The Gift of Life
Peripheral artery disease is one the most common forms of cardiovascular disease there is, affecting nearly 12 million people in the United States. However, it also is one of the most missed- and under-diagnosed, and that's what makes the disease so dangerous.
"This year, I'm going to celebrate
every holiday there is to the hilt."
—Noreen Peterson, with husband
Bill at their home in Tinley Park.
Noreen Peterson is not the type of person who lets much slow her down. Perhaps that's why she decided to venture down the stairs of her Tinley Park home at 3 a.m. on a dark December night in 2008 to get something to eat. Noreen, who just turned 70, has been an insulin-dependent type 1 diabetic since the age of 15, and if anything, being chronically ill has only fueled her spirit of determination.
Despite her age and history of bypass surgery at age 60, Noreen still cashiers three days a week at Walt's Food Center on Harlem Avenue. She still drives her son, Neal, who struggles with hydrocephalus and has been legally blind for 10 years, to and from the Tinley train station so he can pursue his passion of playing percussion with the symphonies of Chicago. She still dyes her hair red, and each year, she and her husband, Bill, produce and bottle their own wine. Well, except for last year.
Steps to a
Many people with PAD can be treated with simple lifestyle changes, such as:
Get your blood pressure below 140/90 mmHg.
Reduce your LDL (bad) cholesterol to less than 100 mg/dL and increase your HDL (good) to greater than 40 mg/dL.
Be physically active for at least 30 minutes a day.
Consume less than 300 mg of cholesterol a day; keep saturated fat intake lower than 10 percent of daily calories. Avoid trans fats.
Watch your weight.
Source: American Heart Association
Learn about cardiac services at Palos
On the December night in question, just 10 days before Christmas 2008, Noreen was awakened by what she quickly recognized as a reaction to low blood sugar. She was feeling cold and clammy, heart racing. She needed food. So she got out of bed and headed for the stairs that would take her down to the kitchen, but you know what they say about that first step.
Noreen missed it. She fell the entire length of the split-level hardwood stair case. Noreen's husband came running when he heard the commotion, and he remembers her lying at the bottom of the stairs with her legs "twisted unnaturally." Noreen had a large gash in her head that required 13 stitches, along with a minor concussion. Her pelvis was broken in two places, and her right wrist was so severely crushed that today there's a pin and plate holding it together.
Noreen spent the next four months in either the hospital or a rehabilitation facility. With nursing care, she was able to return home in mid-April. That's when her condition took a turn for the worst.
While in rehab, Noreen had developed a diabetic ulcer on her foot. By the first of May, the infection was the size of a half-dollar. Her ankle had swollen to the size of her thigh, and the heat and redness were starting to travel up her leg. Her physician suspected that poor blood flow to her foot was preventing the ulcer from healing, and he suggested she see a specialist. Noreen made an appointment with Dr. Sanjeev Pradhan, an Oak Lawn-based vascular surgeon, on Tuesday for the following Friday. But before she could keep that appointment, she was back in the hospital. The infection was not only jeopardizing Noreen's leg but her life.
Noreen was diagnosed with peripheral artery disease (PAD), a form of cardiovascular disease that affects the limbs and a condition for which diabetics are at extremely high risk. Left untreated, Noreen probably would have lost her leg, at best. At worst, she could have suffered a debilitating or even fatal heart attack or stroke.
PAD affects between 8 and 12 million people in this country, and millions more may have the condition and not know it. That's a problem because people with clogged or weakened blood vessels have a six- to seven-times higher risk of heart attack and stroke. Even more unsettling: One third of those with vascular disease who have a heart attack or stroke die from it. Knowing what to look for before symptoms start can give both you and your physician a leg up on PAD.
Of Life and Limb
PAD is a form of vascular disease that leads to blood clots and circulation problems in the blood vessels of the limbs, according to the American Heart Association (AHA). A blocked artery can keep oxygen-rich blood from reaching muscles in the arms and legs, especially when needed during activity or exercise.
While vascular disease typically occurs in the vessels that carry blood to the arms and legs, the carotid arteries in the neck, which supply blood to the brain, also can be affected. A stroke can occur when a piece of the clot in the carotid artery breaks off and travels to the smaller vessels in the brain.
"One of the main underlying causes of PAD is artherosclerosis, or hardening of the arteries," explains Dr. Pradhan, who specializes in both invasive and non-invasive treatments for vascular disease. "The person who has vascular disease more than likely also has heart disease, and vice versa."
But because PAD often is mistaken for simple leg pain or arthritis that the patient and doctor both may associate with aging, it can be much more difficult to detect, according to the AHA. The classic symptom of PAD is dull, cramping pain in the legs, hips or buttocks that occurs when you exercise and stops when you rest - called intermittent claudication. Other symptoms of the condition include:
- Numbness or tingling in the legs, feet or toes, which occurs while lying flat but improves when sitting or standing;
- Changes in skin color (pale, bluish or reddish coloration);
- Cool skin in the legs, feet, arms or hands;
- Infections or sores that do not heal.
