Do I Really Need Surgery for Peripheral Artery Disease?

For the first time in what seems like forever, Judith Taylor sleeps without interruption. She’s not awakened by pain or numbness in her feet caused by the peripheral artery disease (PAD) she was diagnosed with 3 years ago. She doesn’t need an extra blanket and socks to keep her left foot, which had the poorest circulation, warm.

“This foot was so cold it would wake me up in the middle of the night,” says Taylor, 68, a minister in Shreveport, LA. “Now it’s the foot that keeps the other one warm.”

As one of the more than 8.5 million Americans with PAD — a narrowing or blockage in the arteries that feed the extremities, most often the legs — Taylor found relief through an angioplasty. Whether to do it was hardly even a question: Her blockage was severe; the pain and discomfort were interrupting her sleep and her life.

Taylor had two procedures within 2 years. Each involved putting stents in; she stayed in the hospital for several days.

“You need to see your doctor, because treating PAD will be different for everyone,” says Sarah Samaan, MD, a cardiologist with Baylor Scott & White The Heart Hospital in Plano, TX.

“For some mild cases, walking may improve it and that’s perfect,” Samaan says. “But you need to have the workup done, know what you’re dealing with, what kind of blockage there is and how severe it is.”

For mild cases, risk-reduction pharmacology may be enough, said Matthew Corriere MD, a vascular surgeon at the University of Michigan Health Frankel Cardiovascular Center.

“They may not have symptoms,” Corriere says, “but they’re still at increased risk for heart attack and stroke. We put them on low-dose aspirin and a statin. This decreases the risk of PAD progression, but also reduces risks related to coronary disease and stroke risk.”

For them, there would be no point in having surgery or undergoing a less invasive procedure. They’re feeling fine; they’re managing their chronic disease.

From the start of the disease, doctors stress the importance of these key things:

• Stopping smoking, the main cause of PAD
• Getting diabetes under control
• Starting an exercise routine

But if pain and discomfort worsen and PAD interferes more and more with daily life, other options are also on the table.

“The tipping point of whether or not to take the next step might be pain symptoms that don’t go away and limit their quality of life,” Samaan says. “Non-healing wounds on the legs would be another, leading to a procedure or operation to restore blood flow.”

Some situations, such as chronic limb-threatening ischemia, leave little choice as to care. Patients might be in pain all the time, Corriere says. Maybe they have an ulcer on their foot that poor circulation keeps from healing and has led to gangrene on one or more of their toes.

“With those patients, we have to do a procedure,” Corriere says. “Their blood flow limitation is much more severe. We try to do a revascularization if we can — an angioplasty or a stent or bypass.”

Especially if symptoms are ignored for too long, “there can be such severe and irreversible damage that a patient may lose a toe, a foot, or even part of the leg,” Samaan says.

Care is tailored to a patient’s specific situation: symptoms, size and type of lesion, and location of blockage, says Corriere. He has done extensive research on the shared decisions between people with PAD and doctors.

“What we find is that individual patients have different expectations and goals,” Corriere says. “Sometimes they’re in line with medical recommendations and sometimes they are not. Some patients are risk averse. If they learn their blockage won’t get worse with what they’re doing already, they’re happy to have mild symptoms and get left alone.

“Others want everything done that can be done. Sometimes we do it and sometimes we have to establish mutual expectations.”

Many PAD procedures, such as Taylor’s most recent angioplasty, don’t require an overnight hospital stay, and results are immediate. Afterward, you only need to limit your activities for a few days.

For revascularization surgery, you may spend 2-4 nights in the hospital. Recovery is slower and probably involves being seen by a physical therapist.

Corriere would like people with PAD to remember this: No matter what treatment they get, it isn’t a cure.

“I see some people who don’t get counseling about PAD’s chronic nature and come see me because they’ve had a stent in their leg for 5 years and now are having trouble with it,” Corriere says. “They tell me they thought it was cured. But it’s never cured; we contend with it.”

For Judith Taylor (who is neither a patient of Corriere nor of Samaan), that’s OK. She can sleep through the night; she can walk without pain. And she’s determined to do all she can to stay the course.

“It’s up to me to keep that artery open,” Taylor says. “With that blockage I had, I could’ve lost my leg,” she said. “You have to walk every day, and I can do that. Keep walking and the vessels stay cleaner. I’m motivated to get out of that pain.”

Above all, “Don’t give up. Ask questions. Do your part as a patient,” Taylor says. “We all have something we can do to work with our medical team, if only to pay attention and let them know what’s going on.”

“I felt better almost immediately,” Taylor says. “You cannot imagine how good my spirits are. You try to be friendly and optimistic all the time. But being in constant pain really does take a lot out of you.”