Introduction

Peripheral arterial disease (PAD) is a common condition in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD).

Although many people with PAD have no symptoms, some people have painful aching in their legs brought on by walking. These aches will usually disappear after a few minutes of resting.

If you experience recurring leg pain with exercise, see Dr B C Shah. PAD is usually diagnosed through a physical examination by Dr B C Shah.

They will also measure the blood pressure in your leg, using the ankle brachial pressure index (ABPI). This involves comparing blood pressure readings from your arm and your ankle. A difference between these readings may indicate PAD.
Why does it happen?

Peripheral arterial disease is a cardiovascular disease, meaning it affects blood vessels. It’s usually caused by a build-up of fatty deposits in the walls of the leg arteries. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.
Who is affected?

Rates of cases of PAD are strongly associated with older age. It is estimated that it develops in:
2.5% of people under 60
8.3% of people aged 60–69
19% of people over 70

Men are more likely to develop the symptoms of PAD earlier in life than women.

There are certain things that can increase your chances of developing PAD and other cardiovascular diseases, including:
Smoking –by far the single most significant risk factor
Diabetes – both type 1 and type 2 diabetes
High blood pressure
High cholesterol
Treating and preventing peripheral arterial disease

PAD is largely treated through medication and lifestyle changes.

Completely stopping smoking and exercising regularly are the main lifestyle changes that can ease the symptoms of PAD and reduce the chances of the condition worsening.

The underlying causes should also be treated, such as reducing high blood pressure and cholesterol and treating diabetes. Medication can be used to improve blood flow. In some cases, surgery may be needed to treat PAD.
Complications of peripheral arterial disease

While PAD is not immediately life-threatening, the process of atherosclerosis that caused it can lead to serious problems.

Having PAD means you have a much higher risk of developing other serious cardiovascular diseases, such as:
coronary heart disease – a condition where the supply of blood to the heart is restricted, putting you at risk of a heart attack
stroke

Also, if the symptoms of PAD worsen, there is a risk that tissue of the lower leg will begin to die (this is known as gangrene), which in severe cases requires the lower leg to be amputated.

If treatment is successful, and lifestyle changes are maintained, your situation will usually improve.

However, if you are unable or unwilling to make lifestyle changes, especially if your leg pain is getting worse, it is estimated there is a:
One-in-five chance you will experience a non-fatal heart attack or stroke
5% chance that one or both of your legs will need to be amputated
One-in-three chance you will die prematurely

Symptoms of peripheral arterial disease

Many people with peripheral arterial disease (PAD) do not have any symptoms. However, you may feel painful aching in your leg muscles triggered by physical activity such as walking or climbing stairs.

The pain usually develops in your calves, but sometimes your hip, buttock or thigh muscles can be affected. The pain can range from mild to severe.

The pain will usually go away after 5–10 minutes when you rest your legs. Other symptoms of PAD may include:
Hair loss on your legs and feet
Numbness or weakness in the legs
Brittle, slow-growing toenails
Ulcers (open sores) on your feet and legs, which do not heal
Changing skin colour on your legs, turning pale or bluish
Shiny skin
The muscles in your legs may shrink
Men may develop impotence (erectile dysfunction)
When to seek medical advice

If you experience recurring episodes of leg pain, make an appointment with Dr. B C Shah, especially if you are a smoker or have a confirmed diagnosis of diabetes, high blood pressure and/or high cholesterol.

Many people mistakenly think recurring episodes of leg pain are part of growing older. This is not the case. There is no reason why an otherwise healthy person should experience leg pain.
When to seek urgent medical advice

Some symptoms may suggest the supply of blood to your legs has become severely restricted and you may need to see a doctor urgently. These include:
Being unable to move muscles in the affected leg
A sudden loss of normal sensation in the affected leg
Feeling a burning or prickling sensation in the affected leg
Your toes or leg suddenly turns white or blue
The skin on your toes or lower limbs becomes cold and numb, and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain
Causes of peripheral arterial disease

Peripheral arterial disease (PAD) is usually caused by a build-up of fatty deposits on the walls of the arteries inside the legs. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.

People with PAD can experience painful aching in their leg muscles during physical activity because the muscles are not receiving the blood supply they need.

Like all tissue in your body, muscles in your legs need a constant supply of blood to function properly. When you are using your leg muscles, the demand for blood increases four-fold. But if the arteries in your legs are blocked, the supply of available blood cannot meet the demand.

This shortfall between supply and demand causes your muscles to experience painful aches which usually get better when you rest your legs.
Increased risk of PAD

There are some things that cannot be changed which may increase your chances of developing PAD, such as a family history of heart disease and atherosclerosis, or your age.

As you get older, your arteries naturally begin to harden and get narrower, which can lead to atherosclerosis and then PAD.

However, there are many things that can dangerously speed up this process. These are described below.
Smoking

Smoking is the single most important thing that increases your risk of PAD. Smoking can damage the walls of your arteries. Tiny blood cells, known as platelets, will then form at the site of the damage to try to repair it. This can cause your arteries to narrow.

