September Meeting, Riverview

As we ate our lunch, Sheila Turkel opened the meeting, issued the usual invitation for attendees to become members and for members to become more active, and announced the Heart Walk on October 5. She then introduced the speaker, vascular surgeon Dr. Stephen Kolakowski, and his topic, PVD: peripheral vascular disease.

Dr. Kolakowski told us he grew up in Neptune, left for school, spent eight years in training in Philadelphia, returned about a year ago, and is glad to be back. He trained in general surgery and then specialized in vascular surgery.

Arteries, he told us, carry oxygenated blood from the heart and fan out to the rest of the body; veins bring blood back to the heart to be re-oxygenated. When we’re born the arteries are clean little pipes with no blockages; PVD (also called PAD, peripheral artery disease) really means blockages in the arteries.

As Dr. Kolakowski described it, PVD is a lot like the coronary artery disease (CAD) that we know and try to avoid. PVD, CAD, and stroke are all different aspects of atheroscerosis, hardening of the arteries. They have similar risk factors, and if you have one of these conditions you’re at risk for the others. Like heart disease, PVD develops over many years, narrowing the arteries so they can’t supply our legs or hands or brain with all the oxygen and nutrients they need.

Question: When a vein is taken from your leg to bypass a coronary artery, how can you get along without it? Answer: the leg has two major veins, the saphenous vein and the larger femoral vein. Taking out the femoral vein would cause problems, but if the saphenous vein is taken out the femoral vein will take over.

Hardening of the arteries, atherosclerotic disease, is caused by the accumulation of plaque in the arteries. Plaque consists of cholesterol, platelets, calcium, a combination of stuff that sticks to the inside of the artery wall and narrows the lumen, the space inside the artery that the blood flows through.

After the age of 70, about one in three people will have some peripheral vascular disease. That doesn’t mean they all have to be treated, but we have to be aware of it.

Prevention: Dr. Kolakowski says everybody over the age of 50 should be taking low-dose “baby” aspirin to reduce the risk of artery blockages. Everybody over 50 is at risk. Men are more at risk than women, partly because more men smoke than women. That may change over time, but women still have a hormonal advantage.

Some risk factors for atherosclerosis are also risk factor for aneurysms. The aorta is the big artery that comes out of the heart and runs down the middle of the chest and belly. Over time the aorta can develop a bulge, called an aneurysm. Once that occurs we have to watch it to make sure it doesn’t rupture and bleed. Family history, smoking and high blood pressure are the main risk factors. An aneurysm can be surgically treated, but once it has ruptured the chance of survival is less than ten percent.

Family history, smoking and high blood pressure are also the main risk factors for peripheral vascular disease. Others are high cholesterol, triglycerides (fats carried in the blood, related to cholesterol), homocysteine, overweight (Dr. Kolakowski said Philadelphia, where he got his training, is the fattest city in the world) - these are also the familiar risk factors for coronary artery disease.

The first symptom of PVD is “intermittent claudication,” pain in the calf when you walk that goes away when you rest. The arteries are too narrow to supply blood fast enough, and you get cramping, sometimes weakness, tightness, or other symptoms. Typically, every time you walk a certain distance you get the same pain; if you don’t, it probably isn’t PVD. Over time, the condition can worsen if not treated: the distance you can walk without pain keeps getting shorter.

The next stage of PVD is called “critical limb ischemia.” and that’s when you’re getting pain at rest, and in other parts of the leg. This stage usually requires some kind of intervention. The next stage after that involves ulcers on the feet and toes that don’t heal, and you risk losing a toe or a foot. As the disease progresses the skin gets darker and blacker. That’s gangrene, and the condition is no longer reversible because the tissue is dead and must be amputated. Unfortunately he still sees people come to his office in that condition.

Diagnosis of PVD starts with a general physical examination, asking the patient a few questions and feeling your arteries.

The next test is the “ankle-brachial index”: measure the blood pressure at different levels in the leg, and in the arm, and if the leg readings are much lower that indicates PVD. Another noninvasive test is ultrasound, looking at the arteries, the blood flow in them and how much plaque is there.

Next could be an angiogram, a minimally invasive test like cardiac catheterization, that can tell exactly where an artery is blocked. A CAT scan or MRA (like an MRI but for arteries) can be useful, and he showed us a couple of images - one showing an aneurysm!

Treatment is, first of all, good health: good diet (to control sugars and cholesterol) and exercise (to control blood pressure and develop collateral circulation). No smoking. Medications for cholesterol and blood pressure can help. Aspirin and Plavix make blood platelets less sticky. Pletal can reduce the symptoms but does not treat the problem.

If intervention is needed, various things can be done with a catheter inserted through a needle puncture in the groin to reach the blocked artery. Angioplasty and stenting involve inflating a balloon inside the artery and expanding a stent in it to keep the artery open - like opening coronary arteries, but the stents are bigger. Cryoplasty involves freezing the artery. Atherectomy consists of scraping away the plaque.

A blocked artery can be bypassed with another blood vessel or a piece of tubing, but this is more invasive and recovery takes much longer. Another approach is endarterectomy, often used for the carotid artery that supplies the brain: surgically opening the artery and scooping out the plaque.

The final treatment, if part of the leg has died (that’s gangrene) is amputation. It gets the patient healthy again.

Now we know that avoiding peripheral vascular disease is one more reason to live right.