What lies beneath

What lies beneath

After running around hospitals for five months, Sandhya Tomar’s problem was finally diagnosed at Sir Ganga Ram Hospital in New Delhi.

Since January this year, the 50-something Lucknow-based officer with the Uttar Pradesh Grameen Awas Parishad has been battling a severe pain in the leg that foxed most of the doctors she consulted. Finally, she reached G.B. Pant Hospital in New Delhi, where doctors suspected a peripheral arterial block and referred her to Sir Ganga Ram Hospital. Here, vascular surgeon Rajiv Parakh conducted a Doppler test and confirmed that the arteries in both her legs were blocked. She would immediately need a bypass surgery as even an angioplasty/stenting procedure would not work.

Bypass surgery? Angioplasty? Yes. It’s not just in the case of the heart where these procedures are performed. Atherosclerosis (blockages of the arteries) can affect arteries anywhere in the body, including the limbs, the kidney and the neck region (carotid arteries that supply blood to the brain). Very often, atherosclerosis in the peripheral arteries (outside the heart area) goes undetected and untreated, leading to much discomfort to the patient. Vomiting, nausea, ulcers, high blood pressure (BP) and shooting pain in the affected region are all symptoms of peripheral arterial disease (PAD).

More worrying is the fact that if atherosclerosis is in the peripheral arteries, doctors say it is a sign that it is also likely to be in the coronary arteries and vice versa. According to Dr Parakh, one in four people who have had heart attacks are potential candidates for peripheral vascular attack. Smokers, those with high BP, high cholesterol and diabetes, and those suffering from stress are all at risk. Though, often, people who are not in the high-risk category, such as Tomar, can also be affected.

On 15 January this year, she woke up with shooting pain in her legs. She could not sleep. “I used to cry with pain and this continued for three weeks," she said. The pain then moved to the foot. She consulted neurosurgeons, orthopaedists and other specialists who kept prescribing calcium and testing her serum creatinine and uric acid levels. Her blood pressure shot up—but this was attributed to a recent bereavement in the family. She then visited homeopaths who asked her to soak her leg in salt water. At this point, she started developing ulcers in the ankle, which led doctors at G.B. Pant to refer her to a vascular surgeon.

Tomar was probably diagnosed just in time. Doctors say severe peripheral arterial disease leads to blocked blood flow in the limbs, which causes tissue death (gangrene) and, in extreme cases, leads to amputation. “The biggest stumbling block in detecting peripheral arterial disease is the lack of awareness on the issue among lay people and even doctors," says Dr Parakh. Everybody knows about heart attacks and how arterial blocks lead to it, but nobody immediately extrapolates it to other regions of the body, he says.

The irony, as Atul Mathur, associate director, interventional cardiology, Escorts Hospital in New Delhi, points out, is that the first balloon angioplasty in the world was actually performed in the leg. “Perhaps, because it is not as life-threatening as arterial blockages in the heart, PAD hasn’t got the attention it deserves," says Dr Mathur.

But now, the good news is that alert cardiac surgeons and vascular surgeons are keeping their eyes open to the possibilities of arterial blocks in areas of the body other than the heart. Praveen Chandra, director, cardiac cath lab and senior cardiologist at the Max Devki Devi Heart and Vascular Institute, New Delhi, describes how whenever they have to do an angiogram on the heart, they peep in on the other arteries as well. “Even during cardiac bypass procedures, we have started to glance at other arteries as a matter of routine," he says. If they spot another block anywhere else, they tend to address that as well immediately. “That’s why it’s called a ‘fly by angiography,’" he grins.

Binda Malik, 59, is one such patient whose renal artery block was detected after a cardiac bypass surgery. Despite a successful cardiac bypass surgery performed at Escorts in New Delhi, some of her old symptoms persisted—vomiting, nausea and erratic BP despite medication. Dr Chandra, who was then with Escorts, immediately checked out her other arteries and found the renal (kidney) arteries all blocked.

It’s been over three years since the stent was put in Malik’s renal arteries and she says she has not had a moment of discomfort after that. “My blood pressure has also been in control since then," she says. In the case of kidney arteries, the preferred line of treatment is angioplasty. “In 99% of the cases, stenting works, and we have all but stopped bypass surgeries in this area," says Dr Chandra.

According to him, it’s a 10-15 minute procedure and the patient can go back to work on the third day. Also, stents are getting better and better as technology advances and non-invasive procedures make things easier.

Angioplasty is the option in case of partial blockage of arteries in the legs, but where blockages are severe, surgery is often required—but unlike the cardiac bypass surgery, where a vessel from some other region of the body is grafted, here a plastic tube is used.

“We can do a graft from another vessel but usually do not, because if there is a future artery block in the heart, we would like to leave it to be used for that," says Dr Parakh.

In the case of the carotid artery, Dr Mathur says that in the last decade, angioplasty has emerged as the main line, though a procedure called endarterectomy (surgical removal of plaque from the artery) is another option.

Either because of good detection facilities now or because of increased risk behaviour, doctors are seeing more cases of peripheral arterial blocks. Estimates suggest that one in four hypertensive or diabetic patient in India above the age of 45 has peripheral vascular disease.

So, whose speciality is the peripheral arterial system? It’s usually the preserve of vascular surgeons but several cardiac surgeons are now gaining expertise in the area. Both Dr Chandra and Dr Mathur are essentially cardiac specialists. “The procedure is exactly the same. All it needs is a good knowledge of the arterial system," says Dr Chandra.

At Sir Ganga Ram Hospital, Dr Parakh says, there have been cases where the blockage has spread so far and deep that neither angioplasty nor surgery could offer a solution. This is where stem cell therapy comes in.

Armed with a grant from the department of biotechnology (DBT), doctors at Sir Ganga Ram Hospital are working on this. When a 45-year-old villager, a chronic beedi smoker from a low-income group, came in with severe leg pain, doctors found that his case was too severe for surgery. Stem cells were extracted from his blood and injected into the affected region. But stem cell therapy takes a long while to show results—six weeks to three months, says Dr Parakh.

Even as they monitor the first test case which, at four weeks is progressing well, the team is getting ready for the next one.


What is PAD?

Peripheral arterial disease (PAD) occurs when a fatty material builds up on the inside walls of the arteries that carry blood from the heart to the head, internal organs and limbs. The build-up of plaque on the artery walls is called atherosclerosis or hardening of the arteries. Atherosclerosis causes the arteries to narrow or become blocked, which can reduce or block blood flow. PAD most commonly affects blood flow to the legs.

How do you detect it?

• ABI (ankle brachial index test: Rs100), shows up calcification. Test recommended once a year after the age of 45.

• Doppler scan: Rs1,500-2,000. It is similar to an ultrasonography (USG) examination.

• Angiogram: Roughly Rs7,000. Basically done to provide the surgeon a roadmap of the arteries.

Treatment options

• Angioplasty/ ballooning: Angioplasty means dilating a narrowed area in the artery with a balloon. In 90% of the cases, angioplasty is followed by ‘stenting’. A stent is a special metal coil that is left in the ballooned angioplastied artery to prevent it from closing down again. The cost of a peripheral arterial stent is between Rs30,000 and Rs35,000 and the whole procedure costs around Rs1.25 lakh.

• Bypass surgery: Rs90,000–1.5 lakh.

• Stem cells therapy: So far, only experimental in India. But estimates suggest it could be around Rs75,000.

Support medication such as statins and blood thinners (aspirin) for life.

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