Peripheral Angioplasty

Dr Naid Rahim, Dr Matthew Gibson, Dr Farhan Ahmad and Dr Archie Speirs are experienced in the treatment of artery blockages using angioplasty and stents - minimally invasive, pin hole procedures under X-ray guidance. This technique has a high technical success rate, is very low risk and often performed as a day case.

This webpage describes the causes of artery blockages, how they are investigated and the angioplasty technique. If you would like to have a consultation to discuss your situation in more detail, please call Berkshire Imaging on 0118 921 3177

What causes pains in the legs on walking?

Arterial narrowing or blockage is most commonly due to a build up of fat deposits (atheroma) in the arteries. Figure 1 shows how blood travels to the legs.

The main blood vessel in the body (the aorta) divides sequentially in the legs giving off branches to the muscles until the final division occurs below the knee with 3 small (tibial) vessels taking blood to the foot.

Blockages at any level within this “arterial tree” can cause symptoms. Compare figure 1 to Figure 2, a CT angiogram used to diagnose problems with the leg arteries. There are two main types of symptoms that can occur intermittent claudication and critical limb ischaemia.

FIGURE 1:

SCHEMATIC DIAGRAM OF THE LEG ARTERIES

FIGURE 2:

A NORMAL CT ANGIOGRAM OF THE LEG ARTERIES

Who gets blockages within the leg arteries?

This condition is most common in people who smoke or have diabetes. Other risk factors include raised cholesterol, high blood pressure, increasing age and lack of exercise. These patients are not only at risk of blockage to arteries in their legs but also elsewhere in the body such as the vessels supplying the heart or brain and are therefore also at higher risk of heart attacks and strokes.

Intermittent claudication

Intermittent claudication is pain in the calf, thigh or buttock which occurs on exercise (for example walking a certain distance) and is relieved by rest. Sometimes it occurs at such a short distance that it can affect simple tasks like walking to the shops or playing a game of golf. Intermittent claudication usually means there is a tight narrowing or blockage affecting an artery usually above the knee (see Figure 1).

Critical limb ischaemia

Critical limb ischemia is a term used when the supply of blood to the leg or foot is severely limited when resting. It can result in constant foot pain or breakdown of the skin in the foot resulting in ulceration. Some patients get pain in the foot at night which is relieved by dangling the foot out of bed (which improves the blood circulation to the foot and reduces pain temporarily). Critical limb ischaemia can mean that there are tight blockages in the arteries in the calf as well those above the knee. (see Figure 1).

How is lower limb peripheral vascular disease diagnosed?

There are many problems other than arterial blockages that can cause pain in the legs or ulceration of the skin in the lower leg. Nerve irritation from the back (sciatica), arthritis and muscle injures can all be mistaken for arterial disease and conditions such as diabetes and varicose veins can cause skin ulceration even when the arteries are normal. A vascular assessment helps to diagnose when people have symptoms related to their arterial circulation. This will include a medical assessment following which specialist tests may be requested to confirm the diagnosis.

Clinical assessment:

Your doctor will take a history which will include your symptoms and risk factors for peripheral vascular disease. An examination of the legs will include feeling your leg pulses.

CT and MRI angiography

Both CT and MRI provide very detailed pictures of the arteries and in our practice are the investigation of choice to identify arterial narrowings in the legs. See Figure 2 above. Both involve injection of contrast (dye) in to a small vein in the back of the hand or arm.

How are leg artery narrowings treated?

The first line treatment for intermittent claudication is aimed at reducing risk factors for the development of further arterial disease. Table 1 lists some possible treatment options. Collectively this is known as “Best medical therapy”.

Best medical therapy for Peripheral vascular disease

Smoking cessation

Exercise / weight reduction

Reduction in cholesterol – diet / tablets

Anti-platelet agents – aspirin

Screening and Treatment of diabetes – foot care

Treatment of high blood pressure

Some patients with intermittent claudication will improve simply by walking or exercising as much as they can and with best medical therapy. However sometimes symptoms can persist despite these measures or symptoms are so severe that they prevent simple or enjoyable daily activities. In these cases arteries can be unblocked by angioplasty or surgical bypass.

Critical limb ischaemia is different. It is unlikely to improve with best medical therapy alone. These patients are at high risk of requiring an amputation and they require either urgent angioplasty or surgery to save their toes, foot or even leg.

Angioplasty and stenting

Angioplasty, inflating a balloon inside the artery narrowing, is usually the treatment of first choice when arteries need to opened. Stents (metal tubes or frames) are occasionally placed inside the artery to hold it open.

Angioplasty and stenting is performed by a specially trained Consultant Interventional Radiologist in a dedicated x-ray imaging suite. The procedure is much less invasive than surgery resulting in a faster recovery and far fewer complications. It can normally be performed under local anaesthetic or light sedation and is often arranged as a day case.

Angioplasty involves making a tiny 'pin-hole' incision at the top if the leg to insert a wire into the artery which is then navigated to the blockage. Over the wire a balloon is fed through the blockage and inflated to open it. A stent, if needed, can be placed over the same wire. Once successfully treated, all the wires are removed and a small plug placed in the vessel to seal the hole.

FIGURE 3:

Angioplasty procedure of calf arteries. The patient presented with foot pain and ulceration and underwent urgent successful angioplasty of the lower leg arteries.
A: The angiogram demonstrates only one vessel in the lower leg with a further vessel occluded (arrow).
B: The occluded blood vessel is opened using a balloon thereby improving blood flow to the foot and relieving symptoms.

FIGURE 4:

Angioplasty and stenting of the pelvic (iliac) arteries. The patient presented with pain in both buttocks and legs when walking short distances (intermittent claudication) and underwent angioplasty and stent insertion in the iliac arteries.
A: The angiogram demonstrates severe narrowing in iliac arteries on both sides
B: A wire is carefully passed through the narrowed vessels and balloons are inflated on both sides and stents have also been inserted
C: The final picture shows successful treatment with resolution of symptoms

Surgical bypass

Surgery is far more invasive, requires a general anaesthetic, has more adverse events and takes a great deal more time to recover from. Bypass means using a patients vein or artificial graft material to re-direct blood flow to avoid a blocked artery. It is normally reserved for patients who have very long blockages when angioplasty is unlikely to be successful.

Our practice:

We work closely with Mr Tim Magee and other local consultant specialists, and perform over 250 angioplasty cases each year. Our results compare favourably with those of other centres and we routinely submit our cases to a national registry. We endeavour to treat all our patients on a day case basis where they are looked after by specialist nurses in our dedicated Interventional Radiology recovery suite.

Further Information

Patient information sheet

British Society of Interventional Radiology, www.bsir.org

Cardiovascular and Interventional Radiological Society of Europe, www.cirse.org

If you would like to discuss these treatments with one of our specialists please contact Berkshire Imaging on 0118 921 3177

Berkshire Imaging LLP . The Forbury Clinic . 23 Craven Road . Reading . Berkshire . RG1 5LE . Telephone: 0118 921 3177
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