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OPTIONS FOR UNBLOCKING ARTERIES

DEAR MAYO CLINIC: What are the treatment options for peripheral vascular disease?

ANSWER: Peripheral vascular disease refers to disorders of the blood vessels outside the heart and brain. For example, atherosclerosis (“hardening” caused by fatty buildup) in arteries supplying the legs is referred to as lower-extremity peripheral arterial disease (PAD). The Centers for Disease Control and Prevention recently reported that nearly one-fifth of the U.S. population aged 40 or older has lower-extremity PAD, characterized by arterial narrowing or blockage. Patients with PAD typically report problems with exercise-induced muscular pain, cramping, or weakness of the legs that is relieved by rest. Medically, that’s called claudication.

Patients with advanced PAD may have leg pain even when resting, a limp when walking, non-healing ulcers of the lower legs, or, in severe cases, gangrene. And the disease can affect arteries not only to the legs but also to the arms, intestines, or kidneys, among other organs.

Treatment for PAD falls into two main areas: controlling risk factors through lifestyle changes and medication; and endovascular (within-the-blood-vessel) therapy or surgery to open the affected arteries. Aggressive treatment of cardiovascular risk factors is particularly important, as PAD patients are also susceptible to heart attack and stroke. Smoking cessation, treatment of hyperlipidemia (elevated levels of cholesterol and/or triglycerides), increased physical activity, and control of weight, high blood pressure, and diabetes can — along with relieving PAD symptoms —reduce risk of death from cardiovascular disease by 10 to 15 percent.

For patients with mild to moderate claudication, such conservative therapy may suffice. But often, lifestyle changes are complemented by treatment with medications. One option is an antiplatelet drug (such as aspirin), which makes the blood platelets in damaged blood vessels less likely to stick together and form clots that cause further arterial blockage.

Another class of medication in common use is cholesterol-lowering drugs, which include niacin, statins, fibrates, and bile acid sequestrants. By decreasing the amount of cholesterol, especially LDL (the “bad” form of cholesterol), these drugs eliminate some of the primary material that creates atherosclerosis.

For patients with moderate to severe symptoms, more aggressive therapy may be indicated. Typically, an imaging study (such as an MR, CT, or conventional angiogram) pinpoints the location and extent of the arterial blockage. Then, “less invasive” endovascular therapy, made possible by the tremendous technological progress that has occurred in recent years, may be employed. In angioplasty, for example, a balloon is attached to a catheter — a long, thin tube — that is inserted into the groin artery and threaded through the arterial system to the narrowed peripheral artery. The balloon is then inflated to open the narrowed areas. In some cases, a metal stent, which is a kind of wire-mesh tube, is placed within the artery to keep it from collapsing.

Other endovascular alternatives for enlarging a narrowed artery include a laser or a cutting blade (atherectomy). The success and durability of these procedures depend on the location, length, and degree of narrowing (stenosis) of the blockage. Short lesions that involve large arteries that are not yet completely blocked are most likely to be treated successfully with these techniques. Endovascular therapy frequently can improve symptoms significantly and without the need for an operation. Typically, these procedures are performed on an outpatient or 24-hour-hospital-stay basis.

Surgery may be required for patients with extensive PAD that is not amenable to or not best treated by endovascular techniques. The procedure involves bypassing or replacing the section of blocked artery either with one of the patient’s own veins or an artificial blood vessel — made, for example, of polyester or polytetrafluoroethylene (PTFE). Typically, the patient is in the hospital for 3-5 days following surgery. Such treatment can provide long-lasting relief and restore or improve function of the affected extremities.
— W. Andrew Oldenburg, M.D., Vascular Surgery, Mayo Clinic, Jacksonville, Fla.

Additional Resources:
Peripheral Vascular Disease

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Medical Edge from Mayo Clinic is an educational resource and doesn’t replace regular medical care. To e-mail a question, go to www.mayoclinic.org, or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For health information, visit www.mayoclinic.com.