Peripheral Arterial Disease (PAD) and Varicose Veins --- March 11, 2008

Sunita Srivastava, M.D., FACS Surgeon Department of Vascular Surgery Cleveland Clinic Heart and Vascular Institute

Cleveland_Clinic_Host: Welcome Dr. Srivastava, and thank you for being with us today. It is wonderful that you can join us. We look forward to an interesting chat today. Welcome! Let's begin with one of the questions!
Speaker_-_Sunita_Srivastava, M.D.: Thank you for logging in and your interest in vascular disease.

Defining Peripheral Arterial Disease (PAD)

kelly: What is the difference between PVD and PAD? What are the causes?
Speaker_-_ Sunita_Srivastava, M.D.: This is a great question that a lot of people ask. Both are the same disease just different acronyms. PAD is peripheral arterial disease and PVD is peripheral vascular disease. Most people who have this process have risk factors that include high cholesterol, hypertension, family history, diabetes, renal failure and history of TIA or strokes in the past. Anyone with these risk factors may have arterial disease. Symptoms may include pain/cramping with walking variable distances, pain in the foot with elevation and then inability to heal small wounds on the foot.

lex: Can you have PAD when you’re young (in your 20’s)? There is a family history, and I have been experiencing some (unexplained) leg pain. How do you know when to go to the doctor?
Speaker_-_ Sunita_Srivastava, M.D.: PAD is not as likely to occur with young age despite family history. However, a good physical exam and history from your doctor will be helpful in eliminating it as a possibility as well as identifying some other potential causes for your pain. Other possibilities that would need to be evaluated are a blood clot in your vein, trauma to your leg and bony injury. That is why it is important to see your doctor.

newtonm: My mother has bad leg pains, not every day, but when she has pain, it is bad. She believes it to be arthritis. How do you know the difference? Or what is actually causing the leg pain? I guess I'm basically asking what are the signs and symptoms that point to PAD instead of some other ailment. How is it diagnosed?
Speaker_-_ Sunita_Srivastava, M.D.: Leg pain can have many causes. Sometimes it can be arthritic, muscular cramping at night or even pain from lack of circulation. She should get a physical examination to determine if her circulation is normal by her internist or even a vascular surgery consultation. Typically vascular blockages cause pain in the calves with walking, lack of healing in the legs, and sometimes pain when the feet are up relieved by dangling the feet or just getting up. I would advise seeing her physician to determine if she has a vascular component to her pain.

lindas: If you have PAD, does that increase your likelihood of having other arterial problems and vice-versa?
Speaker_-_ Sunita_Srivastava, M.D.: PAD is a marker for diffuse (system wide) arterial disease. Patients will likely have arterial blockages elsewhere i.e. heart, carotid (neck arteries) and it may lead to heart attack and stroke. One of the key elements in identifying patients with PAD is to help reduce the chance of heart attack, stroke and death from the arterial blockages that are likely everywhere but may not be identified.

brandon13: What exactly is Intermittent Claudication?
Speaker_-_ Sunita_Srivastava, M.D.: Intermittent Claudication is cramping or pain in the leg when walking variable distances. If it is consistent, please see your doctor. Keep in mind how far you can actually walk (city blocks) before you get the pain as it may determine treatment options for you. Keep walking as much as you can.

KS: How common is recurrent leg pain after a bypass? Is there any way to prevent this?
Speaker_-_ Sunita_Srivastava, M.D.: Pain after a bypass can be the result of many factors. Swelling, incisional discomfort, walking differently because of surgery, ill fitting shoes after surgery are just some of the possibilities. Post op, your doctor should have you on a regimen of walking and periodic visits to assess your bypass for continued flow. Any sudden changes in your symptoms or appearance of your leg could indicate a problem with your bypass and should be brought to the attention of your vascular surgeon.

Treatments Options for PAD

HGD: What are some of the ways PAD is treated?
Speaker_-_ Sunita_Srivastava, M.D.: There are several ways to treat PAD
1. The most common treatment recommendation is a focused walking regimen to improve exercise tolerance and recruit collateral blood vessels to kick in for your blockages. This is a first line treatment which works quite well for most patients.

2. Medications including Pletal or trental may also be used as treatment. Some studies indicate that these drugs will improve walking tolerance. However, they have side effects including heart failure and should only be used under the supervision of your doctor.

3. Minimally invasive procedures are used to diagnose and treat the blockages. An angiogram can clearly identify the blood vessels blocked. The physician can also try to cross the blockage with a wire to potentially balloon it open or stent it open depending upon where the blockage is and how extensive it is. There are many techniques to open the blocked blood vessels but this does involve coming to the hospital and having it performed in a procedure room or operating room under minimal anesthesia (like a colonoscopy).

4. A final treatment option is open surgery to create a new channel using your vein or sterile plastic tubing to bypass your blockages.

carlp10: What is new and upcoming in the treatment of PAD? Are there any new medical breakthroughs?
Speaker_-_ Sunita_Srivastava, M.D.: This is an exciting question to answer! Currently there are several research trials investigating new technology to debulk and ameliorate the plaque in blood vessel walls.

