Peripheral Arterial Disease Treatment and Aneurysm Repair

Peripheral arterial disease treatment starts with the right work-up, and the referral should arrive with three investigations already done: viral serology, creatinine clearance and a CT peripheral angiogram. If no arterial cause for the pain is found, look for a neurogenic one. Medical treatment comes before any operation, and the choice between surgery, stenting and doing nothing is best made with a vascular surgeon.

That is the arterial half of the masterclass Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, gave to general practitioners on vascular surgical problems. It covers the referral work-up for peripheral arterial disease, the neurogenic mimic, the medical options he outlined before considering the scalpel, the surgical and endovascular options, disease below the knee in frail patients, and aneurysms, where the image matters more than the report and the choice of repair changes the cost by tens of thousands of dollars. The principles that frame every vascular referral are in the complete guide to vascular problems in general practice.

Peripheral arterial disease symptoms in the clinic

Peripheral arterial disease (PAD) heads Dr. Purkayastha's list of the arterial conditions a general practitioner meets. In his description, it presents as leg pain, an occlusion in a lower-limb artery or atherosclerotic changes. The classic symptom is intermittent claudication: cramping pain in the calf, thigh or buttock that comes on with walking and settles with rest, because narrowed arteries cannot meet the muscles' demand for blood during exercise. At the severe end, chronic limb-threatening ischaemia causes pain at rest, ulcers that do not heal or gangrene.

A sudden, painful, cold and pulseless limb is a different problem. Acute arterial occlusion needs the nearest emergency department immediately, not a clinic work-up, as the pillar guide explains.

The three-part referral work-up for peripheral arterial disease

When a GP suspects PAD, Dr. Purkayastha asks for three investigations at the point of first contact, before the referral is sent.

1. Viral serology. The patient will need contrast dye injected for angiography, so viral status should be known in advance. The serology can also give a clue to a viral cause of the vascular disease, although most peripheral arterial disease is atherosclerotic. He noted that it is not unusual for a viral aetiology to present as an aneurysm. HIV-associated vasculopathy, which can cause both aneurysms and arterial occlusions in younger patients, is well described in sub-Saharan Africa.
2. Creatinine clearance. This gives a rough measure of kidney function and tells the team whether a reasonable amount of contrast can be injected to obtain the images. Reduced kidney function raises the risk of contrast-associated kidney injury.
3. CT peripheral angiogram. A CT scan with intravenous contrast that maps the arteries of the limbs. At times it is so conclusive that the referring doctor can send the patient's details and the angiogram with a specific request, such as an embolectomy or a bypass graft, or whatever appears reasonable and rational for that patient.

The three tests are deliberately linked. The angiogram is the decision-making investigation; the serology and creatinine make it safe to perform and sometimes explain why the disease is there at all.

Neurogenic claudication: when the arteries are not the cause of the pain

When the arterial work-up does not explain leg pain, the next step is to look for a neurogenic cause. Dr. Purkayastha's most practical warning concerned the patient whose arterial work-up does not explain the symptoms. "Do not leave it there," he told the audience. Suspect a neurogenic cause of the pain and follow it up, either by imaging the lower back or with a nerve conduction velocity study, and separate the two problems before referring.

The commonest mimic is neurogenic claudication from lumbar spinal stenosis. It also causes leg pain on walking, but it is typically relieved by sitting or bending forward rather than by simply standing still, and it may come on with prolonged standing. Many older patients have both conditions at once, which is exactly the trap: arterial disease that is real on imaging may not be what is causing the pain.

His own case of an elderly woman with real but irrelevant arterial disease, whose pain largely resolved without any vascular intervention, is described in the pillar guide.

Peripheral arterial disease treatment: medicines before the scalpel

Dr. Purkayastha introduced the treatment of PAD with a line from one of his favourite novels, Gabriel García Márquez's Love in the Time of Cholera, in which a physician regards the scalpel as proof of the failure of medicine. For peripheral arterial disease, he stressed, there are multiple medical options before surgery.

Two drugs are used for the walking distance and symptoms of arterial narrowing:

• Cilostazol, a phosphodiesterase-3 inhibitor that dilates arteries and inhibits platelets, and the drug with the strongest evidence for improving walking distance in claudication. It must not be used in patients with heart failure.
• Pentoxifylline, which improves the flexibility of red blood cells so that they pass more easily through narrowed vessels. Major guidelines (ACC/AHA) consider it ineffective for claudication, and cilostazol is preferred where a drug is needed.

For the presenting complaint, which is pain, Dr. Purkayastha points to amitriptyline or another tricyclic antidepressant at a modest dose: enough to give the patient reasonable relief from pain and a good night's sleep, without interfering with daily activities. This is symptomatic relief only: tricyclics do not treat the arterial narrowing, and PAD guidelines do not include them among the treatments for claudication.

These symptomatic drugs sit on top of the foundation that guidelines set for every patient with PAD: stopping smoking, an antiplatelet agent, a statin, control of blood pressure and diabetes, and structured exercise. Those measures reduce the risk of heart attack and stroke, which is where most patients with PAD come to harm.

