Peripheral arterial disease: Should I have surgery?

Peripheral arterial disease (PAD) is a narrowing or blockage of arteries in your arms and legs. It causes poor blood flow. When you walk or exercise, your leg muscles don't get enough blood and you can get painful cramps.

PAD is caused by plaque buildup on the inside of arteries. Plaque is made of extra cholesterol and calcium in your blood. Over time, plaque builds up along the inner walls of the arteries, including those that supply blood to your legs.

Poor blood flow may cause intermittent claudication. This is tightness or squeezing pain in the calf, thigh, or buttock during exertion, such as walking up a steep hill or a flight of stairs.

High cholesterol , high blood pressure, and smoking add to plaque buildup and PAD.

Lifestyle changes and medicine often can stop plaque buildup. They can improve the quality and length of your life. Many people have less leg pain after trying these treatments for several months.

If you smoke, quitting is the best thing you can do when you have peripheral arterial disease (PAD). Smoking makes your symptoms worse. It also increases the chances of amputation and other problems.

Nicotine replacement products, medicines, and counseling can double your chances of quitting.¹ Medicines include bupropion, nortriptyline, and varenicline (Chantix).

Your doctor also will strongly advise you to:

• Follow a heart-healthy diet.
• Start an exercise program.

You will probably need to take cholesterol-lowering medicines. People with diabetes should try to keep their blood sugar levels in a target range.

People with PAD who have intermittent claudication have a higher risk for early death than other people the same age. Aspirin and strict blood pressure control can reduce this risk.

If you still have symptoms after making these changes, you may need angioplasty or bypass surgery. But you will still need to make lifestyle changes for the best long-term results.

There are two types of procedures:

• Angioplasty . The surgeon puts a small, thin tube called a catheter through a blood vessel in your groin and guides it to the affected artery. When the tube reaches the narrowed part of the artery, the surgeon inflates a balloon. The balloon presses the plaque against the wall of the artery. This improves blood flow. A small tube called a stent often is placed in the artery to hold it open.
• Bypass surgery. This surgery helps blood make a detour, or bypass, around one or more blocked arteries. The type of surgery used depends on the affected leg artery or arteries. You may have:
  • Aortobifemoral bypass, for narrowing of the aorta and the iliac arteries.
  • Femoropopliteal (fem-pop) bypass, for narrowing of the arteries in the thigh and knee.
  • Femoral-tibial bypass, for narrowing of the arteries in the lower leg or foot.

Bypass surgeries can be done with a vein or with a man-made graft. Vein grafts can keep the blood vessel open longer than the man-made grafts.

More than one type of procedure may be done at the same time. For example, a bypass surgery may be done at the same time as a less invasive angioplasty. These procedures may be done at the same time to treat different levels of disease and different-sized arteries.

A less common surgery is called an endarterectomy. An endarterectomy is typically done on the large femoral artery, which is in your groin and upper thigh area. This surgery is done to remove fatty buildup (plaque) and to increase blood flow to the leg. This surgery is done by cutting open the femoral artery and removing the plaque. This surgery may be done by itself, or it may be done at the same time as bypass surgery or angioplasty.

The choice of angioplasty or bypass surgery depends on the:

• Risks of the procedure.
• Size of the arteries.
• Number and length of the narrowing or blockages in the arteries.

For example:

• Angioplasty works best in larger arteries. It has the best rates of success in the aorta and iliac arteries.
• In the femoral arteries, angioplasty works better if the area that is narrowed is short.
• Angioplasty has become more common for problems in the popliteal and tibial arteries. In the past, doctors preferred bypass surgery over angioplasty in these arteries.

All surgeries have risks. Angioplasty has fewer life-threatening risks than bypass surgery.

Risks of bypass surgery include:

• Infection.
• Bleeding
• Heart attack or stroke.
• Leg swelling.
• Failed or blocked grafts.

Risks of angioplasty include:

• Rupture of the artery.
• Bleeding at the site where the catheter goes in.
• Sudden closure of the artery.
• Blood clots.
• Allergic reaction.
• Kidney damage.

The worse your disease, the more likely you are to need angioplasty or bypass surgery. Your doctor might advise you to have one of these procedures if you have intermittent claudication and any one of these problems:

• Symptoms limit your lifestyle or job.
• Exercise has not relieved your symptoms.
• Medicines have not relieved your symptoms.