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Sample Consultation for Peripheral Arterial Disease

This hypothetical consultation about peripheral arterial disease is presented for purposes of general information. This hypothetical consultation is not medical advice. If you think you may have this condition, please see your doctor to discuss your individual case and the exams and treatments that are best for you.

Background

Peripheral arterial disease (PAD) is a common circulatory problem that affects 10 million people in the United States. PAD is present in 1 of every 20 adults who are over 50. In PAD, the arteries that supply blood to the arms and legs become partially blocked. As a result, the affected limbs do not receive an adequate blood supply.

Consultation

Doctor: Good morning. What can I do for you today?

Patient: I’m having some pain in my legs when I walk. My primary care physician has worked with me on this, but we have not made much progress. At my insistence, he has referred me to see you.

Doctor: Okay. Let me ask you a few questions. First, how old are you?

Patient: I am 64 years old. 

Doctor: How long have your legs been bothering you? 

Patient: I would say that I first noticed it around the age of 60, so it’s been about four years. 

Doctor: Can you describe a bit about when this pain comes on? What makes it better or worse?

Patient: Well, I’m not a fan of exercising. I know that I’m overweight, I smoke, and all that stuff.  If I do try to go for a walk with my wife, it definitely starts hurting after about 100 yards or so. I have to stop for two or three minutes and then I’m still only good for another 100 yards. So, I really can’t walk. And, you know, lately even just taking my dog for a short walk on flat ground, my legs start to hurt me

Doctor: It sounds like it’s been getting worse over the last few years, from what you are describing.

Patient: How far I can walk is less and less. And the pain is increasingly uncomfortable, yes. 

Doctor: Have you ever had a heart attack? 

Patient: No.

Doctor: From your symptoms, history of smoking, and sedentary lifestyle, it sounds like you may have what is called peripheral arterial disease. That refers to plaque buildup in the artery, in this case in your leg somewhere, that is obstructing blood flow whenever you try to exercise. 

Patient: You mentioned the word “plaque.” I’m not sure that I know what that is.

Doctor: Plaque is essentially a manifestation of a condition called “atherosclerosis,” which is hardening of the arteries. It is a buildup of hard, gritty material that starts causing a narrowing of the artery in which the blood is traveling. It can affect you in anywhere in your body - your heart, the arteries going to the brain, or the arteries going to the legs. In this case, you are having a manifestation in a specific place, but it is a much more systemic disease.

Patient: So the same thing that killed my father with his heart attack, that same disease is now in my legs?

Doctor: Exactly. 

Patient: What do we need to do?

Doctor: Well, the first thing is to confirm that this is the cause.  Most of the time, we can tell that just based on examining you and what you are describing. But there are a couple of other conditions that can masquerade as this, so to really confirm it we first like to start off with a test in which we measure blood pressures up and down your legs. That tells us whether there is a reduction in blood flow compared to your arms, for instance. That would indicate that there is a blockage somewhere. If it is confirmed, the next step would be to get an arteriogram, which would show us clearly where the blockages are and what the options are for treating them. 

The doctor performs a physical examination and orders an arteriogram. One week later, the patient returns to the clinic to discuss the results with the doctor.

Doctor: Good to see you again. On your examination, I could feel that your pulses are diminished in the legs compared to what a normal pulse exam would feel like. That is certainly an indication that you have some blockage in your artery somewhere. 

The arteriogram which you and I did last week shows that you have a blockage in the artery in your thigh on one leg. That blockage is the typical kind of blockage we see as people get older and it is the most common cause of having leg pain upon walking. 

Patient: How big is that blockage?

Doctor: It is about 5 centimeters long, but the length of it is less important than the location and the options for treating it.

Patient: And mine is where?

Doctor: Yours is right in the mid-thigh. There are three options. First, we can do nothing and have you go on a walking program. However, it sounds like you have tried this before and it was not successful. Second, we can treat it without an operation, using an intervention that we call an endovascular approach. That might involve doing a balloon angioplasty of that area or putting a stent in the artery to improve the blood flow through it. The third option is to do a bypass graft using either your own vein or a synthetic graft. The area of obstruction is bypassed so that the leg gets direct blood flow. (Read more about vascular and endovascular surgery)

Patient: Why can’t you just cut it open and take out the plaque? 

