Vascular Disease Foundation - Fighting Vascular Disease... Improving Vascular Health.

Interactive Learning : Ask the Doctor

 

Ask the Doctor Live Chat Transcript - Wednesday, April 16

 

Dr. John F. Angle

University of Virginia Health System

Vascular Disease Foundation Board of Directors

 

 

Moderator- VDF: Thank you for joining us today!  I would like to introduce Dr. Angle, he is now ready to take your questions about PAD.


Susan: How common is it for a stent to close up? If it starts to close up, can it be cleaned out or do they have to put in another stent?  How do they get rid of the old one?         

Speaker- Dr. Angle: Susan that is an excellent question. Stents are commonly used for treating PAD. They are great for getting vessels open but don't last forever. In short, stents in the larger vessels tend to last a very long time while stents in smaller vessels tend not to last so long. If your stent is in your pelvis in the iliac artery it is very likely to stay open for many years. If it is in the thigh in the femoral artery, then about 80% are open at a one year. When they do start to close down, we have lots of tools to get them open again.          

If someone has a stent that becomes severely narrowed, we usually start with balloon angioplasty. If that doesn't work or if we don't think that is going to work we have sometimes tried laser therapy, a device that scraps the lining of a vessel called atherctomy" and sometimes place another stent. It just depends on what your doctor sees on your arterial studies. Sometimes the best solution to a narrowed stent is a bypass operation."     


Moderator- VDF: This next question was e-mailed to us ahead of time: How do you live with untreatable PAD? At this time the pain is severe and my foot is blue and swollen. But have been told it can't be treated do the severity of my disease. Please help!         

Speaker- Dr. Angle: When further interventions for PAD are not an option, some people just have to live with the pain. I know it can be quite miserable. Pain medications are, on rare occasions, the only treatment option.


Abby: What causes PAD? I've read that smoking and high blood pressure cause it. Is that true? I'm 63 and in OK shape (don't exercise much) and am worried about this pain I have in my legs. What should I do?

Speaker- Dr. Angle: Abby, your question is an excellent one. Atherosclerosis is the underlying disease. Atherosclerosis is multifactorial: It’s partly due to diet and other risk factors (like smoking) but also is partly a normal part of aging and tends to run in families. In short, the important thing to know is keep track of the risk factors for PAD--they are the things you can do something about!! Control your risk factors and you will minimize your risk of atherosclerosis and PAD.

You should also get screening for PAD. Your doctor can do a simple test called an ABI.  It is measure of the blood pressure in your legs. If the blood pressure in the legs is too low, it is a sign that blockages are developing and further testing is indicated.


June: I have had PAD for over ten years, and have had multiple stents. I have followed the rules re: walking; quit smoking in 1964; I am almost 84 years old and trying to avoid an offered surgery--namely bi-aorta-femoral surgery. I really hope to avoid this perilous surgery at my age. I walk with a walker (for comfort purposes); do you think that delaying this surgery can do damage--I am really afraid and can still do most things that I want to do. It is painful after a very short distance of walking?

Speaker- Dr. Angle: Dear June: Treatment for PAD is very individual. Every procedure has risk and how much PAD affects a person's quality of life varies from one person to the next. Your treatment options are (1) medical management (controlling risk factors for developing worse PAD and some drugs to help keep clots from forming, (2) angioplasty for some types of blockages, and (3) for some severe blockages. If you are someone with severe blockages and a lot of symptoms, then surgery may be your best option. However, putting off surgery is not necessarily wrong and does not necessarily put you at increased risk. Get second opinions if you like, but the most important person to ask, other than yourself, is your family doctor who should know you best.     

Speaker- Dr. Angle: June, Plavix is probably a good idea if you can tolerate it. It won't help your legs get better, but may help slow down things getting worse. In addition, in combination with aspirin, it seems to help reduce the risk of events due to atherosclerosis such as heart attack and stroke. I understand your concerns about surgery. I do need to clarify that waiting on surgery isn't an immediate risk to your heath, but waiting can make surgery more difficult or even impossible later on. Sorry I can't be more help on that one--you and your doctor will have to chat about what's best for you.    

Pain with walking is common with PAD, as you know. Pain in your legs may also be made worse by arthritis and other problems. What we do know is that claudication often improves if you keep walking, so, after careful consultation with your family doctor you may want to try gradually increasing your walks, despite some pain, to increase your exercise tolerance. Pain medications are sometimes a necessary part of treatment for PAD but only with careful consideration of the risks and benefits with your family doctor.


Kevin: I am a former smoker with a history of hypertension in my family. I have read that smoking causes PAD. Is this true and do I need to be concerned? I have low-blood pressure, am active and 44 years old.

Speaker- Dr. Angle: Kevin, It sounds like you are doing all the right things. The risk factors for PAD are the same ones as for heart attack: smoking, blood pressure, cholesterol, in-activity, poor diet, family history, male (sorry you can't do anything about that one!) and age (another inescapable one). Its sounds like you are doing fine as long as your weight is in the zone and you have your cholesterol checked regularly. As always, consult with your family doctor.


Linda: Are there any drugs available to dissolve blockages?

Speaker- Dr. Angle: There is not a drug for specifically dissolving blockages. If someone gets a blood clot in there leg vessels it can cause sudden pain. For that we have drugs to dissolve the blockage. Atherosclerosis causes fibrous-fatty plaques that grow over months to years. These block arteries too but are tough to manage. We do know that correcting high cholesterol will slow down the growth of these atherosclerotic plaques and in rare cases can even lead to some shrinkage over time. However for the time being we generally use stents or bypass to manage arterial blockages.


Gary: Hi Doctor, Where in St. Paul, MN can I go to get treatment for my PAD? I have a dry sore on the back of my heel and it is so very painful. I’ve been taking oxcydne for this, I have had one stent in my left leg in 2005, no pain is back. Can I have another stent put in? I’m Type 2 Diabetes since 1989, thank you, Gary.

Speaker- Dr. Angle: Gary, It sounds like you are already getting excellent care for a complex issue. If you have leg pain, a history of diabetes and known stents, you definitely need to get re-evaluated. In many cases stents narrow down or block and can be re-opened. Your disease may have progressed and you may benefit from additional therapy. VDF's Web site does have a Find a vascular specialist" link that you can find here: www.vdf.org/resources/findspecialist.php that may be of some help in finding a doctor in your area.


Amelia: I have pain in my legs when I rest. Usually when I stop to watch TV for the evening.  Is this PAD?  Should I get tested? I'm fairly active but I did smoke for 20 years.

Speaker- Dr. Angle: Amelia, leg pain can be caused by many things. PAD is one cause of leg pain. Usually PAD causes pain with activity, but in severe cases can cause pain at rest. Problems with veins can also cause leg pain, so a visit to your family doctor is warranted. They can do simple screening tests, which we talked about a little earlier to figure out if you have PAD.


Maria: Is stenting the same as the "silverhawk" procedure that's been in the news lately? 

Speaker- Dr. Angle: Maria, we use several devices to open vessels. You hear most commonly about stents being used to push a blocked vessel open. Sometime we will attempt to remove some atherosclerosis from a vessel using a device called an atherectomy device (e.g. Silverhawk). We also can use lasers and other devices. There is no clear evidence on which devices are best for which applications. Most of the literature is with stents and head to head comparisons of many of these devices are lacking.   


Moderator- VDF: Thanks to everyone for joining us today! That's all the time we have for your questions. Thanks to Dr. Angle for his time and we wish you a healthy day!

Disclaimer

The material provided on VDF's Web site and Live Ask the Doctor chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.