Peripheral vascular disease is a form of atherosclerosis, a hardening of the arteries, and is a progressive disease process.  It can result in blockages in arteries of the brain, arms, kidneys, and legs. Atherosclerosis is caused when fatty substances build up inside the artery walls over time and create an occlusion which restricts proper blood flow. In the peripheral or non-heart vessels, this is most likely to occur in the iliac arteries (lower abdomen leading to the legs), the femoral and popliteal arteries (legs), the renal arteries (kidneys) and the carotid arteries (in the neck leading to the brain) and subclavian arteries (arms).

Disease Symptoms
When organs and muscles in the body receive an insufficient supply of oxygen-rich blood, they literally become starved and alert you to this fact by producing pain. If the blockage occurs in the arteries supplying the legs, the resulting symptom is a cramping pain in the hips, thighs or calf muscle and can limit even casual walking. If the pain is relieved with rest, we call this condition "intermittent claudication ". If blood circulation becomes so severely restricted that the legs and feet are perpetually starved for nutrition, gangrene -- death of the tissue -- can occur. Without treatment, the entire foot or possibly part of the leg may have to be amputated However if discovered in time an appropriate treatment regime may be possible to avoid this devastating event.

Other symptoms of peripheral vascular disease in the lower extremities include: coldness of the leg and foot; paleness of the leg or foot if elevated; blue/red discoloration of the foot or toes; dry, fragile or shiny-looking skin; numbness, tingling or pain in the leg, foot or toes; and sores that do not heal. Symptoms of peripheral vascular disease in the renal arteries include hypertension (high blood pressure) - consistently higher than 160/100 despite adequate medication therapy and/or abnormal kidney function blood tests.

Diagnosis
Techniques used to diagnose PVD include a medical history, physical exam, ultrasound, X-ray angiography and magnetic resonance imaging angiography (MRA).

If symptoms are mild to moderate, the disease can be well managed by lifestyle changes such as:

Lifestyle changes to lower your risk include:

Stop smoking (smokers are 2 to 25 times more likely to get PAD).

Control diabetes.

Control blood pressure.

Be physically active

Eat a low-saturated-fat, low-cholesterol diet.

Treatment
Percutaneous transluminal interventions for the treatment of acute and chronic PVD include angioplasty, stenting, atherectomy.  When compared to surgical intervention, percutaneous procedures generally offer the potential for reduced risk, quicker recovery, and overall cost-effectiveness.

Angioplasty
Angioplasty is a non-surgical procedure that can be used to dilate (widen) narrowed or blocked peripheral arteries. A thin tube called a catheter with a deflated balloon on its tip is passed into the narrowed artery segment. Then the balloon is deflated and the catheter is withdrawn.

Stenting
Often a stent — a cylindrical, wire mesh tube — is placed in the narrowed artery with a catheter. There the stent expands and locks open. It stays in that spot, keeping the diseased artery open.

Atherectomy
Atherectomy is a treatment by which plaque is selectively removed from atherosclerotic diseased arteries.

For consideration of any of our peripheral vascular clinical studies contact Dr. William Gray, wgray@crf.org or Dr. Issam Moussa at 212.305.7060, imoussa@crf.org

Abdominal Aortic Aneurysm

Aortic Aneurysm

An aneurysm is when a blood vessel becomes abnormally large or balloons outward. The abdominal aorta is a large blood vessel that supplies blood to your abdomen, the pelvis, and legs.

Causes
The exact cause is unknown, but risk factors for developing an aortic aneurysm include: High blood pressure, smoking, high cholesterol, and obesity. An abdominal aortic aneurysm can develop in anyone, but it is most frequently seen in people over 50 with one or more risk factors. The larger the aneurysm, the more likely it is to rupture. When an abdominal aortic aneurysm ruptures, it is a true medical emergency. Aortic dissection occurs when the innermost lining of the artery tears and blood leaks into the wall of the artery.

Symptoms
Aneurysms develop slowly over many years and often have no symptoms. If an aneurysm expands rapidly, tears open (ruptured aneurysm), or blood leaks along the wall of the vessel (aortic dissection), symptoms may develop suddenly.

