Characteristics of diseases

The blood vessels that send blood from the heart to our organs are called arteries.
 Arteries supply nutrients and oxygen to all of the body’s organs and tissues, but aging makes them harder and more fragile. Anyone over 50 years of age undergoes this change, which is called arteriosclerosis. Arteriosclerosis can be classified pathologically into three types. The most common of these is atherosclerosis. This occurs when cholesterol, a type of fat, accumulates in the walls of the arteries, making them narrower, and thus impairing blood flow. Eventually, accumulated cholesterol may become exposed and form blood clots, causing further circulatory problems. This atherosclerosis can occur throughout the body, but it can be especially severe in some areas. Especially vulnerable sections are the carotid arteries, the coronary arteries, and the leg arteries. Atherosclerosis from the neck to the brain can cause a stroke, while atherosclerosis to the coronary artery (arteries to the heart) can lead to angina pectoris (strong chest pain) and myocardial infarction. Atherosclerosis to the legs causes pain due to ischemia; when left untreated, the blood flow is further interrupted altogether, resulting in necrosis of the toes and foot. This is called arteriosclerosis obliterans (ASO), which mainly appears in males between the ages of 50 to 90 years (90%). In this case, this type of arteriosclerosis (whichi is called atherosclerosis) causes fat to accumulate in the walls of these vessels, causing the arteries to become narrower, and eventually interrupting or blocking the flow of blood to the legs. Half of the persons affected by ASO also have ischemic heart disease (blocking the flow of blood to the heart, causing heart attack). One in four of them also have narrow cervical and brain arteries, causing stoke. The leg arteries are very long, extending from the navel to the toes. Moreover, there are two of them, left and right. The fact that this is an extensive area means that blockages can develop in several places, making this a troublesome illness. There are places in the arteries that supply blood to the legs which are more prone to clotting, including the following 3 sections. The arteries in your body separate at the navel, to the right and to the left. Up to the point where the legs meet the body, they are called the iliac arteries. The arteries in your thighs are called the femoral arteries, from the knees down they are called the crural arteries (popliteal arteries eventually splits into 3 blood vessels: the anterior tibial artery, the posterior tibial artery and the peroneal artery). Places prone to blockage are the iliac arteries (pelvic type occlusion), the superficial femoral arteries (femoral type occlusion), and the crural arteries (crural type occlusion) (Fig. 1-a, b, c). Half of the patients develop atherosclerosis in both legs, so all in all there are six areas prone to development of this problem.

Fig. 1-a Fig. 1-b Fig. 1-c

Diagnosis

Some people do not develop any symptoms, even though their legs are already starting to clot (this period is called Fontaine stage I). As the sickness evolves, among the first symptoms we see is pain in the calfs after walking about 300 meters, requiring a stop to take a rest each time before continuing. The medical term for this is intermittent claudication, and this period is called Fontaine stage II. These symptoms may also ocur in some neuropathies to the back, such as lumbar spinal canal stenosis and intervertebral disc hernia, so it is extremely important to diagnose whether the case is artery-related, nerve-related, or a combination of both. If it is artery-related, taking a rest, even while standing, should be enough to overcome the pain, but if it is nerve-related, the patient will feel uncomfortable while starting to walk and will not be able to rest standing up. In these cases the patient is likely to feel low back pain and cramping in the legs. As the blocking the blood flow to the legs worsens, the distance walked after resting becomes shorter and shorter. When claudicators are injured in the foot or toes, and small wounds appear at this point (Fig. 2), they spread, and become large ulcers which are extremely difficult to cure (Fig. 3). As the blocking the blood flow becomes worse due to progression of atherosclerosis, the pain to the legs is so intense that it doesn’t allow the patient to sleep. This symptom is called “rest pain”, and classified into Fontaine stage III. This happens right before the legs start deteriorating. Finally, the outer sides of the feet and ankles start to deveop gangrene. This is called Fontaine stage IV (see Fig. 4). Leaving it untreated will cause futher deterioration, and gangrene will abruptly extend to all of toes ( Fig. 5-a), dorsum of foot ( Fig. 5-b), sole ( Fig. 5-c), and above the anke (Fig. 5-d).

To diagnose the symptoms, the blood pressure at the ankles is measured (Fig. 6) and compared as a ratio with that of the upper limbs to see how much lower it is. If blood pressure at the ankles decreases up to 0.7 times when compared it in the arms, patients complain intermittent claudication (which is calf pain after 300-500m walk or during going up stairs and getting better after 10-15 minutes rest). When the blood pressure at the ankles is half or lower than the blood pressure taken in the arms, the patient’s quality of life is severely impaired, and the life-span become shorter due to progression of atherosclerosis in the important organs. Patients often may ocur mental disorders. In order to be able to walk and run normally, vessel implantation sugery (bypass surgery) as soon as possible is recommended. A claudicator shown on Fig. 7 who had undergone bypass surgery attained to climb the Himalayas 3 year after surgery.

