PROCEDURES FOR PERIPHERAL ARTERIAL DISEASE

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Joel Daniels
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1 PROCEDURES FOR PERIPHERAL ARTERIAL DISEASE Improving Blood Flow and Relieving Pain

Learning About PAD Your doctor has told you that you have peripheral arterial disease (PAD). This means the arteries in your legs are either narrowed or completely blocked.

2 Learning About PAD Your doctor has told you that you have peripheral arterial disease (PAD). This means the arteries in your legs are either narrowed or completely blocked. You may already have tried lifestyle changes to help relieve your symptoms. Now, your doctor is recommending a procedure to help improve blood flow. PAD can t be cured. But treatment can help to keep the disease from getting worse. Who Gets PAD? Certain conditions and habits increase the chances of developing PAD. These are called risk factors. The most common risk factors include: Smoking. Diabetes. Heart disease, such as coronary artery disease (CAD). Being age 50 or older. High blood pressure. High blood cholesterol. PAD and Your Health Having PAD makes it more likely that other arteries in your body are narrowed. Arteries that carry blood to the heart or brain can be affected. This puts you at an increased risk for a heart attack or stroke. What Are the Symptoms? PAD can cause claudication. This is cramping or aching in your buttocks, thighs, or calves with exercise, such as walking. The pain goes away when you stop moving and returns when you move again. Climbing stairs or walking uphill may make it worse. As PAD gets worse, you may have pain more often. 2

3 Treating PAD PAD can sometimes be controlled with lifestyle changes alone. These changes include quitting smoking, exercising daily, and managing health problems such as diabetes. Medications may also help. Your doctor is likely to ask you to try these measures first. If they don t lessen PAD symptoms, surgery or other procedures may help improve your quality of life. Your Role Reading this booklet can help you learn more about PAD treatments. It can also tell you what to expect and how to prepare for treatment. You and your doctor will work together to decide how to treat your PAD. Before making a decision about treatment, be sure to get all your questions answered. Ask your doctor to tell you about the benefits and risks of all your options. By being informed, you can help your doctor ensure that your needs are met. 3

4 Understanding Arteries With each beat, your heart pumps oxygen-rich blood throughout the body. Arteries carry this blood to your organs and muscles. Veins then return oxygen-poor blood to the heart. If an artery is damaged, blood flow may be slowed or blocked. This means your organs and muscles don t get all the oxygen they need. The Flow of Blood Through Arteries Blood leaves the heart through the aorta, the body s main artery. From there, it flows into large arteries in the abdomen and thighs. These branch into smaller vessels in the legs and feet. Abdominal aorta Iliac artery Femoral artery Popliteal artery Tibial arteries Carotid artery Heart Kidney Muscle tissue Smooth lining Middle layer Outer wall A Healthy Artery An artery is a muscular tube. It has a smooth lining and flexible walls that allow blood to flow freely. Active muscles need increased blood flow and oxygen. Healthy arteries can meet this need. 4

5 When Blood Flow Changes Arteries become stiffer and thicker with age. Artery linings can be damaged by smoking, unhealthy cholesterol levels, diabetes, and other factors. This allows plaque (a buildup of fat and other materials) to form within the artery walls. The plaque narrows the space inside the artery and can limit blood flow. Plaque forms Plaque builds up Blood clot A Damaged Artery PAD begins when the lining of an artery is damaged. Plaque then starts to form within the artery wall. At this stage, blood still flows normally, so you re not likely to have symptoms. A Narrowed Artery If plaque continues to build up, the space inside the artery narrows. The artery walls become less able to expand. The artery still provides enough blood and oxygen to your muscles during rest. But when you re active, the increased demand for blood can t be met. As a result, your leg may cramp or ache when you walk. A Blocked Artery An artery can become blocked by plaque or a blood clot. This prevents oxygen from reaching muscle below the blockage. Then you may feel pain when lying down. In time, the affected tissue can die. This can lead to the loss of a toe or a foot. With PAD, more than one area of a leg can be affected. The dark areas show where narrowing or blockage often happens. 5

Your Evaluation Your health history, a physical exam, and certain tests help determine whether you have PAD. Other tests can show which arteries are narrowed or blocked.

