Medical Associates Clinic

 Quality Care Close To Home

Central  South  Dakota  Medical News
The Clinical View
by P.E. Hoffsten, M.D.

WHAT IS PERIPHERAL VASCULAR DISEASE?

    A gentleman came to the clinic recently concerned about his legs hurting.  He described a shopping trip with his wife in which he walked from one end of the mall to the other, a distance of about a quarter of a mile.  He stated that he had to stop three times because his legs hurt so bad.  He said he didn’t hurt when he got out of the car to go into the mall but after walking for only a few minutes, his calves began to ache and then cramped.  He slowed down and then stopped altogether sitting on the nearest bench.  With this, the aching in his calves improved in a few minutes and he was able to walk further but there was recurrence of the pain again making him stop and rest.  Granting that this was more walking than he usually did, he still felt it was unusual for him.  There was no difficulty breathing and he didn’t develop chest pain and there was no pain in his back or his arms.

       After the usual joke that his wife made about not wanting to go shopping with her, it appeared that this was a new symptom for this gentleman.  After he had been to the mall that time, he went out and tried to walk around his farm.  He hadn’t done that much this winter and found that the trip out to the barn recreated the pain in his calves.

       He acknowledged that at 68 years of age, he was “getting older” and maybe this was just a fact of aging,  He took no medications, not even an aspirin a day.  He had smoked cigarettes for many years but had turned to a pipe in recent times.  He didn’t know his cholesterol and he didn’t know what his blood pressure was.  He hadn’t seen a doctor in years.

       His story makes a perfect example of a condition called claudication caused by peripheral vascular disease.  This is a condition in which plaque and scarring slowly build up in the arteries that supply the legs with blood.  Like many conditions that happen slowly and are found suddenly, he tried to attribute the problem to sleeping wrong, a recent struggle he had had with fixing a leaky pipe in the basement, and finally just being out of condition over the winter.

     The truth is that the arteries of the legs become stopped up due to the same things that seem to cause blockage in the arteries to the heart causing heart attacks or blockage to the brain causing strokes.  The risk factors of high blood pressure, high cholesterol, diabetes and smoking cigarettes, don’t just effect the heart or the brain but they also affect the arteries that supply the legs.  Rarely, the arms are also involved but this is relatively unusual.  Why some people have their hearts or their brains affected with relative sparing of the arteries to the legs is not clear. Cigarette smoking seems to make the leg problem more frequent and severe.

       To diagnose the problem specifically, review of the person’s history and symptoms is the first step.  Often examination of the person’s feet will show that the pulse on the top of the foot is not present.  The next step is the use of something called doppler studies in which the blood supply to the legs can be measured using sound waves to trace the leg circulation.  This is a painless test taking about an hour.

       Once the diagnosis is made, the question of how to treat the problem can be addressed.  As with all healthcare problems, treatment can be divided down.  The first choice that some people make is to do nothing.  I once had an elderly gentleman say that as long it was not cancer of his leg, he didn’t need anything else.  He just wouldn’t walk so much sofast and he didn’t want anything else done.

       A second choice would be perhaps the most difficult and that is lifestyle modification. The condition will get better if the person discontinues the cigarette habit, gets his blood pressure controlled, brings the cholesterol into the normal range and then begins to progressively walk a little bit more each day on purpose to increase his conditioning and exercise capability.  That is asking a lot for an elderly individual who hasn’t thought about those things much less done them for 70 years.  The advantage of lifestyle modification is that it is cheap, there are no side effects, and in milder cases, it will be enough to stop the problem.  Addition of an aspirin per day, would also be recommended.

       The third choice that might be made is to use medications to the change the disease process or the symptoms.  There are medications that will relax the arteries to the legs and allow better blood flow.  Some of the newer medications are predictably expensive although the side effect profile is relatively minor.  In more moderate cases of peripheral vascular disease, medications can help 7 out of 10 individuals with leg pain that occurs while walking.

       The fourth possibility to treat severe cases is to do surgery to re-establish the blood flow to the legs.  The surgery can be quite drastic such as correcting an aneurysm in the abdomen or quite simple such as using a balloon to stretch a blocked portion of an artery open again. Sometimes, a bypass graft using a cloth material is necessary and sometimes simply stripping the plaque material out of the artery can be effective.

       Surgery is usually reserved for those people who can not be treated through other means or those who have “limb threatening disease”.  Peripheral vascular disease is the second leading cause of amputation of a foot or a leg.  The leading cause is diabetes.  Amputation, taking off a person’s toe or their foot or even up to the knee, is sometimes necessary when the blood supply to the foot has been so badly compromised that it can no longer stay alive.  These are very tragic situations especially considering that for most people peripheral vascular disease is a preventable problem and if detected early, limb saving procedures can be done.  The healthcare professionals at your local clinics are well aware of how serious this problem is and how to deal with it.