Q: My 57 years old father feels pain in his thighs and legs when he walks for 500 metres or so for the last 10 months. Earlier, it was only in the left leg but now both the legs pain. The doctor suggested some exercises but it didn’t help. We consulted another doctor who diagnosed it as some vascular disease due to smoking. His lipid profile and blood sugar tests were normal. We got colour arterial doppler done for both the lower limbs and it showed low amplitude biphasic flowing left CFA, SFA, popliteal and its branches ATA, PTA. The right CFA and SFA also showed low amplitude triphasic flow. Diffuse intimal thickening with marginal plaques are seen involving the common iliac arteries on either side. Colour doppler and spectral display revealed turbulant flow with flow acceleration. The DPA showed low amplitude flow. The aorta showed triphasic flow. Impression: Bilateral flow limiting Vasco-Occlusive disease involving mainly the common iliac arteries (L>R). He took Trental 400 mg BD and Proxyvon BD for 25 days but there was no improvement. Then the doctor asked us to stop Trental and prescribed Zilast 100 mg BD instead. But after taking this medicine twice, my father felt nauseous and sleepy the whole day and so he stopped it. What should be the next course of action? He doesn’t want to go for surgery. He has already quit smoking three weeks back. Please suggest.

A:Your father has certainly got Peripheral Vascular Disease (PVD), This is affecting Iliac arteries on both sides, left worse than right and also distal vessels to some extent. The fact that the claudication is coming on at about 500 mts and the flows in the limb vessels on Doppler assessment are either low amplitude triphasic or biphasic signifies that there is stenosis (narrowing) and not occlusion of the iliacs. Even though the Doppler report does not show the Ankle Brachial Index but I do not believe that your father has severe enough disease to need surgical intervention at present. He needs to optimise his medical treatment and persevere with this management for some time. I have noted that one of the risk factors, i.e. smoking has been taken care of, that he has stopped smoking. Thankfully he does not suffer from high lipids and high blood sugar but we need to look for other risk factors like hypertension and other blood conditions. The main stay of the medical management is as follows:

• Starting antiplatelet therapy with Aspirin or Clopidogrel
• He should also start with at least one statin, even if his lipids are in the normal range as there is evidence that taking statins does modify the PVD disease or at least stops the deterioration.
• He needs to start regular exercise, not casually but regimented. He could even go on the treadmill and starting slowly and gradually building the pace and the distance. The diet needs to be modified to low fat and high roughage and vitamins. I have also noted he has been having Cilostazol, apparantly he could not tolerate the medication. My advice would be to start with a lower dose and increase slowly to normal dose.
• If the optimised medical treatment does gives relief, that is, improve the situation so the quality of life is better, then the same may be adhered to. If the situation deteriorates, i.e. there is rest pain, gangrene or ulcer or if the quality of life is significantly impaired then one should seek intervention. In this case it would be investigating with Duplex scan and MRI of the arterial system of the legs and then deciding to intervene further. More than likely it should be DSA and angioplasty (ballooning of the artery) and not surgery. It is usually prudent to use stenting of the iliacs in preference to surgery. Surgery is the option of last resort, when angioplasty is not possible or will not be productive. Surgery may also be considered if the angioplasty fails.