Arteries – Arterial conditions

Arterial conditions are vascular diseases affecting the arteries — the vessels that carry oxygen-rich blood from the heart to the body’s tissues. They are treated with medication, surgery or endovascular procedures depending on the diagnosis: from arteriopathy of the legs and carotid stenosis to aortic aneurysm and visceral artery disease. A vascular surgery evaluation establishes the severity of the disease and the solution that suits each patient.

Arterial conditions at a glance

• Conditions covered: chronic obliterative arteriopathy of the lower limbs, carotid stenosis, abdominal aortic aneurysm, upper limb arterial disease, visceral artery disease
• Main cause: atherosclerosis — fatty plaque building up on the artery walls
• Risk factors: smoking, diabetes, obesity (BMI over 30), high blood pressure, high cholesterol, advancing age
• Diagnosis: clinical vascular examination + Doppler ultrasound, CT angiography, MR angiography, arteriography, laboratory tests, ECG
• Treatment: lifestyle change → medication → surgical or endovascular treatment

How does the arterial system work?

The arterial system is an essential part of the circulatory system, formed of three main structures:

• The aorta — the body’s most important arterial vessel, originating in the left ventricle of the heart. It rises briefly, forms the aortic arch, then descends as the descending aorta, made up of the thoracic and the abdominal portion. The arteries towards the head, neck, limbs and organs branch off from it.
• The systemic arteries — carry oxygenated blood and nutrients from the heart to all organs and tissues.
• The pulmonary arteries — carry deoxygenated blood from the heart to the lungs, from where the oxygenated blood returns towards the heart.

Besides transporting blood, the arterial system delivers nutrients to tissues and cells, takes part in eliminating carbon dioxide and waste products, maintains the protein balance and supports the proper functioning of the immune system. A damaged arterial system has devastating consequences: myocardial infarction and stroke are direct results of disease at the arterial level.

What favours the appearance of arterial disease?

• smoking
• diabetes
• obesity (body mass index greater than 30)
• high blood pressure
• excessively high cholesterol
• advancing age

Chronic obliterative arteriopathy of the lower limbs

Also known as peripheral vascular disease, this is an arterial disease caused by the narrowing of the arteries, which limits the blood flow to the legs.

Causes and contributing factors

The causes include plaque appearing inside the blood vessel and the narrowing of the arteries due to fatty deposits, with reduced blood flow and poor tissue perfusion. Risk factors: smoking, high cholesterol, raised blood pressure, diabetes, high homocysteine levels and a family history of atherosclerosis or coronary artery disease.

Symptoms and complications

The disease can persist for a long time in an initially asymptomatic stage. Later on the following appear:

• intermittent claudication — pain like a muscle cramp in the legs, appearing when walking and limiting activity (the most typical sign)
• pain at rest, at first at night, then almost permanently
• diminished muscle strength
• a feeling of coldness in the feet and toes
• lesions and pain in the lower limbs
• erectile dysfunction in men

Other physical signs: pale toes and feet during activity or when raised, hair loss on the legs and toes, the feet turning red when hanging down, blue or red patches due to reduced blood flow, leg ulcers and gangrene (blackened skin).

Diagnosis and treatment

The diagnosis is established through a clinical examination and an evaluation of the whole vascular system: the pulse intensity is recorded and the lower limbs are examined for skin lesions. Imaging investigations follow (vascular Doppler ultrasound, CT angiography with contrast, MR angiography), along with laboratory tests and an electrocardiogram (ECG).

Treatment begins with a change of lifestyle, continues with medication, and the definitive solution in advanced cases is surgical — see lower limb artery surgery and angioplasty with stenting.

Abdominal aortic aneurysm (AAA)

An abdominal aortic aneurysm is a dilated area in the lower part of the aorta, appearing through the weakening of the arterial wall. It is located in the abdomen and grows progressively.

Causes and contributing factors

The causes include atherosclerosis, arterial hypertension, vascular diseases, trauma and aortic infection. Contributing factors: smoking, age, male sex, light skin pigmentation, family history and the presence of other aneurysms.

Symptoms and complications

Symptoms can include strong pain in the abdomen, back pain and a pulsating sensation in the umbilical area. The most frequent and most serious complication is the rupture of the aneurysm, with aortic dissection and internal bleeding. The signs of a rupture — back or abdominal pain, low blood pressure and a rapid pulse — constitute a major medical emergency.

Diagnosis and treatment

A medical history and paraclinical imaging examinations are needed: CT, MRI, echocardiography, arteriography/angiography. Treatment involves MRI/CT monitoring, control of the risk factors and medication; surgical treatment is performed in the cases that require intervention — see aortic artery surgery and the minimally invasive variant, EVAR.

Carotid artery stenosis

This is one of the most serious diseases that can cause the death of patients with cardiovascular conditions: the narrowing of the carotid arteries reduces the blood circulation to the brain and significantly increases the risk of stroke.

Causes and contributing factors

The main cause is atherosclerosis. Contributing factors: age (people over 60), male sex, genetic predisposition, arterial hypertension, diabetes, excess weight, a sedentary lifestyle, high cholesterol and smoking.

Symptoms and complications

• speech disturbances, motor and sensory aphasia
• drowsiness, disorientation in time and space
• balance disturbances or vertigo
• intense headache
• paresis of various degrees, facial asymmetry (in the case of facial paresis)
• vision disturbances and, in severe cases, coma

The major complication is stroke.

