Dear Doctor: Could you please tell me about peripheral artery disease? I have it and recently underwent angiograms of both legs, including insertion of one stent. One leg is now normal, but the other is back to square one. Do I just suffer through the sleepless nights of pain while waiting for the inevitable stroke or heart attack?
Dear Reader: Think of peripheral artery disease as being like any other arterial disease. Arteries transfer oxygenated blood from the heart throughout the body. The carotid arteries provide blood to the brain, the coronary arteries provide blood to the heart, and the iliac and femoral arteries provide blood to the legs. The inside of each of these arteries is lined with a thin layer of cells called the endothelium. This smooth layer allows blood to move freely within the artery without sticking or clotting.
Injury to the lining of the arteries leads to a mixture of cholesterol and fibrous plaques accumulating on the walls of the artery. This buildup is known as atherosclerosis and, over time, causes the arteries to narrow. In peripheral artery disease of the legs, the narrowing causes decreased blood flow to the legs. The first sign is cramps, usually in the calves, with walking. As the narrowing increases, the cramps can occur simply while lying down, because blood flow decreases without the benefit of gravity. Your worries about strokes and heart attacks are understandable. As with other arterial disease, such plaques can break off and lead to those potentially fatal conditions.
Smoking cigarettes is the biggest risk factor for peripheral artery disease. In fact, chronic smoking is a risk factor for all arterial disease. Other risk factors include diabetes, high blood pressure, kidney disease, high LDL cholesterol and the unavoidable risk factor of being older than 70.
The first course of action should be controlling any risk factors. If people smoke, they should stop. If they have diabetes, they should make sure to keep their blood sugar low. And if they have high cholesterol, they should lower it with medication and diet.
Second, taking a blood thinner, such as aspirin or clopidogrel, will lower the likelihood of clots forming within the blood vessels.
Third, a gradual course of exercise therapy can improve blood flow and decrease calf pain with walking. People without access to a supervised exercise program should walk three days per week for 30 to 45 minutes. A slow start is fine; a more rapid pace can come later.
Fourth, the medication Cilostazol, which works by dilating the blood vessels and not allowing platelets to clot in the arteries, has been shown to increase the distance that people with peripheral artery disease can walk without pain.
As you have experienced, when symptoms are severe or when blood flow to the foot is severely compromised, surgery may be advised. This can be done by angioplasty and stenting, as you had, or, if symptoms are still unrelieved or if the blockage is too long, a bypass graft can be created to skirt the blocked area so that blood can move through unimpeded.
All that said, speak to your doctor. It's possible that not all your pain at night is related to peripheral artery disease. But if it is, controlling your risk factors, using the medications described above and possibly a bypass procedure (if you are a candidate) may help your symptoms. Your physician is in the best position to recommend next steps.
Robert Ashley, M.D.
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