Blockages of the Arteries of the Upper Extremities

It is relatively rare for atherosclerosis to affect the upper extremities and cause symptoms. Even diabetic patients, who are frequently affected by circulation disturbances of the legs, are rarely troubled by occlusion of the arteries to the upper extremities. The reason for the sparing of the upper extremities from arterial occlusive problems is not entirely clear, but it is a well-documented observation. Having said that, there are a few exceptions. Atherosclerotic occlusive disease of the subclavian artery is seen and occasionally will cause pain in the upper extremities. This pain is typically brought on by exercise and especially with repetitive movements of the upper extremity such as brushing one's hair. For reasons that again are unclear, it is more common for the atherosclerotic plaque to accumulate on the left side than it is on the right side. An examining physician may be alerted to this phenomenon by a difference in the quality of the pulse between the left wrist and the right wrist. The pulse on the left side may appear weaker and this can be confirmed by measuring the blood pressure in both upper extremities. It is common enough for older individuals to have a difference in the blood pressure of their arms that it is a worthwhile test for a physician to check the blood pressure in both upper extremities to be certain that there is not a difference between the two sides. If in fact, there is a difference between the blood pressure in the right and left upper extremity, the arm with the higher blood pressure is considered the accurate blood pressure for that individual. As mentioned, it is rare for patients to actually notice that they have atherosclerotic occlusive disease affecting the upper extremities and most of the time this relatively uncommon condition goes unrecognized. In certain instances, however, the repetitive exercise of the left upper extremity can cause not only pain in the left arm but also dizziness and, in fact, patients have been known to actually faint. This condition is called "subclavian steal syndrome". The anatomical situation is one in which there is a build-up of atherosclerotic plaque in the subclavian artery on the left side with the decreased flow to the left arm. With exercise, the left upper extremity can actually "steal" blood from the brain through the vertebral artery by causing a reversal of blood flow from the brain and down into the left arm. This can result in "syncope". The diagnosis is suspected by the history and confirmed by the finding of a markedly decreased blood pressure in the left upper extremity compared to the right side and further confirmed by noninvasive testing and ultimately by angiography. Treatment is readily available for this condition and consists of revascularizing the left upper extremity by either balloon angioplasty/stenting or surgical bypass from the carotid artery to the subclavian artery (carotid-subclavian bypass), which is a very durable procedure and serves to restore the circulation to the left arm and eliminate the risk of syncope.

Finally, upper extremity arterial insufficiency can be caused by emboli. In this situation, clots can form on the heart valves or in the "great vessels" leading out of the heart (such as the aorta or subclavian arteries) and this can lead to particles of cholesterol debris or blood clot moving "downstream" into the arteries of the arms or hands and causing an acute decrease in circulation. This acute interruption of blood flow can sometimes create an urgent situation requiring surgical intervention. Surgical treatment is usually highly effective in removing the emboli and restoring circulation. Efforts must be made to identify the source of the emboli however, so that recurrence of the emboli can be prevented. Patients will typically undergo transthoracic echocardiography or transesophageal echocardiography and occasionally may need a formal angiogram to assess the arteries in the chest, which lead from the heart to the upper extremities.

Leg Arteries

Peripheral Arterial Disease (PAD):

PAD is blockage of the arteries in the legs, caused by accumulation of atherosclerotic plaque. Risk factors associated with development of plaque in the arteries of the lower extremities include cigarette smoking, high cholesterol levels in the blood, diabetes, and family history. Peripheral arterial disease usually presents with the symptom of "claudication," which is pain in the leg, usually in the calf or thigh, after walking varying distances. Some patients develop "claudication" after just a few steps, while others can walk up to a half of a mile or more before pain forces them to stop. Typically, after a rest period of a few minutes, the patient is able to resume walking again for an equal distance before the pain returns. PAD is most commonly associated with aging. Approximately 30% of people over the age of 70 have some degree of PAD. While claudication caused by PAD is not necessarily a reason to proceed with surgical therapy, evaluation by a vascular surgeon is necessary when a patient has claudication to ascertain the seriousness of the condition. While claudication can be extremely painful and lifestyle limiting, it does not necessarily indicate that limb loss is imminent or even likely. Most patients with claudication due to PAD do not progress to limb loss. When claudication deteriorates into a condition of "rest pain" however , limb loss is a distinct probability. Rest pain means that the patient has pain even when not walking. Typically, rest pain is most intense when a person is attempting to sleep. When we sleep, our blood pressure tends to decrease and this blood pressure reduction leads to a decrease in the head of pressure which is driving blood into the legs around the areas of blockage. 

Testing for PAD:

The patient should been seen by a vascular surgeon. A complete medical history should be obtained and the surgeon will examine the arterial pulses in the lower extremities at the level of the groin, behind the knee, and in the feet. An arterial noninvasive blood flow study may be obtained, which is a noninvasive measurement of the amount of blood which is being delivered to the legs. If a blockage is suspected on the basis of the noninvasive arterial blood flow studies (sometimes called a "Doppler test"), an ultrasound examination of the arteries may be obtained, an MRA (magnetic resonance angiogram) may be obtained, and finally an angiogram may be necessary to obtain a "road map" of the circulation.

