Anatomy and physiology

The main blood vessel exiting the heart is called the aorta. The aorta receives blood from the heart, carries it down to the chest and abdomen giving off branches to the arms, lungs, bowels, and kidneys. At the level of the belly button, the aorta splits into two arteries; the left iliac artery and the right iliac artery which will carry blood down to the legs. The arteries will change names a number of times as the blood vessel passes down the hip, the thigh, the knee, the calf, and eventually the feet.

Atherosclerosis is a disease that describes the formation of plaque on blood vessels. Plaque which is composed of cholesterol, calcium, and fibrous tissue settles on the wall of the artery. With the burden of this plaque, the artery stiffens and narrows. As the artery narrows, blood flow becomes significantly compromised. Ultimately, the artery becomes completely blocked by plaque. The arteries can develop disease that limits blood flow at any level. Atherosclerosis that affects the aorta and its branches is known as peripheral vascular disease. Atherosclerosis that affects the arteries in the heart is known as coronary artery disease.

Atherosclerosis has been linked directly to smoking and high cholesterol. In addition, high blood pressure, diabetes and obesity are also associated with a high risk of developing atherosclerosis.

People with narrowing in their arteries in their legs will often have pain with walking. The classic symptom is calf pain while walking a predictable distance, sometimes as little as 1 block, for others 5 blocks. The pain is so severe that it requires the person to stop and rest. The pain completely resolves at rest. The blood vessels are able to supply enough blood to the legs at rest, but once the muscles are exercised, the blood vessels can not provide enough blood to sustain the active muscle, the muscle becomes fatigued, and then cramps causing pain. If blood flow is severely reduced, the people have pain in their foot even at rest. The pain typically occurs at night time when the legs are elevated in bed. The pain is often relieved by dangling the affected foot over the side of the bed to allow for gravity-aided blood flow. Finally, patients can develop wounds or ulcers in their feet that will not heal as they should over time.

Who is at risk?

Arteriograms are done for people:

To diagnose and potentially treat peripheral vascular disease

To size and potentially treat aortic aneurysms

How is it diagnosed?

Peripheral vascular disease is most often asymptomatic. It is closely linked with heart disease since atherosclerosis usually affects all the arteries in the body, so if you have heart disease you are at high risk of having peripheral vascular disease.

The diagnosis of peripheral vascular disease starts with just a simple physical examination. Your doctor will feel for the pulses in your arms, groin, and legs. A strong pulse in your extremities is a good indicator that your blood circulation is normal. If the pulses in your extremities are weak or absent, your physician will likely send you for a straightforward non-invasive study to calculate the ankle-brachial index. Blood pressure cuffs will be placed on both your upper arms and your calves. The blood pressure will be taken in all four of your limbs while the test-taker listens to your pulse. Normally the blood pressure in your legs is 100-110% of the blood pressure in your arms. An ankle-brachial index (ABI) of 1.0 indicates normal circulation. Anything lower than 0.8 is considered abnormal and is a marker of blockages in your arteries.

The next step is to obtain a study that takes a picture of your blood vessels. Examples of those studies include an ultrasound, a CT scan, and MRI or an angiogram. All three are useful study but they have their different limitations. One unique benefit of an angiogram is that it diagnoses peripheral vascular disease and allows your doctor the opportunity to treat the disease at the same time by either ballooning open a diseased artery or placing a stent. While some doctors go straight to an angiogram, some may opt to have a roadmap of the arteries first with an ultrasound, CT scan, or MRI.

How do I prepare for surgery?

Aside from the studies listed above, nothing else is needed to prepare for an arteriogram. Be prepared for a long day. You will be required to fast after midnight since sedation is provided to keep you comfortable and anxiety free. The sedating medications can sometimes make you nauseous and it can be dangerous to vomit when you are sleepy with a full stomach. The vomit can accidentally be inhaled into the lungs in a non-alert person and cause a bad pneumonia. After the procedure, you will be required to lay flat for a period of two to six hours to allow the puncture hole in your groin to close so that you don't bleed.

How is the surgery performed?

The surgery is usually performed under local anesthesia. While you are laying flat on an xray table, the area where the catheter will be inserted, usually the groin area, will be shaved and cleansed. A needle will be inserted into an artery in the groin. A catheter is inserted through the needle into the artery and up into the aorta. Since blood is not visible on xray, a contrast dye that shows up on xray is used. The dye is squirted into the vessel and lights it up on xray. If there is a blockage found, the artery may be opened up by ballooning it open or possibly placing a stent to prop the artery open.       
                         

Pitfalls of surgery?
 

The earliest complication that could occur is bleeding from the artery under the skin causing a blood clot. If the bleeding is significant enough, it may require a blood transfusion and in rare cases surgery to repair the artery and evacuate the blood.

A second risk of arteriograms is that of renal damage. The dye can be toxic to the kidneys and in diabetic patients and those who may already have renal disease, the dye can cause temporary kidney dysfunction.

What to expect after surgery?

In most cases you can leave the same day of your arteriogram after the requisite amount of time spent lying flat. If an intervention was done via balloon or stent, then you may stay overnight. Lastly, if you had any preexisting kidney disease, your doctor will likely keep you overnight for intravenous fluids. Hydration has been shown to protect the kidneys from the dye. In addition, mucomyst, a medication taken 48 hours around the time of the procedure has also been shown to have some protective effect on the kidneys.