Jalaukaas in coronary block (Bypass to Bypass Surgery)

- Prof. Dr. Muralidhar P. Prabhudesai
M.F.A.M., A.V.P.
Ex- In-charge, Panchakarma Dept.,
Bhaisaheb Sawant Ayurvedic Medical College,
Sawantwadi, Dist. - Sindhudurga, Pin - 416510.

Case report of a pt. with IHD with TVD

Date - 9 March 1995
Name of the pt. – xyz
Age – 65yrs.
Sex – M
Chief Complaints – Dyspnoea on exertion (on walking a few steps, even after talking few words)
- Constipation, passes hard stools after 5-6 days interval
- Poor appetite
- Weakness
- Chest-pain
- Oedema over feet
- Hypertension
- Tingling in Lt. palm
- He used to get up in midnight due to chocking sensation in chest
- Feeling of some swelling (heaviness) in Lt. side of chest
- Consumes lots of Angised / Sorbitrate tabs. per day while walking or talking (20-22 tabs. in a day)
O/E – B. P. 220/110, Pulse – 102/min., Wt.- 59.5 Kgs., Jeevhaa – Saam, Koshtha- Krur, Agni- Manda, Nidra- Khandita, Bala- alpa, Ubhaya Paad-shotha- ++, Twak-sparsha - rookshata ++
Psychologically he was so depressed; he thought that he will never come out.
Past History – This pt. was serving in State Transport (Maharashtra) as Stand –in charge. Due to tight schedule of duties, he was not able to pass urine, whenever mootra-vega was there. As a result of which he developed urinary stones. He had heart-attack in 1980. His CST revealed ischemia. For investigation, he had undergone angiography in Feb. 1982, in Bombay Hospital & he was found to have 12 coronary artery-blocks (five in Rt. Coronary & seven in Lt. Coronary). Due to so many blocks, he was not allowed to undergo bypass-surgery. He was kept on conservative treatment (11 types of tabs. per day) and was admitted in the hospital for 4 mths. & was advised Tab. Angised and/or Tab. Sorbitrate SOS. He resumed his duties as he got little relief.
Due to chronic constipation he used to take Tab. Dulcolax 4 + Patankar Kadha (Laxative) ½ a cup + Kayam Churna (laxative) 1 tsf, very often. Even then he was not satisfied with his bowels (He got relieved temporarily).
After retirement (during 1992 - 1995) again the symptoms got aggravated for which he consulted many physicians but every time there was addition of medicines, without much relief.
He also was detected to have Diabetes mellitus.
Samprapti – Sedentary work (no shareerayas) – malavarodh & waramwar mootravarodh – apaan vaigunya – pratilom gatitah samaan vikruti – aama nirmiti – due to constant mental strain “Kha-vaigunya" in heart (which is moolasthana of Rasavaha & Manovaha srotas) – sthaan-sanshray of aama there – resulting in blocks – again malavarodh due to the medicines given for the ailment & the vicious circle went on. At the same time, Vyana Vayu-dushti (vyano hrudi sthitah…) & Udan-dushti (urah sthanam udanasya) - resulting in bal-hani - shram-shwas & vikruti in vak-pravrutti, prayatna, bal, warna and as mind was involved, due to various tensions (Hrudayam manasah sthanam), he lost his confidence & urja.
Diagnosis - He was diagnosed to have IHD with triple vessel disease + diabetes
With all the medications above, he was not satisfied with the treatment; as he had no much relief.
After retirement again the dose of Tab. Angised & Tab. Sorbitrate was increased since last four years.
After going through his huge file we thought to put him on Shaman (conservatory) treatment, along with the treatment he was advised, initially.
Initial treatment: Abhyantara Chikitsa-
1) Gandharva Haritaki 500 mg. twice a day before meals (apaane)
2) Arogyavardhini Vati 500 mg. twice a day after half of meal (samaan kale – as Munchan karya of Samana vayu was affected) thinking that Kutaki in the formula will do Bhedan of the hard stool. This drug is also Deepak & Pachak, which was expected in this patient.