These technologies include balloons with special coating, coated or drug treated stents, biodegradable stents and instruments to remove plaque in a minimally invasive fashion.

In addition there is ongoing research in drug therapy to alter the plaque accumulation in the blood vessels.

Spider Veins and Varicose Veins

Speaker_-_ Sunita_Srivastava, M.D.: Let’s first review the factors that can cause varicose veins:

1. Family history

2. Pregnancy- the fetus puts a lot of pressure on the main vein in your body especially further along in the pregnancy. In addition, circulating blood volume doubles when you are pregnant. Hormones associated with pregnancy also cause dilation of your blood vessels to accommodate the increased volume too.

carrie: What are other treatments for varicose and spider veins, besides Sclerotherapy? Is one option considered better than others? Is there anything new on the horizon?
Speaker_-_ Sunita_Srivastava, M.D.: Other treatment options for varicose veins include a trial of compression stockings and leg elevation. If this fails to improve symptoms then surgical options can be considered.

New techniques involve passing a laser probe or a heated probe into the greater saphenous vein to obliterate it from within. This technique avoids stripping the vein which was a treatment option in the past.

These new techniques minimize pain, bruising and nerve injury often seen with stripping.

In addition these techniques will remove the pressure in the superficial veins resulting in improved appearance of existing varicosities.

However, larger varicosities can be removed directly with minimal trauma and as an outpatient procedure.

mollie: Can losing weight help prevent varicose or spider veins?
Speaker_-_ Sunita_Srivastava, M.D.: Excellent question! Weight loss can improve and or prevent varicose veins by reducing pressure on the veins. In addition it promotes healthy circulation in both the arteries and the veins.

Walking is the best exercise for blood vessel health.

carrie: How about alternative treatment? I've read about horse chestnut seed extract? Is there anything to it?
Speaker_-_ Sunita_Srivastava, M.D.: There are many "medications" that are advertised to promote vein health that have not been supported in medical research. It is best to consult your physician before embarking upon any alternative medical treatment as it may be expensive, not covered by insurance and potentially interact with your existing drug regimen.

lakewatch: Is there any food or vitamin complex which has been shown to reduce existing plaque in the arteries?
Speaker_-_ Sunita_Srivastava, M.D.: No vitamins or food have been verified by research trials. However, dietary control of cholesterol intake, cholesterol lowering drugs as well as aspirin and Plavix may limit the deposition on existing plaque in blood vessels.

geoswife43: Four days before my husband suddenly died, his GP remarked about the veins in his legs. He said he may need support hose in the future. My husband's cardiologist had not said anything about the veins. Could the veins have been an indicator of something serious?
Speaker_-_ Sunita_Srivastava, M.D.: I am sorry for your loss. That is a difficult question. Compression stockings are indicated for swelling, varicose veins and patient comfort. It sounds like there were some underlying additional medical issues that are more likely related to your husband's death.

Cleveland_Clinic_Host: A large number of questions were received and we apologize if we did not get to your question. We will try to answer as many questions possible in these last few minutes. If you have additional questions, please go to http://www.clevelandclinic.org/health/livepersonchat/ to chat online with a health educator.

cookie: Is PAD a complication of diabetes?
Speaker_-_ Sunita_Srivastava, M.D.: PAD and diabetes can co-exist and are two separate disease entities.

Diabetes is a disease that affects the smaller blood vessels in your organs and extremities. It can worsen the effect of PAD on your circulation because both the large and small vessels may become abnormal.

Diabetes may result in neuropathy which may limit sensation in the foot and increase the likelihood of inadvertent trauma. When this occurs, if there is blockage in the circulation from PAD, the healing may be delayed.

maggie: I have had some numbness in my toes, never all toes at one time, usually after standing for some period. Is this an indicator of vascular disease?
Speaker_-_ Sunita_Srivastava, M.D.: It may be a sign of arterial disease or neuropathy. The best way to tell is to see your doctor who will perform a thorough examination and testing to.

If you have risk factors for arterial disease such as hypertension, high cholesterol, family history, heart attack, stroke and diabetes, you should see your physician.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Sunita Srivastava is over. Thank you again for taking the time to answer our questions today.
Speaker_-_ Sunita_Srivastava, M.D.: I would like to thank the audience for their participation today. If there are any urgent concerns or questions, they should contact us or their local health provider.

There is also an upcoming free public health talk in Beachwood, Ohio in June regarding the diagnosis and treatment of Peripheral Arterial Disease (PAD) and Varicose Veins. More information is available by calling 216.444.3641 or 1.800.548.8502

Cleveland_Clinic_Host: Thanks for joining us everyone! If you missed any part of this chat, please check back soon for the full transcript at www.clevelandclinic.org/webchat. And join us for our next live web chat at 12 noon March 27th 2008: Ask the Nurse about Heart Failure Management. See you next time!

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Cleveland_Clinic_Host: If you would like more information regarding PAD, varicose veins or spider veins, please visit the Cleveland Clinic Heart and Vascular web site at http://www.clevelandclinic.org/heart. For general health information you may also wish to visit www.clevelandclinic.org/health .