heart and blood vessel disorders
Occlusive Peripheral Arterial Disease
Treatment of Occlusive Peripheral Arterial Disease
Control risk factors Exercise Medications Angioplasty Surgery to relieve or bypass the blockage Amputation of a limb if tissue dies The aims of treatment are the following: To prevent the disease from progressing To reduce the risk of heart attack, stroke, and death due to widespread atherosclerosis To prevent amputation To improve the quality of life by relieving symptoms (such as intermittent claudication) Treatments include medications such as those that relieve claudication and those that cause clots to dissolve ( Clot-dissolving drugs ), angioplasty, surgery, and other measures, such as exercise and foot care. Which treatments are used depends on Whether the blockage developed suddenly or gradually The severity of the symptoms The severity of the blockage The location of the blockage The risks related to the treatment (particularly for surgery) The person's overall health Regardless of the specific treatments used, people still need to treat disorders that are risk factors for atherosclerosis (such as high blood pressure, diabetes, and high cholesterol) and quit smoking to improve their overall prognosis. Angioplasty and surgery are only mechanical measures for correcting the immediate problem. They do not control or reverse the process that caused the disease in the first place. Regular exercise can help relieve the pain in most people with intermittent claudication. Exercise is the most effective treatment and may be appropriate for motivated people who can follow a prescribed daily exercise program. Exactly how exercise relieves claudication is not well understood, but exercise probably improves muscle function, improves blood flow, or causes new (collateral) blood vessels to grow. People with claudication should walk at least 30 minutes a day at least 3 times a week, if possible. For most people, following this routine increases the distance they can walk comfortably. Discomfort felt during walking is not dangerous. When discomfort is felt, a person should stop walking until the discomfort subsides and then walk again. The total walking time (excluding rest periods) must be at least 30 minutes to improve walking distance. Exercise is usually most effective when it is supervised by a trained therapist in a Overview of Rehabilitation . Doctors recommend that people with claudication undergo an Good foot care is important. It helps prevent wounds or foot ulcers from becoming infected and painful or resulting in gangrene. Good foot care also helps prevent amputation. Self-care measures include Inspecting the feet daily for cracks, sores, corns, and calluses Washing the feet daily in lukewarm water with mild soap, and drying them gently and thoroughly Using a lubricant, such aslanolin, for dry skin Using unmedicated powder to keep the feet dry Cutting toenails straight across and not too short (a podiatrist may have to cut the nails; the podiatrist needs to know that the person has peripheral arterial disease) Having a podiatrist treat corns or calluses Avoiding adhesive or harsh chemicals to remove corns or calluses Changing socks or stockings daily and shoes often Wearing loose wool socks to keep the feet warm Not wearing tight garters or stockings with tight elastic tops Wearing shoes that fit well and have wide toe spaces Avoiding open shoes or walking barefoot Asking the podiatrist about a prescription for special shoes if the feet are deformed Not using hot water bottles or heating pads Not soaking feet in hot water or chemical solutions Foot ulcers require meticulous care. Such care is needed to treat infection, to protect the skin from further damage, and to enable the person to continue to walk. A foot ulcer must be kept clean. It should be washed daily with a mild soap or antibacterial solution and covered daily with clean, dry dressings. The legs should be kept below the level of the heart to help improve blood flow. People with diabetes must control blood sugar levels as well as possible. As a rule, anyone with poor circulation to the feet or with diabetes should have a doctor check a foot ulcer that is not healing after about 7 days. Often, doctors prescribe an antibiotic ointment. If foot ulcers are not healing, a person may need complete bed rest. If bed rest is required, bandages with heel pads or foam-rubber booties should be worn to prevent bedsores ( Pressure Sores ) from developing on the feet. The head of the bed should be raised 6 to 8 inches (about 15 to 20 centimeters) and the legs kept at or below heart level, so that gravity helps blood flow through the arteries. If the ulcer is infected, doctors usually prescribe antibiotics to be taken by mouth, and the person may need to be hospitalized. Medications to treat diseases, such as high blood pressure, diabetes, and high cholesterol, that cause peripheral arterial disease may be given. Other medications may be given to dissolve blood clots or prevent new clots from forming. The most commonly used medications areaspirinandclopidogrel, which decrease the risk of blood clot formation. Aspirinorclopidogrelis usually given because these medications help prevent clot formation and reduce the risk of heart attack or stroke. They modify platelets so that they do not adhere to blood vessel walls. Normally, platelets, which circulate in the blood, gather and form a clot to stop bleeding when a blood vessel is injured. Recently, combiningaspirinwith a low dose of the direct oral anticoagulantrivaroxabanhas