Peripheral arterial disease

[Alban]

Hi I have peripheral arterial disease with a blockage of the iliac artery . I have searched the web and can only find very limited advise on diving . this affects 1 in 5 over fifty so is relatively common .The information I can find is persons with p.a.d. May also have coronary or carotid artery disease which would rule them out from diving.

P.a.d. Will effect your physical ability also the limbs will feel colder.
My consultant tells me apart from this artery I am phisically in good shape.
I am able to swim 1mile and jog 3 k . I did dive before I knew what was wrong and I did have a cold big toe after 30 minutes.

A statement said p.a.d. May affect inert gas wash out, but it said nothing more or if it was based on any research. I have an appointment again next month and would like to discuss with him about diving. If anyone has any advise or has this condition I would be most gratefully.

Thanks in advance Alban.

 

[TSandM]

Nothing about pressure per se should affect ASPVD (arteriosclerotic peripheral vascular disease). If you don't have claudication (limb pain with exercise) then the abnormality in the artery is not significantly changing flow. With the amount of exercise you're talking about being able to do, I would be surprised if you have a hemodynamically significant blockage.

It is true that ASPVD correlates with increased likelihood of coronary artery and carotid disease, but if you have had no stroke-like symptoms, and with the exercise tolerance you describe, I think you should be considered an acceptable risk for diving.

A lot of people have asymptomatic arterial disease. When I was in medical school, they showed us an aorta from a 12 year old who was killed in an accident, and there was already disease present in his arterial wall. You just happen to be someone who knows about it -- which does raise the interesting question of how your iliac stenosis was diagnosed, and why the test was done.

 

[Alban]

Hi thank you for the reply , I probably havn't given enough details I do get claudication and walking would give me cramps and pain but I go to the gym and have managed to increase distance , I have read the smaller arteries enlarge to bypass and also the muscles react differently which is not quite understood.
Phisical exertion I think would be ok.

The Blockage is 140mm long so a stent ia not possible I have no pulse at the brachi or in the pelvis area.
My everyday life is mostly unaffected by this as it can be managed By excercise. My option is bypass surgery which is a risk I need to evaluate .

I am a 50 year old male 10 stone who has been diving for 20 years . I have done all the big dives I want to do but I miss going out on a dive day with friends .

I understand my toe going cold is a result of restricted blood blow which may off gas slower than it should ?


thanks again ALban

 

[Duke Dive Medicine]

Alban,

The claudication is concerning. You're going to get some fluid redistribution from the affected leg from both immersion and cold-induced vasocontriction, which could further compromise your circulation. Also, I'd be concerned about comorbidities like coronary artery disease. I think you should be evaluated by a diving medical professional if you haven't already.

Best regards,
DDM

 

[Alban]

Thank you for the reply

I have had several blood tests for cholesterol , diabeetes , blood pressure , ecg , sticky blood . but I will talk to the consultant about my concern.
I can understand that as I get colder the blood flow will be further reduced to the leg, is one of the concerns that I will be unable to fin or my toe will become numb ,loose feeling in it and cause some permanent damage ?

I have a very basic and simplistic understanding of decompression so if the blood flow is reduced there would be less n2 in the tissues which would offgas into the veins which are ok . Would the reduction in blood limit the amount of n2 carried ? I am sure things are a lot more complicated than this but I have googled and there is very little information on this .

Time with a consultant is limited so I would like to be a bit more prepared as its only later that remember what I should of asked.

Thank you once again Alban

 

[TSandM]

When you get cold, the blood vessels in your leg constrict (mostly near the skin) to limit the flow and keep the blood around the internal organs. If you already have limited flow, the drop could be significant -- you would probably get cold feet, and you might lose enough blow flow to cause tissue damage. If you have no pulses in your leg, you have really poor flow, and if you have walking claudication, then having to fin into a current or to get back to the boat might not even be possible.

Given your further information, I retract my original statement that you ought to be good to go. You have a major blood flow problem to your leg. I think you ought at least to consult with the surgeon about revascularization options.

I don't think anybody can say what the DCS implications are. Poor arterial flow means poor nitrogen delivery to the tissue; you have no blockage to venous return. I'd be more worried about ischemia (inadequate flow to support tissue needs) than DCS in the leg.

 

[Alban]

Thank you for the reply

Physically I think I would be ok , finning is as much about technique and trim as sheer strength and plenty of disabled people dive . With DCI on a single dive within NDL would I be at more risk ? I guess there is no research on this as there is no commercial value in it. When I said I had no pulse this was with a doctor trying to feel my pulse in the groin I assume I do have a pulse in there somewhere . when I dived My big toe did get cold after 30 minuets and this was in a dry suit with water temp 10 degrees the toe was uncomfortable but not painful but at what point is damage being done?I fully understand that you give a general view on a couple of sentences and I am very gratefull for this. Everyday life the claudication does not affect me it can be managed with excercise .My next meeting with the consultant will be to discuss my options one of which will be bypass surgery a route I am reluctant to go down .There is very little information on the web which makes it difficult to make an informed choice , at the moment I will talk to the consultant about diving if he thinks it would be possible then I would see a Diving doctor but I feel this is very unlikely.



thank you for taking the time to reply I should of made the first post longer and more detailed my apologies for misleading you.

Alban

 

[TSandM]

Alban, you have to realize that there isn't really a lot of research being done in decompression in human subjects. It's expensive research and difficult to control well. Doing research in the very small pool of people with significant arterial occlusive disease who also dive would be prohibitive.

I don't think anybody can really predict whether your leg is more susceptible to DCS because of decreased washout, or whether it's less susceptible because of decreased nitrogen delivery in the first place. I think we CAN say that, with no palpable pulses in your leg, the blood flow to the tissues of the leg is already extremely compromised. If there is no pulse in the femoral artery at all, then the majority of the blood that is keeping your leg alive is flowing AROUND that area, through smaller vessels off the gluteals. That's called "collateral flow", and it's enough in some people, especially if the blockage develops gradually, to keep the leg viable and even permit some exercise. But it's not normal flow, and the areas that are in the worst shape are those that are furthest from the well head, as it were -- in other words, the toes -- and furthest out the vascular tree there, like the skin and nail bed. When you vasoconstrict the vessels in the skin because of cold, you are further reducing the available flow to feed the tissue. How far you are, at baseline, from true ischemia (the point at which tissue gets damaged) I can't say, because I can't see your foot. I do know that people with severe arterial disease develop ulcers in their toes and at their ankles due to the fact that the reduced flow doesn't permit normal tissue repair where there is pressure or minor trauma. This is what would worry me, but you can get a much better answer from your own vascular surgeon than you can from me, because he has the actual diagnostic studies looking at the pressure drops across the blocked areas.

I do think you ought to talk about revascularization. You said that surgery is the only option for you, and that could be, depending on the anatomy of your particular issue. But amazing things are done with interventional radiology these days, and unless someone has specifically told you that that is not possible, it's worth looking into. If your overall health is good enough to permit you to dive (so your heart and lungs are in good shape) even vascular surgery is not that awful, and it often works very well.

 

[Alban]

Thank you for the reply

Angioplasty is considered possibly high risk as the length 120 - 140mm . I guess I am trying to manage my expectations and be a little more prepared before I see the consultant .

Thank you once again for your valued opinions .Alban