Lakeview Hospital - Peripheral Vascular Disease

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.