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Treatment of Peripheral Arterial Disease

Overview
Vascular History
Procedures to Open Blocked Arteries
Interventional Radiology Treatments for PAD
Surgical Treatments for PAD

Overview
The majority of patients with symptomatic PAD can be treated conservatively with medical and non-interventional management. However, in patients with severe PAD symptoms that may risk loss of a leg or patients with severe life-style limiting claudication, more aggressive treatment measures may be necessary. In this latter group of patients, the decision to proceed along an interventional pathway is not always straightforward. This is because the risk of performing any intervention must be carefully balanced against the severity of the claudicative symptoms. It is at this time that a careful discussions with a vascular specialist is paramount.

Prior to performing any intervention most patients will require angiography. This is a technique that involves inserting a small catheter into your artery (usually near the groin) and infusing a contrast agent into your vessels. This provides a detailed picture of the inside of your arteries and clearly demonstrates the severity of your PAD and the amount of artery stenosis and blockage present. Based on this study a plan can be formed as to the optimal treatment options whether it be a minimally invasive “endovascular” approach or formal surgical reconstruction is required. Depending on individual conditions, there are alternatives to angiography that can be performed, and these include magnetic resonance angiography (MRA) or arterial duplex mapping.

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Balloon angioplasty of a stenotic (narrowed) artery.

Vascular History
Before prosthetic grafts for bypasses became available, the first direct surgical reconstructions on the aorta were performed using the technique of thromboendarterectomy. This was first described by Dos Santos of Lisbon in 1947 and involved directly removing an occluding atherosclerotic plaque from the interior of an artery. The initial procedure was performed on a patient with superficial femoral artery obstruction, and Dos Santos termed the procedure disobliteration. Edwin J. Wylie, MD, adapted this technique to the aorta and in 1951 when he performed the first aortic endarterectomy in the United States. With the discovery of suitable prosthetic graft materials for aortic replacement in the 1960s, surgical treatment for PAD became available to even more patients. In 1964, Dotter first performed percutaneous transluminal angioplasty (PTA) using a coaxial system of metal dilators. This procedure proved to have limited application due to the cumbersome nature of the device. However, Dotter's early work paved the way for Grüntzig, who, in 1974, developed a catheter with an inflatable polyvinyl chloride balloon that could be passed over a guidewire. This device became the cornerstone for the percutaneous treatment of arterial occlusive lesions today. In 1985, Julio Palmaz introduced the first stent that helped to improve the results of angioplasty for arterial occlusive disease.

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Procedures to Open Blocked Arteries
There are a number of ways that vascular specialists can open blood vessels at the site of blockages and restore normal blood flow. In many cases, these procedures can be performed without surgery using modern, interventional radiology techniques. Interventional radiologists are highly trained physicians who use tiny tubes called catheters and other miniaturized tools and X-rays to do these procedures.

Sometimes, open vascular surgery is required to remove blockages from arteries or to bypass an occluded area. These procedures are performed by vascular surgeons. Because of the issues, the therapeutic decisions involved in the treatment of PAD can become complex and require the expertise of several overlapping vascular disciplines in a multidisciplinary team.

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Hemodynamic narrowing in the left common iliac artery. Large collateral vessels confirm hemodynamic significance of left common iliac stenosis.

Interventional Radiology Treatments for PAD

Percutaneous Transluminal Angioplasty (PTA) - a tiny balloon is placed in the blood vessel at the site of the blockage. It is then inflated to open the blood vessel.

Stents - a tiny metal cylinder, or stent, is inserted in the clogged vessel to act like a scaffolding and hold it open.

Thrombolytic therapy - clot-busting medications are delivered to the site of blockages caused by blood clots. These medications are often cocmbined with another treatment such as angioplasty.

Stent-grafts - a stent covered with synthetic fabric is inserted into the blood vessels to bypass diseased arteries.

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Successful treatment of the focal high-grade left common iliac stenosis with PTA and stent placement.

Surgical Treatments for PAD
Surgical treatment for PAD today is well standardized, and the outcomes are quite good.

Thrombectomy- this procedure is used only when symptoms of PAD develop suddenly as a result of a blood clot. In the technique, a balloon catheter is inserted into the affected artery beyond the clot. The balloon is inflated and pulled back, bringing the clot with it. Thrombectomy usually requires surgery.

Bypass grafts- in this procedure, a vein graft from another part of the body or a graft made from artificial material is used to create a detour around a blocked artery.

Endarterectomy- these procedures are performed by creating a direct surgical opening of the artery, and removing or excising the plaque which narrows the artery. The artery is then closed leaving it with a normal diameter, allowing blood to flow easily.

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For more information, visit here (surgical bypass) or here (angioplasty).

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