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Do I really need surgery for peripheral artery disease?

Judith Taylor sleeps for the first time in what seems like an eternity, without interruption. She is not awakened by pain or numbness in her feet caused by the peripheral artery disease (PAD) with which she was diagnosed 3 years ago. She did not need an extra blanket and socks to keep her left foot, which had the weakest circulation, warm.

“This foot was so cold it would wake me up in the middle of the night,” said Taylor, 68, a pastor in Shreveport, LA. “Now it’s the foot that keeps the other one warm.”

As one of more than 8.5 million Americans with PAD – a narrowing or blockage in the veins that feed the limbs, mostly the legs – Taylor found relief through a angioplasty. Or to do so was hardly even a question: Her blockage was severe; the pain and discomfort disrupted her sleep and her life.

Taylor had two procedures within 2 years. Each involved inserting stents; she remained in the hospital for several days.

The first kept her artery clean for a year; the second for 8 months. The most recent procedure was an angioplasty involving the insertion of two balloons and a stent in her leg. She went home that same evening and felt better almost immediately.

But the procedure is not a good choice for everyone with the disease. Each case is its own; there is no blanket treatment plan.

PAD treatments vary

“You need to see your doctor because treating PAD will be different for everyone,” says Sarah Samaan, MD, a cardiologist at Baylor Scott & White The Heart Hospital in Plano, TX.

“For some mild cases, walking can improve and it’s perfect,” says Samaan. “But you have to get the job done, know what you’re dealing with, what kind of blockage there is and how serious it is.”

For mild cases, risk-reducing pharmacology may be enough, says Matthew Corriere MD, a vascular surgeon at the University of Michigan Health Frankel Cardiovascular Center.

“They may not have symptoms,” says Corriere, “but they still have a higher risk of heart attack and stroke. We put them on low-dose aspirin and a statien. It reduces the risk of PAD progression but also reduces the risk associated with coronary heart disease and stroke risk. “

For them, it would make no sense to undergo surgery or undergo a less invasive procedure. They feel good; they manage their chronic disease.

From the onset of the disease, doctors emphasize the importance of these key things:

  • Quit smoking, the main cause of PAD
  • To get diabetes under control
  • Start an exercise routine

But as pain and discomfort worsen and PAD interferes more and more with daily life, other options are on the table as well.

When PAD hits a tipping point

“The tipping point to take the next step or not can be pain symptoms that do not go away and limit their quality of life,” says Samaan. “Non-healing wounds on the legs will be different, leading to a procedure or surgery to restore blood flow.”

Some situations, such as chronic limb-threatening ischemia, leaves little choice to give. Patients can have pain all the time, Corriere says. Maybe they have an ulcer on their foot that prevents poor circulation from healing and leading to gangrene on one or more of their toes.

“With those patients, we have to do a procedure,” Corriere says. “Their blood flow restriction is much more serious. We try to do a revascularization if we can – an angioplasty or a stent or bypass.

Especially if symptoms are ignored for too long, “there can be such severe and irreversible damage that a patient may lose a toe, a foot or even a part of the leg,” says Samaan.

Care is tailored to a patient’s specific situation: symptoms, size and type of injury, and place of blockage, Corriere says. He has done extensive research on the shared decisions between people with PAD and doctors.

“What we find is that individual patients have different expectations and goals,” says Corriere. “Sometimes they are in line with medical recommendations and sometimes they are not. Some patients are risk-averse. If they learn that their blockage will not get worse with what they are already doing, they are happy to have mild symptoms and be left alone.

“Others want everything that can be done to be done. Sometimes we do it and sometimes we have to set mutual expectations. ”

Many PAD procedures, such as Taylor’s most recent angioplasty, do not require an overnight hospital stay, and results are immediate. After that, you just need to limit your activities for a few days.

For revascularization surgery, you may spend 2-4 nights in the hospital. Recovery is slower and probably involves being seen by a physiotherapist.

Not a cure

Corriere wants people with PAD to remember this: No matter what treatment they receive, it’s not a cure.

“I see some people who do not get counseling about PAD’s chronic nature and come see me because they’ve had a stent in their leg for 5 years and are now struggling with it,” says Corriere. “They tell me they thought it was cured. But it is never healed; we fight with it. ”

For Judith Taylor (who is not a patient of Corriere or of Samaan), that’s right. She can sleep through the night; she can walk without pain. And she is determined to do everything she can to stay the course.

“It’s up to me to keep that artery open,” Taylor says. “With that blockage I had, I could have lost my leg,” she said. “You have to walk every day, and I can do it. Keep walking and the vessels will stay cleaner. I am motivated to get out of that pain. ”

Above all, “Do not give up. Ask questions. Do your part as a patient, ”says Taylor. “We all have something we can do to work with our medical team, even if it’s just to pay attention and let them know what’s going on.”

“I felt better almost immediately,” Taylor says. “You can not imagine how good my mood is. You always try to be friendly and optimistic. But having constant pain really takes a lot out of you. ”

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