Peripheral Angioplasty

Peripheral vascular disease, or PVD, affects the arteries of the body, and is caused by a disease called atherosclerosis. Two million Americans have significant PVD.

Atherosclerosis is a gradual process in which fat, cholesterol (a fatty substance), and calcium accumulate inside the artery, similar to the way that rust builds up in a pipe. This accumulation of substances called plaque, roughens, hardens, and narrows the arteries, and impedes blood flow. This narrowing is called stenosis.

Nobody knows exactly why atherosclerosis occurs, but certain risk factors seem to contribute to this process. These include:

• high blood pressure (hypertension)
• diabetes
• smoking
• family history of heart disease or vascular disease
• high fat and cholesterol diet
• overweight
• stress
• aging process, over 45 for males, and over 60 for females

Symptoms of atherosclerosis vary, depending on the artery affected, and the severity and extent of the disease. Blood is pumped out of the heart through the large artery known as the aorta. From there it takes several routes to:

1. the coronary arteries, which supply the heart muscle;
2. the carotid arteries, which supply the head;
3. the subclavian arteries, which supply the arms; and
4. the thoracic and abdominal aorta, which further divides to supply the major abdominal organs, such as the kidneys, and the legs and feet.

This information will focus primarily on circulation in the lower extremities since this area is most commonly affected by PVD.

Blockage in the arteries supplying the legs can result in:

• an ache, pain, cramp, or tightness in the calves, thighs, hips or buttocks when walking, which is relieved with a few moments rest (also known as intermittent claudication)
• in severe cases, pain occurring at night or at rest, which is often relieved only when the leg is hung over the edge of the bed or placed on a foot stool
• skin ulcers (sores) or gangrene (dead tissue)
• on occasion, impotence in men

Blockage that occurs suddenly can result in more severe symptoms in the arm or leg. These include:

• sudden pain
• paleness or whiteness
• no pulse
• numbness or tingling
• coolness in one leg when the other leg is warm
• paralysis (inability to move)

Another form of complication of atherosclerosis that can occur in any artery, but is commonly found in the abdominal aorta, is a bulging or "ballooning" out of the vessel, called an aneurysm.

Aneurysms may be without symptoms, or may include such symptoms as:

• a throbbing mass in the abdomen
• abdominal pain or tenderness
• low back pain
• blood in urine or stool

If left untreated, aneurysms continue to grow and can fill with clots, which can travel to the legs. Eventually, the aneurysms may rupture, causing massive internal bleeding and possibly death.

Treatment
Percutaneous transluminal angioplasty (PTA) is the most common non-surgical treatment of PVD. PTA is a procedure that dilates or "opens up" blocked arteries by threading a thin plastic tube called a balloon catheter to the point of narrowing. The balloon is inflated and presses the plaque against the vessel wall in order to restore proper blood flow. The balloon is then deflated and removed from the artery.

Prior to undergoing any treatment for PVD, you will have had a diagnostic angiogram.

During the PTA procedure, the nurses administer medication through your I.V. to relax you. They will also give you heparin to prevent blood clots from forming during the procedure. The entire procedure can take anywhere from 1 to 3 hours.

After the procedure is completed, there may be a waiting period to allow the blood thinner to wear off prior to removing the catheter from your vessel. This could also take from 1 to 3 hours. You will be returned to your hospital room and be required to lie flat for 4-8 hours after the catheter is removed, depending on what is required by your physician. Finger foods will be ordered and you will be assisted with your meals. This will allow the puncture site to begin healing and decrease the chance of complications.

Many modes of treatment are available to our patients. Some patients may require additional and/or alternative procedures. Not every procedure is best suited to work on a given patient. Your physician will discuss the best treatment for you.

Atherectomy

Nicknamed "roto-rooter", the plaque is shaved from the inside of the artery and removed from the artery through a catheter.

Laser

The plaque causing stenosis is evaporated by a laser light that is directed from the tip of a catheter that is threaded into the artery and placed up against the obstruction.

