Peripheral Arterial Disease

Peripheral arterial or vascular disease  disease (PAD, is a very common condition develops most commonly as a result of atherosclerosis, or hardening of the arteries, which occurs when cholesterol and scar tissue build up, plaque inside the arteries. This is a very serious condition. The clogged arteries cause decreased blood flow to the legs, which can result in pain when walking, and eventually gangrene and amputation.
Patients with PAD are at increased risk for heart disease, aortic aneurysms and stroke. PAD is also a marker for diabetes, hypertension and other conditions.

The most common symptom of PAD is called  claudication, which is painful cramping in the leg or hip that occurs when walking or exercising and typically disappears when the person stops the activity.

  • Numbness
  • Burning or aching pain in feet or toes when resting
  • Sore on leg or foot that won’t heal
  • Cold legs or feet
  • Color change in skin of legs or feet
  • Loss of hair no legs
  • Have pain in the legs or feet that awakens you at night

Many people simply live with their pain, assuming it is a normal part of aging, rather than reporting it to their doctor.

These conditions we treat minimally invasive, with catheters , angioplasty and stents, without major surgery.

What is a percutaneous transluminal angioplasty (PTA)?

A PTA is a therapeutic interventional radiology procedure in which a stenosis ( a narrowing of an artery or vein) is opened using a balloon tipped catheter that is inflated to the normal size of the vessel. A stent is usually used to keep the vessel open. A stent is a small, metal, tube shaped scaffold. The stent is pre-mounted on a balloon catheter, and then the balloon is inflated at the site of the stenosis. The balloon is then deflated and removed, leaving the stent in place. A self-expanding stent may also be used. A more detailed explanation of stents follows under What is a stent?

Why is a PTA necessary?

Fatty deposits can accumulate in your blood vessels, reducing blood flow and in some cases, blocking it completely. These deposits may break off into pieces, forming “traveling clots” called emboli that can cause a heart attack or stroke. A PTA can open blocked vessels, restoring blood flow, and reducing these risks.

What is a stent?

A stent is manufactured in one of two different configurations. The first type is called a balloon expandable stent. The stent is securely mounted on a balloon catheter and the catheter is advanced to the level of the narrowing. The balloon is then inflated which presses the stent against the vessel wall. The balloon is then deflated and the catheter removed. The second type is called a self-expanding stent. This stent is “spring-loaded” into a catheter and is secured to the catheter with an overlying sheath. The stent and catheter are advanced to the level of the narrowing, and once positioned, the sheath is pulled back allowing the stent to expand. The stent will expand to the normal size of the vessel. The catheter is then removed. The musculature of the vessel holds the stent in place. After a period of time, the vessel forms a cellular layer over the stent, so the stent basically becomes a part of the vessel. Because stents are made of stainless steel or metal alloys, they resist rust.

How do I know if I am a Candidate for a angioplasty?

Angioplasty is often used as an alternative to by-pass surgery. You should consult your physician to determine which form of treatment is best for you based on your severity of disease. Ask your physician if you should consult an Interventional Radiologist to see if you are a candidate for an angioplasty.

How is the procedure performed?

Several days prior to the procedure you will be given instructions from the Interventional Radiologist’s office staff. You will need to have blood drawn at the hospital or a local clinic for testing. The staff will instruct you on how to prepare for the procedure including modification of your medications if necessary.

The procedure is performed in the interventional radiology suite. First, the nurse will give you a sedative through the intravenous line, which will be placed in your arm. You will feel relaxed and sleepy, but you will be awake throughout the procedure. The Interventional Radiologist will numb an area of your groin with a local anesthetic. He/she will then place a small, thin tube called a catheter into the femoral artery, which is a large artery in the groin. You will not feel any discomfort when the catheter is placed, but you may initially feel some slight pressure. The Interventional Radiologist will then advance the catheter to the area of the narrowed vessel. An angiogram, which an x-ray procedure that studies the arteries or veins, will then be performed to determine the location of the vessel stenosis. Because arteries and veins cannot be seen under x-ray, contrast media (x-ray dye) is used to “visualize” the vessels under x-ray.

