VASCULAR DISEASE - LEGS - Full extract 

When George came into the surgery I could see he was in a bit of bother. There was none of the usual chatter, just straight down to business. " I've had a bugger of a time with my leg," he said. " And it's getting me down." 

George travels to work each day by train. In the last few weeks he had become aware of a pain in his right calf when he was walking up the hill to the station. At first he thought he had torn a calf muscle, but it went away when he stopped for a few minutes, only to come back later. It didn't seem to occur on the way home where the walk is mainly downhill. 

Aside from being a cigarette smoker, George keeps fairly good health. When I examined him, it was fairly obvious that his right foot was a little cooler than his left. Several pulses in his right leg were not able to be felt. Although his problems were not very acute it was important to work out the extent of his vascular disease. I referred him to a vascular surgeon for a full assessment.

Vascular disease can affect any part of the arterial system. When it occurs in the coronary arteries, the person is at risk of angina and heart attack. When it affects the arteries in the neck or the cerebral circulation it can predispose to a stroke. When the main arteries in the legs are affected, the condition is called peripheral vascular disease. Sometimes there is not enough blood supply to the muscle, skin and other tissues. Disabling pain can occur and, in severe cases, gangrene and loss of a limb can be the eventual outcome. 

There are the same risk factors for all types of vascular disease...smoking, high blood pressure, obesity, high blood cholesterol, and diabetes. With attention to these risk factors, a lot of vascular disease could be totally avoided. When vascular disease does occur, the usual sequence is plaque formation and damage to the cells lining the arteries, accumulation of thrombus or clot, and progressive narrowing of the vessel.

With walking, the leg muscles need more arterial blood. If the vessels are narrowed, the muscles become starved of oxygen and a cramping pain occurs. With rest there is no imbalance between supply and demand and the pain subsides, only to come back when the person starts walking again. This is very similar to the way angina pains come on with exertion and then go away with rest. As well as causing pain, vascular disease can also cause leg and foot ulcers. And when the blood supply is inadequate, healing can be slow, at times almost impossible. 

When the vascular disease is mainly in the abdomen, there may be a very different set of symptoms. If vessels that supply the pelvic structures are narrowed, symptoms such as buttock pain and impotence may occur. 

If there is any suspicion of vascular disease, a very careful history and examination is required. A search is made for any reversible predisposing factors, such as smoking and high blood cholesterol. Special care is necessary to check the blood pressure and exclude conditions such as diabetes and angina. People with diabetes are more likely to develop vascular disease. 

Although the evidence is not as clear-cut as with narrowing of the neck arteries, a small dose of aspirin may help to prevent clot formation in narrowed leg arteries. Medications such as ergotamines that are used for migraine can cause arterial spasm and further narrowing, and should be avoided in people with vascular disease. 

As with arterial disease elsewhere, information can be obtained by examining the leg arteries with ultrasounds and duplex scans. These imaging techniques are improving all the time. For more severe arterial disease, referral to a vascular specialist is usually advised. This is important if the amount of walking to reproduce the leg pain is getting less and less. Pain in the legs with minimal exertion or at rest is an acute situation that demands very prompt attention. Likewise, a leg that suddenly becomes cold, white and painful may well be acutely blocked. Urgent medical attention is essential, in case an emergency operation is required. 

Whenever the symptoms of vascular disease in the legs are severe, a special X-ray called an arteriogram is likely to be arranged by the specialist. A catheter is inserted into the leg artery and dye is injected to get a precise image of the arterial tree. If reconstructive or bypass surgery is being considered, a very clear picture of the arteries and their downstream tributaries is essential. 

There are a number of vascular surgery techniques for bypassing severely narrowed arteries. Sometimes a vein from the leg is taken out and positioned above and below the blockage as an alternative blood route. In the abdomen, synthetic dacron grafts can be used to construct bypasses of various sorts. There are even crossover techniques where arterial blood can be diverted from one limb to the other. Where there is narrowing of a short segment of artery, an angioplasty can sometimes be performed; a balloon on a catheter is positioned within the narrowed segment and then inflated to widen the artery. Several other techniques have been developed, including the surgical removal of thrombus or clot from within blocked arteries. 

Health Tips:
* Prevention is the best approach with peripheral vascular disease. Keep an eye on blood pressure and the blood cholesterol level, and avoid smoking.

* If the pain from vascular disease in the legs is getting worse, see your doctor for advice. Pain at rest is an ominous sign and can be a very urgent problem; it may mean that an artery has become fully blocked.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: December 11, 2004