been found to be helpful in treating occlusive peripheral arterial disease. Medications such aspentoxifyllineorcilostazolare taken by mouth to treat claudication. These medications may increase blood flow and thus the oxygen supply to muscles. Either medication must be taken for 2 to 3 months to determine whether it is effective. However, the usefulness ofpentoxifyllineis now in doubt, and many experts no longer recommend its use. In contrast,cilostazolmay result in a 50 to 100% increase in the distance that can be walked without pain.Cilostazolshould not be used by people with heart failure. A class of drugs called angiotensin-converting enzyme inhibitors, helps blood vessels dilate and sometimes improve blood flow. Angioplasty to widen a blood vessel is sometimes done immediately after angiography. When a blockage occurs suddenly, angioplasty must be done as soon as possible to prevent irreversible loss of limb function or amputation. Angioplasty may be done to relieve symptoms and thus postpone or avoid surgery. Sometimes it is used in combination with surgery or a procedure to remove a blood clot. Percutaneous Coronary Intervention consists of inserting a catheter with a balloon at its tip into the narrowed part of the artery and then inflating the balloon to clear the blockage. To keep the artery open, doctors may insert a permanent wire mesh (a stent) into the artery. Some stents contain drugs that are slowly released (drug-eluting stents) and prevent recurrence of the blockage. Angioplasty is usually done as an outpatient procedure. Angioplasty is rarely painful but may be somewhat uncomfortable because the person has to lie still on a hard table. A mild sedative, but no general anesthetic, is given. The success of angioplasty varies, depending on the location of the blockage and the severity of peripheral arterial disease. Afterward, the person is given medication (such asaspirinorclopidogrel) to help prevent clots from forming in the arteries of the limb and to prevent a subsequent heart attack and stroke. Also, Doppler ultrasonography is done regularly to monitor blood flow through the artery and thus detect whether the artery is narrowing again. Angioplasty cannot be done successfully if too many areas of an artery are narrowed, the narrowed section is too long, or the artery is severely and extensively hardened. After angioplasty, surgery may be needed if a blood clot (thrombus) forms in the narrowed area, if a piece of the clot (embolus) breaks off and blocks an artery downstream, if blood seeps into the lining of the artery causing a bulge inward that blocks blood flow (a disorder called dissection), or if severe bleeding occurs. Other devices—including lasers, mechanical cutters, ultrasonic catheters, and rotational sanders—can be used instead of a balloon catheter during angioplasty, but none appears to be more effective. Surgery to remove the blockage or bypass surgery (see figure) may be done if other treatments do not relieve claudication. Surgery is usually done to avoid amputation of a leg when blood flow is greatly reduced—that is, when claudication is incapacitating or occurs during rest, when wounds do not heal, or when gangrene develops. Surgery to remove blood clots (thromboendarterectomy) can be done when thrombolytic medications are ineffective in dissolving the clot or too dangerous. Surgery to remove atheromas (endarterectomy) or other blockages may also be done. Bypass surgery may be done to treat arteries that are narrowed or blocked. In this procedure, blood is rerouted around the affected artery—for example, around part of the femoral artery in the thigh or part of the popliteal artery in the knee. A graft consisting of a tube made of a synthetic material or part of a vein from another part of the body is joined to the blocked artery above and below the blockage. Alternatively, bypass surgery may be done. In bypass surgery, a graft consisting of a tube made of a synthetic material or a part of a vein from another part of the body is joined to the blocked artery above and below the blockage. Thus, blood is rerouted around the blocked artery. Another approach is to remove the narrowed or blocked section and insert a graft in its place. Usually before surgery, doctors assess heart function and blood flow through the heart to determine the relative safety of surgery, because many people with occlusive peripheral arterial disease also have Overview of Coronary Artery Disease (CAD) . Rarely, amputation of the leg is required if part of a limb has died or if there is no good way to restore blood flow to the area. Amputation is done to remove infected tissue, relieve unrelenting pain, or stop worsening gangrene. Surgeons remove as little of the leg as possible. Preserving the knee is particularly important if the person plans to wear an artificial leg. Physical rehabilitation after Rehabilitation After Limb Amputation is important. Exposure to cold, which causes blood vessels to narrow (constrict) and further restricts the blood reaching the tissue, should be minimized. Avoiding drugs and medications that cause blood vessels to constrict is also important. These includeephedrine,pseudoephedrine, andphenylephrine, which are components of some sinus congestion and cold remedies, and illicit drugs includingcocaineand amphetamines. The injection of stem cells into the legs of people with severe deficiencies in blood flow is currently being studied. Stem cells may stimulate the growth of new blood vessels, thereby reducing the need for amputation. 