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Peripheral vascular disease. Taking Ecosprin and Zilast. Is Angiogram the only intervention possible?

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Cardiologist, Interventional
Practicing since : 1998
Answered : 410 Questions
Dear Health For All team's esteemed Doctors,

This query is regarding my father's diabetic and peripheral vascular disease condition. I urgently need some expert opinion on cardiac/peripheral vascular disease and request Health for All to go through the following background and provide me with some critically needed advice and suggestions.

My father is 61 years old and has been a diabetic and hypertension patient since last 15 years. He is under medication (for both blood sugar & hypertension - no insulin) for many years now; but due to erratic lifestyle and unfortunate addiction to chewing tobacco, his sugar levels and BP have been fluctuating especially in the last few months. Currently his vital parameters are stable; however some anomalies exist : for e.g. : blood sugar is high (@ fasting level - 140-150), High BP : 150-160/80, and protein/albumin in urine has been also observed.
All this data is based on the results of a detailed health check up conducted a few weeks ago at Medanta Medicity Gurgaon and also in a leading hospital in Bhubaneswar - Orissa where he is currently based.

Main cause of immediate concern is that, he has been also diagnosed with a peripheral vascular disease of the right arterial vessels (in the lower leg) through a doppler test. The test reports have revealed a 70-80% blockage in the blood vessels in the lower arterial limb. While there is no alarming situation as per doctors, they have recommended an Angiogram procedure to determine the precise location and extent of blockage in the leg, followed by Ballooning operation/stenting to relieve blockage. They have indicated that if left untreated, the blood vessels would get further constricted, and case might become complicated to an extent of a "Leg Attack". They have mentioned that it is difficult to predict the time before the condition worsens. Currently he is on Aspirin medication for blood thinning. Symptomatically he has no severe issue except for occasional pain in the lower right limb during walking/standing beyong 15-20 min, which immediately subsides after sitting down/taking rest

We are apprehensive whether to go for surgical intervention at this stage or not. We are worried about any inherent risks of an Angiogram / Ballooning process, considering his high BP and diabetes. At the same time, we have also been told by doctors that Peripheral Vascular Disease in the leg also indicates strong possibility of similar blockage in cardiac artery/blood vessel. We have consulted multiple doctors in Gurgaon & Bhubaneswar, and there are different view points emerging. Some doctors have suggested parallel angiogram of heart and leg in the same sitting to ascertain blockage in heart and some have recommended a step by step approach - i.e. treat the leg first and subsequently go for heart. But almost all doctors have mentioned that it is possible to diagnose blockages for both heart and leg in a single angiogram session.

We would like to seek your expert opinion on the following :
1. Is surgical intervention the only recourse available to treat peripheral vascular blockage in lower limb ; i.e. is there no medicinal treatment available ? He is currently taking Ecospirin & Zilast in addition to his regular medication for blood sugar control and hypertension.
2. How safe it is to conduct an angiogram ? What is the process and are there some risk factors involved ? Does ballooning of blood vessels solve the problem / or is a stent required as well ? Some articles I read mention that ballooning is only a temporary solution to peripheral vascular blockage and stenting is almost always required.
3. What is the standard/recommended process ? - Angiogram followed by Ballooning/Stenting immediately or in different stages - Is there a gap between diagnosis through Angiogram and the subsequent operation ?
4. On the heart issue, can a single angiogram be used to jointly diagnose blockage in leg and heart ? Is there some non invasive technique available to diagnose blockage in heart - like MRI etc. ?
5. Finally and most important question --- If surgical intervention is unavoidable, which is the best hospital and medical team available in Delhi / NCR region, we should refer our case. I have been consulting Dr. XXXXXXX Parekh from Medicity Medanta, who is in charge of peripheral vascular department, and also approached the team at Alchemist Gurgaon. Alchemist Gurgaon appears to be a clinic and not a super specialized hospital. Should we consult a Cardio Specialist in addition to a Peripheral vascular surgeon ? Please recommend a good hospital and surgeon/doctor for this case.

I thank you in advance for your suggestions/recommendations. I am including my mobile number. Please reach out to me on email/phone. Hoping to hear back from the team at the earliest.

Warm regards,
Mobile : +00-0000
Posted Fri, 27 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Prabhakar C Koregol 1 hour later

Thanks for detailed history.

The questions need to be answered in little different sequence than what you have asked.

Let me start saying what ever your doctors have told you and you read is all true.

Doppler is only an estimate and an angiogram is essential to confirm severity.

An Angiogram can be done in conventional way or CT scan. Both cardiac and leg Angiogram in the same setting. It is generally a safe procedure, main concern is kidney function but shouldn't be a major issue if baseline creatinine level is normal and adequate precautions are taken.

Once the angiogram is done one would know whether medicines would be enough or angioplasty or surgery is needed.

By and large in medical practice of today angioplasty is done along with stenting.

First you should XXXXXXX a cardiologist to have an angiogram done. Later if surgery is required vascular surgeon may be involved.

Medicity is good hospital, you can get all the required procedures done in the same hospital.

If there are no urgent issue a gap can be taken between angiogram and intervention.

Hope I have answered all your queries. Please do write back if you need further assistance.

Wishing your father good health.

Above answer was peer-reviewed by
Follow-up: Peripheral vascular disease. Taking Ecosprin and Zilast. Is Angiogram the only intervention possible? 33 hours later

Thanks a lot for your valuable inputs. It really puts a lot of my doubts into rest.

However I have a couple of more queries, which I also request you to help me with.

1. You mentioned that angiogram is relatively safe as long as kidney parameters like Urea /Creatnine levels are normal. My father's Urea and creatinine level has been found to be absolutely normal. However, there has been minor albumin/protein content found in his urine sample. Doctors have just mentioned that while kidney is not damaged as such, but presence of protein in urine indicates borderline case for kidney. So my query is that would you recommend a conventional angiogram under this situation as well ?