It is estimated that smokers are six times more likely to develop PAD than non-smokers and more than 80% of people who develop PAD are current or former smokers.
Diabetes

If you have poorly controlled type 1 or type 2 diabetes, the excess glucose in your blood can damage your arteries.

People with diabetes are two to four times more likely to develop PAD, and having a combination of poorly controlled diabetes and PAD is a major risk factor for amputation. People with diabetes and PAD are 15 times more likely to need an amputation than people with PAD who do not have diabetes.
High cholesterol

Cholesterol is a type of fat essential for the body to function.

There are two main types of cholesterol:
Low-density lipoprotein (LDL) is the main cholesterol transporter and carries cholesterol from your liver to cells that need it. If there is too much cholesterol for the cells to use, this can cause a harmful build-up in your blood and lead to atherosclerosis. For this reason, LDL cholesterol is known as "bad cholesterol", and lower levels are better.
High-density lipoprotein (HDL) carries cholesterol away from the cells and back to the liver, where it is either broken down or passed from the body as a waste product. For this reason, it is referred to as "good cholesterol", and higher levels are better.

Most of the cholesterol your body needs is made by your liver. However, if you eat foods high in saturated fat, the fat is broken down into LDL ("bad cholesterol").l.
High blood pressure

Your arteries are designed to pump blood at a certain pressure, and if blood pressure is too high (known as hypertension), the walls of the arteries can become damaged. High blood pressure can be caused by:
Being overweight
Drinking excessive amounts of alcohol
Stress
Smoking
A lack of exercise
Homocysteine

Homocysteine is a type of amino acid (molecule that makes up protein) found in the blood. Research has found that 30%–40% of people with PAD have higher-than-average levels of homocysteine in their blood. And one-in-four people who develop leg pain have extremely high levels.

It has been suggested that high levels of homocysteine may damage the walls of the arteries, leading to atherosclerosis, but this has not been proven.

Vitamin B supplements and eating foods high in folic acid, such as green leafy vegetables or wholegrains, are known to lower homocysteine levels. However, researchers found no significant reduction in risk of cardiovascular disease when people with PAD increased the amount of vitamin B and folic acid in their diet.
Diagnosing peripheral arterial disease

If Dr. B C Shah suspects a diagnosis of peripheral arterial disease (PAD), he will carry out a physical examination of your leg.

PAD can cause a number of noticeable signs and symptoms, such as:
Shiny skin
Brittle toenails
Hair loss
The pulse in your leg being very weak or undetectable
Leg ulcers

Dr B C Shah may also ask about your symptoms and personal and family medical histories.
The ankle brachial pressure index

The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assessing how well you are responding to treatment.

While you rest on your back, Dr B C Shah will measure the blood pressure in your upper arm and your ankle. These measurements are taken with a Doppler probe, which uses sound waves to determine the flow of blood in your arteries.

They then divide the second result (from your ankle) by the first result (from your arm).

If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same and the result of your ABPI would be 1.

But if you have PAD, the blood pressure in your ankle will be lower due to a reduction in blood supply, so the results of the ABPI would be less than 1.

In some cases, ABPI may be carried out after getting you to run on a treadmill or cycle on an exercise bike. This is a good way of seeing the effect of physical activity on your circulation.
Further testing

In most cases, Dr B C Shah will be able to confirm a diagnosis of PAD by doing a physical examination, asking about your symptoms and checking your ABPI score.

Further testing is usually only required if:
There is uncertainly about the diagnosis – for example, if you have symptoms of leg pain but your ABPI score is normal.
You do not fit the expected profile of somebody with PAD; for example, you are under 40 and have never smoked.
The restriction of blood supply in your leg is severe enough that treatment may be required.

Additional hospital-based tests that can be used include:
Ultrasound scan – where sound waves are used to build up a picture of arteries in your leg. This can identify exactly where in your arteries there are blockages or narrowing.
Angiogram – a special liquid known as a contrast agent is injected into a vein in your arm. The agent shows up clearly on a computerised tomography (CT) scan or magnetic resonance imaging (MRI) scan and produces a detailed image of your arteries.

In some cases, the contrast agent may be injected directly into the arteries of your leg and X-rays may be used to produce the images.
Treating peripheral arterial disease

There are two main types of treatment used in the management of peripheral arterial disease (PAD).

These are:
Making lifestyle changes to improve symptoms and reduce your risk of developing a more serious cardiovascular disease (CVD), such as coronary heart disease
Taking medication to address the underlying cause of PAD and reduce your risk of developing another CVD. For example, a statin can be used to lower your cholesterol levels.

Surgery may be used in some cases. For example, if you experience pain in your leg while resting or if there is tissue loss. These treatment types are discussed in more depth below.
Lifestyle changes

The two most important lifestyle changes you can make if you are diagnosed with PAD are:
If you currently smoke, you should stop.
Take regular exercise.
Smoking

Quitting smoking will reduce your risk of PAD getting worse and another serious cardiovascular disease developing.

