Got gunk? If we’re talking about the artery-blocking kind, about half of Americans would answer “yes.” Atherosclerosis refers to the buildup of plaque in the blood vessels, and it’s particularly common in the lower extremities, a condition known as peripheral arterial disease (PAD). Mild PAD may not kick up red flags, but at its worst, the disease can lead to amputation. Roper St. Francis Healthcare vascular surgeon Dr. Jon Rehfuss introduces us to this stealthy disease that impacts up to 12 million U.S. adults ages 45 to 84 (even if they don’t know it).
Sneaky Symptoms
“A narrowing of the arteries that supply blood to the legs and feet isn’t necessarily a problem that requires an operation,” assures Dr. Rehfuss. Blood flow usually isn’t reduced until vessels are narrowed by 50 percent. Even then, if a person doesn’t move far or fast, symptoms may not arise. “At rest, our feet don’t need a lot of blood flow. If you’re not that active, the blood supply you have might be enough.”
A blocked vessel also may not completely cut off blood flow, because blood can still move through minor pathways. “Our arteries branch into increasingly smaller blood vessels the further they get from the heart,” explains Dr. Rehfuss. If atherosclerosis blocks the major leg arteries, blood can route around the blockage via “collateral” arteries. “Think of a wreck that halts interstate traffic,” says the surgeon. “Cars can still use back roads to get home, it’ll just be a lot slower.”
A Step Ahead
Since PAD takes years to develop, and many people experience subtle or no symptoms, diagnosing the condition can be tricky. “PAD is often discovered incidentally when a patient receives a CT scan for some other reason,” says Dr. Rehfuss.
An Ankle Brachial Index (ABI) test, which measures and compares blood pressure in the ankle and upper arm, is the first-line test for diagnosing abnormal blood flow to the feet. While a doctor may order testing in high-risk patients such as smokers and those with diabetes or high cholesterol, widespread screening for PAD is not recommended, explains the doctor. “In the absence of symptoms, I wouldn’t offer an operation, but I would still recommend maximal medical therapy.” Only severe symptoms require surgical intervention.
Go with the Flow
In its mildest form, PAD causes the legs to hurt when walking, known as claudication. “This muscle pain usually begins when the patient walks a certain distance and stops when they rest,” says Dr. Rehfuss, who begins treatment with conservative measures. “Because claudicants have a very low risk of amputation, any intervention we do is aimed at lifestyle improvement rather than limb salvage.” That means controlling diabetes and blood pressure, quitting smoking, being active and taking medications such as aspirin and cholesterol-lowering medications. The most important step, though, is to engage in a regular walking program to boost muscle tone and develop those collateral arteries. “The more you walk, the more you’ll be able to walk.”
Limbs in Limbo
When blood flow to the legs and feet becomes severely impeded, patients face the greater danger of chronic limb-threatening ischemia (CLTI). Early forms manifest in resting pain, usually across the ball of the foot, while more advanced cases involve foot or leg wounds that won’t heal. “This could be either a traumatic injury or gangrenous wound where the toe turns black,” says Dr. Rehfuss. Left untreated, CLTI can result in below- or above-the-knee amputations, so when a patient’s PAD reaches this level, surgery is necessary to improve blood flow and save the limb.
“We aggressively revascularize CLTI patients,” says the doctor. Such operations involve a number of approaches, from open surgery intended to remove short segments of plaque or reroute the blood with a bypass to less invasive endovascular procedures, such as ballooning a narrowed artery or placing a permanent stent to hold the artery open.
“The decision about which approach to use is fairly complex, with about a dozen variables to consider,” stresses Dr. Rehfuss. “You need a vascular surgeon to properly manage PAD. We operate on every artery and vein in the body except those in the heart and skull.”
Roper St. Francis Healthcare leads the Tri-County in innovative healthcare with a compassionate, patient-first approach. The introduction of the Roper St. Francis Physician Partners Vascular Surgery practice further enhances our offerings with streamlined care to meet the region’s increasingly complex vascular needs and improve the health of the communities we serve. Learn more about our vascular services and locations at rsfh.com/heart-vascular, or connect with our specialists at (843) 720-8448.