17312 Pad Endarterectomy

Overview

Peripheral artery disease (PAD) means fatty patches, called plaque, have built up inside the arteries that carry blood away from your heart. It most often affects the arteries in your legs. When plaque builds up, the artery narrows like a pipe clogged with limescale, so less blood reaches your muscles and skin. An endarterectomy is an operation to clear that blockage. The surgeon opens the artery and gently peels away the plaque and the inner lining it has stuck to, then closes the artery again so blood can flow freely. It is most often done in the artery at the top of the leg, in the groin, and sometimes in the neck artery that supplies the brain.

PAD is common, especially in people over 60. Opinions vary, but many estimates suggest it affects around 1 in 5 people in that age group, and many of them have no symptoms at all. Endarterectomy itself is a well-established operation that vascular surgeons perform regularly.

PAD mostly affects people over 60, smokers and ex-smokers, people with diabetes, high blood pressure or high cholesterol, people with kidney disease, and those with a family history of heart or circulation problems. It affects men and women, and it is more common in people of South Asian and African or Caribbean heritage in the UK, largely because diabetes and heart disease are more common in these groups.

Symptoms

Common symptoms

• Many people have no symptoms at all and only find out when a doctor checks their pulses
• Cramping, aching or heaviness in the calf, thigh or buttock when walking, which eases within a few minutes of resting (doctors call this intermittent claudication)
• You can walk less far before the pain starts than you used to
• Cold feet or lower legs, even in warm weather
• Hair loss on the legs, shiny skin, or skin that looks pale or darker than usual
• Brittle toenails and slow-growing toenails
• Sores or cuts on the feet or lower legs that are slow to heal
• Weak or missing pulses in the foot or ankle
• In men, difficulty getting or keeping an erection

Symptoms in children

• PAD and endarterectomy are adult conditions and are very rarely seen in children
• Children can have rare artery problems from injury, inflammation or being born with narrow arteries, but this is unusual and needs specialist care
• If a child has a cold, pale, painful limb or a weak pulse, that is an emergency — call your local emergency number

Symptoms in older adults

• Symptoms are often put down to 'just getting older', so PAD can go unnoticed for a long time
• People who are less mobile may not notice walking pain, but may notice cold feet, slow-healing sores or toe problems instead
• Rest pain — a burning or throbbing pain in the foot or toes when lying in bed, eased by hanging the leg over the edge of the bed — is a warning sign that blood flow is seriously low
• Older adults are more likely to have other conditions such as diabetes, heart disease or kidney disease, which affect treatment choices
• Confusion or a general decline in an older person can sometimes be a sign of a serious circulation problem and should be checked urgently

Causes

Main causes

• Atherosclerosis — a gradual build-up of fatty plaque, cholesterol and calcium inside the artery wall, which makes the artery narrow and stiff
• Blood clots forming on top of plaque and suddenly blocking the artery
• Inflammation of the artery wall (rare), or damage from injury or previous surgery
• Sometimes no single cause is found, but the same risk factors still apply

Risk factors

• Smoking or having smoked in the past — the single biggest risk factor
• Diabetes, especially if blood sugar has been high for a long time
• High blood pressure
• High cholesterol, particularly a high level of 'bad' cholesterol
• Kidney disease
• Being overweight, especially carrying weight around the middle
• Not being physically active
• A family history of heart attack, stroke or circulation problems
• Increasing age — risk rises from around 60 onwards
• An unhealthy diet high in salt, saturated fat and processed foods

When to see a doctor

See a doctor urgently if:

• Any sudden severe leg or arm pain with a pale, cold, numb limb — call emergency services
• A new foot ulcer, a black toe, or a sore that is not healing after a few days
• Rest pain in the foot at night that is not settling
• After surgery: a wound that is hot, red, swollen or leaking pus, heavy bleeding, or new numbness or weakness in the leg
• Chest pain or breathlessness, which may need same-day assessment

Book a routine appointment if:

• Cramping leg pain when walking that goes away with rest
• Cold feet, hair loss on the legs, or slow-healing cuts on the feet
• Erection difficulties that have come on gradually
• You have diabetes, kidney disease or a strong family history of heart disease and want your circulation checked
• You smoke and want help to stop

Diagnosis

Your doctor will start by asking about your symptoms, your walking distance and your medical history, then examine your legs and feet and feel for pulses in your groin, ankle and foot. A simple, painless test called an ankle-brachial index (ABI) compares the blood pressure in your ankle with the blood pressure in your arm — a lower reading in the ankle suggests narrowed arteries. Most people can be assessed in a clinic without staying in hospital.

