down I am concerned about my risk for stroke. Am aged 59, thin, nearly vegetarian, and very active. I'm thinking blood thinners would be good prophylactic treatment. I just take one baby aspirin and prescription strength potassium daily.
Natalie_Evans,_MD: PAD and DVT have different mechanisms leading to their development. However, recent research has shown that those with DVT may be more likely to develop atherosclerosis. Typically anticoagulants like warfarin (coumadin) are not recommended or beneficial in patients with PAD. However, it sounds like you have a lot going on and it might be worthwhile getting a consultation with a specialist in vascular diseases.
kenny: Are there vascular tests that can check your circulation that do not involve dye?
Natalie_Evans,_MD: Kenny great question. Yes. There is an easy test that can be performed in the vascular lab that involves comparing blood pressures in the ankle to blood pressures in the arm. This is a very accurate way to diagnose PAD. Sometimes we may repeat the test after treadmill exercise. There is no dye and no radiation. It is a very safe test.
Symptoms of PAD
Charla: Very poor circulation in my left foot. Sometimes numb, always cold. What are the things I should do to help this?
Natalie_Evans,_MD: First you should be checked out by a specialist in vascular diseases. If you truly have poor arterial circulation - as determined by a test called the ankle brachial index - the first treatment usually is increased walking exercise. But, I really do recommend getting checked out if you have not done this.
fjpor: With a 90% blockage in left leg in groin area which they say cannot be stented, will exercise 3 X week walking 2 miles on a treadmill help to build collateral arteries? Pain in that calk starts about 7 minutes in and disappears at about the 35 to 35 minute mark and stays gone the remaining 60 minutes. Vascular surgeon says he does not want to do surgery after a doppler and to come back in a year - unless certain symptoms crop up. Right leg was also 90% blocked but stent was placed in Iliac artery during triple bypass to heart where 3 main arteries were totally - 100% - closed off but which caused no symptoms and were aided by 2 collateral arteries which, apparently, built up over many years. Rear artery enlarged and that with collaterals was all that was feeding heart. All of this was done last September. Patient is 76 years old with type 2 diabetes. Any information/suggestions will be appreciated.
Natalie_Evans,_MD: For patients with PAD, we recommend walking for at least 30 minutes 3 times per week for a minimum of 12 weeks to help build collateral circulation and increase walking distance and conditioning. In fact, walking exercise is the first-line treatment for most cases of PAD, even before stents and surgeries.
pilatesgirl: What are the safest forms of exercise for people with PAD?
Natalie_Evans,_MD: Walking exercise, ideally in a supervised setting, which helps to encourage patients, is the best and very safe form of exercise. I also encourage patients who like to bicycle and swim to continue these activities. Ideally, walking exercise should be performed for a minimum of 30 minutes at least 3 times a week.
Okiegal: A couple years ago I had a femoral bypass. During a check up last month they found the graft was closed. I am not having any problems with pain with walking at this time unless I hike a great distance. Is it ok to let it go for now? Or - should I pursue treatment?
Natalie_Evans,_MD: Great question. If your symptoms are not seriously disrupting your quality of life, I would not pursue an invasive treatment. I would recommend continuing to walk at least 3 times a week and making sure you manage your risk factors for heart attack and stroke with strict blood pressure and cholesterol control and taking an aspirin or plavix if safe to do so.
Peripheral Artery Disease – Bypass Surgery and Stents
Vickie: My husband has just been diagnosed with and will be receiving a bypass surgery for the superficial femoral arteries. We have read up on the procedure and are trying to get as much information on this procedure as possible. Of course they will be doing only one leg at a time, however, the one thing that we cannot find an answer to is what is the average normal recovery time after this surgery??? We have a very good and reputable cardiologist who will be performing the surgery, in fact, he comes to our hospital several days a week from your clinic in Cleveland. If you could give us some sort of ball park figure on the time it takes to normally heal and resume activity, it would be greatly appreciated and indeed, will give us an idea on when life can and will begin getting back to normal for us. It has been found that he has a complete blockage in both legs. Thank you very much for any information you could help us with.
Natalie_Evans,_MD: Hi, Vickie. Healing times depend on what type of procedure your husband will be having. You say a cardiologist is performing the procedure, which leads me to believe it’s a catheter-based procedure rather than a true open surgery. For catheter-based procedures, most people are out of the hospital within a day and can in most cases resume their normal activity. For open surgical procedures, hospitalizations are longer and patients can expect several weeks of healing time.
RitaV33: I have stents in two mesenteric arteries and one was unable to be stented. Do they then do bypass surgery as another option? I am not sure of my next steps in treatment. Also - what is the long term success of stenting in this region? What are things I should make sure I do to keep these arteries open.
