Lee Kirksey, MD
Lee Kirksey, MD

Jaikirshan Khatri, MD
Jaikirshan Khatri, MD

Friday, November 16, 2014 - Noon


Description

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. Kirksey and Dr. Khatri answer your questions about PAD.

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Abdominal Aortic Aneurysm

george32:  What can you do for a renal abdominal aortic stent graft that has a significant amount of type Ii endoleak - is surgery required?

Lee Kirksey, MD: At Cleveland Clinic we have 15 years of experience with various types of abdominal aortic aneurysm repair including the use of fenestrated grafts which require renal artery stents. For that reason we often treat type II endoleaks with newer generation stents or other adjunctive embolization procedures. We would be happy to review your images and offer you recommendations or advice regarding treatment.


Mesenteric Artery Disease

barbie: I have an occluded mesenteric artery that needs to be treated - what are the options for surgery?

Lee Kirksey, MD: Occluded mesenteric arteries including the celiac and the superior mesenteric artery, can be treated with either endovascular or open bypass procedures. Most frequently the endovascular approach is the first option and we have a high rate of success with that approach. In cases where the blockages cannot be treated with endovascular approach we have a 35 year experience published and have outstanding results within our group. The determination of which procedure is appropriate is often determined by review of blockage on CT scan or catheter based angiogram images.


Renal Artery Disease

kandi35: 35-year-old female who had an angioplasty of right renal artery this past summer. What is normal follow up? What is the length of time this would last?

Lee Kirksey, MD:  My first impression is that renal artery stenosis at the age of 35 is quite unusual and is most frequently related to fibromuscular dysplasia (FMD) as opposed to atherosclerosis that is the more common cause. That is an important distinction because FMD related renal artery stenosis has a better outcome after treatment with angioplasty. The durability of the angioplasty would also be related to other factors such as if a drug coated balloon was used for the treatment. We participated in several clinical trials which demonstrated that the return of stenosis after treatment with a drug coated balloon is much more delayed compared to conventional angioplasty balloons. In general, follow-up would be indicated every 4 - 6 months with abdominal ultrasound. Our vascular medicine and vascular surgery department have extensive experience with FMD and we have a specialized clinic for treatment of FMD.


Peripheral Artery Disease and Blockage

nvgal:  Are there procedures you would suggest for totally closed off leg arteries that do not require full bypass surgery for the vessels? When do you decide surgery is necessary?

Jaikirshan Khatri, MD:  Depending on the location of the blockage, they can often be reopened even if totally blocked without surgery with catheter based procedures. Unfortunately, success rates are not as high as when the artery still has some flow and if nonsurgical attempts fail, surgery still provides an option for treatment.

greystone:  My husband has PAD. His doctor told him to take baby aspirin and lipitor. He has pain when walking any great distance. Anything else that can be done? Any other medications?

Lee Kirksey, MD:  In addition to aspirin, it would be important to treat his other comorbidities such as elevated cholesterol (as you are). There is evidence that a physician supervised exercises program can be effective in improving the walking distance and functional capacity in patients with claudication like your husband. As you may know, various procedures are also available as an adjunct to these pharmacological or exercise therapies.

kennethfl:  I had a blockage in my left leg several years ago and had a bypass. Now I have a blockage in the right leg - seeing doc in a week to review options. Can this be treated without surgery?

Jaikirshan Khatri, MD:  Yes - but this depends on anatomic considerations. Depending on the location of the blockage, ballooning or stenting may be sufficient whereas other instances, surgery may be the best option for long-term results.

garyglass:  I had angioplasty to my right leg eight years ago. How long does that last? If it blocks again, can I have that treatment again? What is new in angioplasty or non-surgery treatments than what was there back in 2009?

Jaikirshan Khatri, MD:  If you have recurrent symptoms then revascularization is certainly an available option for treatment. There have been many advances in angioplasty since your last procedure including drug coated balloons, drug coated stents, and woven stent technology. All of these new devices have very impressive outcomes data. 


Venous Ulceration

henry:  I have venous ulceration and have been told to wear compression stockings - any other options?

Lee Kirksey, MD:  Ulceration of the lower extremity as it results to venous disease can be caused by venous incompetence and venous hypertension of the leg. Sometimes patients also have a combination of venous and arterial circulation problems. In that instance merely treating the venous hypertension with compression will not be successful unless the arterial component is not addressed to improve leg circulation. The mainstay of diagnosis is the noninvasive vascular lab to identify which veins are abnormal or incompetent. These veins can be treated in various ways including chemical or radiofrequency ablation and injection sclerotherapy. This allows the compression treatment to be more effective in healing the ulceration and also preventing recurrence.


