Peripheral Arterial Disease

   

Peripheral Artery Disease (PAD)

The tip of the atherosclerotic iceberg

Peripheral arterial disease (PAD) is a term that is used to describe vascular disease affecting the arterial blood vessels of the lower extremities. It is a chronic inflammatory condition in the walls of arteries, in large part due to deposits of lipoproteins (plasma proteins that carry cholesterol and triglycerides). It is also referred to as a "hardening" of the arteries or atherosclerosis and is heralded by ischemic symptoms caused by a narrowing or blockage in the arteries.

Mention blocked arteries and most people think of the heart. However, these blockages can affect other areas of your body, especially blood vessels in the abdomen, kidneys, legs, neck, and brain. Atherosclerosis can lead to a range of serious health problems, including high blood pressure, crippling leg pain, heart attack, stroke, aneurysms and even kidney failure. Millions of Americans over the age of 50 have PAD and the prevalence of this condition increases as people age.


Risk Factors

The following risk factors are associated with PAD:


  • Age 50 years or older
  • Diabetes
  • Smoking
  • High cholesterol
  • High blood pressure
  • Obesity
  • Physical Inactivity
  • A family history of heart disease or PAD

Symptoms

When a blood vessel is clogged, smaller blood vessels try to compensate by rerouting blood around the clog. This will eventually fail, however, because these "detours" simply cannot carry as much blood as the larger blood vessel. Starved of oxygen-rich blood, the muscles almost literally cry out in pain. Symptoms of PAD include:


  • Calf pain (i.e. Claudication) - usually starts after a period of walking and is      relieved by a short period of rest
  • Thigh or Buttock pain – occurs when the arterial blockages are present above the groin level in addition to the mid-thigh level, which is typically      associated with calf pain as described above
  • Impotence
  • Feet that are cold to the touch, with toes that may appear discolored or bluish when dangling
  • Weak or absent pulse in the lower extremities

Limb-Threatening Ischemia

If the arterial narrowings or blockages increase in number and severity then the following can occur: rest pain (pain in the forefoot at nite that wakes one up from sleep), non-healing ulcers or gangrene, usually at the foot level. Although not as common as claudication, severe complications can result when the lower extremities are continuously starved of oxygen-rich blood. If left untreated, limb-threatening ischemia can lead to the amputation of the toes or feet. Screening is therefore important to identify patients with PAD. before the occurrence of more serious complications.


Screening and Diagnosis

Diagnosis is made by taking a thorough medical history and performing diagnostic tests to determine how well blood flows through your vessels. Screening for PAD can be completed in our ICAVL accredited non-invasive vascular laboratory.


Who Should Consider Screening?

If you answer yes to any of the following questions, you may benefit from peripheral vascular screening:


  • Do you currently smoke or have a significant smoking history?
  • Do you have high blood pressure, high cholesterol, or diabetes?
  • Have you been diagnosed with heart disease or have a family history of heart disease?
  • Do you have a family history of aortic aneurysm or stroke?
  • Are you over age 55?

Types of PAD Screenings

Carotid Artery Ultrasound

To detect plaque and/or arterial narrowing that may increase the risk for stroke

Abdominal Aortic Ultrasound

To determine the size of the abdominal aorta

Ankle-Brachial Index (ABI)

To compare the blood pressure at the ankle with that in your arm to determine if there is significant lower extremity arterial narrowing or blockage


Please call 714-560-4450 to schedule a PAD screening appointment.