Tests that may be done

• Ankle-brachial index (ABI) — a blood pressure cuff test comparing arm and ankle readings
• Doppler ultrasound — a painless scan that shows how blood is flowing in your arteries
• Duplex ultrasound — a more detailed scan that shows the shape of the artery and where any narrowing is
• Blood tests for cholesterol, blood sugar and kidney function
• CT angiography or MR angiography — detailed pictures of the arteries using dye, used when planning surgery
• A walking test on a treadmill to see how far you can go before symptoms start

What to expect at your appointment

You will usually be seen in a vascular clinic. The visits are often quick, and the tests are painless — some involve lying still while a probe is held against your skin. If surgery is being considered, you will meet a vascular surgeon who will explain the options, the risks and what recovery involves, and you will be given time to ask questions and think it over. You may be asked to bring a list of your medicines and to stop eating and drinking before certain tests or procedures.

Treatment

Treatment for PAD aims to relieve symptoms, protect your foot and leg, and lower your risk of heart attack and stroke. Most people benefit from a combination of lifestyle changes and medicines, whether or not they have surgery. Endarterectomy is one surgical option; others include widening the artery with a balloon and stent, or bypassing the blocked section with a piece of vein or a small tube. Your team will recommend what suits your arteries, your general health and your preferences.

Self-care at home

• Stop smoking — this is the single most powerful thing you can do for your circulation. Ask about local stop-smoking support, which is free in most areas and much more effective than willpower alone
• Walk regularly, even if it hurts a little — a supervised walking programme, or simply walking until the pain starts and then resting and repeating, helps build up your walking distance over time
• Check your feet every day for cuts, blisters, redness or sores, and use a mirror or ask someone to help if you cannot see the soles
• Wash and dry your feet daily, keep toenails trimmed (ask a foot specialist if you have diabetes or poor eyesight), and wear well-fitting shoes and socks
• Take any prescribed medicines regularly, even when you feel fine
• Keep warm, but avoid direct heat such as hot water bottles or sitting close to a fire on your feet, as numb feet can burn without you noticing
• Tell your doctor or nurse about any new foot problem straight away — do not wait for it to get worse

Medical treatments

Doctors usually prescribe medicines to lower cholesterol, control blood pressure and reduce the chance of blood clots, along with careful control of blood sugar if you have diabetes. These medicines do not clear existing blockages, but they slow the disease down and reduce the risk of heart attack, stroke and amputation. Your doctor or pharmacist will explain what each medicine is for and how to take it, and they can adjust the dose if you have side effects — never stop a medicine without asking first. If you have pain on walking, a supervised exercise programme is often the first and most effective treatment. Dietary and lifestyle support, and help with quitting smoking, are also part of the plan. For a blocked artery, an endarterectomy is usually done by a vascular surgeon under general, spinal or local anaesthetic. The surgeon makes a cut over the artery, removes the plaque, and closes the artery, sometimes with a small patch. Many people stay in hospital for a few days and are walking soon afterwards.

When is surgery considered?

Surgery is usually considered when symptoms are seriously affecting your life despite exercise and medicines, when the artery is very narrow, when you have rest pain, a non-healing foot ulcer or a toe that is turning dark, or when a neck artery is narrowed enough to raise your stroke risk. It may also be needed for a blocked artery in the groin that is not suitable for a balloon or stent. Your surgeon will weigh the benefits against the risks for you personally — for example, heart or lung problems can make surgery riskier, and a less invasive option may be safer in that case. The decision is yours to make with your team, and it is completely reasonable to ask for more time or a second opinion.

