Dr. Zdan Korduba, an anesthesiologist at St. Luke’s-Roosevelt Hospital Center in New York, wound up having one toe amputated, losing months of work and feeling like a total chump for missing symptoms he’d have spotted right away in a patient.
Beginning five years ago, he says ruefully, he began noticing that his legs hurt after tennis: “I got tremendous cramps, but I put it off as being out of shape.” Before long, he found he “couldn’t walk the same distance as before. I kept denying this to myself. My diabetes was not the best controlled, either.”
Seven months ago, he couldn’t even walk two blocks from the garage to the hospital without tremendous pain in his right leg. “It hit me I was in trouble. . .If a patient had come to me with these symptoms, I would have diagnosed it as peripheral vascular disease. But on yourself, you’re the worst patient there is. It was denial.”
Like Korduba, an estimated 10 million Americans, many of them over 50, have peripheral vascular disease, or PVD – clogged arteries in the legs (and occasionally, the arms) that trigger numbness or intense pain (a kind of “heart attack” in the legs) during even minimal activity. Many, like Korduba, are in denial, chalking up their pain to age or arthritis.
In fact, so many people go undiagnosed and untreated that, beginning today for a week, a coalition of medical organizations is taking the unusual step of offering free screening and referrals for peripheral vascular disease at 500 hospitals across the country, including three in the Boston area. (See sidebar for locations.)
Peripheral vascular disease is caused by the same phenomenon that clogs coronary arteries and triggers chest pain – atherosclerosis, the build-up of cholesterol-filled plaques. Just as angina, or chest pain, is a sign the heart isn’t getting enough oxygen-rich blood, especially upon exertion, leg pain after a minimal amount of walking means leg muscles are starving for oxygen, too.
And since atherosclerosis is a body-wide process, clogged arteries in the legs are often a sign that those that supply the heart and brain may be dangerously narrowed as well, notes Dr. Cameron Akbari , a vascular surgeon at Beth Israel Deaconess Medical Center in Boston.
In fact, if you have peripheral vascular disease and heart disease, you have six times the risk of dying of a heart attack as someone who has heart disease alone, says Dr. Rodney Raabe , director of radiology at the Sacred Heart Medical Center in Spokane, Wash., and co-director of the screening program “Legs for Life.”
But PVD can be a life-wrecker in its own right, too. It not only severely impairs mobility but can lead to skin ulcers and gangrene and ultimately, may require the amputation of toes, feet or legs, especially in diabetics, who are at high risk of circulatory problems to begin with, says Dr. Max Rosen , an interventional radiologist at Beth Israel.
Now, if you’re a reasonably active sort whose legs feel crampy after you overdo the weekend jock thing, don’t panic. There’s a world of difference between legs that feel sore the morning after a strenuous workout and legs that cramp up after a short walk across the kitchen or down the block. “People with PVD can’t do half an hour on the treadmill,” says Rosen.
PVD is also different from (though sometimes confused with) the leg pain that occurs during sleep, or sciatica, pressure on a major nerve to the leg caused by a ruptured spinal disk.
The hallmark of PVD is the pain’s utter predictability. It comes on after a set amount of walking – often only a few minutes – and goes away when you stop, then starts up again when you walk the same distance again.
Screening for PVD is easy – and painless. The doctor or nurse simply takes your blood pressure on your arms and on your lower legs and calculates what’s called the ABI, or ankle-brachial index. The pressure should be roughly the same. If it’s lower in the legs, it means blood flow to the legs may be compromised.
If the screening shows you have or are at risk for peripheral vascular disease, you’ll be referred for further testing. This includes more sophisticated blood pressure monitoring all up and down on the legs and a “Doppler” ultrasound test as well.
This non-invasive test shows how fast blood is moving through blood vessels; if it speeds up in one spot, it means the blood is rushing to get through a narrowed area. If there’s no flow at all, that’s obviously even bigger trouble.
For some people, doctors may also recommend an angiogram, in which they thread a small catheter through an artery in the groin, inject dye, and watch on an X-ray screen to see where blood vessels narrow dangerously.