Research has found people who continue to smoke after receiving their diagnosis are five times more likely to have a heart attack and seven times more likely to die from a complication of heart disease than people who quit after receiving their diagnosis.

People who stop smoking usually notice an improvement in their symptoms and an improvement in their ankle brachial pressure index (ABPI) score.
Exercise

Evidence suggests regular exercise helps reduce the severity and frequency of PAD symptoms, while at the same time reducing the risk of developing another CVD.

Research has found that after six months of regular exercise, a person can::
Walk for two to three times longer before experiencing pain
Walk a lot further before experiencing pain
see a 20% improvement in their ABPI score

If you are diagnosed with PAD, it is likely you have not taken part in regular exercise for many years (although this is not true for everyone, such as previously fit people with type 1 diabetes).

The exercise programme usually involves two hours of supervised exercise a week for three months. But ideally, over time, you should be aiming to exercise daily for the rest of your life, as the benefits of exercise are quickly lost if it is not frequent and regular.

The preferred exercise is walking. It is normally recommended you walk as far and as long as you can before the symptoms of pain become intolerable. Once this happens, rest until the pain goes and begin walking again until the pain returns. Keep using this "stop-start" method until you have spent at least 30 minutes walking.

You will probably find the exercise course challenging, as the frequent episodes of pain can be upsetting and off-putting. But if you persevere, you should gradually notice a marked improvement in your symptoms and you will begin to go longer and longer without experiencing any pain.
Medication

Different medications can be used to treat the underlying causes of PAD while reducing your risk of developing another CVD.

Some people may only need to take one or two of the medications discussed below, while others may need all of them.
Statins

If blood tests show that your levels of LDL cholesterol ("bad cholesterol") are high, you will be prescribed a type of medication called a statin.

Statins work by helping to reduce the production of LDL cholesterol by your liver.

Common side effects of statins include:
Digestive disorders, such as constipation and diarrhoea
Difficulty sleeping (insomnia)
Pain in the muscles and joints
Feeling sick (nausea)
Antihypertensives

Antihypertensives are a group of medications used to treat high blood pressure (hypertension).

It is likely you will be prescribed an antihypertensive drug if your blood pressure is higher than 140/90mmHg if you do not have diabetes, or 130/80mmHg if you do have diabetes.

A widely used type of antihypertensive is an angiotensin-converting enzyme (ACE) inhibitor.

ACE inhibitors block the actions of some hormones that help regulate blood pressure. They help to reduce the amount of water in your blood and widen your arteries, which will both decrease your blood pressure.

Side effects of ACE inhibitors include:
Dizziness
Tiredness or weakness
Headaches
A persistent dry cough

Most of these side effects pass in a few days, although some people find they still have a dry cough.

If side effects become particularly troublesome, a medication that works in a similar way to ACE inhibitors, known as an angiotensin-2 receptor antagonist, may be recommended.

ACE inhibitors can cause unpredictable effects if taken with other medications, including some over-the-counter ones, so check with Dr B C Shah before taking anything in combination with this medication.
Antiplatelets

One of the biggest potential dangers if you have atherosclerosis is a piece of fatty deposit (plaque) breaking off from your artery wall. This can cause a blood clot to develop at the site of the broken plaque.

If a blood clot develops inside an artery that supplies the heart with blood (a coronary artery) it can trigger a heart attack. Similarly, if a blood clot develops inside any of the blood vessels going to the brain, it can trigger a stroke.

You will probably be prescribed an antiplatelet medication to reduce your risk of blood clots. This medication reduces the ability of platelets (tiny blood cells) to stick together, so if a plaque does break apart, you have a lower chance of a blood clot developing.

Low-dose aspirin (usually 75mg a day) is usually recommended.

Common side effects of aspirin include:
Irritation of the stomach or bowel
Indigestion
Nausea (feeling sick)

If you are unable to take aspirin (for example, if you have a history of stomach ulcers or you are allergic to aspirin), an alternative antiplatelet called clopidogrel can be used.

Side effects of clopidogrel include:
Diarrhoea
Pains in your stomach and bowel
Nosebleeds
Bruising
Blood in your urine
Blood in your stools
Naftidrofuryl oxalate

Naftidrofuryl oxalate improves blood flow in the body, and is often used if you prefer not to have surgery or your supervised exercise programme has not led to satisfactory improvement in your condition.

Side effects of naftidrofuryl oxalate include:
Dizziness
Headache
Stomach pains
Diarrhoea
Rashes
Surgery

There are two main types of surgical treatment for PAD:
Angioplasty – where a blocked or narrowed section of artery is widened by inflating a tiny balloon inside the vessel
Bypass graft – where blood vessels are taken from another part of your body and used to bypass the blockage in an artery
Angioplasty vs bypass surgery

Both types of surgery have their own set of pros and cons.