6 Your Evaluation Your health history, a physical exam, and certain tests help determine whether you have PAD. Other tests can show which arteries are narrowed or blocked. You may be referred to a specialist who evaluates and treats blood vessel problems. Your Health History You ll be asked about the symptoms and risk factors you may have for PAD. Be sure to mention any medications you re taking, including aspirin, blood thinners, and herbal remedies. Physical Exam Plaque can form in blood vessels throughout the body. For that reason, your doctor will feel for pulses and listen to blood flow in the major arteries. Your upper arms, neck, and abdomen are likely to be checked. Your feet and legs will also be examined for signs of PAD. These can include nail problems, changes in color and temperature, and sores that don t heal. Tests to Measure Blood Flow You may have tests that check the blood flow in your legs and feet. These tests are quick and painless. Ankle-brachial index (ABI) compares blood pressure in your ankle with pressure in your arm. Duplex ultrasound looks at the blood flowing through your arteries. It can show changes in blood flow due to artery narrowing or blockage. An evaluation for PAD is likely to include ultrasound. 6

Imaging Tests Other tests can show the amount of narrowing or blockage in an artery and its location. Your doctor will use the results to recommend a plan for treatment.

7 Imaging Tests Other tests can show the amount of narrowing or blockage in an artery and its location. Your doctor will use the results to recommend a plan for treatment. Arteriography In this test, x-rays help locate the narrowing or blockage in the artery. You are given medication to keep you comfortable and pain free. Then, a long, thin tube (catheter) is inserted into an artery, usually in your groin. It is carefully threaded to the affected artery. When the catheter is in place, a contrast fluid is injected into the artery. This makes the blood flow show up clearly on x-rays. Several images (arteriograms) are taken. A procedure to treat the artery problem may be done right after arteriography. Your doctor will discuss this with you in advance. Other Imaging Tests You may have other tests to help detect a narrowing or blockage. Contrast fluid allows the condition of the arteries to show more clearly. CT arteriography uses computer-generated x-rays to provide detailed images of arteries. MR arteriography uses a strong magnet and radio waves to produce images of blood flow in the arteries. This arteriogram shows narrowing in both iliac arteries. The sites are shown in the circle above. Risks and Complications of Arteriography These can include: Bleeding, bruising, infection, or pain at the catheter insertion site An allergic reaction to the contrast fluid Blood clots Artery damage Kidney problems 7

These use a catheter to reach the affected part of your arteries. Catheters are usually inserted through small punctures. Endovascular procedures for PAD include angioplasty and stenting.

8 Forming a Treatment Plan PAD is often treated with lifestyle changes and medications. But they may not be enough to relieve your symptoms. For that reason, your doctor may recommend a procedure to open the artery. Endovascular Procedures For a short narrowing or blockage, endovascular procedures may be used. These use a catheter to reach the affected part of your arteries. Catheters are usually inserted through small punctures. Endovascular procedures for PAD include angioplasty and stenting. Angioplasty uses a tiny balloon to open blocked arteries. Stenting is the insertion of a tiny wire mesh tube into an artery to hold it open. Bypass Surgery Bypass surgery may be the only option for longer or more severe narrowing or blockage. This treatment uses a bypass graft to reroute blood around an artery in the abdomen or leg. The damaged section of artery is not removed during this procedure. Changing for Life Long-term lifestyle changes are a key part of care for PAD. They can help reduce risk factors that damage arteries. Making these changes is important even after treatment. By staying committed to a healthy lifestyle, you can help slow the progress of this disease. For a slightly narrowed artery, your symptoms are likely to improve if you stop smoking, exercise daily, and eat low-fat foods. These measures help improve blood flow throughout your whole body. This can reduce your risk of heart attack and stroke. 8

Preparing for a Procedure Before an endovascular procedure or bypass surgery, you are likely to have tests to assess your overall health. The types of tests depend partly on your risk factors.

9 Preparing for a Procedure Before an endovascular procedure or bypass surgery, you are likely to have tests to assess your overall health. The types of tests depend partly on your risk factors. Follow all instructions you are given for preparing. Testing Before Treatment To help ensure that your procedure goes smoothly, you may have one or more of these tests: An ECG (electrocardiogram) checks the health of your heart. You also may have a test that measures how your heart responds to stress. You won t have to exercise during this test. A routine chest x-ray helps detect lung problems. Some blood tests show how well your kidneys are working. Others assess the blood s ability to clot. Blood sugar levels are also likely to be checked. Getting Ready for the Procedure Being well prepared can make you feel more at ease on the day of your procedure. Be sure to: Tell your doctor about all the medications you take, including vitamins, herbal remedies, and other supplements. You may be told to stop taking medications before the procedure. You are likely to receive special instructions if you have diabetes or use blood thinners. Stop eating and drinking as directed before your procedure. Arrange for an adult family member or friend to drive you home. Pack a bag if you re likely to stay overnight. 9