Surgical and endovascular options for peripheral arterial disease

When medical treatment is not enough, the surgical avenues are, in Dr. Purkayastha's word, multi-pronged:

• Embolectomy with a Fogarty balloon catheter: a catheter is passed beyond the clot, the balloon is inflated and the clot is drawn out.
• Open arterial repair and bypass: the diseased segment is bypassed or reconstructed surgically.
• Endovascular stenting: a stent is placed from inside the artery through a puncture, without opening the limb.

Endovascular work now covers the whole arterial tree. His team stents everything from the aortic arch down to the aortic bifurcation and on into the peripheral arteries, every artery in the body apart from the coronaries, which his practice does not cover. The vascular surgeon, he said, has stepped into the endovascular zone, and peripheral stenting is done more often than ever before. His conclusion for referring doctors is that it always helps to have the vascular surgeon involved in choosing which option is used.

The hybrid operating room

Much of this work now happens in hybrid operating rooms, which combine a full surgical theatre with fixed angiography imaging. Dr. Purkayastha showed the hybrid theatre at Auckland City Hospital in New Zealand, where he worked for a couple of years. Using image intensifiers and the imaging gantry, the team gains entry to the vessels and uses contrast to see them, managing in a single, shorter procedure problems that would otherwise need a major vascular operation and a long, protracted recovery.

Below-knee arterial disease in a frail patient: bypass or angioplasty?

In a frail, elderly patient with arterial disease below the knee, Dr. Purkayastha would avoid angioplasty and, if intervention is genuinely required, favour a bypass using the patient's own vein. During the discussion, the moderator described a 78-year-old patient with arterial disease below the knee, for whom some doctors had suggested angioplasty while senior vascular surgeons felt nothing needed to be done.

Dr. Purkayastha's view was clear. In a frail patient, angioplasty below the knee gives reasonable short-term results but nothing very promising in the long term. If intervention below the knee is genuinely required, it is more often than not a surgical one, and if a bypass is created, it is more often than not a reversed vein bypass rather than an artificial graft. In a reversed vein bypass, a segment of the patient's own vein is harvested and turned end to end, so that its valves do not obstruct arterial flow, then used to carry blood around the blockage. "Below the knee, try to do the simpler, older, easier things," he advised, favouring open surgery with the patient's own vein.

Trial evidence comparing vein bypass with endovascular treatment below the knee is mixed, and the decision in each patient depends on frailty, the quality of the available vein, the pattern of disease and the goal of treatment. That is precisely why the decision belongs with an experienced vascular surgeon, and why, in some frail patients, the right answer is medical treatment alone.

Aneurysms: send the CT angiogram, not the report

The same image-first rule governs aneurysms, whether they arise in the abdominal aorta, the thoracic aorta, or the femoral artery and below. The most useful thing a general physician can do is obtain a CT angiogram. It tells the vascular surgeon, with no uncertainty, what needs to be done.

Dr. Purkayastha was specific about what a report cannot do. A line saying "infrarenal abdominal aortic aneurysm" or "suprarenal abdominal aortic aneurysm" (below or above the origin of the kidney arteries) tells him very little. The image tells him his landing zones, the maximal diameter and the modality he would choose. In his view, an aneurysm only makes sense on two kinds of study: catheter angiography or CT imaging.

Size is central to timing. In current guidelines, repair of an abdominal aortic aneurysm is generally considered once the diameter reaches 5.5 cm in men or 5.0 cm in women, or sooner if it is growing quickly or causing symptoms. Below those thresholds, patients are usually kept under scheduled ultrasound or CT surveillance.

Recommendations that do not fit the anatomy

Referrals sometimes arrive with very fancy recommendations attached, and Dr. Purkayastha gave examples:

• TAVI for a hugely dilated aortic root. Transcatheter aortic valve implantation replaces a diseased aortic valve; it does not treat an aneurysm of the aortic root, which needs surgical repair of the root itself.
• Standard endovascular repair for a suprarenal abdominal aortic aneurysm without a chimney stent. An aneurysm that extends above the kidney arteries cannot be sealed by a standard stent graft without covering the arteries to the kidneys and, often, the gut. Techniques such as chimney stents, or branched and fenestrated grafts, exist to keep those arteries open.

His advice is to make a basic recommendation and nothing very fancy, and to remember that time-tested open repairs are, at times, still the modality of choice. Valve disease itself is the subject of his separate masterclass on valvular heart disease.

Aneurysm repair cost: open repair versus stent graft

The choice of repair has large financial consequences, and Dr. Purkayastha put figures on it. In his estimate, an open abdominal aortic aneurysm repair costs in the region of USD 10,000 to 15,000. An endovascular (stent graft) repair costs around USD 45,000 to 50,000, because the graft alone costs about USD 30,000. The difference can approach USD 40,000.

This is why he wants the image, not a suggestion. With the CT angiogram, and ideally the DICOM files that allow him to reconstruct the anatomy in three dimensions, he can tell a referring doctor which repair the patient actually needs. A recommendation for an expensive endovascular repair made because an AI tool suggested it, when the anatomy calls for an open repair, can add tens of thousands of dollars to the cost of care.

The venous half of the masterclass, from varicose veins and deep vein thrombosis to pulmonary embolism, is covered in DVT diagnosis, varicose veins and anticoagulation, and the session's discussion of below-knee disease is in the Live Discussion from this masterclass. Dr. Purkayastha's separate masterclass on coronary artery disease covers stenting and bypass of the heart's own arteries.