Lower extremity artery disease: How is it treated?

The article was professionally consulted by a Doctor of Cardiology - Thoracic Surgery, Vinmec Central Park International General Hospital.

Lower extremity peripheral artery disease is a medical condition of the arteries behind the external iliac arteries, which are the arteries that feed the lower extremities. The pathology occurs due to narrowing of the arterial lumen, causing reduced blood flow to muscles and related organs such as skin and nerves downstream. In fact, patients with peripheral artery disease are 6-7 times more likely to have a heart attack or stroke than those without the disease.

Peripheral artery disease is the most common manifestation of atherosclerosis, although it can also result from thrombosis, embolism, fibromuscular dysplasia, and arteritis.
The main cause of lower extremity artery disease is atherosclerosis. Risk factors for atherosclerosis include: age (common in ages 55-60); gender (male/female = 3/1); cigarette; diabetes mellitus; hypertension ; dyslipidemia ; increased homocysteine ​​in the blood.

The disease usually causes acute or chronic anemia (lack of blood supply). Symptoms of the disease vary from calf pain during exercise (the technical term is called “claudication”) to pain that persists even at rest (the “critical limb ischemia” phase).
Peripheral artery disease progresses through several stages: The first is leg pain that occurs when the patient walks or exercises and the pain goes away when sitting down. This intermittent claudication will worsen over time, varying in severity from mild discomfort to severe pain, partial necrotic ulceration. Claudication may progress to critical limb ischemia. This is the most dangerous form of peripheral artery disease of the extremities and is defined as follows: pain at rest due to ischemia, pain that is persistent especially in the feet and pain at night, progressing to the appearance of ulcerative or necrotic lesions of the extremities due to ischemia (biological loss of tissue).

The goals of treatment for peripheral artery disease are to reduce the risk of atherothrombosis in the vascular system and to improve symptoms, if present.
3.1.Treatment of risk factors a) Stop smoking
Smoking is an important risk factor for atherosclerosis. Smoking will increase LDL and decrease HDL, increase blood CO, promote vasoconstriction in atherosclerotic blood vessels. In addition, cigarette smoke has the effect of increasing platelet adhesion, increasing fibrinogen, Hct and consequently increasing blood viscosity.
Stopping smoking will help slow the progression of peripheral artery disease and other heart-related diseases.
b) Blood sugar control
Diabetes promotes the general process of atherosclerosis, causing ischemic complications in the peripheral blood vessels, peripheral neuropathy, and decreased resistance to infectious agents. These factors easily lead to foot ulcers and foot infections.
c) HMG - CoA Reductase Inhibitors (statins)
Current evidence supports the use of statins in the treatment of hypercholesterolemia for primary and secondary prevention of cardiovascular events. The use of simvastatin 40 mg was associated with a reduction in cardiovascular events (12% reduction in overall mortality, 17% reduction in vascular deaths, 24% coronary events, 27% strokes, 16% peripheral vascular interventions).
In patients with peripheral artery disease, the target LDL concentration should be <100 mg/dL (<2.59 mmol/L) and correction for elevated triglycerides and low HDL is required. In high-risk patients (multifocal atherosclerotic lesions), the target LDL concentration should be <70 mg/dL.
d) Controlling blood pressure
The antihypertensive treatment goals set in patients with peripheral artery disease remain the same as in the hypertensive general population. Target blood pressure should be <140/90mmHg and should be less than <130/80mmHg for people with diabetes or kidney failure.
e) Antiplatelet
Antiplatelet reduces vascular problems. The CAPRIE study demonstrated a greater efficacy of clopidogrel than ASA in the secondary prevention of patients with atherosclerotic disease (stroke, myocardial infarction, and peripheral artery disease).
In addition, the combination of clopidogrel with ASA did not significantly increase the effectiveness of prevention but also increased the risk of bleeding.
3.2 Symptomatic treatment and functional improvement a) Exercise
Supervised exercise improves severity of intermittent claudication. The training regimen can be used on rolling mats or walking on the street with enough intensity to produce an intermittent limp, then rest until the pain is gone and repeat, each training session lasts about 30 -60 minutes. Each training session will be conducted 3 times a week and for 3 months.
This remedy can relieve the symptoms of the disease after several months. Although the effect appears to be slow, it is considered the basic treatment for all patients with peripheral artery disease. It is very helpful to practice and monitor at rehabilitation centers. If you can't go to a rehabilitation center, ask your doctor to create a suitable exercise plan for you.
b) Drug use
To date, only cilostazol and naftidrofuryl have been recognized for the treatment of claudication and functional improvement. Cilostazol: This is a phosphodiesterase III inhibitor with vasodilator, metabolic and antiplatelet effects.
Naftidrofuryl: The drug belongs to the group of 5-hydroxytryptamine type 2 antagonists and has the effect of improving muscle metabolism and reducing red blood cell and platelet aggregation. The dose used in the trials was 600 mg/day. Side effects of the drug are mild gastrointestinal disturbances.

3.3. Revascularization: Vascular interventions and vascular surgery Most patients with lower extremity peripheral artery disease have a long course of progression, with compensation through collateral vessels. Peripheral artery disease patients presenting with intermittent claudication affecting quality of life should be considered for revascularization by endovascular or vascular surgery.
Choice of recanalization by endovascular or surgical intervention depends on age, comorbidities, lesion type (according to TASC lesion classification). Surgery is often recommended in patients with limb artery dissection for which long-term outcomes and low cardiovascular risk are associated with surgery. It is generally agreed that endovascular intervention should be the treatment of choice for TASC lesions A and B and that vascular surgery is the treatment of choice for TASC lesions C and D.
Lower extremity peripheral artery disease is a disease that has an important impact on the quality of life, the risk of death in elderly patients and has many comorbidities. Due to the insidious nature of the disease, patients and doctors are less alert to this pathology. Therefore, early intervention combined with aggressive medical treatments to reduce risk is an important factor in improving the patient's quality of life and symptoms.
Currently, Vinmec International General Hospital is a medical unit equipped with a Hybrid room system. Hybrid operating room at Cardiology Center is equipped with state-of-the-art equipment such as DSA angiography machine, anesthesia machine with the most closely integrated patient hemodynamic monitoring software (PiCCO system, entropy, . ..). Therefore, the Hybrid operating room can meet the requirements of surgery and angioplasty, coronary stenting, aortic stent graft, open heart surgery, heart valve replacement for congenital heart diseases with modern minimally invasive techniques. most invasive, safe, help patients recover health soon.
Master. Doctor Nguyen Duc Hien has more than 12 years of experience in the field of cardiology, especially Cardiovascular and thoracic surgery. Currently, he is a Doctor of Cardiology Surgery, Cardiovascular Center, Vinmec Central Park International General Hospital.

The article references the source: Vietnam Cardiology Association