However, in some cases, PAD produces no symptoms at all. The worsening infection on Noreen Peterson's foot was the only sign of a completely blocked artery in her leg. Since foot ulcers are common in people with diabetes, her doctor pursued standard treatment.
"Noreen had a typical necrotic ulcer on the heel of her foot," Dr. Pradhan recalls. "The ulcer was relatively large, and it was infected. They had been trying to treat it conservatively with wound care and antibiotics for several weeks with no success."
Noreen finally had her appointment with Dr. Pradhan after she was admitted to Palos Community Hospital because the infection on her foot was rapidly moving north. If something weren't done immediately, the ulcer could have cost her the leg, if not her life.
On the Right Track
In addition to a health history and physical exam, there are several non-invasive ways to diagnose vascular disease. An ankle-brachial index that compares the blood pressure in the arm to a reading in the ankle is one of the easiest for detecting damaged vessels in the legs. A ratio of less than 1, meaning the pressure in the leg is lower, is sign of a problem, explains Dr. Pradhan.
A physician then will use ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) to confirm, pinpoint and gauge the severity of the blockage, Dr. Pradhan says. In Noreen's case, a simple ankle-brachial index indicated that there was poor blood flow to her foot, that and the fact that her wound was not responding to treatment. A CTA confirmed the blockage and identified the precise location of the clot.
"The CTA showed a complete occlusion of the main blood vessel in her leg, from the lower thigh to upper calf," says Dr. Pradhan. "There were small branch arteries that were feeding the leg, but they weren't enough to heal the ulcer. Because of the length of the occlusion, a non-surgical solution, such as balloon angioplasty or stent, would have had a low likelihood of success and durability."
Treatment for PAD depends on a variety of factors, including age, mobility, severity of disease and location of the blockage. If the problem is found early, the solution is often simple. Most cases can be treated with lifestyle changes that include exercise, a healthier diet and smoking cessation. Your doctor also may recommend medications to prevent clotting, or to control high blood pressure, cholesterol or diabetes.
If the disease is more advanced, either an interventional procedure or surgery may be recommended. Options include:
- Angioplasty, which uses a catheter with a balloon to pass through the blocked artery;
- Stent implantation, using a metal mesh tube to hold the artery open;
- Atherectomy whereby a special catheter is used to gently shave and remove plaque from the artery; and
- Bypass surgery, which creates a detour around the blockage using your own vein or artificial tubing.
In some cases, no treatment is necessary. "Just because a patient has a narrowing or occlusion, it doesn't mean that it needs to be treated," says Dr. Pradhan. "The body often develops natural bypasses, called collaterals, which allow blood to flow around the blockage. Any treatment or procedure would involve much more risk."
"As medicine has progressed, so has the technology and procedures for diagnosis and treatment," Dr. Pradhan says. "We can do things in much less invasive ways now. Vascular surgeons are trained in both surgery, and minimally invasive angioplasty and stenting techniques. They know the advantages and disadvantages of each modality, and can offer treatment that is specifically targeted to each patient's need in order to obtain the best outcomes."
But for Noreen, considering the severity of her infection, the extent of her blockage and the risk of losing her leg, surgery was the only option. Dr. Pradhan performed bypass surgery on May 20, using a plastic tube because Noreen's veins were too small for the procedure. Within a week, she was moved to a rehab facility, and on July 3, Noreen was able to go home.
With another three months of wound care and physical therapy, Noreen's ulcer finally healed, and she was able to return to her job and her life. Nearly 10 months after the fall that started it all, Noreen went back to her cashier position at Walt's on October 19, and this year, she and her husband, Bill, are already making plans to bottle another batch of Peterson wine.
They are both humbled by the experience and grateful. "All of her doctors and nurses discussed her condition and worked together to help her recover," Bill says. "The personal touch was just amazing. When she was getting shot up with antibiotics four times a day, the nurses were very tender and conscientious. They ran additional tests to understand her condition. Everything was explained with a smile, and they answered all of our questions. I'm convinced that if the doctors hadn't taken the extra time, I wouldn't have her with me today."
"When I was at Palos, I was getting well," says Noreen. "I had promise and hope. On a scale from 1 to 10, plus 10! Plus 20! My experience was beyond measure. I fell into having the best doctors there are, and they're all at Palos."
The coordination of care Noreen received certainly helped heal her wounds, inside and out, but it was her spirit of determination that saw her through the 10 months of recovery required to get back on her feet again. "I missed Christmas, New Year's, my birthday, my husband's birthday, Easter and Mother's Day," she says. "This year, I'm going to celebrate every holiday there is to the hilt!"
May there be many more to come.