Advice and Information
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon
1. What is atherosclerosis?
It is a progressive disease of the arteries
[vessels that carry blood] which starts the day we are born and
stops the day we die. However, it may vary from an extremely slow
to an aggressive disease. It is not a degenerative disease as
most people feel. The arteries become hardened [sclerosis] and
narrow, so the blood that flows through them decreases. It is
similar to the lime scale that forms in water pipes.
Is more or less a generalized disease - albeit patchy in
It may affect any vessel in the body, like the heart vessels,
the arteries that supply the brain and the leg arteries.
The leg arteries are the ones more frequently affected, followed
by the arteries that supply the brain
2. What does
patients this decrease in blood flow causes little trouble, as the
narrowing is not significant. As the course of atherosclerosis is
extremely slow, the serious event is usually preceded -years in
advance- by small signs and symptoms of ischaemia [inadequate
blood supply], like angina, mini strokes or intermittent
claudication [pain on walking]. Only rarely the first event is
dramatic - a stroke or sudden death. However, very few people
reach “old age” without a potentially dangerous degree of
atherosclerosis. Half of all deaths are caused by circulatory
problems, the basis of which is atherosclerosis.
3. Who is affected by
are much more likely to be affected by
atherosclerosis than women. Women’s protection weans off with age,
the disease increasing rapidly after menopause, and by “old
age” the risks are similar in both sexes. At any age the protection
is wiped out by diabetes.
depend on the extent and the level of blockage
may cause mild or no symptoms
may cause mild symptoms
at two levels
will cause moderate symptoms
blockages at two levels
usually cause severe symptoms
blockages at 3 levels and especially when the calf
vessels are affected, the leg may be threatened.
The simple answer is that all people are affected
by the disease and everyone is at risk of developing symptoms,
however, some are much more than others. Even those with the
lowest risk are more likely to die from cardiovascular causes, but
they will get the disease later in life.
4. What is the cause of
There isn’t any single cause for arterial disease. It
is more likely to be caused by a combination of factors,
amongst which the wear and tear effect, the genetic
[inherited, familial] predisposition and the high
concentration of low density lipoproteins in the blood,
reflecting the high intake of saturated fat in the diet are the most
Although we do not know what actually initiates
atherosclerosis, we know a lot of factors which accelerate it [risk
High blood cholesterol [a specific fat
substance] concentration. The normal levels should be less than
5mmol/lt. Unfortunately, in most middle aged people is above
6.3mmol/l. Reducing the cholesterol levels in the blood reduces
significantly the risk of cardiovascular death.
High blood pressure. People with
diastolic [the low reading] blood pressure more than 85mmHg are at
risk of developing symptoms attributable to atherosclerosis at an
earlier age and also show a higher risk of cardiovascular death.
Diabetes. People with diabetes develop
atherosclerosis at an earlier stage and is quite often dramatic.
Diabetes affects the small vessels in the legs and the kidney in
particular and quite often the damage is not only irreversible but
often not even reconstructable.
Diet containing high quantities of fat
[especially saturated, animal fat].
It causes spasm of the arteries,
makes the blood sticky [thrombotic effect] and accelerates the
effect of all other risk factors [apart from causing lung cancer as
well]. The number of cigarettes smoked seems less important than the
mere fact of smoking.
incidence of arterial disease with blockages increases by :
in people who smoke 15 cigarettes daily
when the number of cigarettes is more than 35
About 5-14% of patients will develop severe
symptoms within 5 years of diagnosis.
Combination of risk factors.
These combinations cause the most problems. Most vascular diseases
are caused by such combinations, because the arteries stand
reasonably well to one risk factor in isolation. The risk of heart
attack is trebled if the patient smokes, has a serum cholesterol of
6mmol/l and has a diastolic blood pressure greater than 85mmHg.
5. What can I do against
There isn’t much you can do to avoid the disease;
however, there is much you can do to slow it down.
Have regular exercise
Change your diet. Eat whatever flies
[poultry, etc.], swims [fish], drops [fruit] or grows [wheat,
vegetables]. Avoid animal fat. Red wine is also helpful. It is
better to have more frequent and small rather than a single large
Lower your cholesterol. Walking and
regular exercise is the best means to reduce the cholesterol and
increase the beneficial cholesterol called HDL. If your blood
cholesterol level is high and cannot be brought to normal by strict
diet, your doctor may prescribe some specific drugs [simvastatin,
Look after your blood pressure.
Take a small dose of aspirin
[75-150mg] daily. Affects the platelets, an essential factor in
atherosclerosis, reducing the overall risk by 25%.
good care of your feet; avoid injuries
Consult your doctor early
if you develop symptoms.
1. What is intermittent claudication?
As atherosclerosis has progressed, it causes
either a narrowing or a blockage in the arteries taking blood to
your leg. Over the years, cholesterol and calcium build up
inside the arteries like lime scale. The muscles get oxygen and food
from the blood, therefore, when walking, the demands for blood are
higher. Because of the blockage, the muscles are deprived from blood
and send a signal [pain] to make it understood. This pain you
feel on your legs making you limp is called claudication. It
appears on exercise and eases off if you stop for some minutes. You
are then able to continue walking, but the cramping pain will come
back after a while.
measurement of ankle pressures
normal cases the pressure measured at the ankle by ultrasound
is the same as the arm blood pressure [ratio AP/BP = 1.0]
patients with blockages is less than 1, <0.8 in mild
claudication, <0.6 in severe, < 0.4 in critical
The functional effect of the blockages can be easily
checked by measuring the blood pressure at your ankle [a quick and
painless test done by your specialist].
Occasionally more sophisticated tests may be needed
to establish the position of the blockages, like a Quick-Scan,
Duplex Ultrasound or even arteriography.