Fig. 2 Fig. 3 Fig. 4 Fig. 5-a Fig. 5-b Fig. 5-c Fig. 5-d Fig. 6 Fig. 7

Treatment

Fontaine stage-I does not require invasive treatment, but the patient will be better take drugs in order to prevent progression of atherosclerosis. In the case of Fontaine stage-II, results can be noted after taking antiplatelet medicine that has a vasodilative (artery-widening) effect. Please consult with your vascular surgeon on what drugs are appropriate for your treatment. If, with this treatment, the patient is again able to walk long distances, then it is only necessary to continue taking the prescribed medicine. It is recommended that this medicine be continued from 6 months to one year, if it does not affect the patient’s daily life. If the patient is not satisfied with the results, then surgery will be necessary. We will explain what types of surgery are available. In the case of Fontaine stages III-IV, not treating the sickness will make amputation below or above the knee necessary. To avoid major amputation, blood vessel transplant (bypass surgry) is imperative.

Concerning amputation of the lower limbs

With increasing diabetic patients, numbers of patients who underwent major amuptation are increasing in every countries. It is estimated that every 30 seconds a leg is lost to diabetes thus leading to over one million amputations per year in the world. The prevalence of amputations is basically due to a misunderstanding or an optimistic idea of doctors who recommend amputation: The doctors believe every amputees can retrieve sufficient ambulatory function and return to work, with good QoL by earlier amputation and earlier rehabilitation. However, there are wide variation between studies: Hagberg (Prosthet Orthot Int 1992;16:168) reported 96% amulatory function and Houghton demonstrated only 16 % (Br J Surg 1992;79:753). This wide difference is probably due to the difference of patients’ preoperative status, and the former’s result are clearly biased towards current vascular amputees. Elderly amputatees commonly require longer rehabilitation, and many of them will never walk on an artificial limb. Wheelchair-bound patients suffer unacceptable disability, and QoL impairment. Most of elderly never retrieve ambulation function, and regret the amputation. TASC II (International Consensus Reports) summarizes higher mobidity and motality rates of amputation, with 30% reamputation and death in another 30% at 2 years after amputation. Regardless of the evidence, the doctors, who might be your doctor, still continue to promote amputation, and recommend you amputation with insufficient or incorrect information about your expected ability after amputation. As long as you do not reject amputation, you will be sent to operation room for amputation.

Why does amputation is performed below or above the knee?

One might think that toe gangrene (Fig. 50) or ulcers(Fig. 51-a) will heal easily once they are removed, but this is not so. Not only do the wounds not heal--they become bigger (Fig. 51-b). This can only be cured by amputating the leg below the knee (Fig. 52-a) and prosthesis is necessary after amputation (Fig. 52-b). Amputation of the leg below or above the knee is called major amputation. Amputation may result in death: 20% of the patients die within a month of the surgery. After amputation, the patient needs rehabilitation therapy to learn how to walk with an artificial leg (prosthesis, Fig. 52-c). Among young people this takes up to 3 months. For people 70 years old or older, it can take up to 6 months. The surgery is successful if the patient can start walking again; however, because there are many cases in which atherosclerosis occurs in both legs (Fig.52-d), within 6 months ischemic ulceration and gangrene may develop in the opposite leg. Finally, it might become necessary to amputate the other leg, sometimes even before the patient is able to walk again. Seniors whose legs have been amputated will no longer be able to start walking by themselves. The pressure of the prosthesis against the operative site of amputation might cause new ulcers. Without using artificial limbs, the patient is left bed-ridden. When this occurs, the atherosclerosis advances. Moreover, inside the hardened arteries, atheromas appear, facilitating the formation of blood clots or thrombi, (Fig. 53). At some point, these thrombi will suddenly start being produced in a wide area, rapidly choking the arteries. This is called acute thrombosis, a disease that claims many lives (Fig. 54). A study carried out in Denmark with 2880 people who underwent amputation showed that in 4 years 25% of the patients died, while 40% had their opposite leg amputated as well. Only 36% of the patients were reported to have undergone this operation only once. In other words, we must be aware that if even a small ulcer is not treated properly the patient is likely to lose both legs—and in the event that the patient undergoes amputation, it is probable that he or she will not live for long. In order to return to a normal life, it is important to have as much help from our legs and toes as possible (Fig. 55-a, b, c, d). This is why bypass surgery is absolutely necessary.