Living with this condition

After an endarterectomy, most people notice warmer, less painful legs and can walk further. The wound usually takes a few weeks to heal and you may have some bruising and soreness. Your team will tell you when you can shower, drive, lift heavy things and go back to work — usually a few weeks for lighter jobs. Keep checking the wound and your feet, and go to your follow-up appointments. Expect to be seen again to check your circulation, and let your doctor know about any new symptoms.

Lifestyle tips

• Stay smoke-free — it is worth asking for help more than once if the first attempt does not work
• Build activity into your day: short, regular walks, gardening, swimming or cycling all help
• Sit less — stand up and move every hour if you can
• Aim for a healthy weight, and ask for support if losing weight feels hard
• Keep alcohol within sensible limits
• Look after your feet and wear shoes that fit properly
• Take your medicines as prescribed and go to your reviews
• Keep blood pressure, cholesterol and blood sugar in the target range your doctor sets for you

Diet and exercise

Eat plenty of vegetables, fruit, wholegrains, beans, lentils, nuts and oily fish, and choose olive or vegetable oils instead of butter and lard. Cut down on salt, processed meats, sugary drinks and fried or packaged snacks. This kind of eating pattern helps your cholesterol, blood pressure and weight all at once, and it is the same advice that protects your heart and brain. For exercise, aim to build up gradually — a brisk walk most days, working towards around 150 minutes a week if you can, plus some gentle strength work such as carrying shopping or chair-based exercises. If walking brings on pain, walk until it starts, rest until it settles, then carry on. That pattern is safe and helps your muscles build new small blood vessels.

Mental health and emotional wellbeing

It is very common to feel anxious or low after a diagnosis like PAD or after surgery. You may worry about your leg, about walking too far from home, or about what the future holds. Pain and reduced mobility can also chip away at your mood, and you may feel frustrated or lose confidence. These feelings are understandable and treatable. Talking to your GP, a counsellor or a support group often helps a lot, and it is fine to say that you are struggling. If you ever feel hopeless or have thoughts of harming yourself, please reach out for crisis support straight away — you deserve help, and it is available.

Prevention

You cannot change your age or your family history, but you can greatly lower your risk of PAD, and slow it down if you already have it. The biggest single step is not smoking, or stopping if you do. Keeping active, eating well, keeping blood pressure, cholesterol and blood sugar in a healthy range, and taking prescribed medicines all make a real difference. If you have diabetes, good control of your blood sugar and regular foot checks are especially important.

Vaccines

Your doctor may suggest vaccinations such as the flu jab and pneumonia vaccine, because long-term conditions like diabetes, heart disease and kidney disease can make infections more serious. Ask your GP or pharmacist what is recommended for you.

Screening programmes

There is no routine national screening programme for PAD in the UK. However, the NHS Health Check for adults aged 40 to 74 includes blood pressure and cholesterol checks, and your GP can check your leg pulses if you have risk factors. If you have diabetes, your annual foot check should include a circulation check. Tell your doctor if you have walking pain, cold feet or slow-healing sores — a simple pulse check takes seconds.

Complications

If left untreated

• Critical limb ischaemia — blood flow becomes so low that the leg cannot heal and causes severe rest pain
• Foot and leg ulcers that do not heal
• Gangrene, where tissue dies and turns black, which may lead to amputation
• A higher risk of heart attack and stroke, because PAD is a sign that arteries elsewhere may also be narrowed
• After surgery, possible complications include bleeding, wound infection, blood clots, nerve damage causing numbness or altered feeling, and the artery narrowing again over months or years

Long-term outlook

The outlook is generally good. Most people who have an endarterectomy get better blood flow, warmer legs and improved walking, and the benefits often last for years. The operation does not cure the underlying artery disease, so the lifestyle changes and medicines that protect your arteries matter just as much as the surgery itself. Many people find that having the operation is a turning point — a reason to stop smoking, get more active and look after their heart. Your team will support you through each step, and there is a lot you can do to keep your circulation as healthy as possible.

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