Once the narrowed vessel has been identified, the Interventional Radiologist will then exchange the catheter for a stent delivery catheter or a balloon catheter. The Interventional Radiologist will direct the appropriate catheter to the narrowed area and either deploy the stent or inflate the balloon to open the vessel. The narrowing is usually caused by a build up of plaque in the vessel. The stent/ balloon pushes the plaque against the side of the vessel, thereby opening the vessel.

After the procedure, the catheter will be removed and the puncture site manually compressed for about 20 minutes to prevent bleeding. After the procedure you will need to lie in bed for 5 to 6 hours. You should plan to spend one night in the hospital for observation. More specific post-procedure instructions will be given to you prior to your discharge.

Stent Graft Repair of an Abdominal Aortic Aneurysm

What is an abdominal aortic aneurysm (AAA)?

The aorta is the largest artery in the body. It carries blood from the heart to the rest of the body. The aorta is normally 2 to 3 centimeters in size. An aneurysm is a weakening in the vessel wall that results in dilatation, or “ballooning” of the vessel wall. If left untreated, an aneurysm may continue to grow and rupture, resulting in life-threatening bleeding. Aneurysms can occur anywhere in the body. An AAA occurs in the aorta between the kidneys and the pelvis. Small aneurysms rarely rupture, so your physician may decide that it is best to just monitor its development through periodic check-ups rather than repair the aneurysm. However, if the aneurysm continues to grow beyond 5.0 centimeters, your physician may recommend treatment.

How is an abdominal aortic aneurysm (AAA) treated?

Conventional Surgical Procedure
The open surgical approach involves making a large incision into the abdomen in order to expose the aorta and its aneurysm. Clamps are applied to the arteries above and below the aneurysm so that the artery may be directly cut open. The section of artery that is abnormally enlarged is replaced by a synthetic tube, which the vascular surgeon sews into place. The clamps are removed and blood flow is restored through the repaired artery. This operation has enjoyed durable success. However, it is a major surgery. There is an approximately 5% chance of fatal complications. The patient usually spends 7 to 10 days in the hospital and is not back to feeling like their regular self for 2 to 3 months.

Endovascular Stent-Graft Procedure 
Recent advances in minimally invasive surgery have made the endovascular repair of an AAA possible. Stent-graft repair is usually performed by an Interventional Radiologist and Vascular Surgeon team in the operating room. The procedure is usually performed under general or spinal anesthesia. Incisions are made in each of the two groins, where the arteries at these locations are exposed. Under x-ray guidance, a delivery catheter (tube) containing a vascular graft iel in your leg into your aorta. At the tip of the catheter are a deflated balloon and a tightly wrapped cloth graft. When properly positioned, the graft is secured in place by inflating the balloon and opening the graft to the diameter needed to prevent blood flow into the aneurysm. The balloon is then deflated and removed along with the catheter. At each end of the graft are hooks that help secure it to the inner walls of the aorta. The graft allows blood flow to continue through the aorta to the arteries in the pelvis and legs, without filling the aneurysm.s guided up through a blood vessel.

Most patients remain in the hospital 1 -3 days following the procedure, and then require approximately 2 weeks recovery at home. The successful insertion of an aortic endograft has less operative stress on the body, no painful abdominal incision, less blood loss, a lower operative mortality, reduced length of hospital stay, and much faster recovery when compared to the open surgical approach. Over time, the aneurysm may shrink, minimizing future threat of rupture. However, there remains a 5-10% chance that the stent-graft may not adequately exclude all blood from flowing in the aneurysm. This is called an “endoleak”. In these unusual occurrences, another catheter based minimally invasive procedure or other surgery may become necessary. Because of this, a more intensive follow-up is required. CT scans are periodically obtained. It is important that patients adhere to follow-up appointments with their doctor and have regular CT scans during the first year after the procedure to ensure that the stent-graft is properly positioned and effective.