An angioplasty is less invasive (it does not involve making major incisions in your body). It is usually performed under a local anaesthetic as a day procedure. This means you will be able to go home the same day you have the operation. You also feel less pain after an angioplasty. However, the improvement in symptoms varies from person to person and may only last for around 6-12 months.

Bypass surgery, which is usually only used when angioplasty is not suitable or if it has failed, has a longer recovery time (around two to three weeks). However, the improvement in symptoms usually lasts for longer than a year.

However, after two years, both techniques have broadly the same success rate of improving symptoms.

Both techniques carry a risk of causing serious complications such as a heart attack, stroke and even death. One study found that the risk of death for angioplasty was around one person in every 200, and the risk for bypass graft was slightly higher – around two to three people in every 100.

Before recommending treatment, a team of specialist surgeons, doctors and nurses will discuss the options with you – including the potential risks and benefits.

Surgery is not always successful in treating PAD and is usually only recommended under the following circumstances:
Your leg pain is so severe it prevents you from carrying out everyday activities.
Your symptoms have failed to respond to treatments discussed above.
The results of tests, such as ultrasound scans, show surgery is likely to improve symptoms.

Both techniques are discussed in more detail below.
Angioplasty

A tiny hollow tube known as a catheter is inserted into one of the arteries in your groin. The catheter is then guided to the site of the blockage.

On the tip of the catheter is a balloon which is inflated when the catheter is in place. This helps widen the vessel. Sometimes a hollow metal tube known as a stent may be left in place to help keep the artery open.

Read more about angioplasty.
Bypass graft

If angioplasty is unsuccessful or unsuitable, a bypass graft may be performed. During surgery a length of a healthy vein in your leg is removed. The vein is then joined (grafted) above and below the blocked vein so the blood supply can be rerouted, or bypassed, through the healthy vein. Sometimes a section of artificial tubing can be used as an alternative to a grafted vein.
Complications of peripheral arterial disease

The build up of fat in the arteries (atherosclerosis) that causes peripheral arterial disease (PAD) can also lead to other serious conditions.
Critical limb ischemia (CLI)

Critical limb ischemia (CLI) is a condition that occurs when blood flow to the limbs is severely restricted from atherosclerosis.

Symptoms of CLI include:
A severe burning pain in your legs and feet even when you are resting; the pain often occurs at night and episodes of pain can last several hours. You may find you have to hang your legs out of bed to get relief.
Your skin turns pale, shiny, smooth and dry.
You may develop wounds and ulcers (open sores) in your feet and legs that show no sign of healing.
The muscles in your legs begin to waste away.
The skin on your toes or lower limbs becomes cold and numb and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain.

If you think you are developing the symptoms of CLI, contact Dr. B C Shah immediately.

CLI is treated using an angioplasty or bypass graft (Read about treating peripheral arterial disease for more information on these operations). However, these may not always be successful and you may be advised to have an amputation below the knee. Around one-third of people with CLI will require an amputation.

CLI is an extremely serious complication that can be challenging to treat. Around one in four people will die from a complication of CLI, such as infection.
Heart attack and stroke

The build up of fat in the arteries in the legs that causes PAD can also affect other areas of your body too, such as the arteries supplying the heart and brain.

Blockages in these arteries can cause a heart attack or a stroke
Preventing peripheral arterial disease

The most effective way to prevent peripheral arterial disease (PAD) or stop your symptoms of PAD worsening is to tackle the build up of fat in your arteries (atherosclerosis).

There are five main ways you can achieve this:
Stop smoking
Eat a healthy diet
Take regular exercise
Lose weight (if you are overweight or obese)
Moderate your consumption of alcohol

These lifestyle changes are discussed in more detail below.
Smoking

If you smoke, it is strongly recommended you quit as soon as possible. T

It is recommended you use an anti-smoking treatment such as nicotine replacement therapy (NRT) or bupropion (a medication used to reduce cravings for cigarettes). People who use these treatments have a much greater success rate in permanently quitting than people who try to quit using willpower alone.

It is recommended you eat two to four portions of oily fish a week. Oily fish contains a type of fatty acid called omega-3, which can help lower your cholesterol levels.

Good sources of omega-3 include:
Herrings
Sardines
Mackerel
Salmon
Trout
Tuna

If you are unable or unwilling to eat oily fish, Dr B C Shah may recommend you take an omega-3 food supplement. However, never take a food supplement without first consulting Dr B C Shah. Some supplements, such as beta-carotene, can be harmful.

It is also recommended you eat a Mediterranean-style diet. This means you should eat more bread, fruit, vegetables and fish and less meat. Replace butter and cheese with products that are vegetable and plant-oil based, such as olive oil.
Weight management

If you are overweight or obese, aim to lose weight and maintain a healthy weight by using a combination of regular exercise and a calorie-controlled diet.
Alcohol

If you drink alcohol, do not exceed recommended daily limits (three to four units a day for men and two to three units a day for women).

