The circulatory system is made up of the heart, arteries, veins, and capillaries. Oxygen rich blood is pumped from the heart and carried by the arteries to all parts of the body. The veins return the blood to the lungs to be enriched with oxygen and repumped by the heart. Arteries and veins are connected by tiny blood vessels called capillaries. This total system provides the necessary nourishment and oxygen to all body cells.
 In normal arteries, the lining is very smooth, allowing the easy flow of blood through the vessel. In lower extremity arterial disease, the lining of the artery becomes rough and thickened by a buildup of cholesterol and plaque. This is often called "hardening of the arteries" but medically is referred to as atherosclerosis. This causes decreased blood flow due to the narrowing or blockage. When blockage occurs slowly over time, often smaller arteries will develop and allow some, but reduced blood flow around the narrowed area. This is called collateral circulation.
Warning Signs & Symptoms of Lower Extremity Arterial Disease
The signs and symptoms of decreased blood flow to the legs can differ greatly, depending upon the location of the arteries involved and the extent of narrowing of the specific artery. When your legs or feet are unable to get enough oxygen and nutrition needed for growth and repair, death of the tissue, or gangrene, can occur. Sometimes a piece of plaque may break off inside the artery and travel down the leg artery until it lodges and blocks off blood flow beyond that point. When the blockage occurs suddenly symptoms tend to be immediate and severe because there is not enough time for collateral circulation to develop. The following signs and symptoms of advanced lower extremity arterial disease may occur on one or both sides.
- Pain or cramping in the hips, thighs, or calves when walking a specific distance and then is relieved by resting. This is called Intermittent Claudication. Pain in the toes or feet may occur with exercise as atherosclerosis progresses and is referred to as Rest Pain.
- Fatigue, a feeling of tiredness in the buttock or thigh area
- Paleness of the foot or leg when elevated
- Blue or red discoloration of the foot when hanging down
- Painful, blue or purple toes, often caused by emboli
- Absent or faint pulses in the foot
- Numbness, tingling or pain in the foot, toes or leg
- Cool temperature of the foot or leg
- Thin, shiny skin on the legs
- Thickened, brittle toenails
- A sore or ulcer on the foot that does not heal
- Decreased hair growth on the legs, feet, or toes
- Decreased ability to spread toes or move the foot
Risk Factors in the Development of Lower Extremity Arterial Disease
Arterial disease and atherosclerosis cannot be totally cured or prevented, but certain habits and lifestyles add to the risks. For assistance in reducing the risks click on the highlighted term. The following list are considered risk factors in the development of Lower Extremity Arterial Disease:
Diagnosis of Lower Extremity Arterial Disease
If Dr. King suspects that you have lower extremity arterial disease, he will ask you specific questions about the signs, symptoms, your lifestyle and medical history as well as physically examine you carefully. The diagnosis of lower extremity arterial disease is made through the examination of the overall appearance of the legs and feet, as well as the type of symptoms present, and whether or not pulses in the legs, feet and groin can be felt, or palpated by the doctor. Special tests may ordered after the exam and they fall into two basic categories, non-invasive and invasive.
Non-Invasive Testing
Non-Invasive testing is done in the vascular laboratory either at the Beachwood office or at the hospital. This is performed to check the blood flow to your lower extremities. Non-Invasive tests are painless and have no risks or side effects. They do not involve the use of needless, x-rays, or dye and no special preparation is required before the test and no observation is necessaryafterwards. This allows the test to often be done the same day of the regular office visit, schedule permitting. They are done as an outpatient and all tests take less than one hour to perform. The results are given to Dr. King for evaluation and will be discussed with you, usually by telephone. There are several types of Non-Invasive tests that may be ordered, including arterial blood pressures, waveforms, and an exercise test.
- Doppler Ultrasound provides a sound analysis of the blood flow at different points along the leg. Blood pressure cuffs are placed around your arms and legs, and then the pressure readings are compared. You may be asked to walk on a treadmill and the blood pressures will be repeated. From these tests, the location and severity of your disease can be determined.
- Duplex Scans are sensitive tests that provide an image of an artery or vein on a screen through the combination of Doppler ultrasound and ultrasound imaging to view the blood flow in color while listening to the blood flow sound. This is very useful for locating plaque or blockages in an artery, for measuring the size of an artery and its blood flow as well as checking for reflux of the veins and incompetent valves. This can also be used to measure the size of a vein, which may be necessary to use for a bypass of a diseased artery. For this test, you will need to lie very still after a cold, wet gel is applied to your leg and the technician will move the probe over the artery or vein being studied.