Stent

A small metal mesh is placed on top of a balloon and threaded through the artery to the narrowed area. The balloon is then inflated and the stent is opened and pressed into place against the artery wall, acting as a vascular support. The balloon is deflated and removed, while the stent remains in place allowing for increased circulation. Sometimes more than one stent is used. These devices are permanent, and can only be removed surgically.

Thrombolytic Therapy

Thrombolytic drugs actually dissolve clots to restore blood flow. These are administered intra-arterially (through an artery) and require close observation in the intensive care unit. Closer observation is necessary due to the increased risk of bleeding complications. This form of treatment may require you to lay flat from several hours to several days. Medication will be administered to you to try to make you as comfortable as possible. Your family may be requested to take your personal belongings home during your stay in the ICU.

Complications
Bleeding at the puncture site remains the most common complication. Bleeding could cause a bruise at the puncture site, but it is usually self limiting and requires no treatment. Other rare complications include infection, contrast reaction, clot formation, and damage to the artery which may require surgical repair. The doctor will discuss with you any additional risks or complications which may pertain to your particular case.

Going Home
Before your discharge, your doctor will examine your puncture site and pulses. You will probably be given prescriptions and a follow-up appointment to see the doctor in his or her office.

For the first 72 hours, you will be asked to take it easy. Avoid all strenuous activity and do no heavy lifting. Your doctor would prefer you not to drive home from the hospital, so please make arrangements for this. Please contact your doctor with any questions you may have.

There are a number of ways you can improve your condition and reduce your risks. Smoking decreases the oxygen-carrying capacity of the blood and is a major cause of blood vessel narrowing. Even one cigarette a day can be dangerous.

Exercise
Regular exercise can benefit you in a number of ways. Exercising burns calories and reduces body weight, cholesterol levels, and stress. Exercise also helps to keep control of high blood pressure. Be sure to ask your physician before implementing any exercise program.

Exercise can also improve circulation by enlarging the smaller blood vessels (collateral circulation) around the obstruction. Swimming, cycling, and walking are all excellent forms of exercise. While strenuous exercise is not for everyone, walking is generally safe for all.

Avoid constrictive clothing such as girdles, garters, belts, and tight or improperly fitting shoes and stockings. Wear stockings or socks at all times to prevent blistering. With arterial disease, prolonged pressure can cause sores which heal very slowly when atherosclerosis is present. Wear clothing suitable to the season, as frostbite occurs more easily when circulation is poor.

Poor foot hygiene can lead to infections that heal slowly with poor circulation. Wash your feet daily with mild soap and warm (not hot) water. Dry well between your toes. Check for dry skin, blisters, cracks, and callouses, which allow bacteria to grow and infection to form. Apply non-perfumed lotion to your feet if no sores are present. Clip toenails with clippers, not scissors, and cut straight across. Never go barefoot, and shake out shoes before wearing them to make sure there is nothing inside that might irritate your feet. Wear clean cotton socks to allow your feet to "breathe" and to prevent sweating.

Protect your legs and feet from injury:

• avoid bumping, cutting, bruising or scratching your legs
• do not go barefoot
• avoid shaving legs with hand razors
• avoid using pillows under the knees (pressure may damage the vessel walls, as well as obstruct blood flow)
• protect your feet from excessive heat or cold
• avoid using heat lamps, hot water bottles, heating pads, cream hair removers, or any harsh chemicals on the legs or feet

Learn how to cope with stress since stress increases blood pressure and puts you at high risk for a heart attack. Seek out information about relaxation techniques and stress control programs in your area.

Since atherosclerosis can be a "silent" disease, have regular periodic examinations. Keep all your scheduled appointments. Have your blood cholesterol and sugar levels checked, and monitor your blood pressure regularly. Reduce your risk factors by eating a healthy diet, cutting down or quitting smoking, keeping your weight at a healthy level, and developing good coping mechanisms to reduce stress. Your active participation in managing your vascular disease is very important in maintaining good health.