A unit of alcohol is roughly half a pint of normal-strength lager, a small glass of wine or a single measure (25ml) of spirits. Regularly exceeding recommended alcohol limits will raise your blood pressure and cholesterol level, which will increase the risk of your PAD symptoms worsening and increase your risk of developing another more serious type of cardiovascular disease.

Contact Dr. B C Shah if you find it difficult to moderate your drinking. Counselling services and medication can help you reduce your alcohol intake.
Regular exercise

If you do not have PAD, then a minimum of 150 minutes of vigorous exercise a week is recommended. The exercise should be strenuous enough to leave your heart beating faster, and you should feel slightly out of breath afterwards.

Activities that you could incorporate into your exercise program include:
Brisk walking
Hill climbing
Running
Cycling
Swimming

If you find it difficult to achieve 150 minutes of exercise a week, start at a level you feel comfortable with. For example, you could do 5–10 minutes of light exercise a day and then gradually increase the duration and intensity of your activity as your fitness begins to improve.

Introduction
Deep vein thrombosis (DVT) is a blood clot in one of the deep veins in the body.
Blood clots that develop in a vein are also known as venous thrombosis.
DVT usually occurs in a deep leg vein, a larger vein that runs through the muscles of the calf and the thigh. It can cause pain and swelling in the leg and may lead to complications such as pulmonary embolism. This is when a piece of blood clot breaks off into the bloodstream and blocks one of the blood vessels in the lungs.
DVT and pulmonary embolism together are known as venous thromboembolism (VTE).
Who is at risk?
Anyone can develop it but it becomes more common with age. As well as age, risk factors include:
Previous venous thromboembolism
A family history of thrombosis
Medical conditions such as cancer and heart failure
Inactivity (for example, after an operation)
Being overweight or obese
Warning signs
In some cases of DVT there may be no symptoms, but it is important to be aware of the signs and risk factors of thrombosis and see Dr. B C Shah as soon as possible if you think you may have a blood clot. DVT can cause pain, swelling and a heavy ache in your leg .
Avoiding DVT
There are several things you can do to help prevent DVT occurring, such as stopping smoking, losing weight if you are overweight and walking regularly to improve the circulation in your legs .
There is no evidence that supports taking aspirin to reduce your risk of developing DVT.
Assessing risk
Surgery and some medical treatments can increase your risk of developing DVT. It is estimated that 25,000 people who are admitted to hospital die from preventable blood clots each year.
Symptoms of deep vein thrombosis (DVT)
In some cases of deep vein thrombosis (DVT) there may be no symptoms, but possible symptoms can include:
Pain, swelling and tenderness in one of your legs (usually your calf)
A heavy ache in the affected area
Warm skin in the area of the clot
Redness of your skin, particularly at the back of your leg, below the knee
DVT usually (although not always) affects one leg. The pain may be made worse by bending your foot upward towards your knee.
If DVT is not treated, a pulmonary embolism (a blood clot that has come away from its original site and become lodged in one of your lungs) may occur. If you have a pulmonary embolism, you may experience more serious symptoms such as:
Breathlessness, which may come on gradually or suddenly
Chest pain, which may become worse when you breathe in
Sudden collapse
Both DVT and pulmonary embolism are serious conditions that require urgent investigation and treatment.
Causes of deep vein thrombosis (DVT)
Deep vein thrombosis (DVT) sometimes occurs for no apparent reason. However, the risk of developing DVT is increased in certain circumstances.
Inactivity
When you are inactive, your blood tends to collect in the lower parts of your body, often in your lower legs. This is usually nothing to worry about because when you start to move, your blood flow increases and moves evenly around your body.
However, if you are immobile (unable to move) for a long period of time, such as after an operation, due to an illness or injury or during a long journey, your blood flow can slow down considerably. A slow blood flow increases the chances of a blood clot forming.
In hospital
Because DVT is more likely to happen when you are unwell or inactive, or less active than you usually are, people in hospital are at a higher risk of getting a blood clot.
As a patient, your risk of developing DVT depends on the type of treatment you are having. You may be at higher risk of DVT if any of the following apply:
You are having an operation that takes longer than 90 minutes, or 60 minutes if the operation is on your leg, hip or abdomen.
You are having an operation for an inflammatory or abdominal condition such as appendicitis.
You are confined to a bed, unable to walk, or spending a large part of the day in a bed or chair for at least three days.
If you are much less active than usual because of an operation or serious injury, and have other DVT risk factors such as a family history, you may also be at a higher risk of DVT.
When you are admitted to hospital you will be assessed for your risk of developing a blood clot and, if necessary, given preventative treatment.
Blood vessel damage
If the wall of a blood vessel is damaged, it may become narrowed or blocked, which can result in the formation of a blood clot.
Blood vessels can be damaged by injuries such as broken bones or severe muscle damage. Sometimes, blood vessel damage that occurs during surgery can cause a blood clot, particularly in operations on the lower half of your body.
Conditions such as vasculitis (inflammation of the vein wall), varicose veins and some forms of medication, such as chemotherapy, can also damage blood vessels.
