Vascular disease and new treatments to avoid amputation
with Andrew Feiring, M.D., cardiologist with Advanced Healthcare
Diagnosing and treating vascular disease
Many people are familiar with the risk factors and symptoms of heart disease, but many of the same problems that affect the heart can also affect other arteries and veins throughout the body. Peripheral Arterial Disease, as this problem is called, is much like arteriosclerosis. It starts when a person is young and slowly progresses until it begins to cause problems.
"In the carotid arteries, vascular disease may lead to strokes. In arteries leading to the kidneys it causes hypertension and kidney failure and in the lower extremities it causes pain and cramping and, in advanced cases, infections, ulceration, resting pain and amputations of the affected limb," said Dr. Andrew Feiring, a cardiologist with Advanced Healthcare.
Dr. Feiring estimates that 8 to 12 million people have vascular disease, and that it affects 20% of the population over 60.
Andrew Feiring, M.D., cardiologist with Advanced Healthcare
"When faced with the prospect of a leg amputation, many patients say that they would rather die than lose their leg. This is especially true of older patients who understand that the loss of a limb is equivalent to loss of their independence."
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Risk factors for vascular disease
The risk factors for vascular disease are the same as those for coronary artery disease. These include hypertension, diabetes, cigarette smoking, elevated cholesterol and a family history of vascular or coronary disease. While there is no way to change the genetics inherited from parents, a healthy lifestyle can aid in prevention.
Symptoms of Peripheral Arterial Disease
Peripheral arterial disease (PAD) is the name given to atherosclotic disease when it affects the arteries of the body. The most common site affected are the arteries supplying the legs. Many people do not recognize the early symptoms of PAD because the symptoms may mimic the usual signs of aging. Primary care physicians may not diagnose it in the early stages, often because patients do not report the problem.
The symptoms of PAD are caused by a lack of blood supply to the arteries. As a result, reduced oxygen supply, those suffering from it will experience cramping in their legs when walking. It will typically be relieved with rest.
"As people get older, they have all sorts of leg and back pains, but what separates these arthritic complaints from vascular disease is that peripheral arterial disease results in tightness or cramping in the calf, thigh or buttocks that occurs only with exertion and is relieved with rest. Therefore, patients can usually exercise up to a certain point and feel OK, but as they walk further or increase workload, the amount of oxygen you can supply to the exercising muscles falls below what you need and you have cramping of thighs and calves. It gets to the point where you have to stop and rest a bit and then it's OK to go on," Dr. Feiring explained.
Success story
One of the most heartening things about the new treatments for peripheral vascular disease is how non-invasive the surgery is and how quickly a patient will start to feel better. To illustrate, Dr. Feiring shared the following story:
"We had a patient who had not walked more than a block or two in over eight years. We found he had blockages in arteries supplying both legs and we were able to treat them both in the same day. The following morning, he was waiting for his ride and started walking around and realized he was feeling much better. It was a beautiful spring day. His family came and couldn't find him despite searching the hospital grounds. Police were called to help look for him. As it turned out, he had walked home, fourteen miles, because he hadn't walked in years. His family found him at home eating lunch."
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Vascular disease elsewhere in the body
While the legs are most commonly affected by vascular disease, a patient can also have vascular disease going to the head and the symptoms are usually that of a stroke or TIA (transient ischemic attack, a temporary interference of blood supply to the brain). Vascular disease can also affect the arteries going to the kidneys. Silently and without symptoms, the blood supply to the kidney is slowly choked off. The only change that can tip off a physician to this process is the presence of high blood pressure.
"About ten to twenty percent of people on dialysis are there because their physicians did not realize blockage of the arteries to the kidney is a cause of kidney failure. Kidneys will die off silently if they are choked slowly. By closing the artery, you are depriving the kidney of oxygen. In general, this is a process that occurs over years and years, maybe even decades," Dr. Feiring said.