If you’re diagnosed with mild peripheral vascular disease, the remedy, believe it or not, may be to walk through the pain to force collateral blood vessels to take up the slack and, over time, supply leg muscles with oxygen. People with PVD are often given aspirin, too, notes Dr. Mitchell Rivitz , a radiologist at Newton-Wellesley Hospital. Aspirin makes blood less likely to clot as it travels through narrowed areas of blood vessels.
If those remedies don’t help, doctors can perform balloon angioplasty just as they would for a clogged coronary artery. They insert a small balloon-tipped catheter into the artery under X-ray guidance, inflate the balloon and push apart the artery walls to let more blood flow through.
They may also insert a stent, a metal device that stays in the narrowed area to keep the vessel open, or perform bypass surgery, stitching a small segment of vein taken from elsewhere in the patient’s body to carry blood around the bottleneck in the artery. If the narrowing of the artery is caused by a clot, they may inject clot-busting drugs like t-PA.
Some doctors are also experimenting with injections into the legs of a gene for vascular endothelial growth factor, a protein that causes new blood vessels to grow in the area. They’re also working on using radiation along with stents to stop vessel narrowing.
When Dr. Korduba finally consulted a surgeon, he recommended walking through the pain. It worked, for a while. He kept playing tennis, too, “not well, but I was playing.”
Then, he says, he got a blister on his little toe “which I did not pay attention to.” The pain soon spread to his foot. Before long, his wife noticed a black spot right under the blistered toe. He went back to his surgeon, who admitted him to the hospital immediately.
He had angioplasty, which increased blood flow in his leg overall. But he still had a gangrenous, black spot – dead tissue – in his toe, so the next day, he had surgery to have the toe amputated so that it didn’t cause a life-threatening infection. To make sure the wound drained as it healed, doctors did not close the incision.
That meant staying home from work – it’s been two months so far – and having a nurse come twice a day to clean and pack the wound. “I’m Dr. Mom now,” says Korduba, who spends a lot of time helping his kids with their homework.
And he’s learned two things. “I have now become a kinder and gentler doctor. I’ve been practicing for 29 years, and you get a little jaded. You forget the patient is not just a patient but a human being. When you start looking at the ceiling from a stretcher, you become restless and agitated with any little delay. . . .I’ve certainly learned a lot being a patient.”
He’s also got new respect for how serious peripheral vascular disease can be and for the dangers of denying it. “That denial is the worst thing. This is a sneaky disease. When you get the symptoms, you’re in trouble.” He’s “not looking for glory” by telling his story, he adds. “This is not my finest moment.”
Risks for vascular disease
You are at higher than normal risk for peripheral vascular disease if you are over 50, male or a smoker. Other risk factors include high blood pressure, diabetes, high cholesterol, a family or personal history of heart or vascular disease and being overweight.
Signs that you may already have PVD include leg cramps when you walk that go away when you rest, cold feet and ulcers or sores on your feet that are slow to heal.
To schedule an appointment at a hospital offering free “Legs for Life” screening this week for peripheral vascular disease, check the web under www.legsforlife.org. (Local libraries can help if you don’t have access to a computer.) For a brochure on the program, call 1-877-357-2847 begin_of_the_skype_highlighting 1-877-357-2847 end_of_the_skype_highlighting.
Eight medical centers in Massachusetts are participating in the screening, including three in the Boston area: Beth Israel Deaconess Medical Center (617-667-8194 begin_of_the_skype_highlighting 617-667-8194 end_of_the_skype_highlighting), Newton-Wellesley Hospital (617-243-6800 begin_of_the_skype_highlighting 617-243-6800 end_of_the_skype_highlighting), and North Shore Hospital in Salem (978-741-1215 begin_of_the_skype_highlighting 978-741-1215 end_of_the_skype_highlighting).
The screening is sponsored by the Society of Cardiovascular & Interventional Radiology and supported by the American College of Foot and Ankle Surgeons, the American Radiological Nurses Association and the Society for Vascular Nursing.