Surgery on clogged leg arteries can relieve pain associated with aging

By Warren King
Seattle Times medical reporter

ELLEN M. BANNER / THE SEATTLE TIMES Basil Anton, 69, has a spring in his step as he walks in front of a painting on the wall of the restaurant he co-owns in Puyallup. Anton, 69, recently had surgery to open the blockages in his legs and is now able to get around quite well.

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For more than three years, Basil Anton seemed almost literally on his "last legs." Both of them were nothing but trouble. Getting around became an increasing burden.

Saturdays, when he walked up the Husky Stadium steps, he had to stop three times to ease the pain. The walk to his departure gate at SeaTac on trips to Reno was just as painful.

"It was pretty much a pain in the calf — an aching, ongoing pain. I had to stop for three to four minutes for it to get OK," said Anton, 69, co-owner of Charlie's Restaurant in Puyallup for 30 years.

Anton had lots of company with his leg pain.

Until he had surgery on both legs last May, he was one of more than 10 million Americans with peripheral vascular disease (PVD) — clogging of the main leg arteries with fatty plaque. About 5 percent of people over age 50 have the disease, a type of atherosclerosis of the legs.

Pain in the legs or hip, called "claudication," is the most common symptom of PVD. It occurs because narrowing of the arteries from plaque buildup reduces the amount of oxygen-rich blood flowing to the leg muscles.

Other symptoms in the legs or feet can include loss of leg hair, a skin-color change, poorly healing sores, pain in the feet or toes while resting, and, in the later stages, coolness in the feet. Leg weakness often results when the blockage is high in the leg.

In the worst PVD cases, gangrene can develop, necessitating amputation of the toes, a foot or a leg.

Still, experts estimate only about half of those with PVD have been diagnosed because symptoms take years to develop. And many think leg pain is just a normal part of aging.

A red flag

Clogging of the leg arteries raises a red flag that the same process may be going on elsewhere, in the arteries feeding the heart, for example.

"If a patient has PVD or coronary-artery disease, he has a risk for the other. We'll be watching them," says Dr. William Gray, the Swedish Medical Center cardiologist who operated on Anton's legs.

Anton's operation came none too soon. His symptoms had gone from bad to worse.

His feet were so cold that even when he held them near the fireplace, it didn't help. They became increasingly numb, as if they were asleep, and he worried he would roll over on one foot and injure himself. And everywhere he went, it hurt to walk — including on the twice-daily rounds of his eight food stands at the Puyallup Fair each year.

Anton's doctors weren't surprised. He used to be a smoker, a major risk for PVD. And starting in 2001, he had had three surgeries to open clogged coronary arteries, those that feed the heart muscle.

Other risks for PVD are mostly the same as those for heart disease: diabetes, being overweight, high blood pressure, high cholesterol, lack of exercise and being over 50.

Ultrasound tests showed that the blood flow in Anton's legs was reduced and slowed. So did a test that showed the blood pressure in his feet was significantly lower than in his upper arm. The leg arteries needed to be opened.

The surgery

Gray opened blockages in the superficial femoral artery of Anton's left thigh with angioplasty: A balloon-tipped catheter is threaded through the blood vessel to the blockage, then the balloon is inflated to push back the plaque. A stent, a wire mesh cylinder, was placed at the site to prevent new accumulation of plaque. The same technique is used in coronary arteries.

A stent could not be placed in the Anton's right leg, however, because the blockage in his femoral-popliteal artery was behind his knee. When he bent his knee after surgery, the mesh cylinder could be crushed.

So, on the right leg, Gray used a new technique called the SilverHawk Plaque Excision System, developed by FoxHollow Technologies of Redwood City, Calif.

This system also uses a catheter, but one with a spinning blade that routs the plaque from the artery wall. As the plaque is cut from the sides of the artery, it is packed into the device's nose cone, where it stays until the device is withdrawn from the blood vessel. The SilverHawk also is used when obstructing scar tissue has formed from a previous angioplasty; the tough tissue is difficult to push aside by using another stent, so the device cuts it away.

The new technology carries a slight risk — less than 2 percent, said Gray — of perforating an artery or of breaking loose pieces of plaque that could temporarily block the artery.

"I think it will be an alternative tool for specific uses — across joints and for reblockage of arteries," said Gray. A study comparing the SilverHawk method with other techniques is still under way at four medical centers across the U.S.

About 450 medical centers nationwide have begun using the new technology. FoxHollow Technologies said that in addition to Swedish, they include Northwest Hospital & Medical Center in Seattle; Overlake Hospital Medical Center in Bellevue; St. Joseph Medical Center in Spokane; Good Samaritan Community Healthcare in Puyallup; and Deaconess Medical Center in Spokane. Eight of the centers nationwide are participating in a project that will analyze removed plaque for possible genetic markers that could predict the risk of heart disease, according to FoxHollow Technologies.

Other surgical strategies

Besides angioplasty, stenting and the SilverHawk, physicians also use other techniques to treat PVD.

Bypass operations, which have been around the longest, often are used when the patient has long stretches of blocked artery or is in imminent danger of losing a leg. In this procedure, a vein from another part of the leg or a tube of synthetic material is used to bridge the blockage.

Generally, longer incisions are needed for a bypass, spinal or general anesthesia is required, and recovery can take a few weeks, compared with a few days for the other techniques, physicians say. Because of the stress of the surgery, older patients with heart disease may fare better with the catheter-based techniques, said Dr. Kathleen Gibson, a Bellevue surgeon.

An endarterectomy also may used for long stretches of blockage: A small incision is made near the blockage and an instrument is used to scoop the plaque from the wall of the artery. Recovery time is usually about three days.

Most bypass grafts remain unclogged for at least five years, Gibson said. The other techniques are relatively new for PVD, and not much five-year data is available, Gray said. He believes the newer techniques keep the vessels open about as long as bypass, if the blockage is short or medium-length. But the arteries will remain open only for about two to three years for long blockages, he said.

Walk through the pain?

Before recommending any procedure, some physicians first urge patients to try to walk through the pain of PVD for a few minutes, rest a few minutes and try it again. The exercise may improve the leg muscles' ability to expand and contract, decrease inflammation and increase blood flow, according to a study led by Kerry Stewart of Johns Hopkins University. Gray has reservations about that approach, however. Exercise may increase how far the patient can walk somewhat, but not enough to keep the heart healthy: "It may get you through the grocery aisle, but probably not on a long walk with your grandchildren," said Gray.

Anton remembers his dismay at being unable to walk very much at all — with everyone always waiting on him, with his constant thought, "This can't be; it can't be hurting like this."

Now he has only occasional coldness or numbness in his feet, perhaps from some nerve damage caused by PVD. He walks as far as he wants, thanks to the artery-clearing procedures.

"They changed my life to where I can do the things I want," he said.

Warren King: 206-464-2247 or wking@seattletimes.com

Copyright © 2004 The Seattle Times Company

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