Invasive Testing
Depending on the non-invasive test results and or the severity of the symptoms, an invasive test, known as an arteriogram, may be ordered to evaluate the location of any narrowing, blockage, or defect in the arteries of your lower extremities. This is performed in the x-ray department of the hospital either as an outpatient or during hospitalization. An arteriogram is obtained by injecting dye through a small needle or catheter inserted into a blood vessel. Since it involves the puncture of an artery and the injection of dye, you will be asked to sign a consent form. You will remain awake, although you may be given a medication to help you relax. You can expect the dye injection to cause a brief, hot burning sensation. Once the pictures are taken, you will be required to stay in bed and lie quietly for several hours. Once Dr. King has seen the results from the arteriogram, he will discuss the recommendations for further treatment with you.
Treatment and Surgery
Depending on the results of testing and the symptoms you are experiencing, a treatment recommendation will be discussed with you. For mild disease, treatment is often medication such as aspirin, or if you are unable to take aspirin, Plavix or Ticlid, as well as a serious commitment to lifestyle changes. Stopping smoking and maintaining a low-fat diet to prevent the disease from worsening is usually the suggested treatment combined with an exercise regiment to assist you in developing collateral circulation. You would then be monitored on a regular basis to reassess the situation. For severe or progressive disease, one of several procedures or operations may be required.
Dr. King believes that it is important for patients suffering from claudication to understand your options and have all the information that you need to understand your specific situation. You will be encouraged to ask questions and have family members present for the discussions. With the recent advances in vascular surgery, lower extremity arterial disease may be treated with a low risk of complications. Surgery or non-surgical interventions may improve or eliminate symptoms and restore you to a more independent and comfortable lifestyle. However, surgery cannot cure atherosclerosis. This disease process will still be present. You can help to control the disease by making a firm commitment to keep your regular follow-up doctor appointments, have your routine recommended testing performed in a timely fashion, and most importantly, by reducing your risk factors. This can be done by maintaining a low-fat diet, achieving a healthy weight, taking medications as prescribed and never using tobacco of any kind.
The following non-surgical and surgical interventions may be recommended depending on your situation.
Non-Surgical Interventions
- Balloon Angioplasty, often referred to as Interventional Therapy may be recommended for short areas of blood vessel narrowing. In a number of cases, it is possible to dilate a short area of narrowed blood vessel using a special balloon catheter inserted into a major artery, usually the femoral artery in the groin. This procedure is called angioplasty and patients must meet specific criteria to have successful outcomes. It is performed either in the operating suite or the x-ray department. A small balloon located at the end of the catheter is inflated at the level of the blockage in order to widen the passageway for blood flow. Occasionally a small hollow metal tube called a stent is then placed inside the dilated artery to prevent it from closing again. Patients are usually able to return home that day or the next morning and find the recovery period much quicker than with surgery.
- Thrombolytic Therapy can sometimes be used to dissolve recent blood clots in a vein or artery. In this procedure, special medication is administered through a vein or artery where the blood clot has been identified.
Surgical Options
Surgery is often performed on specific arteries in the lower extremities to improve circulation, increase comfortable walking distance, to relieve rest pain, help heal foot sores and ulcers, and to try to prevent amputation. Surgery in these instances involves removing the plaque or blood clot from a blocked artery or bypassing the diseased artery.
- Endarterectomy is the name of the surgery performed when the diseased artery is opened, the atherosclerotic plaque is removed from the inner wall of the artery and the opening is closed with sutures.
- Thrombectomy or Embolectomy involves the removal of clotted blood from an artery. A small catheter with an inflatable balloon on the end of it is positioned in the artery. This takes the blood clot out with it in most instances. The artery is then closed with sutures.
- Bypass Surgery detours, or bypasses the narrowed or blocked area of an artery. This involves the use of either one of your own veins from another body area or the use of synthetic, manmade grafts. Small incisions are made at various locations in the leg; the bypass graft is sewn to an artery above the blockage and to an artery beyond the blockage. Blood flow is then detoured from the artery through the bypass graft and out to the rest of the leg. There are many types of bypass grafting in the body; the type performed in the lower extremities depends on symptoms, tests, and general health. Types of peripheral bypass include:
- Femoral-popliteal bypass A detour around the blockage is created either by using a piece of your own vein or a manmade synthetic graft. One end is attached to the popliteal artery in the knee area below the blocked, or narrowed area while the other end is attached above the problem area in the groin region at the femoral artery.
- Insitu bypass the saphenous vein, located in the calf and thigh, is used as an artery and detours or bypasses the problematic blocked or narrowed artery. This increases blood flow to the leg.
- Femoral-femoral bypass blood flow is detoured or bypasses through a synthetic, manmade piece of vein graft that has been attached to the femoral artery of the unaffected leg and tunneled under the skin of the lower abdomen over to the other leg's femoral artery below the blockage in the iliac artery in the abdomen.
- Aortobifemoral bypass is performed for lower extremity symptoms caused by aortic and iliac blockages in the abdomen. Amputation is the surgery of "last resort" and performed when all other options have been exhausted or to save a patient's life when they are in imminent danger due to gas gangrene.
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