ARTERIAL DISEASE

What is it?

Arteriosclerosis is a blockage and hardening of arteries.  Arteriosclerosis begins with insults to the innermost lining of an artery.  Proven insults are nicotine, high cholesterol, triglycerides or blood sugar in the blood, and high blood pressure.  The body responds to such insults by depositing such substances as cholesterol, cellular waste, calcium and clotting cells in the cell wall. These deposits, called plaques, grow until they or a newly formed blood clot near them occlude blood flow beyond the artery.  The decreased blood flow leads to tissue ischemia (lack of oxygen) and significant pain.  This pain is worsened by activities that increase oxygen demand or decrease blood flow to the occluded area (elevating the leg, exercising).   This pain in the legs is referred to as claudication. 

 

Now what can I do?

                  If you minimize your risk factors you will improve your current condition and aid in preventing further ischemic attacks.  Risk factors that you can control and improve are to: Stop smoking tobacco, keep your cholesterol low, control your diabetes, lose weight and become more physically active.  By exercising you force your body to grow collateral circulation paths.  In time these new paths will supply blood to once  ischemic (low blood flow) regions.

 

 

What are Indications for Further Intervention?

There are two main reasons to have something done to the arteries in your legs: death of tissue or an impact to the quality of your life. 

 

1.           Gangrene is death of tissue (necrosis) caused by loss of blood supply.   Increased risk for gangrene are either a non-healing sore on your leg(s) or painful ulcers on your feet.  Gangrene puts you at risk for amputation.  A medical intervention is necessary in this instance.

 

2.           The more common situation is when a problem in your leg limits your ability to do the things you want to do in life (cardiac rehabilitation, vacations, golf, etc.)  The underlying tissues in your legs are not at risk for gangrene.  The question that only you can answer is “to what extent is the quality of your life truly affected?” Rarely can this type of claudication lead to gangrene and or the need for an amputation. Exercise can improve blood circulation.  It forces your body to build and depend on collateral circulation.  You will notice your pain during exercise decreasing over time.  Some cases of claudication remain unchanged by exercise.

 

What are my treatment options?

  1. Exercise Program/Risk modification:  This is a conservative approach.  An exercise program may improve collateral circulation in your already ischemic leg.  You may also minimize your risk factors to improve your current condition.  (See above “Now what can I do?”)
  2. Angioplasty:  This is an option if the arteries in your legs are NOT totally occluded.  Angioplasty uses a balloon or stent to open the narrowed arteries. When the decision is made to proceed with an arteriogram, then an angioplasty will be performed whenever possible.  This will be done at the same time as the arteriogram.  The patient can generally go home that same day.
  3. Surgery:  This option is done to open up an artery to remove the blockage or perform a bypass around the occlusion. If an operation is the only viable alternative, then Doctor will discuss with you all the options.

 

What type of Intervention is an ANGIOGRAM / ANGIOPLASTY?

Doctors use “pictures” of arteries and their blood flow to evaluate areas with decreased or no blood flow.  These pictures are taken with Angiography performed by a physician.  The physician injects a small amount of local anesthetic around the femoral artery in the groin.  Then the physician inserts a very small needle and injects a liquid, or contrast to make the vessel visible.  Highly specialized x-ray equipment takes pictures and records any obstruction or narrowing of the arteries.

 

When the decision is made to proceed with an arteriogram, then an angioplasty will be performed whenever possible.  This will be done at the same time as the arteriogram.  Angioplasty places a deflated balloon in the area of narrowing or obstruction.  This balloon is expanded to widen the opening of the artery (lumen).  This temporarily can restore blood flow through a once obstructed region.   After the procedure, the catheter is removed and the physician applies direct pressure to the catheter entry site for 15-20 minutes to prevent bleeding.  You are asked to lie still without bending your leg for 4-6 hours. You can generally go home that same day.  You are NOT to drive home, or take a cab alone.  You will be given more detailed information at the day of your angiogram.

