The word "
sclerosis" means hardening. The term
"arteriosclerosis" refers to hardening of one or more
arteries. When this happens to the normally soft and
supple blood vessels, it interferes with the amount of
blood they carry. Therefore, an organ that is supplied with
blood from a sclerotic artery will get less blood.
Where the blood supply drops below the minimum
normally required, the part will fail to function normally
and eventually will not survive. Thus, where the blood
supply to a part of the brain is sclerotic, the patient can suffer a paralytic stroke. Where the blood to the heart is
decreased, the patient can have either heart failure or a
heart attack. The same decreased function and then death
of the part apply to every area of the body. In the legs
this is particularly obvious by changes in color, warmth
and strength.
Arteriosclerosis is a process that can affect arteries in
all parts of the body. There are marked individual variations
in susceptibility of the part affected and in the rate
with which it occurs. Thus, one may have poor arteries
in the legs and have excellent brain circulation. Everyone
lives with some arteriosclerosis. It becomes a disease
only when function of a part is interfered with. When the
circulation to the legs becomes so poor that it is below
that required for oxygenation and nutrition of the part,
the toes and foot can become gangrenous and threaten the
survival of the limb and life.
What are the symptoms that indicate that my circulation
is impaired?
You may have noticed that you cannot walk as briskly
and as far as you did before. It may be necessary to stop
because of a cramp in the calf or in the hip area, but after
a few seconds you can go on as before. This is the earliest
symptom. After that you may notice color changes in the
toes or foot. They become very pale or red or blue. The
healing of a cut takes more time than it did previously,
or there is a decreased amount of hair on the top of the
toes.
How do you, on examination, know that it comes from
poor circulation and not from straining or overwork
or my imagination?
One examines the extremities for changes that indicate
poor circulation. Thus, the pulses in the foot area, which
should be full and strong, can be weak or completely
absent. The hair on the toes can be absent or scant. By
moving the extremity up and down it is possible to evoke abnormal color changes. The diagnosis of poor leg
circulation can be made very accurately.
Why is one leg worse than the other? Will the same
changes occur on the other side?
Arteriosclerosis is a spotty process. The site where the
sclerosis appears determines what the symptoms will be.
If a car stalls on a rural little used road, the traffic jam
will be less than it would be on a main highway. The
same with sclerosis. If a less important blood vessel is
involved, there may be no symptoms. Pure chance determines
which leg is affected and how badly. While it is
often true that one side can be very bad and the other
normal, usually, in time, the sclerotic process will involve
the other side. However, the extent and seriousness
of the disease may be quite different on each side.
If you are sure of the diagnosis, why do you want to take
this X ray? What is so special about this X ray
that I have to go to the hospital?
This X ray, called an arteriogram, is an actual picture
of the arteries. The examination is done by injecting a
contrast material into a normal artery. The material can
then be photographed as it circulates. This X ray will
then map out the circulation of the legs by showing all the
arteries, the large as well as the small, and the normal* as
well as the diseased. In this way, we obtain a map of
your arterial system. The X ray is really a moving picture
of the blood as it goes through the vascular system. It
will serve to confirm the diagnosis and to indicate whether
your specific problem can be improved by direct surgery.
Can you treat my condition and improve my ability to
walk without an operation?
There is, unfortunately, no specific way of treating the
usual type of arteriosclerosis. We cannot dissolve the scar
or the calcium. There are things that aggravate the
sclerotic process. The most important is that one must stop smoking; stop completely! There is evidence that
cigarette smoking especially impairs the circulation. Associated
medical disease, especially diabetes, requires
carefully controlled supervision. Dietary measure, weight
control and foot hygiene are considerations. One must be
very careful about foot and toe infections and injuries,
since these areas heal poorly and this can be the start of
serious problems. You may carry on a normal existence
with these admonitions. Many of the orally administered
drugs do not influence the disease.
How long can I go on this way, having to stop every
block to catch my "leg breath"?
Possibly for a long time; it may require some adjustments
as far as living closer to where you work and recognizing
that you have to slow down. Ordinarily surgery is
not advised for this symptom. You may be able to go
along this way for many years without surgery.
What does diabetes have to do with it?
