|
| PERIPHERAL ARTERIAL DISEASE PROGRAM
| Program Director |
Thomas Biggs, MD |
| Program Coordinators: |
Julie Mortaloni, RN, Nurse Clinician |
| Phone: |
(651) 726-2701 |
The Peripheral Arterial Disease Program at SPHC was established to care
for persons with blockage in arteries away from the heart, especially
the lower extremities and kidneys.. Peripheral arterial disease, PAD,
is a common problem and a strong predictor for heart disease and
stroke. Symptoms of peripheral arterial disease may range from subtle
to severe. In the past, surgery was considered the only option for
relief of symptoms. Now, however, there are additional treatments
available that make relief of symptoms and management of risk factors
more successful. Surgery is no longer the only choice. In addition,
early detection and aggressive treatment of PAD can reduce or prevent
heart attack, stroke and complications from further arterial blockage.
Program staff includes an interventional cardiologist, nurse
practitioner and nurse clinician. Patients are seen initially by both
the cardiologist and nurse practitioner who do a medical history,
perform a physical exam and develop an individualized plan of care.
Nearly one half of patients seen respond well to medical management
alone. In some cases treatment with angioplasty or surgery may be
recommended. Program staff work closely with a group of vascular
surgeons if surgical intervention is indicated. Referral to a
structured exercise program can also be coordinated as part of the
treatment plan.
What is PAD?
Peripheral arterial disease, or PAD, is a condition in which the
arteries of the legs and less commonly the arms, kidneys, neck and
internal organs become blocked from plaque build up. PAD is the result
of atherosclerosis or plaque build up throughout the body including the
heart and brain. People with PAD are therefore at increased risk for
heart attacks and stroke.
How do I know if I have PAD?
Intermittent
claudication, a symptom of PAD, occurs when there is narrowing of the
leg arteries. Early symptoms of claudication may include pain, cramps
or a tired feeling in the legs that occurs with activity such as
walking or climbing stairs, and is relieved by rest. The pain often
occurs in the calf but can also be felt in the foot, thigh, hip or
buttocks. When PAD is advanced, there may be pain in the legs or feet
even at rest. The ABI compares blood pressure in the arms to blood
pressure in the legs and can be done during a routine office visit.
What causes PAD?
PAD is caused by atherosclerosis,
a common disease that affects the arteries throughout the body. Excess
fat and cholesterol in the bloodstream cause a gradual formation of
plaque inside artery walls, making them hard and less flexible. Over
time, the buildup of plaque gradually reduces the flow of oxygen rich
blood to muscles.
Plaque buildup can also cause small cells or platelets in the
bloodstream to clump on or near the plaque and form blood clots. Blood
clots block the flow of blood and can lead to heart attacks, strokes
and gangrene.
What are the risk factors for PAD?
The following factors can increase the risk for atherosclerosis and PAD:
- Smoking
- High cholesterol levels
- High blood pressure
- Diabetes
- Advancing age
- A diet high in saturated fat
What are the consequences of PAD?
- People with PAD, whether they have symptoms or not, experience
a much higher rate of heart attack and stroke than persons without the
disease.
- Leg pain and fatigue caused by PAD often lead people to reduce their level of activity and decrease the quality of their lives.
- Complications of advanced PAD include skin ulcers, infections, gangrene and occasionally amputation.
How is PAD diagnosed?
Diagnosis begins with an
office visit during which a complete medical history is obtained,
symptoms are reviewed in detail and a physical examination looking for
evidence of arterial blockage is performed.
What tests are used to diagnose PAD?
- An ankle-brachial index may be completed as part of the initial
visit. This is an inexpensive, noninvasive screening procedure that can
accurately identify patients with PAD. With the person resting flat,
blood pressure is measured in both arms and each leg. Blood pressure
results from the legs are divided by blood pressure measurement in the
arm to obtain a value which indicates the degree of blockage in blood
flow to the legs.
