I met my first vascular disease patient at a hospital on the south coast. The vascular ward was high up in a tower block, with lovely views of the sea and the downs, so wasn’t ideal for anyone missing a limb. “Smoky Pete” (as he called himself) used to park his wheelchair next to the lift, and wait. With one arm and no legs, he could navigate the lift but struggled with the door at the bottom which led to the car park. More bothersomely, with only one arm, he found it difficult to light a cigarette. So he would wait for passing staff – he was fond of medical students – to see if he could cajole you into escorting him down and then lighting one up for him. In his prime, before his amputations, Pete had smoked 80 cigarettes a day. “Barely a break between,” he remembered, a wistful look in his eyes. “Epic.”
Pete had lost his limbs to peripheral vascular disease. PVD isn’t very fashionable – for as well as being miserable, disabling and expensive to treat, it is also often preventable. It is hard to see how anyone could boost its profile: a sponsored abseil in support of Britain’s missing feet is an unglamorous proposition. Smoky Pete was not good PR for his disease (neither was the hospital car park, which was full of patients with below-the-knee amputations dragging on Marlboros): but smoking is not the only way to injure your arteries. Anything that damages the blood vessels – hypertension, high cholesterol – can lead to PVD. Poorly controlled diabetes is the main cause of non-traumatic amputation in Britain.
Peripheral vascular disease usually causes symptoms as it progresses. As the arteries “fur up”, their ability to deliver oxygen to the tissues is compromised. You’ll first notice this when your demand for oxygen increases – running for a bus, or walking uphill. As your muscles work harder they need more oxygen, which the partially blocked arteries struggle to supply. This causes pain; the same aching, tightening, oxygen-starvation pain that happens in the chest with angina. In the legs, this is called intermittent claudication, which our vascular consultant used to call “window-shoppers” disease”. Pain in the calves brings the patient to an involuntary halt, forcing him to peer into Carphone Warehouse until the cramp passes.
Eventually, the arteries will become completely blocked. If this happens over a long period of time – chronic peripheral arterial disease – the limb that the artery supplies will start to die. The skin grows cold and mottled, and the claudication pain becomes constant, as the tissues plead for oxygen (pain at night is a hallmark of this condition, as lying flat decreases the last trickle of gravity-aided blood flow: sufferers are awoken by an agonising pain in their feet which can only be relieved by hanging them off the side of the bed). Eventually the skin starts to break down, causing deep arterial ulcers that refuse to heal. By this stage, amputation can be an option the patient herself requests. I remember standing beside a 70-year-old lady’s bed as she begged the vascular team to cut off her foot. “Please just take it off,” she said. “Please just take it off.” Morphine was doing nothing.
If the blockage happens suddenly – as it can if a blood clot becomes lodged in an already narrowed vessel – it is a surgical emergency. This is the foot of the medical student’s “Five Ps”: pale, pulseless, paresthesic (ie with altered sensation), painful and perishingly cold. In other words, dead. The patient needs to go to theatre immediately if there is to be any hope of reopening the blocked artery before the tissue loss becomes permanent. “They need to run there, not walk,” explained the surgeon teaching us this. “If only they could.”
Sophie Harrison is a hospital doctor in South Yorkshire