Medical and genetic conditions
Your risk of DVT is increased if you have a condition that causes your blood to clot more easily than normal. These conditions include:
Cancer (treatments such as chemotherapy and radiotherapy can increase this risk further)
Heart and lung disease
Infectious diseases such as hepatitis
Inflammatory conditions such as rheumatoid arthritis
Thrombophilia (a genetic condition that makes your blood more likely to clot) and
Hughes syndrome (when your blood becomes abnormally "sticky")
Pregnancy
Pregnancy makes your blood clot more easily. This is your body's way of preventing too much blood loss during childbirth.
Contraceptive pill and hormone replacement therapy (HRT)
The combined contraceptive pill and hormone replacement therapy (HRT) both contain the female hormone oestrogen. Oestrogen causes the blood to clot slightly more easily, so your risk of getting DVT is slightly increased. There is no increased risk from the progestogen-only contraceptive pill.
Other causes
Your risk of developing DVT is also increased if you or a close relative have previously had DVT, and if you are:
Overweight or obese
A smoker
Dehydrated
Over 60 (particularly if you have a condition that restricts your mobility)
Diagnosing deep vein thrombosis
If you think that you may have deep vein thrombosis (DVT), see Dr. B C Shah as soon as possible.
Dr. B C Shah will ask you about your medical history and your symptoms. However, it can be difficult to diagnose DVT from symptoms alone, so he may recommend one of the following tests:
D-dimer test
A specialised blood test, known as the D-dimer test, is used to detect pieces of blood clot that have been broken down and are loose in your bloodstream. The larger the number of fragments found, the more likely it is that you have a blood clot in your vein.
However, the D-dimer test is not always reliable. Blood clot fragments can increase after an operation or injury, or if there is inflammation in your body (when your immune system reacts to an infection or disease).
Therefore additional tests like an ultrasound scan need to be performed to confirm DVT.
If the D-dimer test is negative, it rules out the possibility of a DVT in 95% of cases.
Ultrasound scan
An ultrasound scan can be used to detect clots in your veins. A special type of ultrasound, known as a Doppler ultrasound, can also be used to find out how fast the blood is flowing through a blood vessel. This helps Dr. B C Shah to identify when blood flow is slowed or blocked, which could be caused by a blood clot.
Venogram
If the results of a D-dimer test and ultrasound scan cannot confirm a diagnosis of DVT, a venogram might be used.
A special dye is injected into a vein in your foot, which travels up the blood vessels of your leg. An X-ray is taken to see the dye. If there is a blood clot in your leg, the dye will not be able to flow round it and will show up as a gap in your blood vessel.
Treating deep vein thrombosis (DVT)
If you have deep vein thrombosis (DVT) you will need to take a medicine called an anticoagulant.
Anticoagulation
Anticoagulant medicines prevent a blood clot from getting bigger. They can also help stop part of the blood clot from breaking off and becoming lodged in another part of your bloodstream (an embolism).
Although they are often referred to as "blood-thinning" medicines, anticoagulants do not actually thin the blood. They alter chemicals within it, which prevents clots forming so easily.
Two different types of anticoagulants are used to treat DVT:
Heparin
Warfarin
Heparin is usually prescribed first, because it works immediately to prevent further clotting. After this initial treatment you may also need to take warfarin to prevent another blood clot forming.
Heparin
Heparin is available in two different forms:
Standard (unfractioned) heparin
Low molecular weight heparin (LMWH)
Standard (unfractioned) heparin can be given as:
An intravenous injection - an injection straight into one of your veins
An intravenous infusion - when a continuous drip of heparin is fed through a narrow tube into a vein in your arm (this must be done in hospital)
A subcutaneous injection - an injection under your skin
LMWH is usually given as a subcutaneous injection.
A dose of standard heparin can work differently from person to person, so the dosage must be carefully monitored and adjusted where necessary. You may need to stay in hospital for five to 10 days and have frequent blood tests to ensure you receive the right dose.
LMWH works differently from standard heparin. It contains small molecules, which means its effects are more reliable and you will not have to stay in hospital and be monitored.
Both standard and LMWH can cause side effects, including:
A skin rash and other allergic reactions
Bleeding
Weakening of the bones (if taken for a long time)
In rare cases, heparin can also cause an extreme reaction that makes existing blood clots worse and causes new clots to develop. This reaction, and weakening of your bones, is less likely to occur when taking LMWH.
In most cases, you will be given LMWH because it is easier to use and causes fewer side effects.
Warfarin
Warfarin is taken as a tablet. You may need to take it after an initial heparin treatment to prevent further blood clots occurring. Dr. B C Shah may recommend that you take warfarin for three to six months. In some cases, warfarin may need to be taken for longer, even for life.
As with standard heparin, the effects of warfarin vary from person to person, and you will need to be closely monitored with frequent blood tests to ensure you are taking the right dosage.
When you first start taking warfarin, you may need to have two to three blood tests a week until your regular dose is decided. After this, you should only need to have a blood test every four weeks at an anticoagulant outpatient clinic.
Warfarin can be affected by your diet, any other medicines that you are taking, and by how well your liver is working. If you are taking warfarin, you should:
