David Hardy, MD
David Hardy, MD

Friday October 19, 2018 | 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. Arteries are the blood vessels that carry oxygen and nutrient-rich blood from the heart to all areas of the body. PAD occurs in the arteries that carry blood to the arms and legs. Please take this time to ask vascular medicine specialist, Natalie Evans, MD, and vascular surgeon, David Hardy MD, your questions on PAD.

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Prevention and Risk Factors for Peripheral Artery Disease (PAD)

aroland: What types of foods can a person eat that can reduce the risk of PAD?

Natalie Evans, MD: To my knowledge there are no foods that can reduce risk of PAD although you should eat a heart healthy diet. There was an interesting study that showed that patients who ate three oz. of dark chocolate a day had improvement in intermittent claudication (muscular leg pain with walking related to blocked blood vessels). However this was a very small study. Patients with symptomatic PAD would have greater benefit from walking exercise.

EmilioZ: My father had many renal procedures and nothing helped him, things just got worse, he had atherosclerosis, had ballooning, then renal bypass, which caused him leg amputation... And are there any lifestyle changes that can be made to stop this disease so this does not happen to me?

Natalie Evans, MD: I am sorry to hear about your dad's situation. To help prevent atherosclerotic disease from developing, it is important to control risk factors which are high blood pressure, high cholesterol, diabetes, and smoking. There are two risk factors you cannot control: age and family history. It is also important you stay active.

Symptoms of PAD

Douglasc: Is PAD painful? Are there symptoms to look for?

Natalie Evans, MD: Great question! PAD can be painful. Pain is typically in the muscles of the calves or the thighs with walking that improves with rest. But, these symptoms occur in only about 10% of patients. Many patients with PAD are totally asymptomatic but they are at risk for heart attack and stroke - up to 25% of patients over five years. If you are diagnosed with PAD, it is important to be on medications to control your risk for heart attack and stroke.

Douglasc: My mother, 80 y/o, has pain on walking. She had varicose vein stripping in her 30s. Could she have PAD now?

Natalie Evans, MD: Yes! Age is a strong risk factor for PAD. Many elderly adults have PAD but assume that muscular leg pain with walking is a normal feature of aging. It is important for her to get checked out.

Gustavo: My symptoms are: heavy feeling in both legs; knee pain after exertion (short walking distance); and need to stop for pain to quit. I also tend to have shortness of breath... I have had coronary bypass twice. Could this be PAD/PVD? What can be done?

Natalie Evans, MD: The heavy feeling could certainly be caused by PAD and the fact that you have coronary artery disease puts you at risk for PAD. Knee pain is not typically caused by the circulation. If you have walking discomfort that is caused by PAD, the first treatment typically - believe it or not - is supervised walking exercise. Patients who continue to have pain after doing a walking program may be candidates for surgery or stents to improve pain.

Kenneth: My legs hurt a lot. I have a hard time to walk when I get up. Now I find I am constantly shaking my left leg to make circulation better. I am only a little overweight. Was physically active a few years ago but definitely slowed down. My legs look unusually heavy. If I stay on my feet a long time I have more pain some swelling. I also have tingling on that foot. I had lab work which was negative for blood clots.

Natalie Evans, MD: There are a few possibilities here. Since you have swelling it may be possible that you have a component of vein circulation problems. But, PAD can also cause some of these symptoms. If you have not had testing of your arterial circulation, this may need to be performed. Since you have a number of different symptoms in your legs it would be appropriate to see a vascular specialist to try to figure out the various issues.


Diagnosis and Diagnostic Testing for PAD

Pjrealtor901: I have 0.88 on my left leg. Also mild to moderate carotid artery disease administered by Lifeline. Should I be concerned or real concerned? I don’t have insurance so I am a little lost on the urgency I should be.

Dr. David Hardy, MD: In reference to carotid artery disease mild to moderate disease can be concerning. I would recommend obtaining an ultrasound from your certified vascular lab in combination with seeing a vascular specialist. Your vascular specialist can comment on the options you have for treating your carotid disease. These options range from medical therapy alone and some people with severe disease need surgery or stenting.

Natalie Evans, MD: An ABI of 0.88 usually does not cause symptoms but again is a risk factor for heart attack and stroke. It is important that you are on appropriate medications to minimize risk.

fearful-gal: I'm a 48-year-old female who had an angioplasty of right renal artery. I have hypertension since age 30 and am now on three BP meds. I have had renal artery angiograms and ultrasound of legs. Would you suggest any other tests?

