No treatment options from consultant.

[BlueSilverCats]

OH has PAD . He was referred for an MRI looking at getting an angioplasty done after the results.

He saw the consultant today who said there are no treatment options, that the other doctor who mentioned angioplasty was on another planet and all he can do is to stop smoking. I read the letter so this is not coming just from OH. It even mentions that if it gets worse or his leg is at risk, there still isn't much they can do.

They won't even attempt an angioplasty or a stent or a bypass. Nothing they can do and they won't see him again either, just get referred again if things get worse/anything changes.

It literally says in the letter that his recovery is entirely up to OH . Stop smoking, exercise more and that's it. He will stop smoking, so that isn't an issue.

AIBU to think this can't be it?

I want OH to get a second opinion at the very least.Might even look at private, but I have no idea where to start.

@Carriemac here goes nothing.

Unfortunately there
is complete occlusion of his superficial femoral artery as well as proximal popliteal artery. The distal popliteal artery is
BeeGentle but diseased. His run-off vessels are also diseased only peroneal being open. Anterior tibial is diseased and
posterior tibial is occluded.
We have had detailed discussion on management. Surgical or radiological management is not an option in this case. He
continues to smoke and I have emphasised that it is absolutely essential that he must stop smoking because that is 1 single
factor that will determine the future of his leg. In addition he must keep on walking because, unfortunately there is a lot
of collaterals developing in the thigh and hopefully things will improve with time. His risk factors are all modulated and managed.
I do not need to see him on regular basis but he must stop smoking and walk as much as he can. If he develops tissue loss or
rest pain in his foot then please refer him back for further vascular assessment. Even if that was to happen unfortunately
the options seem limited looking at his angiogram. So the key to his legs future is very much dependent on if he manages to
stop smoking completely which will not guarantee but will usually improve the prospects.

If it is as bad as it's been stated, please be gentle. I am probably being unreasonable...

Ok, so essentially the blockages are too widespread, and too distal (in the lower leg) for angioplasty or bipass surgery. He has some evidence of new vessels opening up to compensate for the blocked ones, and exercise will encourage more to open up. Stop smoking so things don’t get worse.

this in a nutshell

stop smoking, exercise by walking or lose the leg and/or his life

bluntly

That letter really is a wake-up call.
Your husband needs to have it on the fridge and on his phone prominently to jolt him when he thinks about a smoke .

He sounds like his feet / foot are really vunerable (and there will be evidence available about the risks of gangrene and amputation which is a huge risk)

He needs to make sure there's no trauma to his feet and legs , if he works outdoors then his footwear needs to protect him. Check for holes and seams which can rub . Things like grit or stones in the shoes .
Indoors no barefeet .

But the smoking - yes he does need to quit , it;s good that he has cut down , he must;ve been suffering symptoms of the PAD to make him do this , but he needs to go non smoker .

It's cos all the main flow pathways down the leg are blocked. Once they're totally clogged off you can't stent them open, and the vessels they'd consider as bypass routes to revascularise are also blocked

Collateral are when bits of the body with poor blood supply make alternative tiny routes through... u can improve them as said in the letter

He's at huge risk of amputation if keeps smoking, sorry x

Smoking cessation is likely not a gp service in your area but there will be a stop smoking service. Some times is pharmacy led or a service like ‘quit your way’ put it into google with your area and see what service is available.

I’m no doctor and don’t know rhe soecifc details, but from what you have said the doctor gave the right advice…

www.nhs.uk/conditions/peripheral-arterial-disease-pad/treatment/

my.clevelandclinic.org/health/articles/23560-collateral-circulation

Yes collaterals are what will save the leg if he follows advice and exercises and stops smoking .

No second option would change that , the op would be futile and presumably the second consultant had a clearer picture after the MRI hence the difference of opinion

Has he tried Stop Smoking Therapy before ?

They can help if the smoker wants to stop but if they choose to continue they're limited .Our local services asks "Are you ready to stop smoking" and if they answer "Not really" or "no" then they don't proceed /
Choose isn't the "right" word , smoking is so addictive , Though the banning of smoking in most public places and the ££ it costs are a good incentive to quit .

Simply put there is no treatment option, and if he doesn't stop smoking immediately he will lose his leg, at best.

This is literally last chance saloon. It's clear from the letter he'd already been told to stop smoking, and hasn't.

Looks like the consultant is trying to be clear and honest.

That is a nice clear letter with very clear advice. There's no option to bypass because all the alternative routes are also in trouble. Stopping smoking and walking IS the treatment. That's not doing nothing,that's the treatment. It's just very hard.

