Claudication

People who have peripheral arterial disease (PAD) or poor circulation commonly suffer from atherosclerosis.  When atherosclerosis, also known as “hardening of the arteries” develops, it is due to the lining of the artery becoming rough and thickened.  The thickening of the arterial walls is caused by a build up of fatty material or plaque, such as cholesterol.  Clogging the arteries and decreasing blood flow.  Plaque build up does not occur overnight but develope over many years.  Ulcers may also form inside an artery.  These ulcers have a rough surface which may cause particles of plaque or blood clots to dislodge into the circulation causing blockage of blood flow.

Atherosclerosis can cause the arteries to the legs to become narrowed or blocked; this is what is meant by lower extremity arterial disease.  Signs and symptoms of decreased blood flow to the legs depend on the location of the arteries involved and the amount of narrowing.  You may notice pain and/or cramps in the hips, thighs, or calves when walking specific distances, which is relieved by rest.  This is called claudication.  This symptom occurs when you walk because the leg muscles need more oxygen-rich blood during exercise, but are unable to get it due to poor circulation.

As atherosclerosis progresses, pain in the toes or feet may occur at rest.  This is called rest pain, and occurs because the arteries are unable to deliver enough blood to the feet at rest.  Rest pain is aggravated by elevation and improved by hanging the foot down in a dependent position.  It usually occurs at night while your feet are up on the mattress and awakens you from sleep.

The most advanced stage of arterial disease is tissue necrosis, also known as gangrene.  As the disease progresses, areas of injury may not heal and skin breakdown occurs, leading to gangrene (dead, black tissue).

Other Signs and Symptoms of Peripheral Arterial Disease (PAD)

  • Decreased hair growth on the legs and toes
  • Paleness or loss of color of the leg or foot when elevated
  • Blue/red discoloration of the foot when hanging down
  • Absence of pulses in the foot
  • Numbness, tingling, or pain in the leg, foot or toes
  • Coolness of the leg or foot
  • A sore on the foot that does not heal.

Risk Factors for Arterial Disease
Studies have been done on people with atherosclerosis, this is to help predict which people will be at a high risk of developing this disease. These people usually have one or more of the following risk factors:

  • Smoking
  • Hypertension (high blood pressure)
  • High cholesterol
  • Diabetes
  • Family history of atherosclerosis
  • Obesity
  • Inactivity

It is important to try and eliminate or minimize the risk factors that you can control, such as smoking, obesity, diabetes, and your activity level.

Diagnostic Testing

Non-invasive Venous Testing
You may eat and drink before the exam and take your usual dose of medications unless instructed otherwise.

Venous Mapping
A vascular technologist will apply gel and a probe on the skin of your leg. He/she will be looking for the presence, location, length, and size of the superficial veins in your legs and will mark these veins with a marker. A written copy will also go into your medical record. Your surgeon may use one or more of the “mapped” veins for bypass surgery. Please DO NOT wash these marks off until after your surgery.

Non-invasive Arterial Testing
You may eat and drink before the exam and take your usual dose of medications unless instructed otherwise.

Ultrasound
This type of test uses ultrasound to send high frequency sound waves into the artery which are reflected by moving red blood cells. This test is used to diagnose blockage or ballooning of the artery and is often used to check your bypass after the surgery.

Magnetic Resonance Angiography (MRA)
This test uses a large scanner with a powerful magnetic field to produce images.  It does not use needles or dye, it is painless.  The test takes about thirty to sixty minutes and requires you to lie very still in a noisy tube-like machine.  Let your doctor know if you are claustrophobic before taking this test.  This test cannot be done on people who have metal implants, such as metal plates, pacemakers, orthopedic screws, or cerebral aneurysm clips.  It is okay if you have fillings in your teeth.  Remove any jewelry or watches before the test.  This test may be used to check for blockage in your arteries if you are not a candidate for a conventional angiogram.

Pulse Volume Recording (PVR)
Blood pressure cuffs are placed at various levels on your arms or legs.  The cuffs are inflated with a standardized quantity of air.  Volume changes that occur beneath the cuff are recorded on graph paper.  From this test the general location and severity of your disease can be determined.  It takes about fifteen minutes to do this test.

Doppler
This is an ultrasound stethoscope. Your doctor or nurse will apply ultrasound gel on areas of your arm or leg to listen to the blood flow. This is used frequently after your surgery to make sure your bypass is functioning properly.

Invasive Arterial Testing

Angiogram
An angiogram is an x-ray of your arteries. This test is done to determine the exact location of disease within your arteries. It is performed by a team of physicians, physician assistants, nurse practitioners, nurses and technicians. You will meet with someone prior to the test. They will review the procedure, possible side effects, and ask you to sign a consent form. Blood work is drawn before the test to determine the ability of your blood to clot and your kidney function.

You will be required not to eat solid food eight hours before, and will need to stop liquids three hours before the angiogram.  You will receive specific instructions regarding your medications, insulin, and blood thinners from your doctor or nurse before the test.

You will not be able to drive for one day following the procedure.  Therefore you will need to make arrangements for someone to drive you home.

If you are diabetic please check your fingerstick the morning of your procedure.

For the test, an intravenous catheter is inserted into a vein in your arm and you may be given intravenous fluids and/or medications to help you relax.  The femoral artery in your groin is most often used to insert a catheter in which to inject dye; however the artery in your inner elbow or armpit may also be used.  The area is first shaven and then numbed with a local anesthetic.

A catheter is inserted into the artery and dye is injected and then x-rays are taken.  You will feel a warm sensation in your body as the dye is injected.  When the catheter is removed, the physician will apply pressure to the insertion site for approximately fifteen minutes.  The procedure takes one to one and a half hours to complete.  After the procedure you will need to be on bed rest with the affected leg or arm straight for four to six hours.  This is to prevent any bleeding at the puncture site.