Treatment

Depending on your overall health and the extent of PAD, the specialists within VISOC may recommend a variety of conservative treatment options, including smoking cessation, control of high blood pressure or cholesterol, taking good care of your feet and following a daily walking program. If the arterial blockages increase in number or severity this may result in disabling claudication (calf pain) symptoms or limb-threatening ischemia more aggressive treatment options may be recommended. These options may range from less invasive techniques such as balloon angioplasty, stent placement or atherectomy (removing plaque using a small catheter) to surgical bypass that essentially re-routes blood around the affected area. We offer the latest in minimally invasive and open surgical techniques to treat the following conditions related to PAD:


  • Upper extremity atherosclerosis
    • Activity-induced arm pain or chronic fatigue
    • Non-healing finger ulcers
    • Subclavian Steal Syndrome
  • Lower extremity issues
    • Leg pain with walking (Claudication)
    • Foot pain at rest
    • Non-healing foot ulcers
    • Gangrene
  • Vasculitis
    • Non-healing, painful finger ulcers
  • Takayasu's arteritis (a.k.a. pulseless disease)
  • Arterial embolism and thrombosis
  • Blue-toe syndrome

Non-Healing Ulcers

Ulcers related to Vascular Disorders

Non-healing skin ulcers typically result from peripheral arterial disease (PAD) but can also be a result of chronic venous insufficiency (CVI). Arterial ulcers occur when blocked arteries starve the lower extremity of oxygen-rich blood and this leads to tissue ischemia (decreased blood supply). Venous ulcers are also a result of tissue ischemia but the underlying mechanism is valvular dysfunction or previous deep vein thrombosis. Chronic leg or foot ulcers can be difficult to heal without appropriate medical care. We are dedicated to preventing the loss of limb through a proactive approach to managing ulcers.


Risk Factors

If you have circulatory problems, such as PAD or CVI, you may be at risk for non-healing skin ulcers. You also may be at risk for non-healing wounds if you have diabetes, as this condition can hinder the body’s normal healing processes. Other risk factors include cigarette smoking, obesity, high blood pressure, high cholesterol and sedentary life-style.


Symptoms

Wounds/skin ulcers that persist for greater than 4 weeks are a problem that requires further medical attention.


Screening and Diagnosis

Our physicians and staff specialize in the diagnosis and prevention of the following types of ulcers and non-healing wounds:


  • Arterial disease
  • Venous disease
  • Vasculitis
  • Infection
  • Neuropathy

Treatment

We will first determine the cause of the ulcer and ensure that you receive appropriate treatment. Conservative measures include wound dressings, off-loading of the involved extremity and non-invasive evaluation of the arterial and venous systems. More aggressive treatment is often required to effect complete wound healing.

Aortic Aneurysms

Aortic Aneurysms

The silent killer

An aneurysm develops when a diseased blood vessel dilates or “balloons” outward. Arterial aneurysms can be found in many locations throughout the body but typically involve the abdominal aorta below the kidneys. Risk factors for developing an aortic aneurysm include hypertension, smoking, high cholesterol, emphysema, genetic factors and male gender. An abdominal aortic aneurysm can develop in anyone, but it is most frequently seen in males over 60 with one or more risk factors. Aneurysms usually develop slowly over many years and often have no symptoms. They are frequently discovered during a work-up for vague abdominal or back pain. The larger the aneurysm, the more likely it is to rupture. If an aneurysm expands rapidly, tears open, or blood leaks along the wall of the vessel, symptoms may develop suddenly. Small aneurysms without symptoms can be followed with periodic ultrasound evaluation to detect changes in aneurysm size. Surgery is generally recommended for larger aneurysms and those that rapidly increase in size. The goal is to perform surgery before complications or symptoms develop.

Another condition affecting the aorta is called a "dissection". This problem occurs when there is a split in the layers of tissue that comprise the aortic wall. Blood can then “dissect” between the layers and cause bleeding or obstruction of blood flow to vital organs.

Risk Factors

Men are four times more likely than women to develop an abdominal aortic aneurysm; it's the ninth leading cause of death in men over age 55. The most common risk factors for an aortic aneurysm or dissection include:

  • Age      - Aneurysms usually affect patients who are 50 to 80 years of age
  • Atherosclerosis      (aka hardening of the arteries) – The large majority of aortic aneurysms      are associated with this condition
  • High      blood pressure - Increased pressure inside the arteries can create stress      on weakened areas within the wall of the aorta
  • Injuries      and hereditary disorders - This includes Marfan syndrome, a connective-tissue      disorder that is occasionally associated with sudden death due to aortic      dissection
  • Smoking      – Smoking at any time in your life increases your risk for developing an      aneurysm and other manifestations of atherosclerosis

