Vascular Disease

with Andrew Feiring, M.D., Cardiologist, Advanced Healthcare

Posted: Feb. 1, 2004

The aches and pains associated with aging, particularly leg pain that flares up while walking and subsides with rest, could be about more than getting old.

“As you get older, plaque builds up and it builds up in different arteries,” said Dr. Andrew Feiring, a cardiologist with Advanced Healthcare who specializes in vascular diseases. “It can build up in the carotid artery, causing a stroke; in the kidney, causing kidney failure and hypertension; in the legs, where it causes claudication leading to amputation; or in the heart, where it causes a heart attack.”

Andrew Feiring, M.D., Cardiologist, Advanced Healthcare "What we have done is to take the 20 years experience we've had in doing coronary artery angioplasty and have transposed that to the arteries below the knee."

Claudication, pain in the calf or thigh muscle that sets in after walking a block or more, and stops – within exactly the same amount of time – after resting, is caused by lack of blood flow to the working muscle.

Risk factors for the condition are the same as those for a host of other diseases – high blood pressure, diabetes, elevated cholesterol, cigarette smoking and aging. It can also be associated with heart disease, not surprising as the cause is the same.

New procedure
“In the past,” Dr. Feiring said, “surgical options for patients with severe blockages in the arteries below the knee were associated with a 5 to 10 percent one-month mortality rate after surgery.”

The only other option was to live with the pain and take medication, have the blocked leg amputated and lose independence, or wait to die of the condition. None were very appealing outcomes, particularly to an older person suddenly discovering that their leg pain is not merely a function of getting old.

Happily, those outcomes are no longer the only ones. Dr. Feiring and his colleagues have pioneered a procedure that, over the past five years, 90 limbs have been treated. Of those cases, no one has died; no one has lost a leg and 93 percent of the patients showed clear improvements.

The data is being published in an upcoming issue of the Journal of The American College of Cardiology.

“Using stents has dramatically improved the safety and the efficacy of treating coronary artery disease, and the arteries below the knee are very similar to the arteries in the heart and are exactly the same size, so we use the same coronary artery stent,” he explained.

The results have been the same for using the metal stents to correct blockages in the arteries below the knee as they’ve been for coronary arteries.

“There’s a 10 to 30 percent recurrence rate within six months,” he said, “and if you’re not one of those 10 to 30 percent, you tend to be fixed.”

Dr. Feiring treats those 10 to 30 percent with the same restenosis he would if it was a coronary artery re-blockage. As these drug-eluting stents, which are coated with a polymer to release a drug that prevents blockages, continue to drop in cost and are used more frequently, chances are that the restenosis rate will also fall.

Carotid angioplasty
Innovation among Dr. Feiring and his Advanced Healthcare colleagues is not confined to one area of treatment.

Closure of the carotid artery, which carries oxygenated blood to the brain, can also be a by-product of the aforementioned risk factors, age among them.

“For 50 years, the only approach to fixing the arteries of the neck has been surgical,” he said. “Over the past eight years, we’ve been developing carotid artery angioplasty to non-surgically treat these arteries.”

Dr. Feiring is one of three area doctors with FDA-sponsored approval to perform carotid angioplasty. The procedure is similar to that of a heart catheterization, and a stent can be inserted.

The groin is punctured with a small needle, a tube is inserted to the level of the carotid artery, a small filter is inserted just past the blockage to protect the brain and a balloon is placed over the wire to the filter in order to stretch the artery. The artery is then stretched, a stent inserted, the tube removed and the surgery finished. Patients are usually awake during the procedure, which is performed under a local anesthetic.

“Patients are frequently up walking three to six hours after the procedure,” he said. “There’s no risk of infection, or the significant blood loss and cranial nerve damage that can occur with traditional surgery.”

Ankle-Brachial Index (ABI)
Dr. Feiring has a simple recommendation for anyone concerned about vascular disease, which can affect arteries and veins, and put patients at risk for stroke, heart and/or kidney failure, or amputation of one or both legs.

“If you asked me what was the most single predictive test of all the tests cardiologists have of who is going to live or die in the next five years,” he said, “I’d say it’s the Ankle-Brachial Index (ABI).”

The simple test involves a blood pressure reading of the ankle, and is performed with a Doppler cuff. Although most family practitioners and internists don’t yet consider them standard equipment, it’s a test that can be done by a primary-care physician who has the cuff, or the physician can refer a patient to have the test done.

The reason most patients don’t think to have the test, he said, is a simple one.

“If you’re among the people who think their difficulty walking is related to the aging process, you don’t ask and your busy physician doesn’t think to ask about it. You have to ask the right questions in order to get the right answers,” he said.

We Have Answers Do you have medical questions or need help finding a doctor? The experts at Columbia St. Mary's and Advanced Healthcare can help. Click here.