Atherosclerosis

Atherosclerosis of the Aorta and Lower Extremity Arteries

Atherosclerosis involving the lower extremity arteries is a relatively common condition. The most typical symptom is intermittent claudication. This symptom is usually described as an aching pain in the muscles of the calf or thigh associated with walking. The symptom is typically reproducible at about the same walking distance each time the patient walks. More severe symptoms of lower extremity occlusive disease may include ischemic pain at rest or ischemic ulceration of the foot or toes. The occurrence of these symptoms tends to increase with advancing age. They are often associated with risk factors such as cigarette smoking, diabetes mellitus and abnormal elevations of cholesterol and triglycerides.

Atherosclerosis tends to occur in a segmental fashion involving the lower extremity arteries. It is often characterized as involving the aortoiliac segment, the femoral popliteal segment or the tibial outflow segment. Individual patients may have disease isolated to a single segment or have multi-level disease. Other individuals such as those with diabetes may have disease confined primarily to the smaller tibial vessels beyond the level of the knee.

Symptoms associated with atherosclerosis

Symptoms associated with atherosclerosis may occur very gradually over long periods of time. Without noticing it very much, an individual may have a progressive decrease in their walking distance until their activities are almost sedentary. Some people may attribute their condition to “arthritis” or simply being “out of shape.”

When pain or tissue ulceration in the lower extremity make it apparent that the arteries are obstructed with atherosclerosis, more objective tests can be obtained to define the extent and severity of the occlusive process. These studies may involve non-invasive pulse volume recordings or Doppler interrogation of the lower extremity arteries as well as invasive tests such as arteriograms. The information obtained from these specialized studies will delineate the severity and extent of the occlusive process. Decisions can then be made whether to continue conservative medical treatment or pursue more aggressive therapy such as balloon angioplasty and stent placement or surgical bypass reconstruction.

 

Many people can be managed with conservative medical management if they have symptoms of intermittent claudication, which only mildly interfere with their daily activities. Risk factor modification and regular walking exercise therapy may help stabilize their disease and maintain their walking ability at reasonable levels.

Others who may have more severe symptoms or be at risk for limb loss due to severe arterial insufficiency might be candidates for a catheter directed procedure such as balloon angioplasty and/or stent placement or direct bypass reconstruction utilizing surgical techniques. For patients who have obstructions localized to the iliac arteries, both interventional therapy with balloon angioplasty and stent placement or bypass reconstruction have excellent long-term durability and symptom relief. For patients who have obstructions involving the superficial femoral artery in the thigh, balloon angioplasty is helpful for only short segmental obstructions.

 

 

 

More frequently, a long bypass reconstruction is necessary utilizing the person’s saphenous vein from the same leg or occasionally a prosthetic bypass graft. Considerable success has been obtained over the past ten to fifteen years utilizing vein bypasses for lower extremity arteries even to small tibial vessels located between the knee and the ankle. Vascular surgeons at The Cleveland Clinic have extensive experience with both primary and reoperations for lower extremity occlusive disease. They have the ability to utilize a wide array of surgical techniques tailored to the individual patient.