Poor Circulation in the Legs-How do you know if you have a circulation problem?

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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