Symptoms

Most aneurysms, especially small ones, have no symptoms. In fact, less than one quarter of aneurysms present with obvious symptoms until the time that it ruptures. Vague symptoms can occur as the aneurysm begins to enlarge and press on nerves, organs or other blood vessels. For an aortic aneurysm, common symptoms generally include:

  • Throbbing      or pulsation in the abdomen
  • Abdominal      pain - if severe, this could mean the aneurysm has ruptured
  • Back      or flank pain – if severe, this could mean the aneurysm has ruptured

An aneurysm that occurs in the chest (called a "thoracic aneurysm") may have the following symptoms:

  • Pain      between the shoulder blades, lower back, neck or abdomen
  • A      dry persistent cough
  • Hoarse      voice (due to pressure from the aneurysm on the nerve that stimulates the      vocal cords)
  • Symptoms      of a thoracic aneurysm or acute aortic dissection are frequently      misdiagnosed

Screening and Diagnosis

Even if an aneurysm does not cause symptoms, it may be detected during a routine physical examination. An abdominal aortic aneurysm can sometimes be felt in the abdomen and thoracic aneurysms can often be seen on a routine chest X-ray. Ultrasound of the abdomen is a highly accurate screening tool that can be used to make the initial diagnosis. More sophisticated imaging technology, such as computed tomography (a "CT scan") or magnetic resonance imaging (an "MRI") is then used to further evaluate a newly found aneurysm.

Treatment

Highly trained and experienced physicians within VISOC offer cutting-edge treatment for thoracic and abdominal aortic aneurysms as well as acute (sudden onset) and chronic (long duration) aortic dissections. In short, acute aortic dissection may require immediate surgery, but in some situations aggressive blood pressure control with IV/oral medication is also appropriate for certain types of aortic dissections. Chronic aortic dissections are generally followed with periodic imaging, and repaired if complicating circumstances arise despite good blood pressure control. Large or rapidly growing thoracic aneurysms usually require surgical repair. Without surgery, the risk of life-threatening aneurysm rupture increases with time and with aneurysm size. Aneurysm repair is performed in one of two complementary ways as follows:

Traditional surgery

Involves an incision in the chest or abdomen through which the aneurysm is opened and replaced with artificial graft material. This method of aneurysm repair offers proven and durable results with a low incidence of long-term complications. However, recovery from this relatively invasive procedure usually requires more time than less-invasive alternatives. The vascular specialists in the Vascular Institute can also perform an open abdominal aortic aneurysm repair using a less-invasive approach in which the skin incision is made in either the right or left flank area. This surgical approach offers better exposure of the abdominal aorta and its arterial branches, as well as results in a shorter hospital stay and a quicker recovery than the traditional open repair.

Endovascular surgery

Involves two relatively small incisions at each groin to expose the common femoral arteries. A stent graft is then inserted through the femoral arteries and appropriately positioned using catheter/guidewire and video techniques. Once the stent graft is deployed within the aneurysm, it effectively diverts blood flow away from the aneurysm sac. Thus, pressure within the bulging aneurysm sac is reduced and the risk of aneurysm rupture is greatly diminished. This type of minimally invasive surgery has a relatively short recovery time and in general causes less physiologic trauma to the body. However, there is increased risk of blood vessel trauma using this technique and long-term periodic imaging is required because there is a small chance that the stent graft may move (i.e. migrate) or that blood flow may enter the aneurysm sac from the ends of the stent graft or from back-bleeding arteries, causing it to once again become pressurized and potentially rupture.

Cancer

Cancer: Liver - Hepatocellular (HCC)

Liver cancers are generally divided into two types: Cancers that start in the liver and cancers that have spread to the liver from another part of the body. Many patients who present with liver cancer cannot have them removed by surgery as the tumor(s) may be too large, grown into vital structures, or too numerous.