@BlueSilverCats I’m so sorry you are having to deal with this, it’s really tough, especially when it’s your loved one who has to make the necessary changes. It’s a horrible addiction in that some people will never give up even when they know it will lead to their death….I do hope your OH can make that choice, sometimes people need to understand that it’s not just atherosclerosis in the legs that will be occurring it will be happening in the major vessels too and puts him at increased risk of heart attack or other cardio- vascular events. Have you any other family members or friends who he listens to , that might be persuaded to talk it over with him?

He was engaged with a stop smoking service before. Went to appts , in contact with the person doing it(consultant?!?) . They requested several times the gp prescribes him meds to help, several emails went unanswered and the GP refused to prescribe. He's looking at ordering them privately now. Well he already filled in an online consultation with Lloyds pharmacy and waiting to see if it goes through.

There has to be a surgical target in the Ct angio. If there isn't one there is no option to operate

@pyjamarama and @Destiny123 thank you for explaining in a way that at least makes (even if brutal) sense to me.

I'm obviously no medical expert , and with all the medical advancements and treatments and things that can be done for so many illnesses/diseases it made no sense to me that nothing else is available. Or maybe I just didn't want it to make sense, because it's terrifying as fuck that it's all up to him.

Lifestyle changes ARE the primary treatment option for his condition, though. If he has e.g. high cholesterol, blood pressure or blood sugar that isn’t already being controlled with medication he should talk to the GP to ensure that is taken care of. But there isn’t a magic bullet for PAD. I don’t know why the first consultant suggested angioplasty and you can certainly ask about that, but I wouldn’t expect the decision to change.

Basically they appear to be saying they will reassess if rest pain, arterial ulcers, gangrene, etc with amputation
Sorry

Slightly OT but with his severe PAD I would also be making sure he's aware of symptoms of heart attack and stroke and have a very low threshold for seeking help if he experiences any of them.

I don't know either. Probably part of why this is such a shock. Because it wasn't an let's see what the MR says , or we'll look at options, it was "you need an angioplasty, I'm sending you to get an MR done to see exact location and then we'll book it." That was after the Doppler. It was mentioned before too.

Then this appt came along with a different consultant and it was all wrong. Well, apparently he's right, but not what either of us expected to hear.

Yeah, it’s really tough when you’re taken by surprise with this stuff. Take a little time to let yourself process that and do everything thing you can to support him. Maybe start going for walks together?

Sorry you are going through this OP, we are responsible for our own health and smoking is a such a tough one to shake. Unfortunately, people can’t abuse their bodies and expect that modern medicine will always be able to pick up the pieces and put them back together- I don’t say this out of judgement, I have my own vices and know I could be healthier, too.

Your consultant has made it as clear as she/he can - there is no equivocating. The next time they will see your husband will be for amputation if he doesn’t follow the advice in the letter.

I’m a vascular surgeon. I agree completely with the treatment plan discussed. It’s a really clear and reasonable letter.
The CT scan has shown a very long blockage not amenable to angioplasty ( sometimes thing progress between duplex and MRI/ CT) . Also a bypass is very unlikely to work in a man who continues to smoke and has also peroneal artery ‘run-off’ . For a bypass to work you have to have somewhere at the bottom for the blood to go. A bypass operation would put OH at significant risk and might lead to limb loss when the graft inevitably blocks . I discuss lots of cases like this at our multidisciplinary team meetings .
The recommendation would be to walk and develop collaterals and to stop smoking . Evidence shows that this can be just as effective as angioplasty with SFA disease and reduces the risk of limb loss in claudicants .

In our area there would be no monitoring either - we would safety.net patients by asking them to represent if the limb worsens. There are not the resources to monitor people and have the same conversations saying - still the same …. In general over 5 years from diagnosis with PAD as a claudicant , 1/3 will get better , 1/3 will stay the same , 1/3 will worsen to become critically ischaemic ie threatened.

OH really needs to wake up and stop smoking . He could use a nicotine vape or patches. I believe that Champix tablets have been discontinued in the UK perhaps why the smoking cessation person didn’t prescribe.

Pointless to see someone in the private sector, I’m afraid . OH would still be discussed by the same regional network MDT and I can’t imagine anyone giving a different opinion. Sorry…

I’m really sorry you’re going through this OP, such a shock when medical opinions change. Now that the PPs (I assume they are medics so understand this) have gone through the letter hopefully that clarifies things at least. Tbh although the message of the letter is very clear once the medical jargon is de-coded, I wouldn’t say it’s at all clear for the non medically trained and I do think it would have been helpful for the consultant to explain things in the letter in the same clear way PPs have. Often appointments are rushed, patients can be in shock if it’s not the news they are expecting and it’s useful to have a written record they can understand to refer back to. I suppose the one positive, although I appreciate also terrifying thing, is that your OH might have the opportunity to reverse this. Wishing you both the best x