Friday, December 06, 2019

Recently, a woman in her late 60s came to my office with discomfort in her left thigh after walking several blocks to shul on Shabbat. Lately she had noticed that the pain had also begun to involve her left calf. The pain was worse when she walked up hills or when she pushed herself. She had sciatica in the past and was worried that her back problems were causing the pain in her leg. Her primary care doctor suggested that she see me for a vascular evaluation. She had smoked cigarettes in the past but quit a few years ago after a mild heart attack. Her blood pressure and cholesterol issues were well controlled with medication. She had a mildly diminished pulse in her left foot.

After an ankle brachial index (ABI) and ultrasound identified a severe blockage, I performed an angiogram of her legs confirming the presence of a 90% blockage in the left common femoral artery (the main artery of the thigh and calf). Her diagnosis? Peripheral arterial disease (PAD) caused by atherosclerosis.

I then performed an angioplasty, which relieved the blockage and resulted in return of normal blood flow to the leg. She went home the same day and sees me in the office for regular follow-up. She no longer has pain in her leg when she walks.

Atherosclerosis is a disease of the arteries characterized by fatty plaque deposits on their inner walls. Many people are aware of atherosclerosis causing heart disease manifested by chest pain or heart attacks. Fewer are aware of atherosclerosis causing vascular disease in the arteries of the lower extremities, known as peripheral arterial disease (PAD). Almost 10 million people in the United States have PAD. As the population ages this number is expected to rise. People with diabetes and cigarette smokers are at increased risk for PAD. Other risk factors include kidney disease and inflammation. PAD affects men and post-menopausal women equally. There is also a genetic component to PAD; however, this aspect is often poorly understood. Because the predispositions are similar, many patients with PAD have coronary heart disease and cerebrovascular disease as well, making patients with PAD at increased risk for strokes and heart attacks.

The first test used to screen for or detect PAD is the ABI. The ABI is a noninvasive test that requires simultaneous measurement of blood pressure in the arms and legs. In those without PAD, the blood pressure measured in the arm should be similar to that measured at the level of the ankle. However, if there is a blockage in the artery in the leg, the blood pressure is lower in the leg than in the arm. Therefore, an abnormally low ABI is suggestive of a blockage in the leg caused by PAD. Targeted screening for PAD with ABI testing among those at risk for PAD is recommended by the American College of Cardiology. Individuals with diabetes, smokers and those with other cardiovascular risk factors should be screened.

Symptoms of PAD vary from person to person. Many individuals with PAD have no symptoms at all. Some people have pain in their legs while walking, but feel fine at rest. Others, with more advanced disease, experience lower extremity pain at rest or even foot ulceration or infection that can lead to amputation.

The diagnosis of PAD can often be made by a careful physical exam. Absent or diminished pulses or abnormal bruits (whistling sounds) can be heard with the stethoscope. As mentioned, the ABI is the initial test for identifying PAD. The ABI is often complemented by a doppler ultrasound or CT scan that can identify the severity and location of the blockage.

Most PAD can be treated with medicine. Cholesterol medication (even in those with normal cholesterol), aspirin and blood pressure medication can prevent the progression of the disease. Regular walking and smoking cessation are the most important lifestyle modifications for those with PAD. Control of coexisting diabetes and high blood pressure is mandatory.

A minority of patients with PAD require procedures, known as revascularization, to open blocked blood vessels. Revascularization can be performed without surgery. Similar to coronary angioplasty, balloon angioplasty and stenting of the lower extremities can be performed through a small catheter in the artery in the groin or wrist. Open surgical bypass or plaque removal is rarely required. Technologies to safely treat PAD without surgery are rapidly evolving, making the procedure safer and more effective.

By Dr. Philip Green

Philip Green, MD, is a cardiologist with expertise in coronary and peripheral vascular disease. As an interventional cardiologist, he has expertise in catheter-based treatments for complex coronary and peripheral vascular diseases. His clinical interests include coronary artery disease, intermittent claudication, abdominal aortic aneurysms, venous thromboembolism including treatment for pulmonary embolism and deep venous thrombosis, critical limb ischemia, renal artery stenosis and carotid artery disease.

Dr. Green received his Doctor of Medicine degree from Albert Einstein College of Medicine of Yeshiva University in 2006. He completed his internship and residency at Brigham and Women’s Hospital, Harvard Medical School and clinical and research fellowships at Columbia University Medical Center.

He lives in Teaneck with his wife, Alana, and three children.

Dr. Green sees patients in Elmwood Park, New Jersey; Columbia University in Washington Heights; Westchester County; and Orange County. Call 212-305-7060
for an appointment.