- Segmental doppler measurements are blood pressure readings
obtained at various levels in the thigh and lower leg. These
measurements may locate areas where blockage is severe.
- Ultrasound is used to visualize areas of blocked or narrowed
blood flow in the abdomen, hips and legs and is often combined with
pressure measurements.
- Arteriography is a procedure during which a long, thin,
flexible wire, called a catheter, is inserted into an artery and
directed to the aorta just above the level of the kidneys. Dye is then
injected and allowed to flow down the aorta and legs to the feet and
toes. Pictures are taken as the dye moves through the legs and can be
used to identify the location and severity of blockages to blood flow
in the abdomen, hips, thighs, legs and feet. This test involves a
puncture usually in the groin and does carry a low risk of
complications.
What can be done?
Three different treatments are available for patients with PAD:
- Medical therapy
- Angioplasty and stenting
- Surgery
The goal of medical therapy is to relieve symptoms and slow the
progression of disease. A combination of medical intervention and
rehabilitation serves as the focus of therapy for most people with
intermittent claudication. Exercise, especially walking, will play an
important part in treatment.
How does exercise work?
The best exercise program for someone with claudication is one that is
supervised and structured to slowly increase the amount of walking to a
goal of about 60 minutes, three times a week. Walking begins slowly for
3-5 minutes until the legs hurt. The person is instructed to stop and
rest until the discomfort resolves. Walking is resumed for another 3-5
minutes followed by another rest period. Walking and rest periods are
gradually increased to 30-60 minutes per session. After a week or two
the exercise becomes more tolerable. By 3 months of therapy, most
people can walk up to 4 times farther then they did before the program.
In some cases medication may be added to further improve circulation
and decrease discomfort. The supervised program should continue for at
least 3 to 6 months. Walking must continue indefinitely, however, for
symptoms to improve.
Why reduce risk factors?
Reducing risk factors for PAD is of equal importance.
- Stop smoking. Smoking causes PAD to progress much more rapidly
and is the most important risk factor that can be changed. Often
symptoms of claudication will improve once smoking stops.
- Lower cholesterol levels. It is recommended that persons with
PAD have total cholesterol levels below 200 mg/dl and especially LDL
levels below 100 mg/dl. A diet low in saturated fat and high in fiber
can help to reduce cholesterol levels. Medications may also be needed
to achieve the recommended cholesterol levels.
- Lower blood pressure. High blood pressure doubles the risk for
symptomatic PAD by causing the artery walls to lose elasticity and
increasing plaque formation. A healthy meal plan that is low in salt
and occasionally the addition of medication may be needed to lower
blood pressure to less than 140/90 mm Hg.
- Control blood sugar. Persons with diabetes are at greater risk
for developing PAD and atherosclerosis. Self monitoring of blood
sugars, a healthy meal plan, regular exercise, weight management and
the appropriate use of diabetes medication are important steps to
keeping blood sugars in a normal range.
- Choose to lose weight. Persons who are overweight can benefit
from even a small weight loss of 5 to 10 pounds. Weight loss will help
to improve blood pressure, lower cholesterol and blood sugar levels,
make it easier to exercise and improve the sense of well being.
- Protect your legs and feet. Taking good care of skin and feet can prevent additional injury.
- Wash feet daily with mild soap and water
- Apply lotion daily to keep skin moist
- Wear shoes and socks at all times, even at home
- Avoid hitting or bumping the legs and feet
- Treat any injury to feet or legs immediately
What is peripheral angioplasty and stenting?
Peripheral angioplasty is a procedure that helps to open blockages in
arteries to the lower body and legs. As in arteriography, a catheter is
inserted through an artery to the area of blockage in the lower body or
legs. A tiny balloon is pushed through the catheter to the blockage and
inflated to compress the plaque against the artery wall. A stent is a
small mesh or metal tube that is often placed at the site of the
blockage to help keep the artery open. This procedure can often be done
during arteriography and may require an overnight stay in the hospital.