The symptoms of rupture include:

Pulsating sensation in the abdomen
Pain in the abdomen that is severe, sudden, persistent, or constant. The pain may radiate to groin, buttocks, or legs.
Abdominal rigidity
Pain in the lower back that is severe, sudden, and persistent. The pain may radiate to the buttocks, or legs.
Anxiety
Nausea and vomiting
Clammy skin
Rapid heart rate when rising to a standing position
Shock
Abdominal mass

Signs and tests
Your doctor will examine your abdomen. The exam also will include an evaluation of pulses and sensation in your legs.  Abdominal aortic aneurysm may be diagnosed with these tests:

Abdominal ultrasound
CT scan of abdomen
Angiography of aorta

Treatment
If the aneurysm is small and there are no symptoms (for example, if it was discovered during a routine physical), your doctor may recommend periodic evaluation. This usually includes a yearly ultrasound, to see if the aneurysm is getting bigger.
Aneurysms that cause symptoms usually require repair to prevent complications.

Endovascular Repair
Before an endovascular AAA repair is scheduled, the doctor uses special x-rays (CT scans and angiograms) to measure the exact size of the blood vessels above and below the aneurysm. Based on these measurements, the doctor chooses an endograft that will fit the size of the blood vessels. To place the endograft, the doctor makes two small cuts near each hip (near the crease between the abdomen and the thigh) to get to the femoral arteries (blood vessels). Through these small cuts each part of the endograft is placed into the patient’s blood stream. X-rays during the procedure help the doctor guide the endograft into proper position. The endograft then expands to become a strong, flexible tube on the inside of the aorta that seals off the aneurysm and reinforces the blood vessels (aorta and iliac arteries). Before completing the surgery the doctor uses an x-ray to confirm that blood goes through the endograft and does not leak into the aneurysm.

Because it uses small cuts, endovascular AAA repair may cause less discomfort after surgery. Many patients have a short hospital stay of only a few days and they can usually return to normal activity within four to six weeks after surgery.

It is possible for problems with the endograft repair to occur without causing any noticeable symptoms. The doctor can check for these problems by getting pictures (CT scans, ultrasounds) of the endograft at regularly scheduled intervals. If a problem is detected it may need treatment with another procedure. Recommended follow-up includes a check up and CT or ultrasound scan at one month, six months, 12 months and every year thereafter.

Not all patients can have an endovascular repair of their AAA.  In order to work properly, an endograft must fit into and completely seal off the aneurysm. If the blood vessel is too large or has too many twists and turns, the endograft will not fit or seal off the aneurysm and the AAA will not be repaired. Doctors are nearly always able to decide which patients can and cannot have an endovascular repair by looking at the patient’s x-rays (CT scans and angiograms).

Carotid Artery Disease

What is carotid artery disease?
Carotid artery disease occurs when the major arteries in your neck become narrowed or blocked. These arteries, called the carotid arteries, supply your brain with blood. Your carotid arteries extend from your aorta in your chest to the brain inside your skull.

Your arteries are normally smooth and unobstructed on the inside, but as you age, a sticky substance called plaque can build up in the walls of your arteries. Plaque is made up of cholesterol, calcium, and fibrous tissue. As more plaque builds up, your arteries narrow and stiffen. This process is called atherosclerosis, or hardening of the arteries. Eventually, when enough plaque builds up to reduce or disturb blood flow through your carotid arteries, physicians call this problem carotid artery disease. Carotid artery disease is a serious health problem because it can cause a stroke.

Some plaque deposits are soft and are prone to cracking or forming roughened, irregular areas inside the artery. If this happens, your body will respond as if you were injured and flood the cracked and irregular area with blood-clotting cells called platelets. A large blood clot may then form in your carotid artery or one of its branches. If the clot blocks the artery enough to slow or stop blood and oxygen flow to your brain, it could cause a stroke. More commonly, a piece of the plaque itself, or a clot, breaks off from the plaque deposit and travels through your bloodstream. This particle can then lodge in a smaller artery in your brain and cause a stroke by blocking the artery.