Dr. David Hardy, MD: I would suggest an evaluation by a vascular specialist. You are dealing with a complex situation. Repeat ultrasound of your kidney blood vessels would be recommended and seeing your local vascular specialist. Currently, you are only on three BP medications and I am not sure if you are optimized on those medicines. This is where your physician could modify your treatment. Besides renal artery narrowing, this could be due to other vascular disorders that again your vascular specialist could evaluate.

Barry: I have a major occlusion in my R superior femoral artery, caused by a blood clot. When discovered, the blockage was 100%. After about three months the blood clot dissolved with the aide of medication. Through exercise and medications, I now have collaterals and my doctor said I do not need an amputation. Is there any way to have repeat imaging done without radiation? I have a history of Hodgkin’s and doctor does not want me to have any other CT scans.

Dr. David Hardy, MD: There are ways to evaluate your legs without radiation. Ultrasound is a great tool to evaluate your blood vessels. There are other tools in the vascular lab we can use to evaluate how much blood flow makes it to your feet. The clot in your femoral artery could be due to several things in your situation, and this would be hard to comment on without knowing more about your case. In general, if you are doing well with exercise and medication, without lifestyle limiting symptoms, I would typically agree that non-operative management is working for you.

Gloria: What type of tests diagnose PAD? Should that be part of a physical exam? I am 60 years old and have not been tested.

Natalie Evans, MD: There is a simple screening test for PAD called the ankle brachial index. Patients older than 65 may be candidates for this screening test; along with patients with risk factors for PAD and patients with abnormal pulses in their feet. Typically the ABI is not done routinely in asymptomatic patients without risk factors.


Medications for Peripheral Artery Disease

qltr2710: What are the current medications, use of statin treatments, aspirin use for PAD?

Natalie Evans, MD: Most patients with PAD should be on a statin, even if their cholesterol is normal, as well as aspirin. Patients with high blood pressure should be on blood pressure medications. Patients with diabetes should have their diabetes controlled with medications. Additionally, recently a blood thinner medication was approved by the FDA to treat certain patients with PAD. Finally, patients should be counselled on quitting smoking if they are smokers.


Treatment of PAD

sydney42: My mom is 90, has COPD, PAD. She has been told by one surgeon to have a procedure to remove the blockages in both her legs. She is allergic to Plavix. She is also high risk and her primary doctor is suggesting this would be too high risk for her. How risky are procedures to open up arteries in the legs?

Natalie Evans, MD: First, if she is not having leg symptoms when she walks, and she does not have non-healing wounds on her legs then I would not recommend a procedure in the first place. Open surgical procedures tend to be higher risk than catheter based procedures. Without knowing more about your mother's particular case, it is hard to quantify the exact risk to her.

samd: I have had PAD for 25 years now. I have had four surgeries multiple angioplasty and stents all in my right leg. I just had surgery two weeks ago to try to improve circulation to my lower leg because it is getting very uncomfortable to walk. The surgeon was unable to do anything and told me that my next step is amputation

Natalie Evans, MD: I am really sorry to hear that you have been told that there is nothing more to do. You may wish to consult a specialist in complex revascularization/limb salvage to determine whether there are any other options.

pawpaw: My mother is 85 years old. She has a blockage at the knee of her left leg. The surgeon said it was calcified that was probably building over some years. Surgeon tried chipping at it without much success. Blood is flowing somewhat through to her foot. She does have beginning signs of gangrene on two toes I don't want gangrene to set in. Would her walking more help delay that from happening?

Natalie Evans, MD: When patients have progressed to ulceration or gangrene, walking exercise typically will not help. Patients in this situation need to have their blood flow restored. You may wish to get further consultation with a vascular expert.


Varicose Veins

earl359: My Mother has varicose veins on both of her legs, she wears compression stockings to help reduce the pressure. I normally help her put them on and take them off at night, and notice that over the years they are becoming worse, and now notice an increase in small red scabs marks near the v. veins. My questions are, do you think that continuing to wear the knee high stockings are a good idea or should she opt for the v.v. surgery to get rid of them. If she would have that surgery would it increase her circulation or worsen it. Also what about elevating the legs is that a good thing to do for these types of people who have poor circulation in their legs?

Dr. David Hardy, MD: Wearing the stockings is a great idea, if they are not causing any discomfort. The lesions/scabs could be areas of concern. If they are over the varicose veins and bleeding she may benefit from surgical treatment of the varicose veins. The only way to be sure is to have your vascular specialist evaluate her.