Doctor: Technically, you can do that, but it doesn’t work well because the vessels are small.  When you open up the artery and take out the plaque, most of the arterial wall is involved with it, so you end up not leaving much. So it is safer and more durable to do a bypass or angioplasty.

Patient: Well, I have tried the walking thing and it’s clearly not working.  Between the other two choices, which one do you recommend for me?

Doctor: I would recommend that we start with an endovascular therapy approach.  There are several benefits to doing it that way.  There is no recovery time, because it is not an open surgery, and it will give you benefit if the procedure is successful. The down side is that it tends to not be as durable as an operation. 

Patient: What do you mean by “not as durable?”

Doctor: I mean that it may not take care of the problem over the long term. But if symptoms begin to reappear six months to years later, we can either re-treat it with an angioplasty or, if you decide you don’t want to deal with it, we can always do a bypass. So we don’t lose anything by trying this approach first.

Patient: How is this done?  s it done here in the office?

Doctor: No, it is done in the operating room under local anesthesia. We numb up the skin and we introduce a small needle and then we put a tube called a catheter into the artery, and we inject contrast dye. That catheter then allows us to get a picture of the artery. Then we pass a wire across the blockage and use a balloon to open the blockage up.

Patient: If you are using only a local anesthetic on my skin, will I feel pain in the artery when you’re opening the blockage up?

Doctor: No. There are no nerve endings in the artery, so you will not feel the procedure. 

Patient: Will I have to stay in the hospital overnight?

Doctor: You can usually go home the same day.

Patient: Is this the same kind of thing they do on hearts? 

Doctor: Yes, the principle is the same. Except that we try not to put the stents in unless you really need it. 

Patient: What kinds of complications might I face?

Doctor:  I’m glad you asked that. Although it’s rare, there are complications that can occur. Anytime you are given a contrast dye, it can hurt the kidneys if you have any history of kidney problems. In most cases this is temporary. The risk is higher if you are older and diabetic. You can get some bleeding from the puncture site where we put in the needle initially.  We take utmost care, but it does happen about 1 percent of the time. The third thing that can occur is that in the process of trying to open up this blockage. Very rarely, but it can happen, a piece of the plaque can break off and cause an obstruction of an artery downstream. In that case, we may need to do some additional work through endovascular means. Rarely, we may have to do an operation to get blood flow back to the leg.

Patient: How long does the procedure take?

Doctor: It takes anywhere from about 45 minutes to 3 hours.

Patient: What happens afterwards?

Doctor: We will have you remain lying down for a period of time. We’ll observe you to make sure that you are not having any complications, and then when you’re ready, we will send you home.

Patient: When will I resume walking?

Doctor: You can start walking the same day or the next day. 

Patient: Will there be any limits on what I can do?

Doctor: For a few days after the procedure, you should not lift anything too heavy. There are no other limits.

Patient: When can I go back to work? 

Doctor: You can go back to work the next day if you like.

Patient: Will I have to take blood thinners?

Doctor: You don’t usually need to take blood thinners, but you certainly would be advised to take an aspirin every day. 

Patient: How much aspirin do you recommend?

Doctor: A full adult aspirin, a 325 mg tablet, every day.

Patient: You have mentioned an open procedure, which I believe you called a bypass. What exactly is involved in that?

Doctor: We insert a graft to carry blood around the blockage.  The graft goes from above the blockage to below the blockage.  In that way, we bypass the obstruction. 

Patient: What is the graft made of?

Doctor: It is best to use your own vein for the graft. If your vein is not of good quality, we can use a synthetic graft. We sew this graft into the normal sections of the artery above and below the blockage, providing direct blood flow and bypassing the area of disease.  It is usually done under an epidural anesthetic or general anesthesia, so the anesthetic risk is a little higher than it is with an endovascular approach. The other major difference is that you are usually in the hospital for 3 to 5 days, depending on how well you recover from the operation. 

Patient: So this is obviously less comfortable than the endovascular method?

Doctor: It is.

Patient: Do you have to make a big incision?

Doctor: They are not big incisions.  There are two incisions about three inches long.  It is an operation, so recovery time is a little bit longer, but it tends to be more durable than the endovascular procedure.

Patient: I think I would like to do the endovascular treatment. How do I go about scheduling it?

Doctor: My office will schedule it for you.We’ll need to get some preliminary blood tests today and then we will set it up for you.

Patient:   Great!

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