Treating Peripheral Vascular Disease

with Andrew Feiring, M.D., Vascular Surgery, Advanced Healthcare

Posted: May 1, 2004

Given the following choices: stroke, death, amputation of a limb or loss of independence; which is likely to be the one most feared by the elderly?

Dr. Andrew Feiring found the answer when he conducted a small study of his patients.

“Overwhelmingly, people said loss of a limb was the No. 1 concern and death was the least,” he said.

Andrew Feiring, M.D., Vascular Surgery, Advanced Healthcare "Once you have rest pain or an ulcer on the foot, you have about a 25 percent chance of having an amputation. In addition, your chance of dying within the first six months is approximately 25 percent and your chance of dying within three years of this diagnosis is 60 percent."

Dr. Feiring, a vascular surgeon for Advanced Healthcare, wasn’t asking the question out of mere curiosity. The incidence of vascular disease, which affects between 5 and 8 million Americans at any given time, rises with age.

What is vascular disease?
Vascular disease is caused when plaque (a combination of cholesterol, fat or other foreign matter, such as calcium) builds up in an artery, blocking blood flow to the area beyond it. If the blockage is in one of the arteries immediately around the heart, the condition is called coronary artery disease. If it’s in any of the other blood vessels located in the legs or other extremities, it is peripheral vascular disease (PVD).

Blockages can occur in a single area or in multiple areas. Dr. Feiring compared the body’s circulatory system, which is responsible for carrying blood throughout the body, to the pipes in a house. If you have blockage in the water pipes going to one area of your home, it may indicate other rooms where the pipes have reduced flow.

For PVD, the most common area of blockages occurs in the legs. The first symptom, claudication, is pain which occurs during activity and stops as soon as the activity is stopped. For some patients, a course of exercise therapy, lifestyle changes and medication are enough to halt the progression of the disease.

Others are not as fortunate.

“A proportion of people with PVD will go on to develop rest pain,” Dr. Feiring said, “because blood flow in the legs has diminished to a point where they don’t get enough blood supply to the muscle, even at rest.”

As a result, the tissue in the affected area begins to break down, causing ulcerated sores on the toes or heel. From the doctor’s standpoint, this is problematic for three reasons. It’s a marker of severe disease, and it’s very hard to treat. It is also extremely painful.

Until recently, Dr. Feiring said, the only real treatment to try and save the limb has been pain control. The other option, short of amputation, was a very involved and risky surgery which was pioneered 30 years ago.

“The chances that the surgery will cause death within 30 days are five to 10 percent,” Dr. Feiring said. “Chances that the graft will stay open are somewhere between 20 and 50 percent, and that’s only over a three- to four-year period.”

A new therapy
With so little to lose, Dr. Feiring set out to apply advances in treating blocked coronary arteries to PVD. Four years ago, he tried something that had not been done before, and to track the results.

“I performed angioplasty on these patients, but instead of using a balloon, we inserted medicated stents to keep the arteries open,” he explained.

Before receiving this new therapy, Dr. Feiring and his team evaluates to make sure the patients don’t have active coronary artery disease. Post-stent placement, the patient is given blood thinners and monitored to make sure cholesterol levels remain within the normal range.

Dr. Feiring is reporting the results in a study, which he recently submitted to the “Journal of the American College of Cardiology.”

Between the 76 patients in the study, there were 86 affected limbs. Patients ranged in age from 39 to 101; the average age was 76. Fifty-four percent of the patients had diabetes, 60 percent were active smokers and 80 percent had smoked at some time in their lives.

Those percentages are important to note, said Dr. Feiring, because the incidence of PVD in smokers is three to four times that of non-smokers and diabetics get PVD at twice the rate of the general population.

The results of the new procedure were encouraging.

“We had no mortality the first year and the amputation rate was about 4 percent. It may have been even lower had the patients come to us earlier,” Dr. Feiring said.

The average hospital stay for Dr. Feiring’s patients was a little over a day; all received exercise prescriptions post-surgery. Some came in regularly for monitored treatment. Others resumed walking and – most important – their ulcerated sores healed on their own because normal blood flow was restored.

“The results have been excellent and there was very little in the way of procedural complications,” Dr. Feiring said. “It’s been very gratifying.”

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