Vascular surgeons primarily perform procedures within the veins, arteries, and other vessels that transport blood throughout the body. One common issue that arises among patients is the development of a stenosis, which is the narrowing of the artery. A decrease in the diameter of the vessel is dangerous because it can cut off the blood supply to major muscles and organs. Blood flow can also be halted by the buildup of fatty deposits commonly known as plaque. A notoriously sticky substance, plaque consists of cholesterol, calcium, and fibrous tissues. As plaque builds up and accumulates over time, the arteries begin to narrow and harden in a process known as atherosclerosis. Also known as Peripheral Arterial Disease (PAD), the buildup of plaque can cause severe damage to vital organs like the brain. For example, the accumulation of plaque in the carotid arteries, which extend from the aorta in the chest to the brain, is thought to be a cause of strokes.
“Severely reduced flow may cause a stroke, but we think most strokes are actually due to small bits of plaque washing up into small vessels that supply oxygen directly to the brain cells,” said Dr. Jerry Cohn, a vascular surgeon and assistant professor of surgery and radiology at the Medical College of Georgia. “This helps explain why many patients have ‘mini-strokes’ as a warning sign before they suffer a real stroke.”
In addition, simple wounds found on the legs can be exacerbated because of conditions like PAD. Because of a lack of adequate blood flow, a minor scrape or injury can turn into a progressively enlarging ulcer. As a result, atherosclerosis can lead to chronic leg swelling, causing changes in the skin that make it fragile and prone to ulceration.
“By far and away the most common cause of lower extremity wounds is diabetes,” said Dr. Christopher Walls, a vascular surgeon at the Savannah Vascular and Cardiac Institute in Savannah, Georgia. “Diabetes affects both the small blood vessels in the feet as well as the nerves to the legs. This results in poor circulation in the toes and feet and changes in the shape of the foot and the way in which weight is distributed.”
Ulcers can develop as a result of neuropathy, a frequent occurrence among diabetics. Resulting in a loss of sensation or numbness in the feet, neuropathy limits the ability of people with diabetes to recognize pain, minor trauma, or increased pressure on their feet. This loss of protective sensation can lead to skin breakdown, ulceration, and even advanced infections. Foot deformities such as hammertoes, bunions, and other malformations can occur and cause skin breakdown and ulcers as well.
Vascular maladies must be treated seriously, and there are numerous options for treatment available to physicians and patients. Patients with advanced cases of PAD may need to consider conventional open surgery. While this is a proven technique, there are higher risks and longer recovery times associated with those operations. General anesthesia is required and hospital stays can last usually between five to seven days.
“Some patients with the most advanced disease may require open surgical bypass procedures,” said Dr. Walls. “These procedures involve the use of an extra vein, taken from another part of your leg, or an artificial graft which is sewn into the normal artery above and below the area of blockage to go around the blocked segment. This type of surgery typically has very good long term results but does require hospitalization and a longer recovery.”
For people with severe blockages in their carotid arteries, doctors could recommend performing a carotid endarterectomy. Unlike other open surgeries, this procedure requires a small incision and has a very short recovery time for patients.
With new advances in research and medical technology, vascular surgeons can treat most patients without surgery. One example is angioplasty, which involves the threading of a small tube with a balloon attached through the skin and into the artery in the groin. The balloon is then guided across the blocked artery and inflated to open the blocked artery. Once the catheter reaches the blocked artery, the doctor will inject a dye and take pictures known as an angiogram. The doctor can view the angiograms on a video monitor during the procedure in order to determine the size of the blockage. The balloon is then inflated and as it expands it compresses the plaque against the walls of the artery. Afterwards, the balloon is deflated and removed along with the catheter. In other cases, a metal stent may be implanted to keep the artery expanded and to allow continuous blood flow. Stents are wire mesh tubes, and unlike balloons, can be placed inside the artery for a longer duration of time.
“Stent technology has improved significantly in terms of the low profile of the delivery system and the increased strength and improved metal design,” said Dr. Cohn. Stenting does have limitations in certain arteries where there is excessive motion like across the groin or knee, both frequent sites of plaque formation. Even the latest generation of stents is prone to recurrent plaque formation over time, and these vessels may require re-intervention.”
Another option for doctors involves the use of atherectomy devices that shave away the plaque that form on the walls of the artery. The device slowly sands away cholesterol and hard plaque into microscopic-sized particles that are washed away by flowing blood. Similar to stenting, a typical procedure takes from one to two hours in an outpatient setting, and patients can be up and walking within a few hours.
People can reduce their risk of PAD by refraining from smoking, exercising, and eating a healthy diet. Smoking is a major factor associated with PAD, and quitting smoking may not remove the leg pain entirely, but it will certainly keep arterial blockages from worsening.
PAD is an increasingly growing problem in the United States. The disease affects approximately over eight million people, including up to one in five individuals older than age 60. However, the overall general awareness of PAD in the United States is only estimated at around 25 percent. By increasing knowledge of the disease and preventative measures, rates of PAD will hopefully decrease.