Treatment
The treatment depends on the symptoms, which are considered for convenience into the following:
Mild to moderate claudication
The treatment is conservative, as in around one third of affected persons, the symptoms will be alleviated with treatment.
General changes to lifestyle, such as:
- Stopping smoking
- Regular exercise. Walking 80% of the claudication distance, then resting, and then resuming walking. The claudication distance may be improved due to the probable development of collateral circulation, and because of improved muscle function because of increased muscle use. This must be for 30 minutes a day, at least 3 times a week.
- Care must be taken to not injure the leg because of the impaired healing ability of the affected limb(s) as a result of the reduced circulation, the injury is likely to take a long time to heal, and may turn into a long- standing ulcer.
- Care to avoid exposure to cold
- Avoid medications that reduce peripheral circulation such as beta blockers and medications that contain ephedrine or pseudo ephedrine.
Treatment of cardiovascular risk factors:
- Long term treatment with daily Aspirin (75mg to 150mg per day) and/or Clopidrogel (75mg per day). This is to prevent the formation of thrombus (clot) on already existing arteriosclerotic disease which would precipitate acute ischaemia of the limb. It is also to prevent heart attack and stroke. Click here for Stroke guidance treatment page.
- Treat hypertension (high blood pressure). Click here for Hypertension guidance treatment page.
- Treat hyperlipidaemia. Click here for IHD guidance statins page.
- Test for, and provide optimal treatment for Diabetes Mellitus. Click here for Diabetes guidance treatment page.
Disabling Claudication
This is when there is a markedly reduced exercise tolerance, and when daily life is affected, because the narrowing of the artery (arteries) involved has become more severe.
Percutaneous Balloon Angioplasty
This usually takes place after angiography. A catheter with a balloon at its tip is inserted into the affected artery in the leg, (femoral artery) for example, but can be used in the iliac and upper limb arteries as well. The balloon is then inflated to crush the area of atheromatous blockage, dilating the artery.
The success rate has improved; it is less invasive, and easier to repeat than by-pass surgery, and it can improve outflow.
In the aorto- iliac vessels only, a tiny mesh stent is put in place to keep the lumen of the artery open, especially in the part of the artery below the area of blockage. This is to prevent dissection of the artery wall, and possible subsequent aneurysm formation.
Stents (tiny mesh tubes) are not used below the groin. As they are not helpful and would be likely to poke through the skin, on movement of the lower limb.
This procedure (leg arteries) can be performed under local anaesthetic.
The diagram below shows bilateral common iliac stenoses
This diagram shows a Balloon Angioplasty insertion
This diagram shows the situation Post angioplasty.
For those with rest pain
Arterial Surgery
This usually means bypass surgery where a graft which is either made from synthetic material or from a vein in the body acts like a flexible pipe, being attached to the artery both above and below the blockage, diverting the blood and ensuring circulation in the limb.
However, in larger arteries such as the aortic and iliac arteries and the femoro- popliteal arteries, the narrowed and blocked section of artery may be removed, and replaced by a graft which is made of synthetic material.
However, surgery can also mean thromboendarterectomy (to remove blood clots) and endarterectomy (to remove atheroma).
The patient must be examined with a view to fitness for anaesthetic and surgery as a person with peripheral vascular disease is likely to suffer from coronary artery disease as well and the general condition may not be good.
The success of the operation depends on the outflow and the outlook for surgery below the knee is not so good as there can be problems at the area of anastomosis (joining) of the vessels and the vessel can become blocked with clot.
Severe Critical Ischaemia
At this stage the person would have severe, multilevel disease and limb- threatening ischaemia manifested by rest pain and skin ischaemia, non-healing ulcer(s) and infection and/or gangrene.
Conservative measures would have been tried as well as other forms of treatment which may include:
- Treatment with vasodilators (Nifidepine - slow release 10mg per day, Trasiderm- Nitro patches applied above the area of the ischaemia - 5mg per leg every 12 hours, prostaglandin analogues and naftidrofuryl oxalate given intra- arterially).
- Lumbar sympathectomy, either by surgical means or by aqueous phenol injections. This is of use in healing ulcers only, by improving blood flow to the skin, but it does not improve blood flow to muscle, so it is not useful in intermittent claudication.
Surgery is performed to save the limb, but amputation may be necessary.
These people with severe disease have an annual mortality from cardiovascular diseases of 25%, and their heart should be investigated.
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Amended April 2008
