Centers of Excellence in Interventional Cardiology and Radiology

Interventional radiology

​Peripheral arterial disease

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Our center has saved the lives of over 4,500 patients in the last 4 years

The most modern equipped angiography room , an exceptional medical team

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Only 24 hours hospitalization

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Generalities

Peripheral arterial disease (PAD) is a common condition in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD).

Why does it happen?

The fatty deposits, called atheroma, are made up of cholesterol and other waste substances. The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis. People with PAD can experience painful aching in their leg muscles during physical activity because the muscles are not receiving the blood supply they need. Like all tissue in your body, muscles in your legs need a constant supply of blood to function properly. When you are using your leg muscles, the demand for blood increases four-fold. However, if the arteries in your legs are blocked, the supply of available blood cannot meet the demand.

The arteries supplying the lower extremities are usually affected, but sometimes the arteries of the upper extremities mey be affected as well. Left untreated, the lesions progress and the tissues supplied by these arteries undergo important, sometimes irreversible impairment.

PAD affects the inferior limbs arteries, but may also affect the neck arteries (carotid arteries), the renal arteries, and those vascularizing the digestive tube (caeliac artery, the superior and inferior mesenteric arteries).

Persons having PAD have not only an increased risk of myocardial infarction and stroke, but may even need aggressive treatment such as limb amputation.

Symptoms of peripheral arterial disease

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Many people with peripheral arterial disease (PAD) do not have any symptoms at all. However, you may feel painful aching in your leg muscles triggered by physical activity such as walking or climbing stairs. The pain usually develops in your calves, but sometimes your hip, buttock or thigh muscles can be affected. The pain can range from mild to severe. The pain will usually go away after 5–10 minutes when you rest your legs. Other symptoms of PAD may include:

  • hair loss on your legs and feet
  • numbness or weakness in the legs
  • brittle, slow-growing toenails
  • ulcers (open sores) on your feet and legs, which do not heal
  • changing skin colour on your legs, turning pale or bluish
  • shiny skin
  • the muscles in your legs may shrink
  • men may develop impotence (erectile disfunction)

PAD can cause a number of signs and symptoms, such as:

  • shiny skin
  • brittle toenails
  • hair loss on your legs and feet
  • the pulse in your leg being very weak or undetectable
  • leg ulcers

The clinical examination usually finds the specific signs of the disease (the 5 Ps): absence of thepulse, paralysis, paresthesias, pain, pallor.

Some symptoms may suggest that the supply of blood to your legs has become severely restricted and you may need to see a doctor urgently.These include being unable to move muscles in the affected leg

  • a sudden loss of normal sensation in the affected leg (paralysis)
  • feeling a burning or prickling sensation in the affected leg (paresthesias)
  • your toes or leg suddenly turns white or blue
  • the skin on your toes or lower limbs becomes cold and numb, and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain

Diagnosis

The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assessing how well you are responding to treatment.

Additional hospital-based tests that can be used include other imaging modalities such as angioCT, angioMRI, angiography.

PAD treatmentincludes lifestyle changes and risk factor reduction, medical treatment, and sometimes surgical or interventional procedures.

The optimal treatment is established depending on the severity of the disease and other associated medical conditions which may increase the surgical risk.

-The surgical procedure (by-pass graft) involves the formation of a ‚path’ (the so called graft) – blood vessels are taken from another part of the body and used to bypass the blockage in an artery.

-The interventional procedure (angioplasty) – the blocked or narrowed section of the artery is widened by inflating a tiny balloon inside the vessel. An angioplasty is less invasive (it does not involve making major incisions in your body). You also feel less pain after an angioplasty.

Indications

• moderate or severe disease – may improve symptoms, stop disease progression, and avoid amputation.

• high surgical risk patients.

• claudication unresponsive to medical treatment.

• rest pain.

• ischemic skin lesions (i.e. ulcerations).

Procedure

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is performed by a technique similar to angiography, under local anesthesia.

After anesthesia, a small incision is made inguinally to visualise the femoral artery, then a sheath is introduced in the femoral artery (a plastic tube allowing the handling of all the necessary equipment).

Then, heparin is administered (an anticoagulant that prevents the formation of blood clots during the intervention). A thin wire (guide) is being introduced through the sheath, reaching the lesion, then passing the narrowed segment, then a catheter (another tube) is introduced over the wire, thus reaching the narrowed segment. After the catheter is positioned (the position of the catheter is verified radiologically) a balloon is inflated with diluted contrast agent to dilate the narrowed lesion, then a stent is placed to maintain the vessel open. At the end, the result is verified angiographically. Sometimes repeated dilations of the stent are needed after the stent has been placed in the desired position. Once the procedure is over, all the catheters are carefully retired. The sheath may be left in place for another several hours.

Is it painful?

No. The procedure is made under local anesthesia, so the patient will not feel any pain during the intervention; after the procedure, antialgic medication is administered if needed.

How long does it take?

The whole duration of the procedure is between 1-2 hours and is performed in the catheterisation laboratory.

Risks

Complications are rare:

• allergic reactions to administered compounds

• reactions to anesthetic drugs

• arteriovenous fistulas

• minor bleeding at the puncture site; hematoma at the puncture site

• fever

• headache, migraine

• infection

• aortic wall lesion or lesion of the artery through which the catheters are introduced; aortic dissection

• intrastent restenosis

• migration of the stent

Before procedure

The pre procedure assessment establishes what type of treatment is indicated (interventional orsurgical). In order to establish the best treatment option certain exams may be needed, as mentioned above, but the main diagnostic test is the angiography.

Before the intervention, the interventional cardiologist must be prevented of any prior history of allergic reactions to drugs or other compounds, or if there is a suspicion of pregnancy. Current medication must be clearly specified (especially anticoagulant medication –like Sintrom, or antiplatelet drugs – aspirin, Plavix), and any other medical conditions must be mentioned.

There are no absolute contraindications to angiography, but certain precautions will be taken in the case of patients having a severely abnormal renal function.

Sometimes, the cardiologist may recommend antiplatelet therapy before the procedure.

Blood tests are taken (hemoglobin level, coagulation tests, renal function tests, or other specific tests)

The patient is admitted the day before the intervention, and he/she should not eat/drink before the procedure.

After procedure

Since the procedure is minimally invasive, the postprocedural recovery is usually very fast.

After the procedure, the patient is monitored in the intensive care unit, then in the chamber where he/she will be hospitalized. Bed rest is necessary for 12-24 hours (bending of the foot will be prevented to avoid local complications at the puncture site).

The majority of patients can leave the hospital the following day, and they can recommence their usual daily activities (however, physical effort avoidance is recommended for a period of time). Indications about recovery and postprocedural treatment will be clearly specified to all patients before being discharged.

Important!

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PAD is a frequent disease, which may be asymptomatic for a long time; when it becomes symptomatic, it usually is the manifestation of serious disease. Left untreated, it can affect the quality of life and may progress to serious lesions requiring even the amputation of a limb. Therefore, early treatment is recommended in order to stop the disease progression and improve the symptoms.

Interventional treatment by balloon angioplasty and stent placement is a modern, minimally-invasive treatment, which permits rapid recovery and reduced hospitalization.

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