Transcription:
Painful Leg Cramps:You Could Have Peripheral Vascular Disease

Melanie Cole (Host):  Pain in the legs can occur as a result of a myriad of conditions. However, conditions such as venous insufficiency or peripheral artery disease may be the problem. My guest today is Dr. Ketul Chauhan. He is an interventional cardiologist with Florida Hospital. Welcome to the show, Dr. Chauhan. Tell us a little about some of the physiology involving the arteries and veins in the lower limbs and how they sometimes get blocked up and we have these issues. 

Dr. Ketul Chauhan (Guest):  Thank you for having me on the show.  The arteries of the legs are no different than arteries of the rest of the body. They are prone to just as much atherosclerosis and plaque build-up just as are all of the other arteries. Half of the physiology is always the same – its cholesterol and all of the stress on the body related. Over time, actually, the leg blockages are more likely to happen than blockage in other places, like the heart or the brain. It’s quite prevalent.

Melanie:  Okay. What would somebody experience?  What red flags? If we hear the words claudication, pain in the legs – but people can get pain in the legs just from musculoskeletal issues. What are some red flags that would signal there are some real issues going on here? 

Dr. Chauhan:  Absolutely.  The biggest thing is decreased blood flow, mostly to the muscles. People start having cramps when they walk which is one of the most cardinal signs of having blockage in the legs. When people experience when they are walking and they experience pain or calf muscles or buttocks pain, that is a pretty good sign of having claudication. But, if people are undiagnosed and they don’t walk much, the peripheral vascular disease can advance. People start seeing color changes in their legs. Start seeing loss of hair and signs like those.

Melanie:  Okay. So then, they go see a cardiologist-- someone such as yourself. What tests do you use to diagnose that they do have some vascular arterial issues?

Dr. Chauhan:  At first, it just pure examination. By looking at it, a lot of times you can tell and just feeling the pulse in your legs. Beyond that, what we do in our office is a sonogram of the leg and that is a pretty good sensitive sign if there is decreased blood flow in the legs.

Melanie:  That shows you whether somebody has some blockages or what. Then, what would be the first line of defense? Do you use medication, interventions? What do you do for somebody if they’ve got some of these issues?

Dr. Chauhan:  It depends on two things. One, how affected they are with these blockages. Just because they have blockages doesn’t mean it always has to be fixed. A lot of times, we can get away with just exercise.  The first line is always exercise.  If you walk past the pain, you’ve forced the legs to make collaterals around the blockages. But, it is more of a supervised exercise – something we’ve prescribed. But, if that does not work, the next best line is that we physically do an angiogram of the legs to see where the blockage is. A lot of times, we can fix them with stents nowadays.

Melanie:  Dr. Chauhan, if you tell them to exercise but then, pain limits their amount of exercise, does that limit the affects that it can have for them? What if they have trouble exercising because of the pain?

Dr. Chauhan:  That’s why we have to prescribe them. What we tell them is to exercise beyond the pain for about 15 seconds, 30 seconds, and over time, you would be amazed at how much exercise capacity is improved. Exercise works better than any medicine, for the most part.  

Melanie:  If somebody does have to have a stenting procedure or an angioplasty and you go in, is this more permanent or is this something that maybe will come back and maybe you might have to redo the procedure?

Dr. Chauhan:  That depends on two factors. One, the risk factor that led them to having blockages those have to be addressed. If patients smoke, they have to stop. Their diabetes has to be controlled. Their blood pressure has to be controlled. If they control the risk factors, their probability of having re-blockages is quite small. The second aspect is, the stent themselves have a certain amount of patency to it. Not just because you stent them every time do they stay open forever. There is about 85% patency over three years. There is a 10-15% chance the blockage is going to come back again just because of the nature of the stents.

Melanie:  If somebody, then, has the situation and we have not discussed yet, doctor, risk factors. Are there certain things that predispose somebody to peripheral artery disease or venous insufficiency?

Dr. Chauhan:  Peripheral vascular disease is the number one. Two and three reason we go to smoking, smoking, smoking. Those are the most common reasons. That’s what we see, the majority of the time people have peripheral vascular disease from.

Melanie:  Is there a genetic component at all if your parents had it?