Our group can provide targeted ablation and embolization treatments to the liver. We use image guidance and minimally invasive techniques to treat the tumors without affecting other parts of the body.


Embolization is a technique whereby a drug or high dose radiation particle is delivered directly to the tumor from a feeding blood vessel. The interventional radiologist performs this procedure through a technique called angiography. The patient is provided a mild sedative and local anesthesia to ensure patient comfort. A small tiny catheter is thread using imaging guidance from the artery in the groin to the artery supplying the tumor. When the catheter is in the appropriate position a high dose of chemotherapy drug or radioactive particle (Yttrium-90) is injected into the tumor(s). The treatment is well tolerated and patients either go home the same day or the next day.


Ablation is a technique whereby the interventional radiologist uses image guidance, typically computerized tomography (CT) scan and ultrasound, to place one or more needles into the liver percutaneously. The patient is generally under general anesthesia for the procedure for comfort and accurate needle placement. The needle is guided through the skin into the tumor. When the needle is in the tumor either radiofreqency (heat), or cryo (cold freeze) is applied to kill the tumor while sparing normal liver tissue. The treatment is well tolerated and most patients go home the same day.


Cancer: Colon Metastasis to Liver

Colon cancer is the fourth most diagnosed cancer in the United States and the second leading cause of cancer death.

50-60% of patients with colon cancer develop metastatic disease (i.e. cancer that has spread outside of the colon). Of the patients who develop metastatic disease, 80-90% of the patients will have cancer spread to the liver. More than half of patients who die of colon cancer have metastasis to the liver at autopsy. Most of these patient’s death are the result of the metastasis to the liver.

Treatment

Directly treating a liver tumor with yttrium-90 kills tumor cells while preserving healthy liver tissue. Patients with colon cancer spread to the liver may have many potential treatment options. Our group offers Yttrium 90 Radioembolization as a locoregional therapy for patient’s with liver metastasis. 


Cancer: Radioembolization (Yttrium 90)

If you or a loved one has been diagnosed with primary liver cancer or cancer that has spread (metastasized) to the liver, it is important to learn the facts and evaluate your treatment options.

Yttrium-90® microspheres and Theraspheres®, offered at VISOC, are a targeted radiation therapy that delivers a dose of internal radiation up to 40 times higher than conventional external beam therapy while sparing healthy tissue. This maximizes the treatment’s effectiveness and reduces the risk of injury to the liver. The treatment is typically administered as an outpatient procedure. Yttrium-90 SIR-Spheres® microspheres are the only fully FDA-approved microspheres for patients with inoperable metastatic colorectal cancer to the liver. Theraspheres® is approved by the U.S. Food and Drug Administration (FDA) under a Humanitarian Device Exemption (HDE).

Directly treating a liver tumor with yttrium-90 kills tumor cells while preserving healthy liver tissue Yttrium-90 microspheres are designed to treat liver tumors with beta radiation.

How is Yttrium-90 administered?

Yttrium-90 microspheres are administered through a process called Selective Internal Radiation Therapy (SIRT). During the procedure, an interventional radiologist makes a small puncture, usually into the femoral artery near the groin. A small flexible tube, known as a catheter is then guided through the artery into the liver and millions of microscopic spheres (about a third of the width of a human hair), are delivered directly into the tumor. The entire procedure takes about 90 minutes. Patients will be sleepy during the procedure but able to communicate with the doctor and the team. Most patients return home four to six hours following treatment.

The interventional radiologist makes a small puncture, usually into the femoral artery near the groin. A small flexible tube, known as a catheter is then guided through the artery into the liver.

  1. Liver      anatomy, with presence of inoperable tumors
  2. Normal      liver tissue is highlighted – this tissue receives its blood supply from      the portal vein
  3. Tumors      receive their blood supply from the hepatic arteries
  4. Tumors      can be selectively irradiated leaving normal tissue unaffected
  5. A      micro-catheter is advanced into the hepatic artery
  6. SIR-Spheres      microspheres are released into the arterial blood supply

How do Yttrium-90 microspheres work?

