Most problems with arterial narrowing and blockage in the lower extremities are caused by the gradual accumulation of cholesterol, calcium, and fibrous deposits from atherosclerosis.  This accumulation is made worse by smoking, high cholesterol, diabetes, and high blood pressure, all of which can be controlled or modified by the patient.  In addition, people have inherited (or not) a genetic predisposition for atherosclerosis which at this time is not modifiable.  Patients with a family history of early heart attack, stroke, or leg ischemia are likely themselves susceptible to atherosclerosis and would be well served by reducing their number of modifiable risk factors (e.g., smoking) in order to prevent these major health problems.

Patients are often referred to a vascular surgeon because of a complaint of cold feet or because their family physician has trouble palpating pulses in the feet.  While these symptoms are sometimes associated with arterial occlusive disease, these findings in the absence of other symptoms are of no clinical consequence.

Claudication
The mildest problem of clinical significance caused by arterial occlusive disease is termed claudication.  The patient typically complains that their calf muscles and sometimes other parts of their leg and buttock tightens up or causes pain after walking a certain distance.  The patient typically stops walking for a few minutes and is able to walk about the same distance again before the leg begins to hurt again.  Other conditions, such as arthritis, back problems, muscle injuries and other problems may sometimes be confused with claudication.  Pain that occurs when the patient stands before walking or pain that is affected by the weather is typically not related to arterial occlusive disease.

Confirmation of this diagnosis is accomplished by the combination of the characteristic symptoms coupled with a measured decrease in arterial pressure in the leg; this typically may be measured with a regular blood pressure cuff placed around the ankle or more sophisticated noninvasive tests performed by the vascular laboratory.

It should be stressed that this degree of atherosclerosis is serious but generally can be managed non-operatively in the majority of cases.  Cessation of smoking, a vigorous walking program, and control of risk factors is sufficient to keep symptoms manageable in 90% of cases.  Regular follow-up with a physician is useful to detect those persons in whom the occlusive disease progresses beyond claudication such that early intervention may be performed to avoid limb loss.  Drug therapy with PletalÔ may be of benefit to some patients who do not have a history of heart failure.

However, if the symptoms are sufficiently bothersome to the patient, invasive therapies including, when appropriate, angioplasty or surgical bypass can be discussed.  This is usually best done in consultation with a vascular surgeon who can accurately describe the risks and benefits of intervention.  In patients with only claudication, the decision to intervene is ultimately the patient’s.  The trade-off of an improved quality of life versus the potential for morbidity and mortality from a procedure should always be carefully weighed, even though these risks are generally quite low in good hands.

Limb Threatening Ischemia
In some cases, atherosclerosis progresses beyond simple claudication to produce a group of problems generally termed limb-threatening ischemia.  Patients in this group need to have some intervention performed in order to improve leg blood flow in order to prevent limb loss.  Without an effort to improve circulation, limb loss rates of 65 to 90% can be expected.

Patients with limb threatening ischemia may at worst present with gangrene.  Black, foul-smelling toes or patches of skin indicate that the leg is dying from the lack of blood flow.  Less dramatic are cuts and raw open areas termed ulcers that do not heal because of limb ischemia.  So-called non-healing ulcers are often excruciatingly painful.  Diabetic patients frequently get such lesions which are resistant to all forms of ointments, salves, antibiotics, dressings, skin grafts, or any other intervention that does not involve an effort to improve leg blood flow.

The third common presentation of limb-threatening ischemia is termed rest pain.  This is typically described as a pain that starts in the toes or forefoot that wakes the patient from sleep and is relieved by the patient dangling or standing up on the leg.  This condition is sometimes confused with neuropathic pain seen in diabetics and others.  Neuropathic pain typically bothers the patient as he or she is trying to go to sleep but does not wake the patient from sleep.  Patients can have both conditions simultaneously. Evaluation again includes a history and physical from the vascular surgeon and a measurement of leg blood flow in the vascular laboratory to confirm the diagnosis.

Arterial Imaging
In patients with limb threatening ischemia or in those patients with claudication who decide to undergo a procedure to improve leg blood flow, a road map of the arteries is usually obtained in order to guide the intervention.  This can be done with an arterial ultrasound, magnetic resonance (Magnetic Resonance Arteriogram –MRA), or ideally with X-rays and injected contrast (angiogram or arteriogram).  These studies allow the surgeon to identify which arteries are affected and what form of intervention would be useful in each situation.

Angioplasty and  Stenting
Short narrowings and occlusions of arteries going to the legs may be treatable with angioplasty.  This involves the insertion of a catheter into an artery (usually in the groin area) and passing that catheter through the narrowed area.  A balloon on the catheter is inflated in the narrow area to open up the artery.  In many cases, a metal cage called a stent is inserted and left in the opened artery to keep the narrowing from recurring.  This form of therapy is less invasive than conventional surgery and usually requires only an overnight stay.  This form of treatment works best in larger arteries (above the groin) rather than the smaller arteries below the groin.  In addition, many arteries are too blocked with atherosclerosis to be opened with these less-invasive techniques.

Aorto-Ilio-Femoral Bypass
For those patients with blockages in the arteries above the groin who are not treatable with angioplasty, bypass surgery is usually necessary.  The arteries involved, the aorta (the single main artery coming from the heart), the iliac arteries (in the pelvis), and the common femoral arteries (in the groin area) are relatively large and may be replaced reliably with an artificial artery made of polytetrafluoroethylene (Gore-tex) or polyester (Dacron).  These are moderately to severely stressful operations with a high rate of success.  Patients can expect to spend three to seven days in the hospital following such procedures. 

Femoral-Distal (Leg) Bypass
For patients with blockages in the arteries below the groin, the arteries involved are the femoral, popliteal (around the knee), tibial (in the calf) and pedal (in the foot) arteries.  These are relatively small arteries and as a consequence are more difficult to repair or bypass than larger arteries.  Although artificial arteries can be used for the largest of these arteries with fair rates of success, the most effective form of bypass uses superficial veins from the patient himself or herself.  Veins from family members cannot be used. These bypass operations are best done by well-trained specialist surgeons.