When Vascular Disease Strikes, Surgery May Be Best Choice
Stanley Ingerman went along for most of his life pretty much like a lot of other people. He endured the normal childhood diseases—he remembers measles and chickenpox. As an adult, he hit six feet tall and managed to maintain a healthy weight, give or take a few pounds, into his mid-50s. Then one night he woke up with an incredible pain in his right leg.
“On a scale of one to 10, it was at least a 7.5,” Ingerman said. “My toes were turning color. There was no blood flow. The pain I was feeling was all the muscles dying. I sat there and cried. I was in the doctor’s office the first thing in the morning.”
Stanley Ingerman went along for most of his life pretty much like a lot of other people. He endured normal childhood diseases--he remembers measles and chickenpox. Then one night he woke up with an incredible pain in his right leg.
"On a scale of one to 10, it was at least a 7.5. My toes were turning color. There was no blood flow. The pain I was feeling was all the muscles dying."
--Stanley Ingerman, Stanford Hospital & Clinics patient
Ingerman, his doctor said, had developed peripheral artery disease, PAD for short. Like a lot of other people with the condition, he had been a smoker—smoking increases the risk of PAD by two to six times—he was over 60 and the disease’s symptomatic pain was in his legs. The arteries carrying blood to his legs had become clogged with fatty deposits. An estimated 8 million people in the United States suffer from PAD.
To treat the condition, Ingerman’s surgery followed the standard procedure: The failed artery in his leg was replaced by a vein from his other leg. With luck, it would last several years. Because he was showing signs of high blood pressure, he was advised to reduce the amount of salt in his diet, to lose some weight and to start exercising regularly. He followed all that advice.
Renewed Challenge
“I was doing everything right,” Ingerman said. But, eight years later, that first fix finally failed when the artery clogged, and Ingerman went through another surgery. In the 18 months that followed, Ingerman’s artery failed three more times and his physicians finally told him he needed to go to Stanford. They had done everything they could.
Ingerman arrived at Stanford Hospital on New Year’s Eve and found himself a patient of surgeon Matthew Mell, MD, medical director of Stanford’s Vascular Clinic and Lab. “He had a great bedside manner,” Ingerman said. “He answered every question I asked and made sure there were no doubts in my mind about what was going to happen. He had a confidence that made me very comfortable.”
Matthew Mell, MD, Medical Director of Stanford's Vascular Clinic and Lab, became Ingerman's doctor. "He had a great bedside manner," Ingerman said. "He answered every question I asked. He had a confidence that made me very comfortable."
What Mell found was that a previous bypass had failed and couldn’t be salvaged. “Generally, when bypass grafts fail after a period of time it’s usually because of the progression of the disease,” Mell said.
The average person’s body contains about 60,000 miles of blood vessels, a combination of veins, which carry blood to the heart; arteries, which carry blood from away from the heart; capillaries, some thinner than a hair, which branch from the arteries all the way out to our toes and fingers; and venules, the tiny blood vessels that connect to the capillaries as the oxygen-depleted blood begins its journey back to the heart for recirculation. Between 5 to 6 quarts of blood flow around the system in the average adult. The accumulation of deposits called plaque, clumps of debris called clots and inflammation of the vessels (vasculitis) can obstruct blood flow, causing a variety of diseases and raising the risk of stroke and heart attack.
Fortunately, in a short-term response, Ingerman’s body had recruited collateral vessels near the collapsed artery to circulate a minimal flow of blood. But the body’s natural response would not be enough to sustain real function for Ingerman’s leg. If Mell could not create a repair that would reach from Ingerman’s groin to below his knee as a substitute for the length of non-functioning artery, Ingerman would lose his leg. Ingerman had a complicated vascular condition brought about by the previous multiple procedures that required intervention that wasn’t necessarily straightforward, Mell said. He would have to find a vein in Ingerman’s other leg that would be a strong enough to maintain steady blood flow; he would also have to maneuver around the scar tissue from the previous surgeries to attach the new vein.
"Before this surgery, I was overweight. I was a couch potato. Now I walk 35 miles a week. I watch the foods I eat and I'm much more aware of what my body feels like from day to day, and of my health."
--Stanley Ingerman, Stanford Hospital & Clinics patient
What You Should Know About Your Vascular System
• The average adult body contains about 60,000 miles of blood vessels which serve as the transport system for 5 to 6 quarts of blood. As oxygen-rich blood leaves the heart, it travels through the arteries; as it returns, it is borne by veins.
• Anything that interrupts the free flow of blood from the heart to the rest of the body can cause problems including limb pain, heart attack and stroke.
• Blood vessels can be obstructed by fat, cholesterol, calcium and cellular waste products. The condition is called atherosclerosis. Blood flow can also be blocked by vessels whose lining has become inflamed.
• Risk factors for blood vessel blockage include diabetes, smoking, high blood pressure, excess weight, age and family history.
• One in four Americans have some form of cardiovascular disease. Between 12 and 20 percent age 65 and older have peripheral artery disease. More than two-thirds will not have any symptoms.
• Symptoms can include pain when walking, as well as aching, cramping, weakness and numbing in the hip, thigh, buttocks or calf. Sores or ulcers on the feet or legs can also be an indication of disease.
• Non-surgical treatments include medication to reduce cholesterol, thin blood and control diabetes. Quitting smoking, losing weight and exercising also help.
For more information about vascular disease care at Stanford, phone 650.725.5227 or visit stanfordhospital.org/vascularcare. Join us at stanfordhospital.org/socialmedia.
Restored Vigor
“He took a vein from my left leg to replace the clogged artery in my right leg and sewed everything back up,” Ingerman said. “I was on my feet and walking the next day. That was painful, but it was just for a short time.” Getting up and moving helped Ingerman begin a regimen of walking, one of the best therapeutic treatments for PAD as well as for recovery from his vascular surgery. Once at home again, “I walked 10 to 15 minutes after every meal in an inside hallway and expanded that by five minutes every day until I got up to half an hour—then I started going outside.”
"Going to Stanford--just the reputation of the hospital--was enough to put me at ease."
--Stanley Ingerman, Stanford Hospital & Clinics patient
As many as 40 percent of people with PAD won’t experience symptoms. For those who do, treatment depends on the length of the blockage. “Some people have a very limited disability because there are so many collateral ways for the blood to get where it needs to go that symptoms aren’t very severe,” Mell said. Because surgical fixes don’t last forever—as Ingerman’s experience shows—choosing surgery as a treatment means weighing its benefits. In Ingerman’s situation, “his risk of amputation was significantly high if we didn’t do something,” Mell said.
Researchers are investigating substitutes for the veins and arteries physicians now harvest from a patient’s body to replace blocked arteries. Having an alternative—possibly some sort of synthetic tubing—would reduce the technical challenges of this type of vascular surgery and speed recovery, Mell said. “But so far nothing has surpassed the long term durability of a patient’s own vein,” he said.
Steadied Future
Mell points out the long stretch of artery in Ingerman’s leg where blood no longer flowed. In the surgery he performed on Ingerman, Mell borrowed a vein from Ingerman’s other leg as a substitute.
Ingerman is much healthier now. “Before this surgery, I was overweight. I was a couch potato. Now I walk 35 miles a week. I watch the foods I eat and I’m much more aware of what my body feels like from day to day, and of my health. I’ve become sensitized to that. This was a wake-up call.”
Mell has told him that even doing everything right, he may develop another clogged artery and might need another surgery. But Ingerman was not overly concerned. “Going to Stanford—just the reputation of the hospital—was enough to put me at ease,” he said. With Mell as his doctor, and the success of his most recent surgery, “I’m very calm about things at this point.”
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