Dr. Chauhan:  No, there is not a genetic component to this. The second most is because we have atherosclerosis which is a plaque build-up.  Plaque build-up is related to cholesterol and your lifestyle habits. So, a combination of smoking and lifestyle habits is what really predominately drives PAD.

Melanie:  When you speak about lifestyle habits, does diet fit into this at all? We hear about plaques and cholesterol and all these sorts of things: fish oils, Omega 3s. Do any of these figure into peripheral artery disease at all?

Dr. Chauhan:  Yes, ma’am. Absolutely. It is a multi-factorial approach. When we start talking about risk factors, you have to address blood pressure. You have to address hyperlipidemia, cholesterol. When you are addressing cholesterol, obviously, it depends on what kind of cholesterol issues they have. If they have triglycerides, obviously, there have different treatments for it. LDL issues and then, statins come into play. There are all of these modalities. It is a multifactorial approach.

Melanie: What about things that they can try at home if they do have some issues with their legs or with arterial problems? Do you recommend compression stockings? Are people supposed to keep their legs up if they notice some edema, some swelling?

Dr. Chauhan:  Now, we are developing into more venous issues. The PAD is what we talked about so far. The venous issue is a whole different story where you have a bad drainage of the legs. The blood flows to the legs but the blood doesn’t come back. Those are because of venous disease. People start out with having big varicose veins, initially, and then that leads to more blackening of the skin. The skin breaks down and there are a lot of edema and so forth. That’s where venous issues come into. The venous issues present themselves with edema as well and those are treated differently.

Melanie:  Does that tend to get worse over time or does it pretty much stay the same?

Dr. Chauhan:  Venous insufficiency is definitely progressive. It is heavily dependent on what happens pathophysiology-wise. The veins of the legs – they have valves in them. Because we are human beings, we stand all the time the blood that comes back from the leg depends on valves to bring the blood back against the gravity. If those valves in the veins go bad, the blood keeps pooling in the leg. The idea is to get rid of the bad veins.  All the blood gets channeled to the proper veins. They are treated, most of the time, with something called ablasion where we put a laser inside the bad veins which is a big highway right underneath the skin. You get rid of the bad veins, all the blood gets back through the proper channels and the legs get better.

Melanie:  Can you get rid of the bad veins? Don’t we need our veins?

Dr. Chauhan:  There are two types of veins in the body the veins which are inside the muscle, which are the most important veins. There are a whole bunch of channels there. There are veins underneath the skin in the legs. Those are not the most important veins. If they are bad veins, they are not used for anything anyway. If they are good veins, then we sometimes harvest them for by-pass. But, if they have gone bad they are of little use regardless.

Melanie: When you get rid of them and you do this ablation, is it still in there? Or, do you actually physically take this vein out or does it just sort of disintegrate within the leg?

Dr. Chauhan:  Correct. In the old days, to get rid of the bad veins, they used to do stripping. It used to be more of a procedure surgical issue. Now, we can do this in a more office based procedure where we put the laser inside of the vein and the vein is literally closed with this laser by a small radiofrequency ablasion. Over time, once that is closed the body, absorbs this closed vein.

Melanie:  That is absolutely fascinating. In just the last few minutes, Dr. Chauhan, give us your best advice for people that might be suffering from peripheral arterial disease or peripheral vascular disease. What you would tell them is the best bit of advice and why they should come to Florida Hospital for their care?

Dr. Chauhan:  Florida Hospital is really, truly at the cutting edge of medicine. That is a given. The second best advice I could give the patient is be vigilant about their symptoms. Look at your legs. See what bothers them. Most of the times, patients are aware if they live a bad lifestyle. If you have a bad lifestyle and you have risk factors and if you start experiencing things in your legs, it is better to get it checked out than not. The bigger implication here, what we’re missing is that if you do have a PAD, the PAD does not kill people. That implies that you are at very severe risk of having heart disease and that’s what hurts people. It’s better to get more vigilant and have it checked out so we can get you on the right track.

Melanie:  Thank you so much, doctor. It’s great information.  You’re listening to Health Chats by Florida Hospital and for more information you can go to FloridaHeartExperts.org. That’s FloridaHeartExperts.org. This is Melanie Cole. Thanks so much for listening.