Peripheral Arterial Disease
Peripheral arterial disease (PAD) is a condition in which arteries in the legs, and less often elsewhere is blocked by plaque. Due to a blockage in major arteries the circulation is impaired and leads to a variety of symptoms. Most, however, remain symptom free. When symptoms do occur, they include cramping pain or discomfort in the calf, thigh or buttocks when walking. Symptoms often cease very quickly when the patient stops walking. If the blockage affects several main stream arteries or multiple levels of the arterial tree then patient’s feet and/or toes hurt continuously and the pain gets worse when the patient is lying down. Also, gangrene or non-healing ulcers occur in cases of advanced arterial disease.
Why is PAD treated and who is affected most often?
Due to the lack of blood supply and therefore lack of oxygen the tissue below the blockage is threatened. In case the foot or leg is affected, the patient might loose his/her limb if the blockage is not repaired adequately or in time. Diabetes is associated with PAD most often and also diabetes is the most common cause of lower limb amputation. Patients most likely to suffer from PAD are diabetics and cigarettes smokers.
How can PAD be diagnosed?
Every patient will be thoroughly assessed by a consultant and most of the time further laboratory test will be required. A blood test, blood pressure measurement on upper and lower limbs will be taken and either an ultrasound scan and/or CT scan will be performed. In case where an intervention is planned an angiogram (dye test) will be performed by vascular surgeon (Fig. 4). All necessary information about the results of above mentioned test will be thoroughly discussed with patient. The patient’s family doctor will be also informed with a letter about treatment options.
What treatment options do we have?
Every patients is unique and therefore a very individual approach will be taken to satisfy everyone’s needs. Not every arterial blockage needs to be treated surgically but those threatening limb viability or causing severe life-limiting limping should be treated by a vascular surgeon.
Open revascularisation or bypass. This classical surgical treatment is performed in situations where a blockage is not suitable for a mini invasive procedure (balloon angioplasty) or under other specific circumstances. Bypass is usually performed under a general anesthetic or spinal anesthesia, and the patient’s native leg/thigh vein is used to a bypass a long arterial blockage. A synthetic material also might be used (Fig. 5). A long incision is needed most of the time to harvest suitable vein graft and therefore recovery time in the hospital is about a week. Subsequent follow up scans are necessary during the first several years to make sure the bypass is working well.
Endovascular treatment. Is preferred treatment option for a short blockage or narrowing. It is a mini invasive option (keyhole surgery) with a short hospital stay. Every patient will be assessed thoroughly with an angiogram and a balloon angioplasty will be offered to every patient as a first treatment option if his/her arterial narrowing is found suitable for this treatment modality. Balloon angioplasty is a minimally invasive procedure in which the surgeon threads a balloon-tipped tube through the arteries until it reaches the one that is blocked. The surgeon inflates the balloon, which compresses the plaque in the artery and widens the vessel. Stenting is also minimally invasive and may be done at the same time as angioplasty. A stent is a small metal-mesh tube that a surgeon inserts to keep the artery open (Fig. 6).