• Diabetes mellitus – Diabetes promotes the development of atherosclerosis by disrupting platelet aggregation and causing endothelium and smooth muscles cell dysfunction. It predominantly affects the smaller blood vessels below the level of the knee (microvascular disease) and significantly increases the risk of an amputation.

• Hypertension (high blood pressure) – Poorly controlled blood pressure damages the arteries and increases the risk of atherosclerosis. A target blood pressure of less than 130/85mmHg is recommended to reduce the risk of PAD.

• High blood cholesterol – Elevated levels of the “bad” LDL-cholesterol are associated with an increased risk of atherosclerosis. Guidelines recommend reducing LDL-cholesterol levels to <70mg/dl which can be achieved by compliance with dietary modifications and medications.

• Bypass surgery – a prosthetic (plastic) tube graft or a harvested vein graft is attached from a proximal healthy segment of the artery to a distal healthy part of the artery, thus allowing blood to flow to the foot and bypassing the blocked arterial segment affected by PAD.

• Wires – These are akin to the railroads over which the other devices pass along to reach the target lesion. They come in various sizes, lengths and stiffness, and must be passed under X-ray guidance across the arterial lesion to be treated.

• Catheters – Catheters are long narrow tubes which are passed over wires to aid in their movement within the vessel. Medications that dissolve clots or cause artery dilatation can also be infused into the vessel via these catheters.

• Balloons – After a wire has been passed across the target lesion, various diameter and length balloons can then be tracked along the wire and inflated to open the narrowed/blocked artery. The balloons are sometimes coated with medication which can reduce the risk of recurrence of the atherosclerotic plaque. The balloon is deflated and removed at the end of the procedure.

• Stents – Occasionally, the atherosclerotic plaque is very bulky and narrows the artery lumen almost immediately after the balloon is deflated. In such instances, a stent (wire mesh-like tube) can be inserted to keep the lumen open. The stent remains in the vessel and is not removed.

• Atherectomy/thrombectomy devices – Specialized devices which can extract out atheroma or clots are occasionally used for very severe cases.

[https://www.emergency-live.com/health-and-safety/anticoagulants-what-they-are-and-when-they-are-essential/]

After surgery for PAD, adherence to lifestyle and dietary modifications targeting the risk factors associated with PAD, can significantly reduce the risk of recurrence of the disease (see above section “How can I prevent myself from getting Peripheral Artery Disease?” for details). Taking the “blood-thinning” medications such as Rivaroxaban or Clopidogrel can also contribute to the prevention of PAD recurrence. Of utmost importance is to attend regular medical appointments and seek medical attention urgently in the event rest pain, ulcers or gangrene occur. The earlier treatment is initiated for recurrent PAD, the better the chances of good outcomes and avoidance of a major amputation.

Conclusion and personal comments

Peripheral arterial disease is increasing in frequency in Singapore, mainly due to the increased incidence of diabetes. It is a debilitating disease which if not treated early, can lead to irreversible gangrene and ultimately lower limb major amputations. The good news is that advancement in technology has allowed surgeons to treat more than 90% of such cases via a minimally invasive endovascular approach. Endovascular surgery has been a game-changer, allowing PAD to be treated under local anesthetic and in many cases as a day surgery procedure, allowing even very frail patients with multiple medical conditions to benefit from surgery and avoid a major amputation.

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Dr Chen Min Qi profile 

Dr. Chen Min Qi is a fellowship-trained Vascular and Endovascular Surgeon who graduated from the National University of Singapore in 2005. He subsequently completed his basic and advanced training in General and Vascular Surgery while obtaining the Member of Royal College of Surgeons of Edinburgh (MRCSed) qualification in 2010, and the Master of Medicine (General Surgery) qualification in 2015. Dr Chen was subsequently successful at the fellowship exams obtaining the Fellow of Royal College of Surgeons of Edinburgh (FRCSed) qualification in 2016.

Upon completion of his advanced surgical training, Dr Chen Min Qi joined the newly opened Ng Teng Fong General Hospital (NTFGH) as a specialist in the Vascular Surgery division. In 2018, Dr Chen was awarded the Health Manpower Development Plan (HMDP) grant from MOH to undergo further subspeciality Vascular training at the internationally renowned St Mary’s Hospital in London, United Kingdom. There Dr Chen gained further experience in surgeries on complex abdominal and thoracoabdominal aortic aneurysms, redo open repair of abdominal aortic aneurysms following failed EVAR surgeries as well as carotid endarterectomy surgery and lower limb revascularization surgeries.

Upon his return in 2020, Dr Chen Min Qi joined the newly formed Woodlands Health as head of their Vascular service, before joining his current practice at the Vascular and Interventional Centre in January 2023.