3) Arjun & Punarnava-mool Quath, 4 tsf after meals (Vyaanodaane) with madhu (which is yogavahi), as anupan. Arjuna is well known for its specific role in Hrudroga. Punarnava is Shothghni & is useful in Hrudroga also (- Dhanwantari Nighantu). Hruday is awasthit sthan of vyana-vayu & this vayu is responsible for Ras-Rakta Samvahan. Vak-pravrutti, bal, urja (which were affected in this pt.) are under control of Udana-vayu, which has its awasthit sthan in Uroguha. So this medicine was given in vyaanodan kale)
4) Shankh Vati SOS ( as the pt. had aadhmaan due to malavarodha)
5) Snehan – As the Pt. was Vata-prakruti according to his age & he had Krura Koshtha & the rutu that time was with vat-prakop (kaalatah) -
1. Abhyantar – Ghrut Sevan (As usual, I had to spend about 15 minutes to convince the pt. about this concept)
2. Bahya - Mahamaash Taila
6) Siddha Jalapaan - Vidang-jeerak-siddha agnisanskaarit Jala (Vidang is Krimighna, which is needed in our area, where people used to drink water from well or river & Jeerak is deepak – Pachak & grahi, so dravashoshak, as the pt. had pedal oedema (udakavah srotovikruti)
7) 4 tsf of Castor Oil at every night, with lukewarm water.
8) Aashwasan Chikitsa - This is very important to support pt.'s positive attitude, especially when dealing with chronic pts. Vaidya should always create confidence in pt.'s mind that he will definitely come out. This helps to modify the state of mind from 'heen' to 'pravar' Satwa. (This is little easier for senior, bald headed Vaidyas).
He was advised to have light meals till his appetite was improved.
After a fortnight when he came for follow-up he was little happy to have bit easy evacuation of his bowels. His appetite was also improved a little more. He was able to reduce the no. of Angised & Sorbitrate by about 12-15 per day.
The same treatment was continued for another fortnight. His symptoms got aggravated in May 1995 after eating Jambu-fal (which is madhur-kashaya rasa pradhan & kashay-ras is known to cause dhamani-sankoch), so he had to increase the dose of Angised & Sorbitrate & as he had a little choking sensation due to ‘Durdin” in June 1995, (because of which he had to increase dose of Angised & Sorbitrate) he was advised to fumigate his bedroom with Vacha & Dhoop.
Then he was admitted in our hospital for Basti-treatment. He was given snehan, swedan & matra-basti of ground-nut oil 60 ml. (in those days Siddha tailas were not available in our area, as nobody was practicing Panchakarma, so we decided to use this oil, as it was freshly prepared in our farms), while going to bed every night for five consecutive nights. (This matra-basti yojana was advised to his on the basis of his 'vat-pradhan age' & malavarodhajanya (i. e. margavarodhajanya) samprapti.) Then after a gap of 2 days (to avoid sneh-saatmya) again matra-basti was repeated for another five nights. After these two courses of matra-basti there was remarkable improvement in his complaints & could get confidence that he will come out of it, soon. But till May 1995, he was not relieved of his chest-pain & he still had to wake up in midnight due to uneasiness in chest & tingling in Lt. palm.
By that time, one of my friend sent me an article from Reader’s Digest (Aug. 1995) titled “Welcome back little blood-sucker” by Alan Road. My friend knew that we were applying leeches for various ailments, in our practice. The article said that “Even though, the leech will suck for only 20-30 minutes bleeding may continue for several hours or so; clearing the most challenging blockage ” – on page no. 82. "Their saliva contains a powerful enzyme capable of rapidly dissolving blood-clots", - on page no. 83. After going through these lines we remembered that our texts, Ashtanga-Hrudaya & Sushrut-Samhita mention the same –
1) Avagadhe Jalaukasaa…………. - A. H., Sutra. 26/54
2) Grathitam Jalajanmabhi: ………..- A. H., Sutra. 26/53
3) Awagadhe Jalauka syaat…… - Sushrut., Shareer., 8/26
Meaning that, leeches are indicated in cases of blood-clots or thrombus.
And then an idea struck my mind – to apply leeches directly over the chest. We discussed our idea with many, but nobody had tried this type of application.
On 07/09/1995 - Pt. told that he was satisfied with his bowel-motions, even after consuming four tsf of Castor Oil, on alternate days. His B. P. was 150/80 mm of Hg.(in spite of stopping all his anti-hypertensive drugs; as he showed signs of hypotension on continuation of the drugs. May be because main cause of hypertension, i. e. tension about his own health, was reduced to a marked extent), Pulse-rate - 78/min. Wt. - 57 Kgs. (as he had no pedal oedema, any more)
We shared the above idea with the patient & after his written consent we decided to implement this novel idea.