Keep your diet consistent
Limit the amount of alcohol that you drink (no more than three to four units a day for men and two to three units a day for women)
Take your dose of warfarin at the same time every day
Not start to take any other medicine without checking with Dr. B C Shah, pharmacist or anticoagulant specialist
Not take herbal medicines
Warfarin is not recommended for pregnant women. They are given heparin injections for the full length of treatment.
Compression stockings
Compression stockings help prevent calf pain and swelling and lower the risk of ulcers developing after having a DVT. They can also help prevent post-thrombotic syndrome – damage to the tissue of your calf caused by the increase in venous pressure that occurs when a vein is blocked (by a clot) and blood is diverted to the outer veins.
After having a DVT, stockings should be worn every day for at least two years because symptoms of post-thrombotic syndrome may develop several months, or even years, after having DVT.
Compression stockings should be fitted professionally. They need to be worn all day, but can be taken off before going to bed or in the evening while you rest with your leg raised.
Raising your leg
As well as wearing compression stockings, you might be advised to raise your leg whenever you are resting. This helps to relieve the pressure in the veins of the calf and stops blood and fluid pooling in the calf itself.
When raising your leg, make sure that your foot is higher than your hip. This will help the returning blood flow from your calf. Putting a cushion underneath your leg while you are lying down should help raise your leg above the level of your hip.
You can also slightly raise the end of your bed to ensure that your foot and calf are slightly higher than your hip.
Complications of deep vein thrombosis
There are two main complications of deep vein thrombosis (DVT): pulmonary embolism and post-thrombotic syndrome.
Pulmonary embolism
This is the most serious complication of DVT. A pulmonary embolism happens when a piece of blood clot (DVT) breaks off and travels through your bloodstream to your lungs, where it blocks one of the blood vessels. This is serious and in severe cases, can be fatal.
If the pulmonary embolism is small, it might not cause any symptoms. If it is medium-sized, it can cause breathing difficulties and chest pain. A large pulmonary embolus can cause the lungs to collapse and result in heart failure.
About one in 10 people with an untreated DVT develops a pulmonary embolism severe enough to cause these severe symptoms or even death.
Post-thrombotic syndrome
If you have had a DVT, you may develop long-term symptoms in your calf, known as post-thrombotic syndrome. This commonly affects people with a history of DVT.
If you have DVT, the blood clot in the vein of your calf can divert the flow of blood to other veins, causing an increase in pressure that can affect the tissues of your calf. Symptoms include:
Calf pain
Swelling
A rash
Ulcers on the calf (in severe cases)
When a DVT develops in your thigh vein, there is an increased risk of post-thrombotic syndrome occurring. It is also more likely to occur if you are overweight or if you have had more than one DVT in the same leg.
Preventing deep vein thrombosis
Surgery and some medical treatments can increase your risk of developing DVT .
If you are considered at risk of DVT, there are various recommendations Dr. B C Shah can make to prevent a blood clot occuring.
Before you go into hospital
If you are planning to have an operation and are taking the combined contraceptive pill or hormone replacement therapy (HRT), you will be advised to stop the drugs temporarily four weeks before you have your operation.
Similarly, if you are taking a drug to prevent blood clots, such as aspirin, you may be advised to stop taking this one week before your operation.
There is less risk of DVT when you have a local rather than general anaesthetic. If it is possible for you to have a local anaesthetic, Dr. B C Shah will discuss this with you.
While you are in hospital
There are a number of things Dr. B C Shah can do to help reduce your risk of DVT while in hospital.
He should make sure you have enough to drink and do not become dehydrated. He should also make sure you start to move around as soon as you are able to.
Depending on your risk factors you may also be offered:
Anticoagulant medicine, which helps prevent blood clots
Compression stockings or a compression device, to help keep the blood in your legs circulating
Compression stockings are worn around your feet, lower legs and thighs, and fit tightly to encourage your blood to flow more quickly around your body. Compression devices are inflatable and work in the same way as compression stockings, inflating at regular intervals to squeeze your legs and encourage blood flow.
When you leave hospital
You may need to continue treatment with compression stockings or an anticoagulant medicine when you leave hospital. Before you leave, Dr. B C Shah should advise you on how to use your treatment, how long it should continue for, and who to contact if you are having any problems.
Smoking and diet
You can reduce your risk of DVT by making changes to your lifestyle, such as:
Not smoking
Eating a healthy balanced diet
Getting regular exercise
Maintaining a healthy weight or losing weight if you are obese
Travelling
If you are at risk of getting a DVT, or have had a DVT previously, consult Dr. B C Shah before embarking on long-distance travel. If you are planning a long-distance plane, train or car journey (journeys of six hours or more), ensure that you:
Drink plenty of water
Avoid excessive alcohol as it can lead to dehydration
Avoid taking sleeping pills as it can cause immobility
Perform simple leg exercises, such as regularly flexing your ankles
Take occasional short walks when possible
Take advantage of refuelling stopovers where it may be possible to get out and walk about
Wear elastic compression stockings

