Bad PAD: Pain in your leg can be more than just a pain in your leg -- it could be peripheral artery disease

By David Steinkraus

Thursday, December 28, 2006 2:11 AM CST

When it comes to leg pain, don't pay attention to what your mother told you, or think that such aches must come with advancing age, or heed your own excuses for inaction.

There are two reasons for doing this. First, because this pain can likely be treated. Second, and more important, because this particular type of pain means your leg may be cut off, or you may die from a heart attack.

It's not cheery, but it is the potential in peripheral artery disease (typically abbreviated PAD and also called peripheral vascular disease). You may even have seen ads about this on television - you know, one of those drug company ads in which sad, aching people take a pill and suddenly have the energy of a manic hamster.

What happens in PAD is that the blood vessels of the legs are narrowed by the same fatty plaques that you've heard about for years in conjunction with heart disease. This is where those two reasons come in.

First, if plaque has narrowed the vessels of the legs, doctors have found that they've also narrowed the coronary arteries that feed the heart, meaning people with PAD have coronary artery blockages which may cause a heart attack. Second, if plaque has narrowed the vessels of the legs, it means those tissues aren't getting much oxygen, and that means gangrene could set in, which leads to amputation if there's no treatment.

PAD is common, researchers have found. It's been known for quite a while although there hasn't been much emphasis on it. If affects about 20 percent of people older than 55 and is widely distributed in the world's older population. About half of the people with PAD don't have any symptoms, although people with PAD are about twice as likely to have a heart attack as people without it.

Wrong opinion Owen Elder is 83 and lives in a tidy house in central Racine. He's in a wheelchair because his right leg was amputated. He ascribes it to a wound in his ankle that never healed, the result of rough boyish play in 1936 and of the death of the other boy. "My daddy told me your leg is never going to heal up now."

It was the folk wisdom of the time; if the person who gave you an injury died before the injury healed, the wound never would.

Modern medicine says he had poor circulation in his lower right leg. He felt numbness in his toes. A couple of years ago, when he felt numbness in the left leg, he went to see a doctor. "These people, when I went the first thing they hollered about, they're going to have to take this leg off. My wife said we're going to have a second opinion on this."

They did. They found Dr. Kellie Brown, a vascular surgeon at Froedtert Hospital in Wauwatosa and an assistant professor at the Medical College of Wisconsin. If you were in the Horlick High School class of 1985, yes, it's that Kellie Brown. She examined Elder and did a bypass, like the bypasses that heart surgeons do. Brown took one of Elder's own veins, connected it to the femoral artery (that's the big one which runs down the middle of your thigh) and then tied it into the smaller vessels below the knee. This provided a greater blood supply for Elder's lower left leg.

Elder still has his wheelchair, but he still has all of his left leg as well. It's no small thing.

Before the bypass, Elder said, he foresaw a life without mobility. He has a prosthetic right leg, but it's hard to manage, and he's fallen four times with it, mostly because he has trouble getting the knee joint to lock and support his weight. Had the surgeons left him his knee, he said, he wouldn't even be confined to a wheelchair.

Worse still, he feared the loss of his ability to drive a car, which he's done since 1947. "I figured I wasn't going to be able to do our chores." But now, with his left leg and his prosthetic right leg, he can drive his wife around the city, or drive to Milwaukee to visit relatives.

Walking long Dot Nielsen, 77, who lives on the west side of Racine, was a fan of walking starting when it became the popular way to stay active in the 1980s. She always had some leg pain. When she was younger, the exercise built vessels to increase the blood supply to her muscles. "So I never was too concerned about (the pain), but as I got older collateral veins didn't take over anymore."

That often happens, said Dr. Diego Hernandez, a vascular surgeon at Wheaton Franciscan All Saints. Pain increases so people walk less although exercise helps relieve PAD.

Only about 7 percent of people with PAD require an amputation, he said, and many cases remain stable.

Smoking is firmly linked to worsened PAD. There is what doctors call a dose-response effect. Lower the dose (smoke less), and the effect diminishes.

Nielsen said Hernandez didn't tell her what might have led to her problem but she's sure it was smoking. When it came time for treatment, Nielsen opted for a new technique which Hernandez performs in Racine.

Instead of doing a bypass in a patient's leg, for many cases he uses a small device to cut the plaque from the inside of a blood vessel.

If you've ever had tree roots cleaned from a sewer, you'll have an idea of how it's done.

The device packs the plaque into a chamber so it doesn't float away and cause damage. When the chamber is full, the surgeon takes it out, cleans it, and puts it back in for another pass.

In a couple of hours, Hernandez said, a team can remove plaque in one leg. This avoids the need for major surgery, several days in the hospital and months of recuperation, he said. Because the patient is only mildly sedated, it also removes the complications inherent in general anesthesia.

"So I went for it because I couldn't walk more than 25, 30 feet without my legs cramping," Nielsen said.

Now she can walk easily again, she said, and her toes are pink instead of grayish.

The device Hernandez uses has been on the market for only a couple of years, so data on its effectiveness is still being collected. To Hernandez it's wonderful. Only about 10 percent of patients, typically those who smoke, require another treatment, he said. He used to do 40 to 50 vascular bypasses a year. "This year I've done two," he said. "That's not my first line of treatment. Now this is."

Good opinions The message in all this, Brown said, is that people suffering from leg pain is that they need to see a specialist, which means a vascular surgeon or an interventional radiologist.

"There's a lot of very good surgeons in this area, and I don't mean to insult them, but whomever was going to take this man's leg off didn't know, doesn't do this every day."

For Owen Elder, there's only one message: "It's always important: If you can get a second opinion, you get it."

Special Offer: Get 5 Weeks of the Journal Times for $7!