Treatment Options for PAD:

When PAD is diagnosed, the vascular surgeon will propose a treatment plan. This plan may involve an exercise program (usually consisting of walking on a daily basis to the point of claudication to attempt to build "collateral blood vessels" around the blocked arteries). Other lifestyle changes including cessation of cigarette smoking, better management of diabetes, weight reduction, and cholesterol-lowering medications. Medications which have been shown to have some beneficial effect in patients with claudication caused by PAD include cilostazol (Pletal), which may improve the walking distance. Other drugs that may be prescribed by the vascular surgeon include aspirin or clopidogrel (Plavix). If it is the opinion of the vascular surgeon that the condition has deteriorated to the point where lifestyle changes and an exercise program are no longer satisfactory treatment options, an angiography may be obtained. If the angiogram demonstrates localized blockages of the arteries in the legs, a balloon angioplasty, stenting or bypass surgery may be recommended. The bypass procedure can be performed either using one of the "extra veins" of the lower extremities, or an artificial arterial bypass (made of Dacron or Gortex) may be used. This decision is made by the vascular surgeon and is usually discussed with the patient prior to operation.

In cases where PAD has progressed beyond the point of claudication and beyond the point of rest pain to the situation where actual gangrene of the tissues of the lower extremity has developed, it is sometimes "too late" to salvage the extremity and amputation may be necessary. More than 50,000 amputations are performed annually in the United States . The amputation level may be either at the mid foot (transmetatarsal), below the knee or above the knee. Amputation is the procedure of last resort and is rarely undertaken prior to an attempt at limb salvage, unless the situation clearly has progressed to the point where time is of the essence and the amputation must be performed as a life-saving maneuver.

Smoking, Diabetes Can Increase Risk Of Dementia; Dementia Risk Factors

Smoking is one heinous habit which is responsible for a number of health hazards. Similarly, diabetes is a chronic condition which can affect the quality of life of a person to a great extent. The two have been popular to increase risks of cancer and heart disease. Now, researchers have warned that the two can clog the region of the brain which is crucial to memory and increase the risk for dementia.

Some recent findings have shown that smoking and diabetes can increase the risk of calcification (calcium salt deposits) in the hippocampus – a brain structure which is important for short and long-term memory storage. Any decline in the functioning of the hippocampus can cause Alzheimer’s disease, which is the most common kind of dementia.

The study, which was published in journal Radiology, found out the association between cardiovascular risk factors such as smoking, diabetes, high blood pressure, and hippocampal calcifications. Around 1,991 people aged 78 years participated in the study, reports IANS. Effects of calcification on cognitive function were also assessed in the study. However, the study suggests a link between the two and does not conclusively determine if smoking and diabetes can increase the risk of hippocampal calcifications.

Link: https://vascular.org/patient-resources/what-vascular-disease

Reference: https://vascular.cmesociety.com/

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Vascular Disease

What is Vascular Disease? 

Most Americans are familiar with heart disease and with the consequences of blockages in the vessels that carry blood to and from the heart. But few people realize that blockages caused by a buildup of plaque and cholesterol affect more than coronary arteries. Arteries throughout the body carry oxygen-rich blood away from the heart so blockages can occur in all arteries with serious effects. Three of the most recognized vascular diseases include:

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm (AAA) is an enlargement or “bulge” that develops in a weakened area within the largest artery in the abdomen. The pressure generated by each heartbeat pushes against the weakened aortic wall, causing the aneurysm to enlarge. If the AAA remains undetected, the aortic wall continues to weaken, and the aneurysm continues to grow. Eventually, the aneurysm becomes so large, and its wall so weak, that rupture occurs. When this happens there is massive internal bleeding, a situation that is usually fatal. The only way to break this cycle is to find the AAA before it ruptures.

Carotid Artery Disease - Stroke

Carotid arteries occur when the main blood vessels to the brain develop a buildup of plaque caused by atherosclerosis, or hardening of the arteries. When the buildup becomes very severe, it can cause a stroke. A stroke occurs when part of the brain is damaged by these vascular problems; in fact, 80 percent of strokes are “ischemic strokes” where part of the circulation to the brain is cut off, usually due to blockages in the carotid arteries. The process is similar to the buildup of plaque in arteries in the heart that causes heart attacks. Strokes are the third leading cause of death in the United States according to the National Center for Health Statistics.

Peripheral Arterial Disease

Peripheral arterial disease (PAD) occurs when atherosclerosis, or hardening of the arteries, causes a buildup of plaque in the blood vessels that carry oxygen and nutrients to all the tissues of the body. As these plaques worsen, they reduce essential blood flow to the limbs and can even cause complete blockages of the arteries. Early on, PAD may only cause difficulty walking, but in its most severe forms, it can cause painful foot ulcers, infections, and even gangrene, which could require amputation. People with PAD are three times more likely to die of heart attacks or strokes than those without PAD.

Link: https://vascular.org/patient-resources/what-vascular-disease

Reference: https://vascular.cmesociety.com/

#VascularConference2019    #VascularConferences   #CardiologyConferences   #HeartHealth    #VascularSurgery  #HeartSurgery   #MitralValve    #NewInnovations