2. You also mentioned that Angiogram can be done in conventional as well as CT scan way. Does CT scan show up as accurate results ? I mean, can we go for CT scan based angiogram for heart/legs without opting for conventional angiogram ? Or do we necessarily need to do conventional angiogram to get best results and diagnosis. What is the trade-off and what would be your final recommendation ?

3. Finally, you also mentioned that it is recommended to visit a cardiologist first to do the angiogram; and if need be, consult vascular surgeon in the second step. I would really like to follow that suggestion. You also mentioned that I can get everything done at Medicity.

However, at Medicity Gurgaon, the doppler test has been done by the H.O.D of Vascular Surgery - Dr. XXXXXXX Parkeh, who immediately recommended Angioplasty/Ballooning surgery. The angiogram has not yet been done. And no test for cardio as well. I guess Dr. XXXXXXX would anyways do the angiogram post admission and before surgery.

In this situation, would it be advisable for me to visit a separate Cardiologist outside Medicity, and get a comprehensive angiogram done first for both heart and legs; and then re-consult Dr. Parekh for the operation (if necessary). I know this is a difficult question, but would really appreciate your neutral advice in this matter.

There is also an option of consulting Dr. XXXXXXX Trehan from Medicity itself, for the cardio angiogram first, before revisiting Dr. Parekh. Would you suggest that ? Alternatively, if you can suggest another good cardiologist in Gurgaon/NCR for the angiogram procedure, I can visit that. And later on after Angiogram, I can go back to Medicity for the operation.

Ideally we would like to do all the procedures at the same place in a single admission, for e.g. Medicity which is closer to home as well.

Hence any suggestion/advice in this regard is really appreciated.

Request you Doctor to kindly help us with these queries. Thanking you again for all the info provided.

Warm regards,
Answered by Dr. Prabhakar C Koregol 7 hours later

Thanks for getting back.

Generally, proteinuria is representative of kidney disease. However, its presence is not a contradiction for a conventional angiogram. It can be safely done, though they will have to take certain precautions. The treating physician would inform you of these precautions.

A CT coronary angiogram (heart) is more of screening tool and if any blockages are found, we need to do the conventional angiogram before offering angioplasty or bypass surgery. However, for leg vessels, it is diagnostic and one can plan surgery or angioplasty just based on CT report.

Though the initial evaluation is by a vascular surgeon, the initial angiogram is done by cardiologists. The major limitation is that even if a vascular surgeon is able to do a peripheral angiogram, they wouldn’t be able to offer coronary angiogram.

It is better that you consult a cardiologist in Medicity where your father can be treated by the same physician. The surgeon and cardiologist can then coordinate so you don’t need to run around unnecessarily.

Finally, though Dr XXXXXXX Trehan is very famous, he is a cardiac surgeon and not a cardiologist and will not be able to do an angiogram. I am sorry I cannot provide you with information on the cardiologists in Gurgaon. You can check the list off cardiologists in Gurgaon at WWW.WWWW.WW
I hope I have answered your query. Please accept my answer if you have no further queries.

Above answer was peer-reviewed by
Follow-up: Peripheral vascular disease. Taking Ecosprin and Zilast. Is Angiogram the only intervention possible? 2 days later

Thanks again for your timely reply on all queries.

I have decided to follow your suggestions and do a preliminary consultation with a cardiologist in Gurgaon / NCR, and I am in the process of hunting for good cardiologists here. Most probably, I would be finalizing Medicity Medanta - as you say, they have all facilities under one roof.

I have one more and final query regarding coronary angiogram. I came to know that in addition to the conventional angiogram and CT angiogram, there is also the technology of Magnetic Resonance Angiogram (MRA), which is supposedly completely non - invasive and does not use any contrast material (like iodine which some doctors have said might further worsen an already weak kidney - proteinuia condition). My query is - how far is this statement correct ? And if MRA is inherently risk free and safe way to determine coronory blockage, would you recommend that we propose an MRA to the cardiologist concerned ? And just how accurate are MRA results, when compared to CT scan and Conventional Angiogram. If you suggest that MRA is a safer technique than CT / Conventional Angiogram, we would like to go for that option for the coronary evaluation.

However, I guess, for the blockage in leg vessels (peripheral), we would need to do a conventional/CT angiogram, to plan further surgical intervention ? Is that correct on my part ? In my father's case, the blockage in legs is already detected based on Doppler test; so in any case we need to go for intervention there. But for the heart, we are thinking of doing a more proactive assessment to put any doubts to rest around blockages. So, we would prefer the least invasive and safest angiogram procedure.

Based on your final comments/suggestions, I would be requesting the potential cardiologist. Ofcourse the final decision would still remain with the treating cardiologist. And once the cardiology sessions/tests are done, we would then involve the Vascular surgeon - going by your suggestions.

Request you to help us clarify this point, before we take a final decision.

Thanks again for all the support extended so far.

Warm regards,

Answered by Dr. Prabhakar C Koregol 3 hours later
Thanks for writing back.
No, a magnetic resonance angiogram for the coronary arteries has not yet attained stage where it can be routinely used. It is useful in clinical practice only in childhood disease to get some preliminary information. It would be not useful for your father. Additionally, even though a MRA can used in leg arteries, it not as accurate as a CT angiogram or a conventional angiogram. Further, the contrast used in MRA is also not 100% risk free and it's also known to cause kidney damage in some patients.
Performing the best investigation is essential before we plan an intervention. A conventional angiogram/CT angiogram is the best investigation towards this end and would be required for the same.
I hope I have answered your query.
Above answer was peer-reviewed by
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