Limb Salvage

donfromcali:  My 75-year-old dad 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. 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:  Here at Cleveland Clinic, we have a multidisciplinary limb salvage team which includes vascular interventionists, surgeons, plastic surgeons, podiatrists and cardiologists. He should be evaluated to prevent the loss of limb. It would be hard to know without details of his process what options are appropriate, however a dedicated team with an aggressive approach can often avoid or minimize the degree of amputation. We would be happy to evaluate his case. 

CanadaLRT:  My uncle had his leg amputated below the knee. I have recently heard about "limb salvage" - what does that mean? Could he have saved his leg? What can be done for him to prevent further amputation? He has PAD, diabetes (which is now in much better control). He is 68.

Jaikirshan Khatri, MD: The biggest effort should be focused on prevention which includes control of diabetes, blood pressure, cholesterol and not smoking. Limb salvage involves opening blocked arteries typically below the knee to allow for wound healing and limb preservation. These procedures are done when preventative measures are insufficient.

Lee Kirksey, MD:  Unfortunately atherosclerosis is a systemic process and when one leg is affected, the other leg may be affected as well in this regard. In addition to management of comorbidities, appropriate shoe ware and monitoring of the other leg is important to prevent the same fate. Although he has undergone amputation on the affected side, the other limb needs to be closely monitored generally every 3 - 4 months, and perhaps even more frequently.

moderator:  What else should patients worry about if they have PAD?

Jaikirshan Khatri, MD:  PAD is just one sign of a much larger problem which affects circulation of the entire body. Patients with this diagnosis need to have careful follow-up to evaluate all associated risk factors such as diabetes, cholesterol, high blood pressure and tobacco use. Having PAD dramatically increases the risk for future heart attack and stroke. Therefore, patients may need additional testing to rule out blockages in other areas such as the heart and carotid arteries.


Symptoms: Ankle Swelling, Leg Pain

EMG:  I am a 75-year-old-woman. Ever since my first pregnancy 48 years ago, in the summer my left leg/ankle would swell. I had blood pressure taken in both legs and was told they were normal and to reduce my salt intake. Now in the last four years, both legs/ankles swell year round. Now I am still told to reduce my salt intake I don't add salt to any food I cook if it can be avoided (baked goods), I limit lunch meat and ham to once a month or less, same with prepared foods. I am now wearing support hose to keep the swelling down.   Should I insist on have an ultra sound done on my legs, especially my left leg?

Lee Kirksey, MD: The more common causes of leg swelling following pregnancy are chronic venous insufficiency and lymphedema. These can be differentiated by venous ultrasound performed in a dedicated non-invasive vascular lab. The distinction is important because the available treatments differ. The mainstay of symptomatic treatment is compression stockings however procedures are available for improving chronic leg swelling and we are happy to evaluate you.

virginia:  I have swelling in my legs. They often feel painful and tired. My doctor said that I need to wear compression stockings. That is it.  It does not seem to help.  Any other treatments?

Jaikirshan Khatri, MD:  Leg swelling can have multiple causes. It sounds like your physician feels that your symptoms are due to venous insufficiency which can improve with compression stockings. However, there are other possibilities that should be explored including heart problems and side effects of medications you may be on.

sbdavisrn:  When sitting with my feet on the floor, my toes and bottom of feet turn a dark purple and become cold to the touch. But - I have good pedal pulses and any type of injury heals quickly. Anything I can do besides compression socks?

Lee Kirksey, MD: The good thing is that your arterial circulation seems to be intact which would be the most severe cause of what you describe. Venous congestion of the lower extremities which ca cause discoloration and sometimes coolness of skin may be managed with compression therapy in the appropriate setting. It's very important however your problem should be evaluated by a professional such as physician who is familiar with the treatment of arterial and venous disorders. Untreated venous insufficiency of the lower extremities can result in leg ulceration and significant functional disability. Our vascular medicine and vascular surgery departments have a broad experience with the treatment of chronic venous disorders. 

carolinnw:  My sister was a double amputee and my brother has had bypass surgery in his legs. I recently am having severe pain in legs - I can’t hardly walk or stand for long period of time. I don't have a lot of money so want to make sure I see the right doctor, have the right tests - pretty sure this is what my family has - but anything you do to help guide me?