Diagnosis and treatment

The diagnosis can be suggested by the presence of a stroke, a transient ischaemic attack or atherosclerotic dementia, and is confirmed through imaging methods: carotid duplex ultrasound, MRI, Doppler examination, angiography, transcranial Doppler ultrasonography. Treatment can be medical, but also includes carotid endarterectomy, carotid angioplasty and carotid bypass — see carotid artery surgery.

Upper limb arterial disease

Arterial disease of the upper extremities is a frequent condition, most often asymptomatic, but one that can also produce symptoms.

Causes and contributing factors

The causes include atherosclerosis, arteritis, arterial fibrosis, fibromuscular dysplasia, Buerger’s disease, connective tissue diseases, cytotoxic medication, diabetes, myeloproliferative disorders, hypercoagulable states and cryoglobulins. Contributing factors: smoking or a history of smoking, high blood cholesterol, raised blood pressure, obesity and a family history of cardiac or vascular disease.

Symptoms and complications

The typical signs include discomfort or pain in the arms, a feeling of tightness, heaviness, cramps or weakness in one or both arms. Although the disease is most often asymptomatic, it can cause exertional pain, ischaemic pain and ulceration.

Diagnosis and treatment

When clinically suspected, the evaluation is done through duplex ultrasound, computed tomography angiography or magnetic resonance angiography. In most asymptomatic patients, medical treatment is the first option. Revascularisation can be proposed in cases of severe or disabling symptoms, bilateral stenosis, stenosis with an ipsilateral arteriovenous fistula for dialysis, in patients planned for coronary bypass surgery, or in those already operated with the ipsilateral internal mammary artery grafted onto coronary arteries and showing signs of myocardial ischaemia. When revascularisation is proposed, both endovascular and open surgical options can be useful, depending on the characteristics of the lesion and the patient’s risk — see upper limb artery surgery.

Visceral artery disease

Visceral artery disease is the narrowing of the arteries that supply blood to the intestines, spleen and liver. The narrowing, caused by atherosclerosis, results in a reduction of the blood flow to these organs.

Causes and contributing factors

Atherosclerosis appears to be the main cause of visceral artery disease and aneurysms. The risk factors include smoking, high cholesterol, raised blood pressure, obesity, diabetes and a family history of cardiovascular disease; the female sex is the most predisposed.

Symptoms and complications

Symptoms begin gradually or appear acutely: cramp-like abdominal pain, especially after meals, weight loss, developing a fear of eating, eating smaller meals, diarrhoea, constipation or vomiting. In patients with acute forms, the symptoms of a blood clot can appear on top of a pre-existing disease, or the clot can reach the intestines from the heart; these patients can have severe pain, nausea, vomiting and/or bloody stools.

The sudden and complete blockage of the superior mesenteric artery causes severe abdominal pain, nausea and vomiting, and is a medical emergency.

Diagnosis and treatment

The most important test for identifying visceral artery disease is arteriography, an invasive X-ray technique. In addition, duplex ultrasound, computed tomography (CT) and magnetic resonance angiography (MRA) can be used. Treatment is based on lifestyle change, but also on interventional options: angioplasty, stenting, thrombolysis or the non-surgical dislodging of the embolus.

What interventions does Dr. Marius Fodor perform?

• Carotid artery surgery — carotid endarterectomy (by eversion or with widening angioplasty) and carotid body tumour surgery
• Upper limb artery surgery — arterial bypass, arteriovenous fistulas for dialysis, scalene syndrome surgery
• Lower limb artery surgery — ilio-femoral and femoro-popliteal bypass, endarterectomy, widening angioplasty
• Aortic artery surgery — open aneurysm repair, aortic endarterectomy, aorto-bifemoral bypass
• Abdominal aortic stent-grafting (EVAR) — the minimally invasive treatment of aortic aneurysm
• Endovascular surgery (angioplasty and stenting) — opening blocked arteries from inside the vessel

When should you see a doctor?

A vascular surgery consultation is recommended if the following appear: pain when walking that stops when you rest (claudication), a feeling of cold or numb feet, wounds that heal slowly, changes in skin colour, repeated abdominal pain after meals, disturbances of speech, balance or vision — or if you have significant cardiovascular risk factors (smoking, diabetes, hypertension, high cholesterol).

Frequently asked questions

Can arterial conditions be treated without surgery?

Yes, in the early stages: a change of lifestyle (stopping smoking, exercise, diet) and medication can control the disease. In advanced stages, endovascular procedures (angioplasty, stenting, EVAR) or classic surgery are needed.

What is intermittent claudication?

The cramp-like muscle pain that appears when walking, after a certain distance, and stops when you rest. It is the typical sign of lower limb arteriopathy, and a progressive reduction of the distance you can walk without pain indicates that the disease is worsening.

What is the difference between open and endovascular surgery?

Open surgery repairs or bypasses the artery through a surgical incision; endovascular procedures treat the vessel from the inside, through an arterial puncture, with a faster recovery. The choice depends on the characteristics of the lesion and on each patient’s risk.

What investigations are needed?

As a rule a complete clinical vascular examination and Doppler ultrasound, and where needed CT angiography, MR angiography or arteriography, plus laboratory tests and an ECG.