The SIRT procedure delivers radiation, which is often used to treat cancer, directly into the liver tumors by using the tumor’s own blood supply. Normal liver tissue takes about 90 percent of its blood supply from the veins, while liver tumors receive about 90 percent of their blood supply from arteries. This allows Yttrium-90 microspheres to target the liver tumors with a tumor-killing dose of radiation via the hepatic artery, while sparing surrounding healthy liver tissue. This typically isn’t possible with conventional external beam radiation.

How are Yttrium-90 microspheres different from other radiation treatments for cancers of the liver?

Yttrium-90 microspheres usually either reduce or eliminate liver tumors after just one treatment. The targeted nature of Yttrium-90 microspheres therapy enables doctors to deliver more radiation to the liver tumors than would be possible using conventional radiotherapy. Also, because traditional radiation is delivered to a general area of the body where cancer exists, it is less exact than Yttrium-90 microspheres. Another limitation of conventional radiotherapy is that it can only be applied to certain areas of the body, often not including the liver. Yttrium-90 microspheres, however, are designed specifically for delivery directly to the liver.

What are the goals of treatment using Yttrium-90 microspheres?

Clinical trials have shown SIRT increases the time-to-disease progression and overall survival without adversely affecting the patient’s quality of life. In clinical studies, Yttrium-90 microspheres have been combined with modern chemotherapy or administered as a monotherapy during a chemotherapy holiday and have been proven to:

  • Decrease      the tumor burden in the liver
  • Increase      time-to-disease progression
  • Increase      survival time
  • Potentially      downsize tumors to liver resection or ablation
  • Provide      palliation of symptoms

What side effects and complications can I expect?

When properly administered, most side effects are typically mild and subside within several days. Post treatment side effects can include abdominal pain and/or nausea which normally subside after a short time and/or with routine medication. Patients may also develop a mild fever that may last up to a week and fatigue which may last for several weeks. As a precaution, we may recommend additional medications with the aim of preventing or minimizing these side effects.

In rare instances there is a possibility that a small number of microspheres may inadvertently reach other organs in the body, such as the gall bladder, stomach, intestine or pancreas. If Yttrium-90 microspheres reach these organs, they may cause inflammation of the gall bladder (cholecystitis), stomach (gastritis) or intestine (duodenitis). These complications are rare, but if one of these occurs, they will require additional treatment. Your treatment team will have received special training to minimize these risks and to prevent them from happening.

 

Cancer: Radiofrequency Ablation

For tumors that may be inoperable in the liver, lung, kidney, bone, soft tissues, radiofrequency ablation (RFA) can be an option. RFA is an image guided minimally invasive local treatment. The technique uses image guidance to place a needle into the tumor. Radiofrequency energy is applied to the tip of the needle which kills the tumor cells with heat while sparing surrounding tissue. The dead tumor usually shrinks and forms a scar.


Efficacy

RFA is usually performed for palliative purposes, however in a select population, RFA can extend patient’s lives. RFA can improve a patient’s survival time and quality of life. The treatment can be repeated if new tumors appear.


Cancer: Needle/Biopsy Ports

Patients treated for certain medical conditions may require repeated intravenous injections of medications. An example would be a cancer patient requiring intravenous chemotherapy.

Our interventional specialists place vein access ports for our patients. A port is a device which consists of a small metal or plastic chamber and a tube. The chamber is placed under the skin through a small incision and the tube is placed into a vein. The port is a more comfortable way for patients to receive intravenous medications and have blood samples drawn.
 

Needle Biopsy

Our interventional specialists are highly skilled physicans who routinely perform needle biopsies with image guidance. A needle biopsy is procedure to obtain tissue from the body to identify the cause of a mass, lump or other condition in the body. Our doctors will use either a combination of Xray, Computed tomography (CT) or Ultrasound (US) guidance to place a needle into the abnormal area and obtain a tissue sample. The procedure is done with local anesthesia and sometimes with a mild sedative. Generally a tiny scar is present after the procedure. Most procedures can be done as an outpatient.