2. Does the blockage ever clear
No, unfortunately not,
but the situation can improve due to opening up of smaller
arteries [collateral circulation] which carry blood around the
block. Many people notice some improvement, as the collateral
circulation opens up, within six to eight weeks of the onset of
3. What is the prognosis and how is
it going to be in a year’s time?
The prevalence of intermittent claudication depends
on age. Is very low for people under the age of 60, but increases
with age [2.4% for people 60-70 years]. Less than 10 % of patients
with lower limb atherosclerosis have intermittent claudication and
only 10 % of patients with intermittent claudication are under the
care of a doctor. The future [prognosis] is generally good for
the limb but poor for the patient as a whole. As atherosclerosis
affects not only the leg but also the heart and the brain vessels,
there is a higher risk of cardiovascular death [myocardial
infarction or stroke]. The average annual risk of death is 5%.
Less than 10% of patients referred to a vascular
surgeon will progress to critical limb ischaemia, a condition in
which the limb is threatened. However, in up to 60% of patients
deterioration will occur in 2-3 years. Within a year, 2% of
patients with claudication will require a major amputation and 6%
will require surgical or radiological intervention for
4. How can I help myself?
There are several things you can do which may help.
The most important is to stop smoking, take regular exercise and
If you are a smoker you must make a sincere and determined effort to
give up completely. Firstly, it speeds up hardening of the arteries
[atherosclerosis] which is the basic cause of trouble and secondly,
cigarette smoke causes spasm of the small collateral vessels,
reducing thus further the amount of blood and oxygen delivered to
The best way to give up is to
choose a day when you are going to stop completely rather than
trying to cut down gradually. If you do have trouble giving up
please ask your doctor who can give you advice on nicotine gum and
patches or put you in touch with a support group. Unfortunately,
although many patients cut smoking down, only 30% give it up
Diet. It is very important not to put
on weight, because the more weight the legs have to carry around
the more blood they will need. Your doctor or dietitian will give
you advice with regard to weight reducing diet. If your blood
cholesterol is high you will need a low fat diet and may also
require cholesterol lowering drugs.
Exercise. There is good evidence that
people who take regular exercise [walking at a regular pace until
pain comes on, then stopping and continue again when the pain
disappears] develop a better collateral circulation. Try to make it
a little further each day and you will almost certainly find that
the distance you can manage without pain slowly but steadily
increases. Regular exercise for at least 6 months has been shown to
improve the claudication distance [distance you are able to
walk without pain] by 180% and the maximum walking distance
If you have a high blood pressure it is important that this is well
controlled by tablets. You should have regular checks by your GP.
Treating Claudication in 50 words.
Stop smoking and keep walking
Take an anti-platellet agent [Aspirin,
ticlopidine or clopidogrel]
Lower blood pressure over 140/90mmHg
Lower cholesterol over 5.5 mmol/l
Diet [low fat, calories, salt]
Loose weight [especially if obese and
Fibrate which lowers fibrinogen
5. What about treatment?
Most people with intermittent claudication do not
The conservative treatment [summarised
in the previous table] suffices in the majority of the cases.
However if your symptoms are severe [claudication distance less than
100m] and make your life difficult, or if they do not improve with
the conservative treatment, further treatment may be necessary.
x-ray of the arteries [arteriogram] is usually performed
first to see what can be done. Short blockages can be stretched open
with a balloon [angioplasty] in the x-ray department. This is
usually done under local anaesthesia and often involves an overnight
stay in the hospital.
Longer blockages can be bypassed using either a
plastic tube or a vein from your leg [bypass graft]. This is
a major operation under general anaesthesia and involves being in
the hospital for about a week to ten days.
The decision about surgery is
usually one for you to make yourself after your specialist Vascular
Surgeon has explained the likelihood of success and the risks
involved. There is an overall risk of 1% of surgery threatening your
limb after failure, plus the risk of surgery and anaesthesia.
However, on average, these grafts remain open in 70% of patients for
5-10 years. Angioplasty has a lower overall risk, however the long
term result is not as good as surgery. Only 50% of balloon stretched
arteries are open after 12 months and the blockage rate is 10-15%
per year afterwards. More detailed information about these
procedures is also available - please ask your specialist.
The exact place of surgery and angioplasty in people
with less severe claudication is unclear at present. The risk of
surgery and / or angioplasty should be balanced against your overall
benefit. However, there is evidence that early intervention is
beneficial as the policy to intervene only on patients with severe
short distance claudication has a number of potential drawbacks:
1) It may be too late
2) It may prejudice the outcome
patients quality of life is reduced
We are conducting a trial to assess this and also the
effect of fat in claudication. You may be asked to participate in
6. Do drugs help?
Although there are quite a number of proprietary
tablets and drugs on the market [vasodilators, haemorrheological
agents etc.] there is very little evidence that they will actually
help - drugs will not unblock the artery. Perhaps your doctor has
already tried one of these drugs in your case, so that you can judge
is the only drug that has a beneficial effect and is usually
prescribed in small doses [75-150mg per day]. It makes the blood
less sticky and lowers the risk of heart attack and strokes.
variety of similar drugs can be used, especially if aspirin causes
to reduce your cholesterol may be necessary if all the other
measures to control it fail.
7. What is the risk of losing my leg?
Very few patients with intermittent claudication end
up with an amputation and your specialist will make every effort to
avoid it. Within a year the risk of amputation is 2% and the risk of
developing a complication that will necessitate urgent intervention
The majority of people with claudication develop no
problems and the condition may stay the same for years if you look
after yourself and follow medical advice.
The most important thing is that you improve your
lifestyle - keep walking, lose weight and stop smoking!
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A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.