Should I have surgery for peripheral arterial disease?
Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
Your decision about whether to have a surgical procedure (angioplasty or bypass surgery) for peripheral arterial disease involves several issues, including the severity of your leg pain (intermittent claudication), concern about the risk of amputation, and the risks of having surgery. Consider the following when making your decision:
- Your doctor may recommend that you try an exercise program and lifestyle changes before considering surgery, because this effort could produce a long-lasting increase in your capacity to walk without pain. And it does not carry the risks of bypass surgery or angioplasty.
- You may want to try an exercise program and lifestyle changes before considering surgery, because these changes could extend your life, while angioplasty or bypass surgery alone will not.
- You may want to have a surgical procedure if you are not able to participate in your usual physical activities and you want more immediate relief from leg pain.
- If you have severe peripheral arterial disease, surgery may save your affected limb and prevent disabling leg pain.
Medical Information
What is peripheral arterial disease?
Peripheral arterial disease (PAD) is poor blood flow in your arteries. Your arteries carry blood to your organs and muscles. If arteries become narrowed or blocked because of disease, they cannot carry enough blood to allow your muscles and organs to work properly.
The most common cause of peripheral arterial disease is atherosclerosis, which is the buildup of plaque on the inside of arteries. The plaque deposits decrease the space through which oxygen-rich and nutrient-rich blood can flow. Poor blood flow "starves" the muscles and other tissues in the lower body.
Reduced blood flow may result in intermittent claudication, which is tightness or squeezing pain in the calf, thigh, or buttock during exertion, such as walking up a steep hill or a flight of stairs.
High cholesterol, high blood pressure, and smoking contribute to atherosclerosis and peripheral arterial disease.
How is peripheral arterial disease treated?
Lifestyle changes and medicine often can stop or even reverse the buildup of plaque in your arteries and improve the quality and length of your life. In many people, leg pain decreases after they have used these treatments for several months.
Quitting smoking is by far the most important factor in treating peripheral arterial disease. And studies show that nicotine replacement therapy; use of the medicine bupropion, nortriptyline, or varenicline (Champix); and supportive therapy significantly increase long-term success in quitting.1 This success can be critical, because continued smoking is associated not only with PAD symptoms getting worse but also with a poor outcome, including a higher chance of having an amputation.2 If you use a nicotine replacement product or take the medicine bupropion or nortriptyline, you can double your chances of quitting tobacco for at least 6 months.1, 3
Your doctor also will strongly advise that you follow a heart-healthy diet and an exercise program. You will probably need to take cholesterol-lowering medicines. People with diabetes should try to keep their blood sugar levels as close to normal as possible.
People with PAD who have intermittent claudication have a higher risk for death, mainly from stroke and heart attack, compared to other people the same age. ASA and strict blood pressure control is often recommended to reduce this risk.
If these measures do not reduce your symptoms, angioplasty or bypass surgery may be considered to treat severe or limb-threatening peripheral arterial disease.
What kinds of procedures are done for peripheral arterial disease?
Your doctor will recommend either angioplasty or bypass surgery if you decide to have a surgical procedure for peripheral arterial disease. Surgical procedures to treat peripheral arterial disease include:
- Angioplasty. This is a procedure in which the surgeon inserts a small, thin tube called a catheter through a blood vessel in the groin and guides it to the affected artery. When the tube reaches the narrowed part of the artery, the surgeon inflates a balloon to press the built-up plaque against the wall of the artery and improve blood flow. A small, expandable wire-mesh tube called a stent often is placed in the artery to hold it open.
- Bypass surgery. The types of surgery used to treat PAD are categorized according to the location of the affected leg artery or arteries. Common surgeries include:
- Aortobifemoral bypass, for narrowing of the aorta—the major abdominal artery—and the iliac arteries, which branch off from the aorta.
- Femoropopliteal (fem-pop) bypass, for narrowing of the arteries in the thigh and knee.
