Peripheral Vascular Disease
As we get older, it is a natural thing to get pain in our legs when walking, right?
Wrong. Pain in the legs or feet while walking should not be considered a normal part of aging. It could be a sign of peripheral vascular disease, or PVD the buildup of fatty deposits (plaque) in the arteries beyond the heart. This buildup can block blood supply throughout the body, but most dangerously to the brain, kidneys, and legs.
Patients with even a moderate amount of arterial blockage may not have noticeable symptoms. Others may have symptoms, but not realize that their difficulty with walking is a result of PVD. Without the awareness of PVD, this problem may go undiagnosed, with patients suffering unnecessarily.
James F. McKinsey, MD, Bi-Campus Chief, Division of Vascular Surgery, answers readers' questions about PVD.
Q: My doctor mentioned lower extremity vascular disease is that different than PVD?
JFM: PVD may also be called lower extremity vascular disease or Peripheral Arterial Disease (PAD).
Q: What are the most common symptoms ?
JFM: Claudication (pain in the calf, thigh or buttock while walking), pain in the feet with elevation of the legs, and wounds or sores on the feet or legs that do not heal.
Q: How dangerous is PVD?
JFM: Even those with mild disease face an increased risk of heart attack and stroke. The leading cause of death in people with PVD is coronary artery disease (the buildup of plaque in the arteries of the heart), resulting in a heart attack. If PVD goes untreated, a patient's foot or leg may have to be amputated.
Q: I am overweight. Am I at risk for PVD?
JFM: Yes. PVD shares the same risk factors as heart disease smoking, elevated cholesterol, diabetes, lack of exercise, and hypertension which are frequently associated with being overweight or obese.
Q: How is PVD treated?
JFM: First, most patients need to make lifestyle changes such as quitting smoking, eating a healthier diet, and exercising more. Some people need medications to help lower cholesterol or blood pressure. In serious cases, patients can be treated with a minimally invasive procedure. A minority require surgery to clean out or bypass the arteries.
The main risk factors for PVD are preventable: smoking, elevated cholesterol, diabetes, lack of exercise, and high blood pressure (hypertension). People with chronic kidney disease or diabetes who also smoke face an especially high risk of developing PVD. "Family history also plays a very important role in whether patients will develop vascular disease," says Dr. McKinsey. Although the specific genetic markers for PVD have not yet been identified, it is clear that certain populations (such as Hispanics and African Americans) have a higher predisposition to diabetes and PVD, and that some families have a genetic predisposition to developing PVD.
Correcting the preventable risk factors (through smoking cessation, regular exercise, and control of diabetes and hypertension) is very effective in treating PVD. "Those who don't do well are those who have a genetic predisposition and who don't do anything to reduce their risk," Dr. McKinsey says.
Screening for PVD
Screening for PVD is simple, noninvasive, and cost-effective. It is done by measuring the blood pressure at the ankle with a blood pressure cuff and comparing this measurement with the blood pressure taken at the arm. Many cardiologists and vascular surgeons have this equipment in their offices today.
Nonetheless, screening is typically not reimbursed by insurance, and there is widespread debate about whether screening for PVD should be made a routine healthcare measure. Logic would tell us that it is important to be aggressive about identifying and controlling risk factors, but studies have not been done to scientifically prove that screening improves survival.
According to Rajeev Dayal, MD, Assistant Professor of Clinical Surgery at Columbia University College of Physicians and Surgeons, "Screening is a very easy and cost effective tool that can detect PVD, and potentially help to identify patients who have undiagnosed coronary artery disease." He and colleagues at NewYork-Presbyterian Hospital advocate that primary care physicians should regularly screen patients for PVD as part of routine checkups. Geriatricians in the U.S. also want to implement routine screening, but have faced resistance from insurers and challenges in purchasing the necessary machines.
Overall, most doctors recommend screening for people who smoke or have other risk factors. "If PVD is found early, it can be treated before extensive tissue loss occurs, potentially avoiding extensive surgical bypass procedures or even amputation," says Dr. Dayal. "When patients hear that they have PVD, it helps to convince some of them to stop smoking, lower their cholesterol, exercise more regularly, and make other lifestyle changes."
Research on PVD at NewYork-Presbyerian Hospital
The Division of Vascular Surgery is involved in a range of clinical trials on PVD. "Whether a patient is best served with the newest form of atherectomy, the latest design in bare metal stents or even gene therapy, we have it available within the Division of Vascular Surgery," says Nicholas J. Morrissey, MD, Director of Clinical Trials for the Division of Vascular Surgery.
In April 2008, Dr. McKinsey presented at the American Surgical Association the results of a study of almost 600 atherectomy procedures. This study at NYPH was the largest series with the longest followup ever published. Two thirds of the patients in the study had limb-threatening ischemia (would need an amputation if not treated). Over 94% of patients were able to salvage their legs and maintain good circulation three years after treatment, a result that is comparable or superior to outcomes achieved by open surgery.
Dr. McKinsey is the National Principal Investigator in the DEFINITIVE trial (Determination of Effectiveness of the SilverHawk® Peripheral Plaque Excision System (SIlver-Hawk Device) for the Treatment of Infrainguinal Vessels / Lower Extremities), which aims to evaluate the effectiveness of the treatment of patients with all types of PVD who are treated by minimally invasive atherectomy.
Another important study at the Division of Vascular Surgery focuses on the treatment of patients with PVD and diabetes. "Diabetic plaque is very different than nondiabetic plaque," explains Dr. McKinsey. "Diabetics tend to have hard, calcified plaque, and this leads to a higher risk of gangrene. Patients with chronic renal failure have a similar type, and there is a relationship there. By evaluating all the treatment options especially minimally invasive options as well as medical and gene therapy we are hoping to identify the safest and most effective method to treat patients with PVD."