Peripheral artery disease (PAD) is a condition where arterial stenosis results in reduced blood flow to the lower limbs. The impact of PAD on patient quality of life is substantial and parallels the impact of well-known chronic conditions such as chronic obstructive pulmonary disease and severe chronic heart failure. The natural history of PAD is variable and influenced by both the severity of the patient’s macrovascular and microvascular disease as well as by the patient’s risk factor profile. Prevention of arterial events is the goal of treatment in PAD, and there is a large evidence base for the benefits of interventions such as diet and exercise therapy, lipid-lowering, anti-platelet therapy, and blood pressure lowering in PAD patients. Interventions to improve or restore the blood supply to the limb, such as supervised exercise programs, particularly in patients with critical limb ischemia, have been shown to be beneficial. Peripheral vascular disease affects blood circulation, especially in the legs and feet.
Minimally invasive arterial catheter-based procedures to treat PAD have grown rapidly over the last decade, and particularly in the last 12-18 months, with innovation in devices, techniques, and patient management protocols. This growth reflects the advantages of minimally invasive endovascular therapies compared with open surgery. Endovascular therapies are less invasive and lower risk for patients, are less painful, allow quicker return to work and daily activities, and use local rather than general anesthesia for most procedures. Importantly, rapid advances have also been made in the evidence and data on which to base decision making for endovascular revascularization. The success and low risk of endovascular measures matched with and following the advent of newer generation devices (stents and drug-coated balloons) have many advantages on rerouting patient care towards percutaneous revascularization of more complex and higher-risk patients. Some of these benefits, taken from the evidence supporting the revascularization hierarchy, may include earlier mobilization and discharge, reduced discomfort, faster return to work and improved quality of life, and decreased procedure and hospital costs.
Definition and Prevalence
Peripheral artery disease is a condition where arteries narrow, reducing blood flow to the limbs. Peripheral arterial disease (PAD), also known as peripheral vascular disease (PVD), due to atherosclerosis, is a serious disease affecting more than 200 million people worldwide. This is an important first step towards establishing a full-fledged vascular centre to address the complex nature of this serious disease that is associated with high morbidity and even death. As minimally invasive interventions continue to evolve and yield good results and quick recovery, standby surgical back-up is not necessary. Hence, embarking on a vascular centre is timely to serve the need of the growing number of patients with peripheral artery disease or venous disorders.
Causes and Risk Factors
Overview of the services provided by Vascular and Interventional Centre for treating peripheral artery disease with minimally invasive procedures.
Peripheral artery disease (PAD) occurs due to progressive narrowing and blockage of the arteries of any part of the body except the heart. The cause of the unusual location of obstruction is because the arteries from the heart are large with straight and soft shape, while the peripheral arteries are small and pointed, also strong or weak depending on the location where they pass.
Usually, the disease covers two main parts of the body: Carotid in the neck and lower limb arteries. There are a number of risk factors that increase a person’s risk of developing arterial disease. These are usually similar to heart disease. The more of the following risk factors that apply, the higher the risk of developing arterial disease.
1) Diabetes: Diabetes damages the arteries of the body.
2) Cigarette smoking: Smoking is one of the most important risk factors for peripheral arterial disease.
3) High blood cholesterol: Fat deposits can clog the arteries.
4) Primary and secondary high blood pressure symptoms: The force exerted by the heart and the pressure in the arteries is abnormally high.
5) Radiation: Nearly 5 days of radiotherapy for cancer treatment to the lower abdomen or pelvis usually can cause abdominal arteries to narrow when associated with Buerger’s Disease.
The Role of Vascular and Interventional Centre
The Vascular and Interventional Centre in Singapore is comprised of vascular surgeons and interventional cardiologists. The methods applied for the diagnosis and treatment of peripheral artery disease comprise angiography, stent implantation, angioplasty, as well as the methods of peroxide therapy, linear reperfusion to remove arterial lesions. Peripheral artery angioplasty is a minimally invasive treatment of peripheral artery diseases. When performed by experts, it provides a very high success rate and low risk of complications.
The use of minimally invasive treatment in peripheral artery disease enables the patient to recover within a shorter time and carry out his/her daily activities from the time of the initial diagnosis with minimal discomfort. In the vascular and hemodynamic surgery unit, peripheral balloon and stent applications are carried out uninterrupted within 24 hours. Stent graft support is also provided with the desired treatments to be performed. Peripheral arterial disease treatment may include lifestyle changes, medication, or surgery.
Advantages of Minimally Invasive Procedures
The advantages of minimally invasive procedures in treating peripheral artery disease are numerous, not only for the patients but also from a healthcare system perspective. Rapid recovery and an ambulatory procedure setting are the major advantages of these procedures. These patients can continue their daily life one day after the procedure. It is enough for the patient to be at rest for 3-4 hours after the procedure. The patients undergo general anesthesia insufficiently, thus they do not have to be fasting throughout the day of the procedure. There is no need to stay at the hospital before and after the procedure. The healthcare system also benefits from these procedures due to the early discharge of the patients and the rapid reuse of the operation room.
Moreover, the hospital stays are less than one day. The bleeding volume is minimal. Patients with peripheral artery disease are usually old and high-risk for bleeding. The mortality and morbidity risk increase with age, in addition to comorbid conditions such as anticoagulant or platelet inhibition, hypertension, stroke, diabetes, chronic renal failure, advanced chronic obstructive lung disease, cancer, dyslipidemia, and atrial fibrillation. These minimally invasive procedures can be applied to frail elderly patients. Unfortunately, the risk of intraoperative fatality is high, and there is a significant risk of an abortive procedure due to the comorbid conditions in major amputation operations. The absence of hospital stay also reduces postoperative congestion, infection, and delirium. Since the procedures are rapidly effective, the risk of typical coronary complications, such as a heart attack, and mortality is low. The old patient might not survive despite the success of the operation. In these procedures, we can learn that the flow has been reinstated and verify that the patient feels better.
Diagnosis of Peripheral Artery Disease
The main diagnosis method for peripheral artery disease (PAD) is to check the pulse on the dorsalis pedis each time the periodic health check-ups are performed. Palpation is used for checking dorsalis pedis or femoral pulse. If there is no pulse, auscultation with a stethoscope could help indicate the presence of atherosclerosis (using the Doppler II device). For the diagnostic assessment of PAD, the ankle brachial pressure index (ABPI) measurement test and duplex ultrasound are the primary clinical tools in many clinical settings. The device can be used to apply compressive stress to the arm and leg to increase blood pressure. A Doppler device or an oscillometric device can be connected to a blood pressure cuff to detect changes in the blood flow sound signals before blood pressure measurements and echoes by lung sounds during systolic blood pressure changes.
The diagnostic tool used to measure ABPI accurately should include: the oscillometric method with the assistance of fully automated devices, continuous or simple Doppler ultrasound measurement, or, in critical situations, auscultation with a Doppler ultrasound probe. The foot vessel pressure is measured at the posterior and dorsalis pedis. If non-invasive arterial pressure measurements show that the systolic index in the foot is <0.5 times that in the arm, PAD shall be diagnosed. Adverse events include, for instance, stenosis or arterial occlusion, numbness or paralysis of the limb. PAD has been shown to be associated with a lower systolic index in leg measurements. The type of ABI/OI failure was used to perform non-invasive diagnostic tests. Finally, other PAD patients with normal ABI may also develop symptoms gated by significant artery stenosis (fast walking during exercise, ischemic convulsions at rest) and may require further diagnostic imaging testing to establish PAD.