What are you to do if you have a heart attack

While you are alone.

If you've already received this,

It means people care about you.

The Johnson CityMedicalCenter staff actually

Discovered this and did an in-depth study

On it in our ICU.

The two individuals that discovered this then did

An article on it, had it published and have had it incorporated into ACLS and CPR classes.

It is very true and has and does work.

It is called Cough CPR.

A cardiologist says it's the truth,

If everyone who gets this sends it to 10 people,

You can bet that we'll save at least one life.

It could save your life!
Let's say it's 6:15 p.m. And you're driving home

(alone of course), after an usually hard day on the job.

You're really tired, upset and frustrated.

Suddenly you start experiencing severe pain

In your chest that starts to radiate out

Into your arm and up into your jaw.

You are only about five miles from the hospital

Nearest your home.

Unfortunately you don't know if you'll be

Able to make it that far.

What can you do?

You've been trained in CPR

But the guy that taught the course didn't tell

You what to do if it happened to yourself.
Since many people are alone when they suffer a heart attack, this article seemed to be in order.

Without help, the person whose heart is beating improperly and who begins to feel faint,

Has only about 10 seconds left before losing consciousness.

However, these victims can help themselves by coughing repeatedly and very vigorously.

A deep breath should be taken before each

Cough, and the cough must be deep

And prolonged, as when producing sputum

From deep inside the chest.

A breath and a cough must be repeated

About every two seconds without let up

Until help arrives, or until the heart is felt to be beating normally again.

Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and

Keep the blood circulating.

The squeezing pressure on the heart also helps it regain normal rhythm. In this way, heart attack victims can get to a hospital.

Interventional radiology of peripheral vascular disease comprises therapeutic measures with imaging system. It includes recanalisation of arteries in symptomatic patients.
IMAGING – To identify site and degree of vascular problem
(i)Color Doppler.
(ii)MR Angiography and CT angiography
(iii)Catheter Angiography

The arterial occlusive disease can be 1. Chronic or 2. Acute
I.CHRONIC ARTERIAL OCCLUSIVE DISEASES

1.Angioplasty and Stenting- Balloon angioplasty/stent: opening of narrow or blocked blood vessels using a balloon; may include placement of metallic stents as well (both self-expanding and balloon expandable).

2.Endovascular stent grafts- In certain situations like long arterial occlusions. Lesions not suitable for angioplasty and stenting endovascular stent graft/ covered stents are used.

II ACUTE ARTERIAL OCCLUSIVE DISEASES

1. Arterial embolism in arteries of extremities

Angiographic signs of embolic occlusion are abrupt occlusion, convexly bent filling defect, intact vascular system proximal and distal of embolic occlusion, multiple occlusion and occlusion at bifurcation.
2.Acute thrombosis in extremity arteries

Angiographic criteria of thrombotic occlusion
The occlusion has blurred, cloudy demarcation, atherosclerotic changes and arterial stenosis are present.
treatment:
(i)Pharmacological thrombolysis –It is used within two weeks of thrombotic occlusion.Intra arterial urokinase./r-TPA is used to treat these lesions.

(ii)Mechanical Thrombectomy
These percutaneous mechanical thrombectomy procedures are efficient at relieving obstruction in short period of time with little or no thrombolytics and hence increase efficiency while diminishing cost of procedure. There are rotational thrombectomy devices which treat occlusions up to 6 months

Please visit my website www.irtreatments.com for detailed information.
Interventional Radiology is a sub-specialty of radiology that utilizes various imaging techniques to guide percutaneous microinvasive to treat various diseases.
In fact, Interventional Radiology could be termed “Pinhole Surgery” because of the small holes that are made in the skin to perform these procedures. Some of the sophisticated equipments used to do these procedures are Cath lab, Color Doppler, Laser and radiofrequency ablation equipment .Advantages to patients include less risk, less pain and shorter recovery times. Three broad categories under interventional Radiology are Vascular, Neurovascular and Non- vascular interventions.
Vascular interventions are about treatment of peripheral blood vessels like angioplasty, stenting, endovenous ablation of varicose veins, embolisations and management of vascular malformations. Neurointerventions offers endovascular treatment of cerebral arteriovenous malformations, intracranial aneurysms and intrarterial stroke therapy. Non vascular interventions offer biliary stent, drainage procedures, disc treatment, pain relief, and radiofrequency tumor ablation. Besides what is mentioned above Interventional Radiology encompasses many other procedures.