The dye acts like a diuretic, or water pill, so you may need to urinate frequently.  You should drink a lot of fluids to help flush dye from your kidneys.  Notify the nurse or doctor if you have any pain, numbness or tingling during or after the procedure.

Some of our patients will need to take a medication called Mucomyst the day before the procedure.  Is is a small amount of a clear liquid with a bitter taste that can be taken in a small amount of fruit juice.

ONLY if we have indicated that you will need it, it will be taken as follows:

  • One dose at 3pm the day before the procedure
  • One dose at 7pm the evening before the procedure
  • One dose in am of procedure just prior to leaving for your test

Please let your doctor or nurse know prior to the test if you are allergic to contrast dye or shell fish.  Then we will take appropriate precautions.

ADMISSION PROCEDURE
You will be admitted on the Vascular Surgery service under the care of the Vascular Surgeons.  Your referring physician and any other medical specialists will be notified of your admission and surgery date.

If an angiogram is ordered on the day of admission, you should report to the specified area at the instructed time.  Otherwise, you will receive a phone call from the Admitting Office with instructions for your arrival.  If you do not receive a phone call by noon, please contact our office.

If you are to be admitted the day of surgery you will need to have pre-admission testing prior to your scheduled surgery.  At pre-admission testing you will meet with an anesthesiologist, and nurse.  You may have blood work, a urine test, EKG, and a chest x-ray.  They will review pre-operative instructions including fasting and medications to take the morning of surgery.

The whole procedure takes approximately two to three hours.  If you need to have any other testing we will try to schedule it the same day.  If you are to be admitted the day before your surgery the above tests will be performed when you are admitted.

For same day surgery the hospital will notify you the day before your surgery after 2:00pm to tell you what time to report to the hospital.  If your surgery is on a Monday you will be notified the Friday before your surgery.

TREATMENT FOR LOWER EXTREMITY ARTERIAL DISEASE

Risk Factors
Eliminate or minimize your risk factors for atherosclerosis; don’t smoke, see a doctor to control your blood pressure or diabetes, eat a low fat and low cholesterol diet, lose weight if overweight, and perform regular exercise.

Angioplasty and Stenting
This procedure may be used for short areas of blood vessels narrowing.  This would be done at the same time as your angiogram if the doctor felt that is would be successful.  A small catheter with a balloon is inflated and pushes the plaque against the inner wall of the artery making room for more blood flow.  Then a stent is left in place to keep the artery dilated.  The balloon is deflated and the catheter is removed.  Dye is then injected and x-ray pictures are taken to make sure the artery has opened adequately.  You will stay overnight in the hospital.

An antiplatelet agent is usually given prior to the procedure and for some time after 1-3 months or longer.  These are used to reduce the risk of platelet aggregation (clumping) and thrombus (clot) formation.  Plavix and aspirin are common antiplatelet agents that are generally prescribed before and/or after your stenting.

Surgery
Depending on the exact location and extent of your blockage the doctor will determine what surgery will be performed.  Your doctor will have a general idea of what surgery needs to be performed after talking to you about your symptoms, and reviewing your tests.  There are a few different types of surgery available.

What can I expect after surgery?
Postoperatively you will spend some time in the Post Anesthesia Care Unit (PACU) or Recovery Room, approximately two to three hours. Then, you will be transferred to a hospital room

Days 1 and 2 - Immediately after surgery you will be on bed rest and will not be allowed to eat or drink.  Usually the following morning after being seen by the doctor you will be allowed out of bed to walk, and can resume eating.  When you are out of bed, it is important to keep your legs elevated to minimize swelling.  It is normal to have some swelling in the operative leg.  If you have an urinary catheter, it will be removed the day after surgery.  The nursing staff will keep a pillow under your legs to prevent pressure on your heels.  It is important to keep pressure off of your heels at all times while you’re in bed or in a chair.  Physical therapy will be ordered if the nursing staff and/or physicians feel it is necessary for your recovery.

Days 3 to 7 - You will be encouraged to walk.  The nurses will assist you until you are walking steadily.  You may need a walker for safety initially.  Once you are walking and moving around, and your doctor feels you are ready, you will be discharged from the hospital.  The time of discharge is 10:00am

DISCHARGE INSTRUCTIONS

What can I expect when I go home?

  • No driving for two weeks after discharge
  • It is normal for you to feel tired.  This may last for four to six weeks.
  • It is important for you to push yourself to get up everyday, get dressed, and take short, frequent walks.  You should gradually increase the distance of your walks.
  • When resting, you should elevate your legs.  It is normal to have swelling in the leg that was operated on.  The swelling may last up to two months.
  • Avoid prolonged standing as this will increase the swelling.
  • Before leaving the hospital, you will be given a prescription for pain medication.  It is important to take the pain medication to allow you enough comfort to walk and to perform light duties.

Wound Care

  • Along your surgical incision you will have staples or sutures.  These will remain in place until you return for your post-operative office visit, which is approximately two weeks after you are released from the hospital.  You should take a shower, not a bath, every day.  You should cleanse your incisions gently with soap and water only.
  • Pat the area dry after the shower
  • If drainage is noted along your incision it needs to be painted with Betadine and covered with a dry, sterile dressing.

What to Report

  • Redness that extends away from your incision
  • Drainage, note the color, odor and amount
  • Temperature greater that 101f for twenty four hours
  • A sudden change in the ability to move or use your leg, or a loss of the ability to feel your leg
  • A sudden increase in the pain that is not controlled by your pain medication

It is important to keep your follow up appointments.  If any problems occur, do not hesitate to call the Vascular Group.  There is always someone there to answer your questions.

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