Angina in legs

[Momto3]

Good morning!

Thank you for taking my question.  

My dad had CABG x 4 in 1998 and has been experiencing leg discomfort.  He is on Zetia and Crestor for cholesterol control.  The doctor suggested that the achiness he is experiencing in his legs could be angina.  He explained that although it is not directly connected to the coronary arteries, the same theory applies (blockage in the arteries).  An ultrasound showed blockages in both legs and an arteriogram has been scheduled.  At that time, the doctor will attempt to "break up" the buildup in the arteries.  I understand that these questions are generally directed to a vascular specialist, but thought maybe you could offer some insight.  My questions are as follows:

1)  My dad has regular blookwork and checkups to monitor for changes as a result of taking medications.  How likely is it that the leg discomfort is actually a side effect of the cholesterol medication?  Is that something that would show up on a test result?

2)  Assuming the blockages are the sole cause of the discomfort, what is your opinion on stenting?  This doctor prefers to unblock the arteries as opposed to stenting?

3)  Are there specific questions we should be asking?  The doctor wants to perform the arteriogram to assess the situation and then break-up the blockages one leg at a time.  

Thank you so much for any suggestions, advice or insight.  

Have a great day!

connie

[Momto3]

Hello

Just thought I'd let you know that my Dad's procedure went well.  The doctor ended up putting in 2 stents in my Dad's pelvis.  He believes that by opening the arteries in his pelvis, there will be improved blood flow to his lower legs.  Hopefully, we'll be hitting the walking trails again very soon : )  

Thank you again for your kind assistance and valuable suggestions!!  

Connie

[Momto3]

Thank you for your well wishes.  Now, I've got to help my dad figure out the best way to proceed.  He is scheduled for the arteriogram on Monday.  I really think a second opinion might be helpful, but I'm not sure he wants to go in that direction.  

Thank you again!  I was so happy to read the doctor's very informative and thoughtful response.  I want only the best for my DOD  (dear old dad)  : )

BTW, I've never fished, but I love your avatar!

[Flycaster305]

That was very interesting.  It shows us how a well-phrased question gets a very informative answer. I wish your father well with the procedure.  

[Cleveland Clinic]

PVR's are used to document or follow progression of the disease.  Since it is quite obvious, based on your dad's symptoms and clinically, you were able to ascertain that the disease is progressing based on progression of his limitations, it is not necessary to do that test.  It sound like the arteriogram and the angioplasty, if successful, would really improve your dad's quality of life.  I would go for it.  Make sure the physician that is taking care of your dad has reasonable experience with this procedure.  It is not a technically difficult procedure to perform.  Based on our experience at the Cleveland Clinic we typically like to use stents when possible because they tend to stay open.  It is certainly never a problem.  I am not sure that the fact that they are foreign to the body is a good enough reason not to put them in.  We do it here all the time.  They work very well.  

[Momto3]

Thank you so much for the very thorough response to my question.  We certainly appreciate the time you have taken to offer such a valuable service.  To address a few of your thoughts/questions:

1)  My dad experiences the leg discomfort (he describes it as achiness), it is pretty much what you described with claudication.  He will walk for a short distance, stop to "regroup" and continue until he needs to stop again.  The length of time he is able to walk has been lessening.  

2)  My dad quit smoking about 25 years ago, in his 40's.  Fortunately, he has managed to steer clear of cigarettes since that time!  Exercise is a bit of a challenge given the leg pain.  But, he has been trying to walk the perimeter of his neighborhood pool (less stress on the legs) a few days each week.  

3)  You asked about the degree of obstruction on ultrasound.  We were told that both legs showed claudication (calcium) from the hips down.  It was our understanding that below the knee was worse than the upper part of his legs.  Aside from the ultrasound, the doctor checked all of my dad's pulses to determine the location of the blockages.  You asked "how bad was the obstruction..."  Is there a quantitave measure we should be asking for?  We were given the impression that the arteriogram would provide more information as to the location/severity of blockage.  

4)  Would you suggest we ask about a PVR?  I know he had pressures checked on both arms and legs, but it was done right in the doctor's office.  

5)  The doctor said he prefers not to use stents b/c they are "foreign" to the body and cannot be removed.  Make sense?  

6)  My dad is currently taking coumadin for chronic a-fib as well as medications for CHF, cholesterol control and Diabetes II.  Aside from some SOB and the leg pain, he is relatively asymptomatic and does quite well.  

Again, thank you so much for your advice and suggestions.  I have passed the information along to my Dad so that he (we) can decide how to best proceed.

Connie  

2.  Stenting is usually preferred but that depends on the location of the blockage and the size of the artery where the blockage is located.  Also depends on other things such as whether the patient can take blood thinners for a month or so.

3.  First you should make sure that the pain is truly due to the blockages.  How bad was the obstruction in the legs on the ultrasound?  We now recommend a test called PVR's, which is similar to a heart stress test but of the legs.  Documentation of severe blood flow compromise with walking is a very sensitive finding.  You should also ask why he doesn't want to use stents.  

[Cleveland Clinic]

1.  Majority of the muscle aches related to cholesterol lowering medications is not completely understood.  We believe that there is some sort of mitochondrial toxicity that leads to these symptoms.  This condition is diagnosed based on symptoms and response to discontinuation of the medication.  There are no tests to identify it.  The symptoms usually go away with discontinuation of the medication.  Sometimes spacing out the medicine out to every other day, or lowering the dose, or even changing to a "sister" medication can help.  Some physicians advocate taking Coenzyme Q but there is enough data out there to say that is probably not as effective as we would like it to me.  A very small percentage of patients develop a serious condition known as statin induced myositis which leads to similar aches but more severe, associated with weakness and typically the muscle breakdown markers found in blood are elevated (Creatinine Kinase (CK)).  This condition typically warrants hospitalization and obviously complete discontinuation of the medication.  Muscle aches due to poor circulation, typically referred to as lower extremity angina or cluadications, have a very characteristic pattern.  They typically occur with exertion, unless very severe, when they can occur at rest, usually with lying down.  The symptoms are always reproducible, meaning that the patient can always tell that their symptoms will occur at a certain point during their walk.  They usually resolve with rest and resuming the activity will bring on the symptoms again at the same distance as before.  The patients typically find themselves walking for a certain number of blocks before their symptoms start, they then rest a few moments to let the circulation catch up and then can restart their walk, to be followed by the same cycle.    Exercise and smoking cessation are the first line of therapy.  Very debilitating symptoms now-a-days are treated with angioplasty and stenting.

2.  Stenting is usually preferred but that depends on the location of the blockage and the size of the artery where the blockage is located.  Also depends on other things such as whether the patient can take blood thinners for a month or so.

3.  First you should make sure that the pain is truly due to the blockages.  How bad was the obstruction in the legs on the ultrasound?  We now recommend a test called PVR's, which is similar to a heart stress test but of the legs.  Documentation of severe blood flow compromise with walking is a very sensitive finding.  You should also ask why he doesn't want to use stents.