When diagnosed with Peripheral Arterial Disease (PAD), here are questions that you might ask your provider.

Make certain you know about your choices. We have a list of questions that you can consider as prompts to help you understand more about your condition and the options open to you. If you do not know the answers to these questions, make sure to discuss them with your healthcare provider at your next visit.

• You should ask your healthcare provider about the risks and benefits of different treatments as they relate to patients with exactly your conditions. This is important because some treatment decisions, such as whether to have percutaneous treatments or surgery for persistent leg pain, depend precisely on the size and location of the blockages in your blood vessels. There is no “one size fits all” answer.
• What are the risks and benefits of just using medicine to treat PAD for me, with my set of conditions?
• What medicines would you recommend for me?
• For me, with my conditions, what are the risks and benefits of surgery? What, if any surgery, would you recommend for me?
• Should I have a percutaneous intervention, such as a stent, or should I consider bypass surgery? (For patients who have been offered percutaneous interventions).

The general indications as to when to shift to surgery over minimally invasive treatment, which may be:

• Repetitive failures of a minimally invasive procedure.
• Blockage is severe or long or many blockages over a long segment.
• Size of the blood vessel. Smaller ones do better with bypass. The lower you go in the leg the more superior bypass gets.
• If there is a shift from minimally invasive options to surgery, ensure that whoever is recommended to do the surgery has the requisite skills.
• Your physician should welcome questions about their experience and qualifications, and this is something you should understand.
• What are your personal rates of complications for these procedures? How many patients do you treat for PAD annually, and how many do you see for each of the treatment options we are discussing?
• Does the American Board of Surgery certify you in Vascular Surgery?  Do you have special training to treat PAD?  What percentage of your practice is care for PAD patients?

In addition to considering the list of questions to ask your provider, below we have included additional information to guide you if you are facing this diagnosis.

How is PAD diagnosed?

The test to make the diagnosis of PAD is both simple, available, and cheap. It is called the Ankle -brachial index known as ABI. Basically, the blood pressure in your leg should be the same as your arm. If it is lower, you have PAD. All you need for the test is a blood pressure machine. It is not recommended to do expensive imaging tests like MRI or CAT scans because taking pictures of the blockages is not necessary except in advanced cases where surgery is being considered.

Should I check an ABI even if I have no symptoms?

There is no recommendation to screen the public for PAD since the precautions you need to take if you have a diagnosis are the same that I recommended for everyone under healthy living. As a matter of fact, screening has been linked to the performance of unnecessary surgical procedures. In some situations, checking an ABI in the presence of risk factors, like diabetes, smoking, or hypertension, can indicate a higher risk situation, and could encourage the patient to be more serious about healthy living and avoiding the causes of the condition.

What are the medications I need to take if I have PAD?

If you have a diagnosis of PAD, you need to take a mild blood thinner like aspirin. This will make the blockage, more stable and less likely to cause an acute problem. You may also need to take a medication to lower cholesterol and the family of drugs that is the most helpful are called statins. These drugs will help make the blockage stable and less likely to cause an emergency situation. If you have muscle cramps when walking, a medication called Cilostazol can help. Cilostazol improves the ability to walk for a longer distance but does not work immediately and should be taken at least for 6 to 8 weeks before giving up on it.

Are there any other medical conditions that cause symptoms similar to PAD?

The leg cramps you get with PAD are similar to the leg symptoms you get if you have disc problems or spinal stenosis in your back. Your physician should be able to figure out what you have, although it is not always straightforward. Both back problems and PAD are diseases of aging, and many patients have both. This possibility should be discussed, if you are considering an operation since if you have both conditions and you have surgery for only one, you may not get relief.

When should I have a surgical intervention?

You absolutely will need the blockages opened up if you have pain in your legs without walking (providers refer to this as “pain at rest”) or if you have an ulceration or a wound that is not healing within a few days. in this case, failure to operate could lead to amputation. You should think very carefully, however, before agreeing to an intervention, if you have muscle cramps when you walk a certain distance (claudication). In these cases, why an intervention will make you walk better immediately, many interventions have short-lived results, and many are associated with potential complications. Once you go through the pathway of surgery, it is difficult to go back.

What are available treatment options, and which are better?

The two categories of interventions available to treat PAD are minimal invasive interventions and open surgery.

Using minimally invasive interventions, the blockage is opened using catheters that are placed in position through an access point in the groin or the arm. Tools like balloons, small knives, lasers, and stents are often used to make that happen. In open surgery, a vein is harvested from somewhere else in your body and is used to replace the blood vessels that are blocked. Sometimes, an artificial tube can be used instead of your vein. Minimally invasive methods do better if the blockages are short and limited and bypasses do better if you have many or long blockages.

Should I be involved in deciding what is the best operation for me?

Physicians regularly have different opinions regarding what is the best way to treat a particular pattern of disease and you should absolutely discuss the options with your physician. You need to understand the trade-off between minimally invasive interventions, which are easy and safe, but where the results could be short-lived, versus bypass surgery, which requires a hospital stay of a few days and is associated with long incisions on your leg. The bypass results tend to be more durable than minimally invasive procedures and can give you relief for many years.

Things to Consider:

1. Do not be afraid to ask questions to your provider and we always recommend having a note taker with you during the consultation to document the meeting.  How often have you reached your car after a long consultation and realized you have forgotten some of the facts that were shared?
2. Ensure you know the status of your provider if you are about to embark on an intervention.
3. After a consultation always take time to reflect on your understanding of the next steps. If there is any confusion or doubt, you can follow up and have a discussion with your primary care provider. You will have been given a lot of information over a short period of time so taking this time to fully understand choices is important.
4. Do not shy away from a second opinion from a different surgeon, you should discuss coverage of this with your insurer, generally, this is a service they not only cover but recommend. Your physician knows that getting another professional view is good practice and will be supportive of this approach.  Also, Medicare always allows a second opinion if a doctor recommends you have surgery or a major diagnostic or therapeutic procedure. (Check restrictions).
5. Always discuss coverage with your insurer and be certain to understand if there are any restrictions and in or out-of-network coverage issues.