Diabetes has an effect on the blood vessels. It appears
to be associated with earlier arteriosclerosis and with more
advanced disease than is seen in the nondiabetic. Diabetic
peripheral arteriosclerosis is of special signficance because
smaller and more vessels are involved than in the sclerotic
process without diabetes. All of which adds up to the
simple fact that the disease is likely to be more advanced
in the diabetic and therefore less amenable to totally
corrective surgery. In addition, infections in the diabetic
can be more serious than in other individuals. In other
words a specific diabetic artery disease is added to the
burden of general arteriosclerosis.
Will these changes also occur in my hands?
Arteriosclerosis of this type is very rarely seen in the
hands. There are blood vessel diseases of the upper extremity,
but they are not of this type.
Why don't you recommend surgery as soon as walking
becomes difficult?
In certain selected instances it is advised. It depends on
where the artery is blocked. But in many instances the
individual may go a long time, a lifetime, without getting
into more serious difficulty. You must realize that the
operation is no panacea, and the results are not always
satisfactory from the point of improving function. Sometimes
the limb may not even be salvaged.
When will I have no alternative but to consider surgery?
Direct arterial surgery is recommended when there is
evidence that the viability of the tissue of the leg is starting
to be compromised. At that time there is marked impairment
in the ability to walk as further evidence of
"nutritional" starvation (equaling too little blood). Once
this starts, there is no alternative to surgery. If this reestablishment
of circulation cannot be successfully accomplished,
the chances for prolonged limb survival are
poor.
When is arterial surgery not advised?
Arterial surgery is not advised when the X-ray examination
(the arteriogram) shows that it is not possible to
get a good result. In order for there to be improvement,
the increased volume of blood that can be brought to the
limb must be able to get to the involved parts. That is,
it must be able to "run off" into diseased areas. Direct
arterial surgery cannot help where the vessel pattern
shows innumerable blocks that cannot be detoured. The
X-ray study determines what can be done.
If arterial surgery can't be done, is there no other
surgical alternative?
Yes, another procedure is done very frequently. There
is a large experience with removing the nerves that increase
the number and the blood carrying capacity of small blood vessels. This nerve cutting operation is called
a sympathectomy. Unfortunately it does not significantly
influence the blood going to the muscles of the leg, nor
does it directly affect the diseased arteries. It primarily
increases the blood supply to the skin. This operation
is far less risky than direct arterial surgery, but it accomplishes
far less and is undertaken in a last effort
because no other procedure is available. It is hoped that
this operation will permit new (collateral) capillaries to
open up to deliver blood to the poorly supplied diseased
tissues.
What does it mean if the toes have already become blue?
There is a significant indication of very poor circulation.
It often represents or directly precedes the appearance
of gangrene.
What kinds of arterial surgery are performed?
Several methods can be used, singly or in combination,
to bring about an improved blood supply. A block can
be removed or a completely new circulation established
by detouring about the block with one of your own
veins or a plastic tube. A diseased artery can be completely
replaced or it can be reamed out.
What are the chances of getting better?
This depends on how advanced the disease already is
and where it is. Generally, if the diseased vessels are the
large ones of the lower abdomen and pelvis, it is possible
to effect good reconstruction. If the diseased vessels are
below the knee or calf, the results are not as good. The
results with diseased vessels in the thigh are variable.
Can the operation make me worse, and what happens if it
doesn't work?
No one likes to think about these possibilities, yet they
are the reality. If the operation doesn't work, the leg may be worse off because the manipulation and operative
procedure compromise collateral circulation and can
cause thrombosis of the other arteries. If the procedure
does not significantly improve the blood flow, there is
strong probability that the effort to salvage the limb will
fail.
Circulatory Problems in The Legs
Can you predict in advance whether the operation
will work?
It is obviously impossible to make that prediction. If
the surgeon could, he wouldn't advise surgery for those
who he knew could not be improved. The possibility for
improvement exists where the tissues are still relatively
healthy and where the runoff vessels are open. Where
either of these features is definitely compromised, the
results of the surgical effort will be unsatisfactory.
Can my sexual performance be related to this, for this
became impaired at the same time that I got pain in the
buttocks and a decrease in the ability to walk distances?
Yes, this happens when the sclerosis involves the end
of the large
blood vessel (aorta) in the abdomen. In such
a case, the blood supply to the sexual organs is reduced,
resulting in impaired sexual performance in the male.
Women are not affected by this.
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