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Peripheral artery disease and intermittent claudication

Description

An in-depth report on the causes, diagnosis, and treatment of peripheral artery disease.

Alternative Names

Peripheral arterial disease; PAD; Peripheral vascular disease;

Surgery

In severe cases, surgery may be needed to open blocked blood vessels. Many surgical procedures can be accomplished with minimally invasive endovascular techniques, such as angioplasty and stenting, which can help open small blocked arteries below the knee and prevent amputation. If there is extreme blockage in the leg artery, bypass surgery and vein grafting may be required.

Leg Bypass Surgery

For many years, leg bypass surgery was the main type of surgery used for extensive PAD. This procedure involves the creation of a tube (graft) that acts as a new blood vessel. Grafts can be made from synthetic material (artificial vein) or from a vein taken from a different location in the patient's leg (natural vein). The graft reroutes blood flow in the leg, around the blocked artery. In one study, the natural vein remained open after 4 years in nearly half of the patients, while the synthetic vein (made from polytetrafluoroethylene [PTFE]) had closed in all but 12% of patients.

Artificial veins tend to pose a much a higher risk for blood clots and the consequences of re-blockage are must more severe than when the natural vein recloses. To keep the artificial vein open, oral anti-clotting drugs such as aspirin or warfarin, may be used. (Such drugs do not work at all with natural vein bypass.)

In general, less invasive surgical procedures such as balloon angioplasty and stenting are now more frequently performed.

Percutaneous Transluminal Angioplasty

Percutaneous transluminal angioplasty (PTA) is an approach that has several variations. The object of the procedure is to open the blocked blood vessels that are causing intermittent claudication. Angioplasty is being increasingly used, especially in patients who have other medical conditions. Some experts believe that it is less expensive and more effective than leg bypass surgery.

The PTA procedure requires only a local anesthetic. Patients can return to normal activity in 24 - 48 hours. Complication rates are low. The effects are not permanent, but it the procedure can be repeated without any greater risk than with the original one.

Anticoagulants such as warfarin or heparin and antiplatelets such as aspirin may used to prevent blood clots occurring during surgery. All of these drugs increase the risk for bleeding. Thrombolytic drugs may be used before, during, or after angioplasty if a blood clot is present.

Reclosure of the blood vessels from blood clotting, even long after surgery, is an important complication. Repeat surgery may be needed. Major complications following surgery include pneumonia, stroke, kidney failure and heart attack.

Balloon Angioplasty. The standard procedure is balloon angioplasty. A thin tube is inserted through an artery in the groin and passed through the blocked artery. A wire is threaded through the tube. A deflated balloon is passed over the wire to the blockage. When inflated, it opens the artery.

Because of the risk for reclosure from blood clots after balloon angioplasty, various other procedures are used or are being investigated.

Stenting . More recent angioplasty techniques use an expandable metal mesh tube (stent). A self-expanding stent called the SMART stent was approved in late 2003. The SMART stent is used specifically for patients whose PAD is caused by a blockage in the iliac artery, which runs through the pelvic area. Stents can be effective in opening arteries, but 20 - 30% of patients have new blockages within a year of surgery. In 2005, researchers began testing a drug-eluting stent coated with paclitaxel. They hope that the drug may prevent blockages from recurring in the leg arteries. A paclitaxel-eluting stent is already approved in the U.S. for treating coronary artery disease.

Drug-Coated Balloon . A new technique uses a drug-coated balloon instead of a stent. The balloon is sprayed with paclitaxel. When the balloon is inflated inside the leg artery, the drug is transferred to the plaque that is causing the blockage. Doctors think that this type of minimally invasive angioplasty surgery might provide an important alternative to stents. Although stents have been very useful in heart surgery, they can sometimes cause later complications in PAD.

Brachytherapy . Another approach uses radioactive implants (brachytherapy) in combination with PTA, which help prevent the arteries from closing after angioplasty. In a major 2002 analysis, this approach produced greater benefits compared to PTA alone, at least in the short term.

Laser Treatment . Laser light pulses are being investigated as a way to vaporize cholesterol plaque and blood clots from the blood vessels. A 2004 report suggested that laser therapy may be particularly useful in patients with PAD who are not good candidates for bypass surgery.

PolarCath . A new type of angioplasty treatment called PolarCath opens blocked arteries by cooling and dilating them with a nitrous oxide-filled balloon. A 2004 study showed that this procedure, also called CryoPlasty therapy, has a 9-month failure rate of less than 20%, which is significantly lower the 40 - 50% failure rate reported after angioplasty or stenting procedures.

Intermittent Pneumatic Compression

Intermittent pneumatic compression (Arterial Flow, VenaFlow) is a mechanical technique normally used to treat leg ulcers or swelling from fluid build-up. The device is an inflatable fabric device that goes around the lower leg. The inflated device puts pressure on the limb. Some devices apply pressure in a wave-like motion that simulates the natural increase in blood flow during walking. A 2002 analysis of 26 studies suggested that this treatment may be beneficial for patients with PAD who cannot undergo surgery. It may even prove to be a viable alternative to medical treatments in some cases.

• Review Date: 3/29/2007
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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