Peripheral arterial disease

Arteries carry oxygen-rich blood from your heart to the rest of your body. In peripheral arterial disease, fatty, hard deposits called plaque build up on the inside walls of the arteries, most often in the legs. This process is called atherosclerosis, or hardening of the arteries. Think of an old water pipe slowly clogging with scale: less and less water gets through.

When the leg muscles and skin do not get enough blood, they complain. At first this happens only when you ask more of them, like walking uphill. As the narrowing gets worse, the leg can hurt even at rest, and small cuts on the feet may stop healing.

PAD is also a warning sign for the rest of your body. People with PAD have a higher chance of heart attack and stroke, so treating PAD is about protecting your heart and brain as well as your legs.

Many people with PAD have no symptoms at all, or they think leg pain is just part of getting older. It is not. The most common symptom is claudication: a cramp, ache or tiredness in the calf, thigh or buttock that comes on with walking and goes away within a few minutes of rest.

The most serious stage is called critical limb ischemia (CLI), now also called chronic limb-threatening ischemia. Ischemia means a lack of blood flow. With CLI you may have burning pain in the foot or toes at night that gets better when you hang your leg over the side of the bed, sores that do not heal after 2 weeks, or skin that turns dark or black (gangrene). CLI puts the leg at risk of amputation and needs prompt treatment.

What we see

People with diabetes need extra care. Nerve damage from diabetes can hide pain, so a foot wound may be serious even if it does not hurt. Check your feet every day, and have any sore that is not clearly healing within 2 weeks seen by a doctor.

Diagnosis starts with your story and an exam. We ask how far you can walk before the pain starts, look at your feet and skin, and feel for pulses. Then simple, painless tests show how much blood is getting through.

Treatment has two goals: to relieve your symptoms and to lower your risk of heart attack, stroke and amputation. Everyone with PAD benefits from lifestyle changes and medicines. A procedure is added when symptoms limit your life, when there is pain at rest, or when a wound needs more blood flow to heal.

Endovascular treatment means working from inside the artery through a pinhole, usually in the groin, sometimes in the wrist or foot. It is what interventional radiologists do. Using X-ray guidance, we pass a thin wire across the blockage and then open it with one or more tools:

Bypass surgery by a vascular surgeon is still the best choice for some long or complex blockages, especially in younger, healthier patients with a good vein to use. We often discuss complex cases with our vascular surgery colleagues so you get the right option, not just the one we offer.

When I look at your angiogram, I am not only looking at the blockage. I want to see whether there is a clear path of blood flow all the way down to the foot, especially to the area where a wound is trying to heal. For walking pain, I usually start with walking and medicines, because many people improve without a procedure. For rest pain or a wound, I move quickly, because time really matters for the leg.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

1. 1
   Getting ready

   You arrive at El Camino Hospital, an IV is placed, and you receive moderate sedation, also called twilight sedation. You are relaxed and comfortable but breathing on your own.

2. 2
   Mapping the arteries

   We numb the skin, usually at the groin, and place a thin tube in the artery. A small amount of contrast dye shows exactly where the arteries are narrowed or blocked.

3. 3
   Opening the blockage

   We cross the blockage with a wire and treat it with a balloon, stent or atherectomy device as needed. A final picture confirms that blood is flowing well.

4. 4
   Closing the pinhole

   The tube is removed and the puncture is sealed with a closure device or pressure. No stitches are needed. Most procedures take 30 to 60 minutes.

1. First 2 hours
   You rest in recovery while nurses check the puncture site, your blood pressure and the pulses in your feet. You can eat and drink, and family can visit.
2. Rest of the day
   Go home with an adult driver and rest. No driving, alcohol or important decisions for the rest of the day after sedation. You may shower that night.
3. First 2–3 days
   Avoid heavy lifting (more than about 10 pounds) and strenuous exercise. Some bruising at the puncture site is normal. Walk around the house.
4. 1–2 weeks
   Skin glue over the puncture falls off on its own. Most people are back to normal activity and a walking program.
5. Follow-up
   We check your leg, often with an ultrasound or ABI, at about 1 month and then regularly, because arteries can narrow again over time.

After treatment you will usually take an antiplatelet medicine, sometimes two for a few months, to help keep the treated artery open. Do not stop these without talking to us.

Most people have better blood flow right after the procedure. Walking pain often improves quickly, and wounds have a better chance to heal over the following weeks. PAD is a lifelong condition, though. Treated arteries can narrow again, and new blockages can form, especially if smoking continues. Some patients need another procedure within a few years.

The habits that treat PAD are the same ones that protect your heart. Keep walking every day, even after a successful procedure. Take your statin and antiplatelet medicine every day. Keep blood sugar and blood pressure at the targets your doctors set. And if you smoke, ask for help quitting: medicines and counseling double your chances.

Look at your feet every day, using a mirror if needed. Keep the skin moisturized but dry between the toes, never walk barefoot, and trim nails straight across. Any new sore deserves a call.