10 Endovascular Procedures Angioplasty is used to widen a narrowed artery or open a blockage. Then a stent may be inserted to hold the artery open. More than one artery may be treated during these procedures. Angioplasty Catheter Balloon A balloon-tipped catheter is inserted into the artery and threaded to the narrowing or blockage. Stenting Catheter Balloon Stent Inflated balloon The balloon is inflated and deflated several times. This presses the plaque against the artery walls. Inflated balloon Open stent Once the artery is open, the balloon is deflated and removed. Blood flows freely through the widened channel. Stent A collapsed stent is mounted onto a balloon catheter and guided across the blockage. The balloon is inflated to open the stent, which locks into place inside the artery. The balloon is deflated and removed. The stent remains in place, holding the artery open. 10

Right After the Procedure You will need to lie flat right after the procedure. You may be asked not to bend your leg for 2 to 6 hours. The blood flow in your legs will be watched closely.

11 Right After the Procedure You will need to lie flat right after the procedure. You may be asked not to bend your leg for 2 to 6 hours. The blood flow in your legs will be watched closely. Most people can go home the same day. At home, take any medications as directed. Follow all the instructions to care for yourself as you recover. In the Months Ahead Be sure to keep appointments with your doctor. The blood flow in your arteries may be retested on a regular schedule. This lets your doctor monitor the health of your arteries. Arteries can become narrowed or blocked again. This may occur months after treatment. If pain returns, contact your doctor. In many cases, a second procedure can reduce symptoms. Risks and Complications Risks of endovascular procedures include: Rupture of the treated artery Bleeding or infection at the catheter site Blood clots Heart or lung complications Kidney problems Loss of toe or foot Death When to Call the Doctor Call your doctor right away if you have: Swelling or bleeding at the insertion site Chest pain or trouble breathing Fever of F (38 C) or higher A change in the temperature or color of your foot A return of symptoms similar to those you had before the procedure 11

12 Bypass Surgery Angioplasty and stenting may not always improve blood flow enough. In some cases, the best option may be bypass surgery. For this, a graft is used to create a new pathway for blood around the blockage. The graft may be a synthetic tube, a vein from your leg, or a donor vein. Abdominal Bypass If the abdominal aorta (a large artery in the abdomen) becomes narrowed or blocked, bypass surgery may be needed. To reach the blockage, the surgeon makes incisions in the abdomen and groin. A graft is then sewn into the artery above and below the blocked section. Once blood flows freely through the graft, the incision is closed with sutures or staples. Leg Bypass To bypass a narrowed or blocked leg artery, a healthy vein from that same leg is often used for the graft. In some cases, a synthetic graft or donated tissue is used. Once the graft is ready, the surgeon makes an incision near the damaged artery. The graft is sewn to the artery above and below the blockage. Once blood is flowing through the graft, the incision is closed with sutures or staples. Vein graft Blocked artery A synthetic graft reroutes blood around a blocked artery in the abdomen. A femoral popliteal bypass ends near the knee. Synthetic graft Vein graft Blocked artery In a distal bypass, the graft ends below the knee. 12

13 Right After Surgery Following surgery, you will be monitored closely. And you will receive medication to help control pain. You ll be able to go home when you can walk on your own, often within a few days. Recovering at Home No matter what procedure you have, these measures help your body heal more quickly: Take aspirin, blood thinners, and pain medications as directed. Care for incisions as instructed. Follow your doctor s instructions about protecting incisions while bathing. Have staples or sutures removed when your doctor recommends. Drink plenty of fluids. Try to walk a little farther each day. Risks and Complications Risks of bypass surgery include: Bleeding Blood clots Infection Heart or lung problems Loss of toe or foot When to Call the Doctor Call your doctor right away if you have: Bleeding or increased pain, swelling, redness, or warmth at the incision sites Fever of F (38 C) or higher Chest pain or trouble breathing A change in skin temperature or color below the bypass site A return of symptoms similar to those you had before the bypass Death 13

Living a Healthier Life Maintaining a healthier lifestyle can help slow the disease.

