Published in Panorama
When the leg arteries harden
Peripheral Vascular Disease (PVD) is a disease that affects different arteries in the body. Cholesterol, calcium and other materials build up on the inside of these arteries. Over time, if this build up continues, it causes the inside diameter of the artery to become progressively narrower, and at times to shut off completely. This disease is called Atherosclerosis or hardening of the arteries. It usually affects certain arteries in the body more than others, the most commonly affected ones being those of the heart, neck and legs.
PVD, particularly atherosclerosis is the disease of this era and according to research the disease process starts early in life, says Dr.Bassel Safi, Specialist Vascular Surgeon, Welcare Hospital, Dubai. Interestingly, the disease affects the Indo-Pak ethnic group at a very young age, as early as in their 20s and 30s unlike the Western population who are affected by the disease in later life. The disease is also in the rise in the Middle East, reveals Dr.Safi. “It is the severity of the disease and the length of time it goes untreated that can make a difference. Although the symptoms and signs of PVD are more common in people in their 60s and 70s, we are seeing much younger patients nowadays with Atherosclerosis. Perhaps the stress and the life style have a role here.”
Males are more affected than females, though after menopause, both men and women are equally at risk of developing the disease, explains Dr. Safi. Also, women smokers are at risk since they lose some of their hormonal protection.
Actually there is no one single cause for Atherosclerosis. There are, however, multiple risk factors. Some of them, extremely relevant to the incidence and the severity of the disease include smoking, Diabetes, high cholesterol in the blood, high blood pressure and family history. Recently, elevated homocystien in the blood has been cited as an independent risk factor for Atherosclerosis, explains Dr.Safi.
What are the earliest manifestations when the legs are affected on account of PVD? Dr.Safi explains, “When the legs arteries are moderately narrowed, the muscles in the legs and the calves in particular are affected, only after the person walks for a certain distance. The cramping-like pain starts gradually and then it becomes severe enough to make the person stop for a few minutes to get relief. The pain is intermittent, associated with every few stretches of walking. That is the early manifestations of PVD in the legs”.
On the progression of the disease, Dr.Safi reveals, “When the Atherosclerosis disease progresses and affects more than one segment of the leg arteries, like when it involves both the pelvic and the thigh arteries or the thigh and the artery behind (or below) the knee, then the amount of blood to the leg is severely reduced, causing the pain to come on, not only after walking, but is rather continuous, more so on the feet and especially at night and when the person is flat. This is called “rest pain”. In some patients an injury to the toes causes necrosis and gangrene (dead tissue) to set in. In other patients, minor wounds and ulcer would not heal.”
At this stage when there is already rest pain and/ or necrosis, the limb is in danger if the situation is not investigated and treated properly. Complications from untreated PVD include necrosis, bad infection and gangrene to set in which would involve surgical intervention including leg amputation in cases of undue delay in treatment. The whole purpose of the surgery on the legs for PVD is to keep a leg for the patient to walk on. These Patients often lose a toe or more, or sometimes the front part of the foot. We, however, try to keep the leg and a portion of the foot for the patient to be able to walk, adds Dr.Safi.
Numbness and tingling on the feet, cold feet, brittle toe nails, hair loss on the legs are some other symptoms and signs of PVD affecting the legs.
Can PVD take an acute form? Dr.Safi explains, “Yes, it can. All what we have been talking about so far is about the chronic disease which progresses over a long period of time. The acute problem is a totally different story. That is when the blood suddenly stops from flowing in the artery causing very severe and excruciating pain in the foot. The leg gets pale, cold and numb. This is an emergency situation. If it is not treated within a few hours gangrene sets in and the leg becomes dead and needs amputation.”
How is PVD diagnosed? Since not too many other conditions cause pain in the legs after walking, history-taking followed by physical examination usually confirm diagnosis of PVD. Absent pulses in the areas where pulses are easily felt (on top of the foot, behind the ankle, behind the knee and in the groin) confirms the clinical diagnosis. In fact, any discoloration on the toes, a wound or an ulcer that takes a long time to heal, should alert patients themselves to the possibility of PVD being the cause, especially if they are diabetics. Having said this, it is very important to note Diabetes alone may not be the sole cause for the delayed healing. These patients must be investigated to rule out PVD as a cause along with the Diabetes.
Ultrasound scan helps to evaluate the severity and the extent of the disease involvement. Angiogram may be advised to have a clear picture of the arteries. This is usually done just before any surgical intervention on the leg is advised.
How is PVD treated? Dr.Safi explains that the treatment for PVD varies according to the severity of the disease. For the mild and moderate involvement where the symptoms are only pain after walking the treatment usually is not surgical. The patient is instructed to control his / her risk factors. There are some medications we can prescribe to the patient with the intermittent claudication to help them walk a bit longer with less pain , but there is no curative medication for it. In certain cases where the intermittent claudication is so severe, where the leg pain is interfering with the patient’s daily activities, an Angiogram is done following which surgical intervention might be advisable.”
Dr.Safi continues, “On the other hand, when patients complain of “rest pain” especially at night or they have a bad infection on their toes or feet, these patient are in danger of leg amputation. They need to be evaluated by a vascular specialist. Often, they need to undergo Angiogram and treated accordingly, either by a bypass or by balloon dilatation to improve the circulation to the legs. The bypass operation involves taking a “spare” vein from the same leg or using a small artificial tube to re-route the blood around the blocked artery. Sometimes balloon dilatation to open the blocked artery is enough to reestablish the blood flow to the leg. And on occasions the combination of both bypass and ballooning are done.
What is the prognosis following the treatment?
It has been proven through numerous scientific studies that the surgical procedures on the leg for PVD has saved so many legs and had improved the quality of life for these patients. That even applies to the elderly patients in their 70s and 80s.
As for the risks of the surgery, of course, most of the patients with PVD are older and have associated (and often significant) other medical illnesses that add to the risk of the operation, reveals Dr.Safi. “We always try to get our patients in the best medical shape before we go ahead with our surgery. With the new advances in the medical field these days, particularly in the Anesthesia and the intensive care units, the risk of all major surgical procedures is much reduced compared to 10 or 20 years ago. Very rarely, patient is denied a leg-saving surgery because of these risks.”
What are the chances of recurrence? Dr.Safi emphasizes, “PVD actually does not recur. In certain patients who already had a bypass or balloon dilatation, the disease continues to progress to involve more arteries. That might cause the bypass or the dilated artery to close down a few years down the road. It is not a must, however, to redo the surgery again in every case. That is the reason we always follow our patients very closely, and for a long time.
Can PVD be prevented? It is more important, however, to prevent the complications of the disease. But to prevent the disease itself is to address the risk factors: stop smoking, controlling hypertension and Diabetes by regular medication, lowering the elevated blood cholesterol, reducing weight, and exercising regularly. These are some of the proven effective measures to reduce the problems associated with atherosclerotic disease, says Dr.Safi.
Patients with PVD should always be aware that it is a progressive disease that might have some detrimental effects on them, especially if they are diabetic. They should be very careful not to get any injury on their feet. Once individuals, particularly diabetics, start having any symptoms that is suggestive of PVD, they should see a vascular specialist immediately. Time is of essence here. Any unnecessary delay might change the outcome of the treatment drastically, emphasizes Dr.Safi.