Angioplasty and stenting often works better in the larger vessels of
the upper thigh, hips and abdomen.
When is surgery needed?
Surgery is reserved for
more severe blockages or when there is evidence that interruption of
blood flow to the leg or foot may result in gangrene or limb loss. In
such cases consultation with a vascular surgeon is needed.
Arteriography will be performed first to more clearly identify the
location and degree of blockage.
Renal Artery Disease
What is Renal Artery disease?
Renal artery disease may be defined as a narrowing of the blood supply
to the kidneys. When kidneys have a normal blood supply, they filter
toxins from the blood and help to keep blood pressure in the normal
range. Some patients with renal artery disease have no symptoms or mild
symptoms, while in others it leads to severe high blood pressure
(hypertension), poor kidney function or even kidney failure and
dialysis. Other terms for renal artery disease are:
- Renovascular disease
- Renovascular hypertension
- Ischemic nephropathy
- Renal artery stenosis
What causes renal artery disease?
Atherosclerosis
(hardening of the arteries) is the most common cause of renal artery
disease. It is caused by a combination of factors including cigarette
smoking, elevated cholesterol, high blood pressure and diabetes.
Atherosclerosis may also cause heart attacks and strokes. The second
leading cause of renal artery disease is fibromuscular dysplasia, a
disease of the artery wall. The cause of fibromuscular dysplasia is
unknown. There are also other unusual causes of renal artery disease.
When is renal artery disease suspected?
Only 3% of
the sixty to seventy million people with hypertension have renal artery
disease. However, because high blood pressure may be improved after
treatment of renal artery disease, it is important to consider this
diagnosis. Some indications of renal artery disease are:
- High blood pressure that requires three or more drugs to control
- "Uncontrolled" high blood pressure despite treatment with medication
- High blood pressure which causes a stroke or fluid buildup in the lungs
- High blood pressure developing in someone less than 20 years old or more than 55 years old
- Worsening kidney function in a person with other signs of
atherosclerosis or after taking certain types of high blood pressure
medication
- Abnormal sounds (bruit) heard when listening to the abdomen with a stethoscope
What tests are used to diagnose renal artery stenosis?
A
dye study (also called angiogram, arteriogram or aortogram) is the best
test to diagnose renal artery disease. During this test a cardiologist
injects dye into the arteries of the abdomen to search for narrowing of
the kidney arteries. The dye study requires a needle stick in the
artery (usually the groin) and may require an overnight stay in the
hospital.
There are several screening tests available for renal artery disease. A
kidney ultrasound (renal duplex sonography) uses an ultrasound probe
placed over the skin to get images of the renal arteries. The test
usually takes an hour to complete and is considered risk free.
Ultrasound of the kidney provides a useful indication of renal artery
stenosis if the test is positive. If the test is negative, however,
stenosis cannot be ruled out.
Magnetic resonance angiography is becoming the test of choice
for diagnosing renal artery stenosis. Magnetic dye is injected into a
peripheral vein, and then the MRI (magnetic resonance imaging) takes a
picture of the renal arteries. The dye is not toxic to the kidneys
Treatment
Three different treatments are available for patients with renal artery disease:
- Medical therapy
- Angioplasty and stenting
- Surgery
Medical therapy for renal artery disease
includes medication to control high blood pressure and regular physical
examinations including blood pressure measurement and blood tests for
kidney function. Generally, patients with renal artery disease require
a procedure when they have severe high blood pressure or kidney
failure.
Two procedures are available to treat renal artery disease.
Angioplasty for renal artery disease is similar to angioplasty for PAD.
A catheter with a balloon is threaded into the renal artery and the
plaque is compressed against the artery wall. A stent is often placed
at the site to keep the blockage open. Results from angioplasty are
generally good, but renal artery disease may recur.
Surgery requires an incision to open the abdomen and a
hospital stay of several days. Usually surgical procedures result in
permanent correction. |