Fortunately, you may be able to prevent or slow carotid artery disease. Quitting smoking is the most important change you can make to avoid this disease. Other ways to prevent carotid artery disease include:

Exercising regularly

Eating a healthy diet

Maintaining a healthy weight

Controlling factors that increase your chances of developing carotid artery disease, such as diabetes, high blood pressure, or high cholesterol, also help prevent the disease.

What are the symptoms?
Carotid artery disease may not cause symptoms in its early stages. Unfortunately, the first sign of carotid artery disease could be a stroke. However, you may experience warning symptoms of a stroke called transient ischemic attacks, or TIAs. Symptoms of a TIA usually last for a few minutes to 1 hour and include:

Feeling weakness, numbness, or a tingling sensation on one side of your body, for example, in an arm or a leg

Being unable to control the movement of an arm or a leg

Losing vision in one eye (many people describe this sensation as a window shade coming down) 

Being unable to speak clearly

If you have any of these symptoms, contact your physician immediately.

What causes carotid artery disease?
Hardening of the arteries causes most cases of carotid artery disease. Experts do not fully understand the cause of hardening of the arteries. Plaque may build up in the arteries because of an injury to the artery's inner lining. Factors that injure artery walls include smoking, high cholesterol, and high blood pressure.

In rare cases, conditions known as carotid aneurysm disease and fibromuscular dysplasia can cause carotid artery disease. Other factors that may increase your chances of developing carotid artery disease include diabetes and having a family history of hardening of the arteries.

What tests will I need?
First your physician asks you questions about your general health, medical history, and symptoms. In addition, your physician conducts a physical exam. Together these are known as a patient history and exam. As part of your history and exam, your physician will ask you if you smoke or have high blood pressure. Your physician will also want to know when your symptoms occur and how often. 

During your exam, your physician will listen for sounds of turbulent blood flow in your carotid arteries. He or she may also measure your blood pressure.

After the history and exam, if your physician suspects you have carotid artery disease, he or she will perform a carotid duplex ultrasound. In this painless test, a technician holds a small ultrasound probe to your neck. The probe emits high-frequency sound waves that bounce off of blood cells and blood vessels to show blood flow and problems with the structure of blood vessels. This test can show your physician how open your carotid arteries are and how quickly blood flows through them.

Carotid duplex ultrasound detects most cases of carotid artery disease. Therefore, your physician usually may not need to perform other tests. However, if ultrasound does not provide enough information, your physician may order one or more of the following:

CT scan and CT Angiography (CTA)

Magnetic resonance angiography (MRA)

Angiography 

How is carotid artery disease treated?
Your treatment will depend on the severity of your condition, and whether or not you are having symptoms from the carotid artery disease, as well as your general health. As a first step, your physician may recommend medications and the lifestyle changes. 

If you have any other medical conditions, make sure to follow your physician's instructions to manage them. For example, if you have diabetes, be sure to monitor and control your blood sugar levels. If you have high blood pressure, your physician may prescribe medications to lower it. If you are smoking, you should quit. Have your physician check your cholesterol levels regularly to be sure they stay within normal limits. Your physician may prescribe medications such as statins to reduce high cholesterol.

Angioplasty and stenting
A newly developed minimally invasive procedure to treat carotid artery disease is angioplasty and stenting. Angioplasty and stenting is usually performed using a local anesthetic. To perform this procedure, your physician may insert a long, thin tube called a catheter through a small puncture site over a groin artery and guide it through your blood vessels to your carotid artery. The catheter carries a tiny balloon that inflates and deflates, flattening the plaque against the walls of the artery. Next, the physician places a tiny metal-mesh tube called a stent in the artery to hold it open. Your hospital stay after angioplasty and stenting is approximately one day.

Carotid stenting is investigational and should be performed under a research protocol, to be included in any of these protocols contact Dr. William Gray at wgray@crf.org or Dr. Issam Moussa at Imoussa@crf.org.