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How can I treat the occlusion in the artery of my leg?

Monday, 28 July 2008
Answered by: Dr. Shiban K. Chaku
Senior Consultant Surgeon,
Indraprastha Apollo Hospitals,
New Delhi
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Q. I am a 30 years old woman diagnosed with a total occlusion of the right femoral artery between right mid to lower one-third of the leg. I feel coolness and numbness in the feet at times. Please suggest me what are the treatment options available?

A.  I have seen young people suffering from occlusive arterial and venous disease, some times both conditions in the same patient at different times and at times with recurring episodes. In your case, the occlusion of femoral artery is of significance. Even though the process of arteriosclerosis begins in the second decade of life but it is normally not advanced enough to cause occlusion of a major vessel like Femoral artery. Particularly, the incidence of atherosclerosis in non-diabetic pre-menopausal patient is quite rare. It would have been helpful to know the type of occlusion in terms of plaque morphology of the occluding lesion as that would have given us the clue as to the under-lying disease process, as platelet plaque or calcium deposit in cholesterol plaque. I would like to suggest following investigations and management. There has to be a three-prong strategy for the management 1. a) To define the lesion and rest of the arterial tree. This can be done first by doing a colour Doppler along with assessing Ankle/Brachial pressure index, which in normal situation should be over 1.0. This confirms the presence of the lesion and measures the intensity of the same. This also gives us a baseline measurement against which success of therapeutic process can be measured and later monitored b) To do a MRI (Magnetic Resonance) Angiography of the vessels this confirms the location and also the quality of the run in (quality of the artery up to the occlusion) and run off (quality of the artery beyond the occlusion), after this assessment and depending on the severity of the symptoms, one can decide about the need to do digital subtraction angiography, this should only be done when the intervention is planned, i.e. if feasible to do the angioplasty at the same time. If symptoms are severe and unremitting and not amenable to angioplasty, they will need to be dealt with by surgical correction, like bypass or surgical angioplasty with or without patch graft. This will address the issue of the present lesion. There is need to do further investigations to find out the cause. 2. This should include the finding out of diabetes, hypertension, hyperlipidemia, and conditions like polycythaemia, which can be done using simple blood tests. There is need to investigate further about the possibility of connective tissue disorder, like rheumatoid arthritis, lupus erythromatosis, and sleroderma/systemic sclerosis. Having excluded these conditions, the most important investigations that need to be done are to determine the presence or absence of anti-phospholipid syndrome, estimation of protein C & S, anticardiolipin antibodies, homocysteine measurement and last but not the least the detection of Factor V Leiden mutant gene. The treatment will depend on the findings and may need prescription of Folic acid or long term anti-coagulants. 3. The long-term management of lifestyle like, cessation of smoking, diet control, exercise regime and avoidance of contraceptive pill. Also in some cases genetic counselling may be required. I am aware of the expense involved in these investigations but there are serious issues, which need to be confirmed or excluded. Also some of the investigations are to be done only once which is a relief. Ignoring the under-lying disease my endanger limb or life and so has got to be taken seriously.

A.  I have seen young people suffering from occlusive arterial and venous disease, some times both conditions in the same patient at different times and at times with recurring episodes. In your case, the occlusion of femoral artery is of significance. Even though the process of arteriosclerosis begins in the second decade of life but it is normally not advanced enough to cause occlusion of a major vessel like Femoral artery. Particularly, the incidence of atherosclerosis in non-diabetic pre-menopausal patient is quite rare. It would have been helpful to know the type of occlusion in terms of plaque morphology of the occluding lesion as that would have given us the clue as to the under-lying disease process, as platelet plaque or calcium deposit in cholesterol plaque. I would like to suggest following investigations and management. There has to be a three-prong strategy for the management 1. a) To define the lesion and rest of the arterial tree. This can be done first by doing a colour Doppler along with assessing Ankle/Brachial pressure index, which in normal situation should be over 1.0. This confirms the presence of the lesion and measures the intensity of the same. This also gives us a baseline measurement against which success of therapeutic process can be measured and later monitored b) To do a MRI (Magnetic Resonance) Angiography of the vessels this confirms the location and also the quality of the run in (quality of the artery up to the occlusion) and run off (quality of the artery beyond the occlusion), after this assessment and depending on the severity of the symptoms, one can decide about the need to do digital subtraction angiography, this should only be done when the intervention is planned, i.e. if feasible to do the angioplasty at the same time. If symptoms are severe and unremitting and not amenable to angioplasty, they will need to be dealt with by surgical correction, like bypass or surgical angioplasty with or without patch graft. This will address the issue of the present lesion. There is need to do further investigations to find out the cause. 2. This should include the finding out of diabetes, hypertension, hyperlipidemia, and conditions like polycythaemia, which can be done using simple blood tests. There is need to investigate further about the possibility of connective tissue disorder, like rheumatoid arthritis, lupus erythromatosis, and sleroderma/systemic sclerosis. Having excluded these conditions, the most important investigations that need to be done are to determine the presence or absence of anti-phospholipid syndrome, estimation of protein C & S, anticardiolipin antibodies, homocysteine measurement and last but not the least the detection of Factor V Leiden mutant gene. The treatment will depend on the findings and may need prescription of Folic acid or long term anti-coagulants. 3. The long-term management of lifestyle like, cessation of smoking, diet control, exercise regime and avoidance of contraceptive pill. Also in some cases genetic counselling may be required. I am aware of the expense involved in these investigations but there are serious issues, which need to be confirmed or excluded. Also some of the investigations are to be done only once which is a relief. Ignoring the under-lying disease my endanger limb or life and so has got to be taken seriously.

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