Diagnosing vascular disease
There are three components to diagnosing vascular disease. The first is to determine if the problem exists, the second is to find out the extent and location of the blockage and the third is to assess the needs of the patient and their lifestyle considerations. Common tools for diagnosing the problem include a physical examination of the legs and feet, measuring blood pressure in the ankles and ultrasound to detect narrowed arteries.
Until recently, the only way to determine the actual site of a blockage was with an angiogram, which involved injecting dye into a person's circulatory system and then taking X-rays. There was a small risk of the dye affecting the kidneys. Today, however, an MRI can pinpoint the exact location of a blockage with great accuracy, and provides information about which treatment is best for each blockage.
Other special vascular treatments at Columbia-St. Mary's
Carotid Artery Stent Supported Angioplasty. People who are poor surgery candidates or have blockage of carotid artery can obtain an angioplasty instead of traditional open heart surgery. The risk of strokes with angioplasty using protective filter is about 1%, while traditional surgery carries a risk of 3% to 6% or higher.
Selected patients with aortic aneurysm can have their aneurysm non-surgically treated by sealing it off with a special type of fabric-covered stent. The initial success rate is 98%.
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New treatments for vascular disease
Fortunately for patients suffering from vascular disease, the new advances from the treatment of coronary artery heart disease are now being applied to other parts of the body, to open arteries and keep them open. "These techniques can provide almost instantaneous relief for many patients," Dr. Feiring said.
According to Dr. Feiring, these techniques are in marked contrast to what was done in the past. Previously, patients with vascular disease had the option of either surgery or learning to live with pain and their limitations. If their disease was causing severe pain in their legs, they might be offered narcotic pain relievers. Once the disease began causing tissue alteration, such as ulcers on the feet and toes in those suffering from diabetes, surgeons might amputate the toes or foot off. Since many of the patients who suffer from vascular disease are older, this meant a serious limiting of activity.
"When faced with the prospect of a leg amputation, many patients say that they would rather die than lose their leg. This is especially true of older patients who understand that the loss of a limb is equivalent to loss of their independence. Also the disease on one leg usually predicts what the other leg is going to look like in the future," Dr. Feiring said.
At Columbia-St. Mary's, doctors have pioneered new angioplasty techniques, especially in the arteries below the knee. "We have translated all the work we have done with the heart in the last fifteen years and are applying it to the area below the knee with very gratifying results," the doctor explained.
Cardiologists use stents in the arteries below the knee to open the arteries and keep them open. Newer, medicated stents, which prevent scarring and the need for follow-up surgeries, will soon be available to make the procedure even more effective.
"Even with ulcers, if we can restore adequate blood supply to the leg, we can prevent an amputation or limit the amputation. If you can save the foot, and preserve the person's ability to walk, the patient doesn't mind losing a few toes. However, if you take the toes off without restoring blood supply, the foot won't heal and you may have to amputate at a progressively higher level," Dr. Feiring said.
He added that angioplasty does not rule out other treatments later, if they are necessary. "You haven't burned any bridges. All you have done is expanded the options for the patient. It's amazing how often vascular surgeons will not even offer patients this intermediate route.
"One of the benefits of Columbia St. Mary's is the wonderful co-operative effort that exists between myself and the vascular surgeons. They have been open to the idea of aggressive angioplasty for peripheral arterial disease. They have seen enough successes to know this is an option for some of their patients," said Dr. Feiring.
Preventing vascular disease
Exercise is a good way to prevent vascular disease and alleviate some of the early symptoms. Walking, in particular, can build up extra blood vessels in the legs to circumvent the blocked ones. The problem is that exercise will only increase the level about 20% to 40%. "If a patient can walk a block, they might be able to increase that to a block and a half. For an older patient with limited needs, such as taking the dog out, that might be enough. Younger patients expect more. You have to tailor the treatment to a patient's needs and lifestyle," Dr. Feiring said.