Natalie_Evans,_MD: It depends on the symptoms that your mesenteric artery disease is causing. Bypass surgery is an option, but it is a big surgery. I would recommend visiting a vascular specialist at Cleveland Clinic to determine what the best approach to treatment is.
PAD and Medications
LarryV: What type of medications are used to treat PAD? Should I be on a special diet? Will it be helped by diet? Can it be reversed? I was told to exercise but it is painful and I get tired. Does that really help?
Natalie_Evans,_MD: Medications for PAD fall into two categories:
First, are medications to help prevent heart attack and stroke, including blood pressure, cholesterol, and diabetes medications, and aspirin or plavix.
Second, are medications to help increase walking distance, but there is only one that works, called Pletal or cilostazol.
A heart healthy diet is best. I recommend one high in vegetables and fruits and low in animal fats and sugar. Reversing the process that causes PAD is challenging but we can help slow or stop it. Finally, regarding exercise, it is the first line of treatment for PAD and in fact has been shown to be more effective than stents.
JillianB: I have Raynauds Syndrome. It becomes worse with each winter. I need to find a doctor to help treat this - can you talk about treatments - I had a sympathectomy in one hand and it did not help. What is the success rate of that procedure and if it didn't help what are other options?
Natalie_Evans,_MD: For severe Raynauds, there are many different treatments, none of which are very well studied. Some patients have tried various medications as well as injections with botox. If you have had a sympathectomy and it did not help, I would suggest a second opinion evaluation. We would be happy to see you here.
Shawna K: My husband had terrible pain in his abdomen a couple weeks ago - he went to the hospital and was diagnosed with a renal dissection. At discharge they put him on coumadin and medication to lower his blood pressure but discussed no further treatment. We have a follow up appointment in 10 days but I am very worried about him and wonder if that is the appropriate treatment and if any procedures should have been done. Will it happen again? Can it happen to other arteries? Is it life threatening? Does he have restrictions on activity? We are both walking on eggshells at this point.
Natalie_Evans,_MD: Renal dissection is uncommon, and I would be interested in knowing more as to why it developed in your husband. I think the treatment he is receiving right now is appropriate, but you may wish to get evaluated by someone who specializes in unusual arterial diseases. We would be happy to see him here.
Superior Vena Cava Syndrome
Felicia: Could you please tell me if a patient has a partially blocked superior vena cava secondary to fibrosing mediastinitis, can you tell how blocked it really is by symptoms of extreme fatigue at times, facial edema and swollen arms, cough, difficulty swallowing food at times, headaches off and on and a heavy feeling in your head ? Not sure yet if SVCS is my DX ,but it sure feels like it. Thanks Felicia.
Natalie_Evans,_MD: Hi, Felicia. Superior vena cava syndrome may cause facial and arm swelling. I would recommend seeing a specialist in vascular medicine or vascular surgery to help you make this diagnosis.
Restless Leg Syndrome
cola99: Is restless leg syndrome related to PAD? I have this and it is very concerning and uncomfortable. Not sure what type of doctor to see at this point or if I should be checked for PAD.
Natalie_Evans,_MD: Restless leg syndrome (RLS) sometimes is seen in patients who have disease of the veins which is different from PAD. If you have concerns about vascular disease I recommend seeing a vascular medicine specialist, a vascular surgeon or a cardiologist who treats vascular disease. People who are at risk for PAD are smokers, diabetics, and people over the age of 65.
jonferlito: Any connection between PAD and Restless Leg Syndrome? Taking 1,800 mg of gabapentin, at night, which has eliminated RLS. Still experience moderate numbness and tingling in toes. No evidence of diabetes during testing, but family history is present.
Natalie_Evans,_MD: We have seen more of a connection between RLS and chronic vein disease. I am not aware of a connection between PAD and RLS, but that does not mean that such a connection does not exist. I would recommend that given your symptoms if you have not been screened for PAD, that you do so.
GeorgeOM: My doctor said I have venous reflux and wants to do venous ablation. Will this improve circulation in the legs? Does this improve the valves in the legs? Will it get rid of the big varicose veins.
Natalie_Evans,_MD: Venous ablation may improve the circulation in your veins, leading to decrease in swelling or ulcer healing if that is a problem for you. Venous ablation does not fix the valves; it only gets rid of the offending vein. Many people notice an improvement in their varicose veins with ablation procedures.
circusman: I am 73 years old and had a cardiac nuclear perfusion scan in February. End diastolic volume is 78 ml and left ventricular end systolic volume is 25 ml. Any cause for concern?
Natalie_Evans,_MD: I don’t read nuclear perfusion scans so I can’t tell you. This is a great question for a cardiologist!
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