Lee Kirksey, MD: My advice would be to see a multidisciplinary group of providers who specialize in treatment of severe peripheral arterial disease (PAD). That dedicated group can both diagnose and treat your PAD as well as other potential problems including cardiovascular comorbidities. This is the approach we use here at Cleveland Clinic and we have found it to be most successful in achieving the best outcomes for our patients. Each patient is different and we customize our treatment to their presentation. 


Prevention

RMDLAWL:  I am a 77-year-old, 170 lb. white male who plays golf three to four days weekly throughout the year and walks regularly with modest additional workouts. In August of 2017, without noticeable symptoms, I suffered a bilateral embolism and was put on Eliquis. I have a heart doctor in St Joe, Michigan who put me through a nuclear stress test after the embolism and I visited with Dr. Bartholomew of Cleveland Clinic last fall who suggested I continue with the thinner and visit this year, which I plan to do. My question is that new protocol suggested to my Internist that I should consider a mild dose of Statin because I have a historical 236 bad cholesterol readying although my good cholesterol is good. My heart doctor suggested we consider it next spring after I undergo an echo. I have no typical symptoms that would suggests a need for the statin but I am considering it. Thoughts as I will be 78 in Feb.

Jaikirshan Khatri, MD: The question related to whether a statin makes sense is related to risk factors for coronary artery disease. We take into consideration factors such as family history, diabetes, high blood pressure. The higher the likelihood of underlying coronary disease the more beneficial a statin. A high cholesterol alone is not reason enough to start treatment for it. The fact that you had a pulmonary embolism does not increase your risk for coronary artery disease. The two are unrelated. 

padpad:  I read on the Cleveland clinic health blog that women who have pad are affected differently than men. They may have worse outcomes for procedures. I am a 45-year-old woman who started to have some pain with walking and was diagnosed with PAD. I have been healthy - eat healthy - my mom had PAD and dad had heart disease. Wondering what I should do and what questions to ask about treatment. Would I be treated differently? Things I should consider? 

Jaikirshan Khatri, MD: Having PAD at your age raises a lot of concerns. The disease is nonspecific to your legs and affect other arteries, specifically arteries to the heart muscle. We know that women often have different symptoms and presentations with coronary artery disease. We have a preventative cardiology group at Cleveland Clinic who can evaluate you to assess risk of more serious problems.


Research and Innovation

dlk1948:  Are there any treatments that can dissolve the plaque or blockage found in the arteries in the legs? What about stem cell treatments for leg arteries?

Lee Kirksey, MD: As a general comment, there are two types of arterial blockages. Those which are long standing such as chronic vs. vascular blockages which are acute occurring within days to weeks. Most chronic or long standing arterial blockages are not amenable to any agent that dissolves the plaque. It is important to understand that statin therapy or cholesterol medications sometimes may stabilize the plaque and prevent growth and acute rupture. For new arterial blockages occurring with days to weeks that are causing acute symptoms, medication is available to dissolve those clots. This treatment is referred to as thrombolysis. Stem cell therapy is still in the investigatory stage and we have a clinical trial at Cleveland Clinic - the Biomet trial - for patients who have limited options for revascularization and are at risk for limb loss. There is great enthusiasm around the use of stem cells in limb preservation.

wswanlund:  Hello Doctors, I am a 72-year-old male with PAD and am hoping for some "miracle" innovations that will help extend my life. Can you please, based on current research and trials, give us a brief on what we can expect in the coming years?

Lee Kirksey, MD:  Life expectancy in patients who suffer from PAD is usually a function of their elevated risk for cerebrovascular disease such as stroke and heart attack, as opposed to the PAD resulting in death. With regards to limb preservation in patients with severe PAD, a number of therapies continue to evolve and enhance our ability to preserve limb function. Some of those technologies include drug coated balloons and stents, as well as biologic agents such as stem cell therapies. Deciding which of these is best is based upon a customized approach for each patient and their symptomatic presentation.

Jaikirshan Khatri, MD: The thing that has to be kept in mind is that prevention is the main focus - so control diabetes, blood pressure, cholesterol and tobacco cessation should be first and foremost. 

bonnie:  Have you heard of EECP to be used for peripheral artery disease to increase circulation to the legs?

Jaikirshan Khatri, MD:  EECP is a therapy used to treat chest pain in patients with blocked arteries to the heart muscle who do not have options for surgery or stents. We are not using it for circulation to the legs.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.