Ulcers

ToriL: I am a 50-year-old female with Peripheral Artery disease. I was diagnosed about 18 years ago. I had two bypasses in my left leg and then it clogged again and I had a bk amputation of the right leg nine years ago. Last year, I developed an ulcer on my right big toe. My vascular doctor did angioplasty on my leg but wasn't able to open the artery. The ulcer has still not healed. I don't have pain in my leg or foot when walking like I did with the right leg before amputation. Is there any other way the artery could possibly be opened?

Dr. David Hardy, MD: I am sorry to hear about your experience with your PAD. The ulceration is concerning especially since it is not healing. The angioplasty of the vessel is a good tool and works a great deal of the time. However, some people ultimately need further evaluation for bypass surgery to attempt healing their lower extremity ulcer/wounds. It sounds as though you have been through a lot but I would recommend further evaluation for revascularizing your foot.


Carotid Artery Disease

missyk: I am set up for a carotid artery Doppler and was wondering what kind of information the doctor can find out from this test?

Natalie Evans, MD: Great question! We can learn lots of things. In our vascular lab, we look at the carotid system; the blood vessels that supply circulation to the back of the brain; and the large blood vessels that supply the arms. Blockages in the carotid arteries can tell us about your risk for stroke.

Selina5947: I am a 60-year-old, healthy, active woman. I have a 100% occluded left carotid artery. My doctor said nothing can be done. 1) how can this happen to me? 2) Is that true? Can you restore blood flow? 3) What should I do to prevent this on the right? My doctor put me on aspirin only.

Dr. David Hardy, MD: I can only imagine the stress of hearing this kind of news. Your doctor is correct in this situation. In general we do not operate on internal carotid arteries that are 100% occluded. Restoring flow in an occluded artery has been shown to have higher risks than benefits. It is true you should monitor your other carotid artery with your vascular specialist with routine carotid ultrasounds. Aspirin therapy is great. Optimal medical management includes statin therapy no matter what your cholesterol is; blood pressure management; exercise regularly and weight management. Diabetes management is also recommended in patients with diabetes.

Bernard: Hello, my wife is mid-thirties and susceptible to carotid artery disease. We would like to have a scan of her arteries and discuss prevention and potential treatment with an expert.

Natalie Evans, MD: I am not sure why you say your wife is susceptible to carotid artery disease. Generally though, atherosclerotic carotid artery disease is very rare in young women. We would be glad to see her at Cleveland Clinic to assess further.


Iliac Artery Aneurysm

Ellen45: I have been diagnosed with left common iliac aneurysm of 3 cm near the bifurcation of the aorta from a CT scan and MRI. I have a left leg popliteal smaller aneurysm found on Doppler exam. I am having some pain and my doctor said I need surgery. What indicates surgery? Are there other ways to treat this?

Dr. David Hardy, MD: Symptomatic aneurysms are an indication for surgery. Pain is one of these symptoms. In patients who are asymptomatic we recommend repair of iliac aneurysms at 3.5 cm. In this case, it appears you are having symptoms and I would recommend treatment in general for this. For popliteal aneurysm we repair symptomatic aneurysms at any size. Asymptomatic patients - we repair at 2 cm diameter.


Renal Artery Disease

Eleanor77: My husband has a CT angiogram showing a small infrarenal aneurysm and a greater than 90% blockage of the right renal artery... What are the options?

Natalie Evans, MD: A small aneurysm typically is watched with repeat imaging. Aneurysms smaller than about 5 cm usually do not require repair. If the right renal blockage is not causing high blood pressure, we typically do not intervene on these. You may wish to have further consultation with a vascular specialist.

StephanM: Renal artery stenosis, angioplasty and stent 2015, recurrent stenosis and angioplasty June 2017 - now has recurrent stenosis - thoughts on treatment?

Natalie Evans, MD: Without knowing more about your case, it is difficult to comment on the various treatment options. Generally, for renal artery disease, angioplasty with or without stenting is usually the treatment of choice. But without further information on why you keep having recurrent stenosis, I can't say much more.


SCAD (Spontaneous Coronary Artery Dissection)

Babs42: I recently had a SCAD event and my mom had one several years ago. I also have had infra-renal artery aneurysms and now have pain in legs. Are these all related?

Natalie Evans, MD: There is a strong possibility that these problems are related.  Cleveland Clinic has a large practice for patients with fibromuscular dysplasia and SCAD. You should consider a comprehensive evaluation in that clinic.

Reviewed 11/5/18

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