 

Scheduling your Angiogram

 

Text Box: 1. Please call the following location to schedule your pre-registration appointment for 3-5 days before your angiogram.   CPMC, Pre-registration and Learning Center ¾ (415) 600-2500 1825 Sacramento Street (@ Van Ness Avenue). The appointment may take up to 2 hours. Non-English speaking patients are encouraged to bring a family member that speaks English, or a translator. You will need to bring your insurance card and a list of your medications. 2. The location to check-in the day of your angiogram: q CPMC, Ambulatory Care Unit (ACU) 2351 Clay Street (@ Webster Street), 6th Floor You should arrive two (2) hours before your scheduled angiogram appointment. 3. You are not to eat or drink anything after midnight (12:00am) the night before your angiogram. 4. Anticoagulants (blood thinning medications) must be stopped at least 3-4 days before your angiogram. Examples are Vitamin E & Coumadin. 5. You may continue to take your heart and blood pressure medications that morning with a sip of water. 6. Diabetic medications like glucophage/metformin or Glucovance must be stopped 24 hours BEFORE the procedure and restarted 48 hours AFTER the procedure. If you are taking insulin, please contact the doctor’s office to get further instructions. 7. You should call our office (415) 221-7056 to make a follow up appointment (about 10 days after your angiogram). The doctor will then discuss your angiogram/angioplasty results and discuss surgical treatments that may apply to your situation.

If I need bypass surgery, what type of commitment is it?

·          Surgery is done as an inpatient. The day of your surgery, you must check in 2 hours before your surgery time.  The procedure itself takes about 3 hours.  You are in the hospital for 4-5 days.  You will need someone to drive you home.

·          You should plan on being off from work/activity for one (1) month.  

·          You cannot fly for 2 months after your procedure.  Your surgical leg should not be exposed to the sun for 6 months.

 

What happens at the hospital?

·          Your procedure will be done under anesthesia.  You will speak with an anesthesiologist before your procedure.

·          After surgery, you may be monitored in the Intensive Care Unit (ICU).  You are transferred to your room for the remainder of your stay.

·          Physical therapy will work with you to walk if necessary.  You can go home after you can get in and out of bed & walk independently. 

·          You will be given a prescription for pain medication before you leave the hospital.

 

What should I expect after I go home?

·          Each day you will see improvement in the range of motion of your legs. We encourage you to walk as a strengthening exercise.

·          While recovering, you want to minimize the amount of fluid that accumulates in your leg.  You must elevate your legs as much as possible.

·          You should shower regularly.  You need to wash your wound vigorously with soap and water to prevent infections.

·          You may drive after about three (3) weeks when you feel safe and have regained the range of motion in your leg(s).

·          You will be seen in our office 10-14 days after being home. 

·      You will have follow-up appointments, including ultrasounds, to evaluate the blood flow to your leg.  ( in 3, 6 and again in 12 months)

 

Scheduling your Surgery

 

Text Box: 1. Surgeries are performed on Mondays, Wednesdays and Fridays. 2. You will be notified of the date and time of your surgery by our office. 3. You need a physical exam by your primary care physician within a month before your surgery. Call to schedule this appointment with him/her after you have your surgery date. 4. You must Pre-register 14 days prior to your surgery. Please bring your insurance card for the pre-registration. (See Pre-registration packet) CPMC, Pre-registration and Learning Center ¾ (415) 600-2500 1825 Sacramento Street (@ Van Ness Avenue). Call for an appointment to pre-register. 5. The location to check-in the day of your surgery is: CPMC Pacific Campus, Ambulatory Care Unit (ACU) 2351 Clay Street at Webster Street, 6th floor 6. You are not to eat solid food for or drink milk products 8 hours prior to surgery. You may drink ONLY clear liquids up to 5 hours prior to surgery. 7. Continue taking your aspirin. Call our office if you have any other questions about medications to take or not to take. 8. Dr. Long will see you at the hospital the day of your surgery. D:\Erin MPA\Rotations\Vascular\VV\FemPop.doc

VASCULAR SPECIALISTS of SAN FRANCISCO
Dr. John Long, Dr. Marc Levine, Dr. Daniel Nathanson
3838 California St., Suite 612
San Francisco, CA 94118
415-221-7056       fax 415-221-7058