Just about everyone knows that smoking causes lung cancer and greatly increases the risk for heart disease and stroke.
That message is out there, loud and clear – through billboards, television spots and radio announcements.
But few of my patients have ever heard that smoking also increases the risk of vascular disease in their legs and ultimately, if left untreated, the loss of a leg.
Even the symptoms surprise patients as signs of a serious disease. Patients come to me with pain in their legs. They can barely walk down the driveway to the get the mail. Or the trip to the grocery store is too much to bear. Halfway down the aisle they have to stop, rest and go home.
When plaque accumulates in the arteries that nourish the heart we call it heart disease. When it restricts blood flow through arteries to the legs we call it peripheral artery disease, or PAD. Surgery and other procedures to clear away the plaque can relieve the pain. That’s reassuring for some. But when I tell them that without one of these procedures they run the risk of losing the leg they’re stunned. They never knew.
I’m a vascular surgeon so I’m biased, but to me their surprise reveals one of the largest failures of our public health system. Somehow, with all the warnings about the dangers of smoking few people know they can lose a limb to tobacco.
The risk of amputation is real. I’m trained to repair blood vessels. But the last time I counted, I amputate almost as many limbs as I save.
About Peripheral Artery Disease
According to the American Heart Association, PAD affects about 8 million Americans. The rate among people older than 65 is between 12 and 20 percent, and only one quarter of those affected are diagnosed and treated. The incidence is even higher among African Americans.
It’s not clear exactly why smoking poses such risks to the arteries in the legs. But the mechanism is similar to what happens in the carotid arteries in the neck and other vessels surrounding the heart. We know that nicotine causes constriction in blood vessel walls, which in turn creates an environment for plaque buildup. These blockages in the vessels around the heart lead to a heart attack. In the legs, these blockages start by causing pain. But finally the poor circulation kills the tissue and leaves no other option but amputation.
In early stages the pain goes away with rest. But as the disease progresses, patients report pain even at night with their feet up in bed. Equally troubling, some patients with vascular disease never experience pain. We can diagnose the disease by comparing blood pressure in the arm to the blood pressure in the legs. Higher pressure in the legs is a sign of disease.
The risk for amputation is even greater in patients with diabetes, which affects small blood vessels and nerves. Patients with diabetes often develop small wounds in their feet, which don’t heal. The combination of diabetes and circulatory problems from vascular disease is a terrible combination.
Preventing Peripheral Artery Disease
Prevention of PAD is similar to prevention of heart conditions. In fact, patients with one disease often have the other. Exercise, weight loss and medication to reduce blood pressure and cholesterol all help. In some patients, we recommend statin (cholesterol lowering drugs) therapy and anti-coagulants. And I can’t stress this enough: if you smoke, it’s time to quit.
Surgery for PAD is similar to procedures patients have for heart disease. We start with less invasive procedures to open arteries, such as balloon angioplasty and stents. Bypass surgery is also an option. Recently a 57-year-old man came to see me with a blockage in the aorta, just before it branches into the 2 arteries that supply each leg. We bypassed the blockage. Today, he’s walking and he has stopped smoking. Incidentally, he was as surprised as my other patients that smoking put him at risk for losing a leg.
I studied public health before I finished my training in surgery, so I’ve thought a lot about the work that needs to be done outside the operating room. The advocacy groups did a great job raising public awareness about the relationship between smoking and lung cancer and heart disease. But no single group took on the crusade to raise awareness about smoking and PAD. I’m glad to say that’s changing, but we still have a long way to go.While I would like to spend my time in the operating room saving limbs, I know that with the high rates of smoking in this region some patients will still lose a leg.