Fig. 50 Fig. 51-a Fig. 51-b Fig. 52-a Fig. 52-b Fig. 52-c Fig. 52-d Fig. 53 Fig. 54 Fig. 55-a Fig. 55-b Fig. 55-c Fig. 55-d

Types of surgery that are available

The most-used type of surgery is a bypass operation, where blood vessels are transplanted to reach around the choked section. The vessels used in bypass surgery are called vascular grafts. Among these there are artificial blood vessels made out of plastics such as polyester or teflon. Sometimes the patient’s own blood vessels are used as substitute blood vessels. In the case of the pelvic type of occlusion, where wide arteries larger than 8 mm become closed, only artificial blood vessels are used for bypass surgery (Fig. 8-a,b,c,d,e). The results of this treatment are good. For the femoral type of occlusion, bypass surgery above the knee (Fig. 9-b right leg) requires artificial blood vessels.On the other hand, arteries below the knee and below the ankle are only 1-3 mm wide, so surgery becomes more difficult. If artificial blood vessels are used for bypass in these areas, they become clotted almost immediately and the syptoms start appearing again. For this reason, the greater saphenous vein, which runs through the inner side of the leg (Fig. 9-a), is transplanted as a substitute vessel in this area of small arteries (Fig. 9-b left leg). The results of treatment will vary among medical centers, but within 5 years no abnormalities occur in 90% of the cases, and in these patients success can be assured for 10 years.

Fig. 8-a Fig. 8-b Fig. 8-c Fig. 8-d Fig. 8-e Fig. 9-a Fig. 9-b

Bypass Surgery's Success Rate: 98-100%

How long do transplanted blood vessels last? The long-term duration rate is 90% after 5 years and 80% after 10 years. The surgery fatality rate (rate of patients dying within one month due to the surgery) is 1-5%, with an average of 2%. Some patients die during emergency surgeries due to such conditions as heart problems with undetected angina pectoris, endocranial arteriostenosis, and pneumonia (especially common among smokers). However, if the patient is properly examined for these conditions and precautions are taken before the surgery, the risk becomes less than 1%. Patients undergoing hemodialysis due to diabetes or diabetes-related nephropathies are at more serious risk.

After bypass surgery, the condition of the patient improves dramatically. Intermittent claudication is completely cured and the patient can participate in various activities just as before the sickness. The ulcers that appeared on the legs also heal. With skin transplants, even widespread ulcers can be cured within 3 weeks (Fig. 10-a before operation, b after bypass and skin transplantation; Fig. 11-a before operation, b after bypass, c skin transplantation; 12-a before operation, b after bypass and skin/muscle transplantation). When the bones are exposed (as in Fig.14-a before operation, b after bypass and skin/muscle transplantation; Fig.15-a,b,c), in a case where the heel could be lost as a result of normal surgical methods, a myocutaneous flap can be used for curing and preserving the heel. Ulcers on the soles of the feet will not recover with just a skin transplant. They require implants of special tissue (Fig. 16-a before operation, b after bypass and skin/muscle transplantation; Fig. 17-a,b,c). This method, in combination with bypass surgery, can help all affected areas, in addition to those which have gangrene, and is the only approach that helps to avoid the amputation of a leg that was deteriorating.

Fig. 10-a Fig. 10-b Fig. 11-a Fig. 11-b,c Fig. 12-a Fig. 12-b Fig. 14-a,b Fig. 15-a Fig. 15-b Fig. 15-c Fig. 16-a Fig. 16-b Fig. 17-a Fig. 17-b Fig. 17-c

Preoperative examination

Preoperative examinations- 2 weeks: X-rays of the lower limbs, cerebrovascular MRA, myocardial scintigraphy/ coronary angiography, and echocardiography.

Latent ischemic heart disease is screened by myocardial scintigraphy, followed by coronary angiography when the scintigraphy is positive, and cardiac function is assessed by echocardiography. Evaluation for arterial occlusion in ischemic limb is performed by MRA or CT angiography, and if both angiographies failed to visualize occlusive lesions, intraarterial angiography is selected for decision making of operation method.

Surgery and hospitalization

If no abnormalities to the heart, postoperative hospitalization = 2 to 4 weeks. If complete bypass surgery to the lower limbs (all obstructed arteries bypassed), postoperative hospitalization = 2 to 4 weeks.

If ischemic heart disease requires cather treatment, bypass surgery is planned 2 weeks after successful PTA. If ischemic heart disease requires cardiac bypass surgery, surgery is either carried out for both areas simultaneously or divided into two parts, with bypass surgery to the legs 2-4 weeks later.]

Prognosis for the legs and transplanted vessels after bypass

As previously stated, the artificial vessels used for the major arteries are 90% secure during the first 10 years, but the remaining 10% require reoperation due to the deterioration of the artificial vessels and/or anastomotic aneurysm. Success rate of reoperation is 100%. On the other hand, transplanted veins below the knee also start developing arteriosclorosis after 10 years (Fig. 18). Venous implants have a life-span of 10 to 20 years, so when they reach this time the patient must undergo surgery again (Fig. 19-a,b,c patient underwent bypass for severe toe ischemia 20 years ago; Fig. 19-d,e,f bypass graft failed (d), and redo bypass was performed (e), and the foot was salvaged ). To prevent the hardening of the implants themselves, the patient must take various medicines, but this treatment is not highly effective. Recently, research involving genetic therapy has begun, but it has not yet reached a stage for practical use.

Fig. 18 Fig. 19-a Fig. 19-b Fig. 19-c Fig. 19-d Fig. 19-e Fig. 19-f

∧Page Top