Go to Your Follow-Up Visits Be sure to keep all of your follow-up appointments.

Exercise Daily Frequent exercise is important for your health. It improves blood flow and helps reduce blood pressure.

Ask your doctor if you should enroll in an exercise program supervised by a healthcare provider.

This increases the risk of infection. To protect your feet: Have a podiatrist (foot specialist) trim your toenails.

See a healthcare provider if you have cuts or wounds on your feet. If You Smoke, Quit!

14 Living a Healthier Life Maintaining a healthier lifestyle can help slow the disease. It can also improve the overall health of your arteries, reducing the chances of heart attack or stroke. Go to Your Follow-Up Visits Be sure to keep all of your follow-up appointments. During these visits your doctor will recheck your blood flow. If problems are found, they can be treated right away. Exercise Daily Frequent exercise is important for your health. It improves blood flow and helps reduce blood pressure. When you resume your walking program, start with short walks. Then increase your distance a little each day. Ask your doctor if you should enroll in an exercise program supervised by a healthcare provider. Take Care of Your Feet Even after treatment, your feet need extra care. Sores or blisters may take a long time to heal. This increases the risk of infection. To protect your feet: Have a podiatrist (foot specialist) trim your toenails. Wear supportive, well-fitting shoes. Avoid high heels and shoes with open toes. See a healthcare provider if you have cuts or wounds on your feet. If You Smoke, Quit! Smoking is the main risk factor for PAD. It interferes with blood flow and injures the walls of the arteries. Your PAD symptoms are likely to come back if you keep smoking. Quitting isn t easy, but these steps may help: Ask your doctor for advice on programs and aids. Get support from family, friends, or support groups. Don t give up it may take 3 or 4 tries to finally quit. 14

Eat Healthy Foods Making healthy eating changes can improve cholesterol levels and lower blood pressure. This can make arteries healthier and help prevent plaque buildup.

15 Eat Healthy Foods Making healthy eating changes can improve cholesterol levels and lower blood pressure. This can make arteries healthier and help prevent plaque buildup. Eating well can also help you lose excess weight and manage blood sugar. To get started with healthy eating, try these tips: Eat more fruits, vegetables, and whole grains. Eat less fat. Also choose the right kinds of fat (vegetable oils, nuts, seeds, fish). Limit saturated fats (red meat, full-fat dairy products). And avoid trans fats (fried foods, fast foods, baked goods). Cut back on salt (sodium), if instructed. Too much salt can raise blood pressure in some people. Limit added sugars (soda, candy, pastries) and refined grains (white bread, white rice, or regular pasta). Manage Health Problems Eating lots of fruits and vegetables is a big part of a healthy diet. Managing other health problems is a big part of keeping your arteries healthy. Talk to your doctor about the best way to control diabetes, high blood pressure, unhealthy cholesterol levels, or heart disease. Here are some general guidelines: Take medications as directed. Don t skip days or stop taking them without your doctor s okay. Have your cholesterol and blood pressure checked as often as directed. Maintain a healthy weight. If you have diabetes, try to keep your blood sugar well controlled. Test your blood sugar as directed. 15

Also available in Spanish Starting a Walking Program Exercise plays a big part in managing artery disease. For that reason, you may be told to walk daily. Start with one or two short walks each day.

For instance, don t walk through pain unless your doctor says it s okay. On the other hand, your doctor may ask you to keep walking even when you feel leg pain. Doing so can help improve circulation.

16 Also available in Spanish Starting a Walking Program Exercise plays a big part in managing artery disease. For that reason, you may be told to walk daily. Start with one or two short walks each day. Then try to increase your time or distance. To Get on Track Be sure to follow any instructions you are given for your walking program. For instance, don t walk through pain unless your doctor says it s okay. On the other hand, your doctor may ask you to keep walking even when you feel leg pain. Doing so can help improve circulation. Over time, this may help lessen your pain. Try the suggestions below to help make your program a success: Warm up and cool down. Walk slowly for 5 minutes before and after you exercise. Don t let bad weather stop you. When you can t walk outside, walk indoors. Slow down or pause to rest if you need to. Track your progress. Each day, record how long and how far you walked. TAKE OUR PATIENT SURVEY. Help us help other patients. Please visit to provide your feedback on this booklet. This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem The StayWell Company, LLC All rights reserved. Made in the USA

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