- Femoral-tibial bypass, for narrowing of the arteries in the lower leg or foot.
The bypass surgeries can be done with a vein or with a man-made (prosthetic) graft. But vein grafts can keep the blood vessel open longer than the man-made grafts.4
The choice of angioplasty or bypass surgery depends on all of the following factors:
- Risks of the procedure.
- Size of the arteries.
- Number and length of the narrowing or blockages in the arteries.
In general, angioplasty works best in larger arteries. Angioplasty has the best rates of success in the aorta and in the iliac arteries, which branch from the lower aorta. In the femoral arteries, angioplasty works better if the area of narrowing is short. In the past, doctors have preferred bypass surgery over angioplasty when the narrowing or blockages are in the popliteal and tibial arteries (which are small arteries). But angioplasty in these arteries is becoming more successful with advances in angioplasty.
What are the risks of surgical procedures?
All surgeries pose a certain amount of risk. In general, the risks of surgery for peripheral arterial disease (PAD) of the legs are similar to those of other types of surgery. These risks include:
- Infection from the incision.
- Bleeding.
- Heart attack or stroke.
- Leg swelling.
- Failed or blocked grafts.
Angioplasty has fewer life-threatening risks than surgery. Risks include:
- Rupture of the artery.
- Bleeding at the site of the catheter insertion.
- Sudden closure of the artery.
- Blood clots.
- Allergic reaction.
- Kidney damage.
For more information, see the topic Peripheral Arterial Disease of the Legs.
Your Information
Your choices are:
- Have surgery.
- Try making lifestyle changes, taking needed medicines, and following an exercise program to reduce leg pain.
The decision about whether to have a surgical procedure takes into account your personal feelings and the medical facts.
Deciding about treatment for peripheral arterial disease Reasons to have a surgical procedure Reasons to use medicine, to exercise, and to make lifestyle changes
- Surgical procedures can restore blood supply and increase the amount you are able to walk for up to 2 to 6 years.5, 6 See the research.
- Surgery is faster than lifestyle changes for improving walking. It may take up to a year to realize the benefits from an exercise program.
- In general, the more severe your peripheral arterial disease is, the more likely it is that you will need surgery.
Are there other reasons that you might want to have a surgical procedure for peripheral arterial disease?
- In the long run, you can gain as much benefit from an exercise program as you can from a surgical procedure to relieve claudication, according to some studies.7 See the research.
- Although surgery increases blood flow and walking distance in the first few months, the long-term benefit is not clear.5, 6
- Making lifestyle changes, such as quitting smoking, exercising, and taking medical treatment can prolong your life.1
- Surgical procedures have risks, such as infection, bleeding, and blood clots.
Are there other reasons that you might not want to have a surgical procedure for peripheral arterial disease?
These personal stories may help you make your decision.
Wise Health Decision
Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about a surgical procedure. Discuss the worksheet with your doctor.
Circle the answer that best applies to you.
I have tried and failed to quit smoking in the past, and I don't believe I can now. Yes No NA* I am ready to quit smoking. Yes No NA My risks from surgery are high. Yes No Unsure I want to be able to exercise without pain now. Yes No Unsure I am able to participate in an exercise program. Yes No Unsure I want to make changes in my life now to live longer. Yes No Unsure I am a candidate for lower-risk angioplasty. Yes No NA *NA = Not applicable
Use the following space to list any other important concerns you have about this decision.
What is your overall impression?
Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have a surgical procedure.
Check the box below that represents your overall impression about your decision.
Leaning toward having a surgical procedure
Leaning toward NOT having a surgical procedure
Return to the topic Peripheral Arterial Disease of the Legs.
| Author: | Douglas Dana Robin Parks, MS | Last Updated: December 20, 2007 |
| Medical Review: | Anne C. Poinier, MD - Internal Medicine David A. Szalay, MD - Vascular Surgery | |
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