On 25/09/1995 - Pt. was admitted in evening. We gave matra-basti of 50 ml. of groundnut-oil, at bed-time.
Next day, on 26/09/1995 we applied five leeches. The leeches left him after about 6 hours. But to our astonishment he had sound & undisturbed sleep that night.
Having encouraged by this result we applied leeches repeatedly after a gap of about a week or two and sometimes after a month even, & day by day the patient showed marked improvement.
Jalauka-application was repeated in Jan. 1996, Feb. 1996 & in April 1996. During all this period he was very happy with Shankh Vati. (It is very easy to know the 'Karmukatwa' of this Vati, as it created 'Vatanuloman' in this pt. so he got relieved with it.) He used to call it - 'a magic pill'.
Again his symptoms were aggravated in June 1996, when he went to meet his only son in Mumbai, so again dose of Angised/Sorbitrate was increased a little. This might be due to the atmospherically polluted conditions in Mumbai. This time we advised him to do Asanas like Pavanamuktasana, Shawasan, & Pranayamas.
By September 1996, his confidence & especially stamina was regained. Tingling sensation in his Lt. palm was stopped, he was able to enjoy undisturbed sleep at night and he was able to walk 5 kms. non-stop & he was able to climb about five stair-cases, initially after resting a while & then many a times without Angised or Sorbitrate. The intake of Angised & Sorbitrate was reduced to maximum two tabs. daily.
Encouraged by the results we decided to investigate the patient by repeating his angiography. After trying a lot we found a source. Fortunately, the head of cardiology department of KEM hospital agreed to carry it out through the donations collected every day, as a special case of research.
After the due schedule of appointment etc. the angiography was carried out, in June 1997, but to our astonishment the reports mentioned that all the previous blocks were increased in size. And naturally the HOD of the department was very annoyed, even though the patient was feeling relieved a lot than before.
After thinking a lot over this case, we came to realize that the previous angiography was done about 13 yrs. ago, when the pt. came to us for the first time. By that time, during those 13 years., many changes must have taken place, which were not on record. This was the main reason why we were unable to present the case, in a conference before Modern Medical Experts, even though there was marked clinical improvement.
This improvement was realized by a Senior Cardiologist in our area, whose advice was sought by the pt. repeatedly, before coming to us. While consulting the case before him, the Cardiologist remarked - "if this is proved, we will have to change all our concepts regarding modern anatomy & physiology……".
The pt., who was told that his life span is not more than 6 months, was awarded a bonus life of 7 more years, that too a pleasant life without any physical or mental stress & he was able to enjoy marriage ceremony of his only son. All this was possible for him because of the Ayurvedic way of thinking. He passed away in 2002, peacefully and without any physical or mental strain.
Many a times it so happens that after Ayurvedic treatment the lab. reports remain unchanged, but the pt. is relieved symptomatically. So, the new entrants in Ayurvedic Stream should take a note of this.
Our Observations in this case -
1) We applied jalaukas for about 12 times, after a gap of at least 8 days.
2) We avoid to take pricks with needle, to apply jalaukas, as we do not like to interfere with their inherited wisdom ( of course, allotted to them, by the God) to seek the site to prick & surprisingly, all the jalaukas applied, sought left lateral part of sternum to suck the blood. Not a single pricked over the central or right lateral part of sternum.
3) The jalaukas took too much time to leave pricked area; many of them took even 7-8 hours, initially. The admitted pt. could move here & there, with one hand over the moist gauze-piece, used to cover the applied jalaukas. (We do not force the jalaukas to leave the site, by applying Haridra or similar………….)
4) Almost all the jalaukas applied initially, vomited dark, very thick, sticky, tantumay & shleshmala blood, while squeezing. It was very difficult to to squeeze them to drain the vitiated blood sucked by them, as a result of which many of the jalaukas, applied initially, were dead after the very first application.
5) The initially squeezed jalaukas got globular & multiple sacs like appearance, as those were not drained properly.
6) Though the pt. was known diabetic healing of the tiny prick wounds took the same time, as in a normal person. (During my professional experience, for last 41 years only, I have come to the conclusion that usually, diabetes cannot be in the list of contraindication for Jalaukawacharan, except in pts. with very high BSL level (above 500 mg/dl.)
7) Not a single Jalauka pricked the same site again for sucking blood.
While concluding -
Whatever relief we could give in this case, the credit goes to the
- Our Gurujan, who gave us inspiration & the 'vision' while thinking about a disease, through Ayurvedic way
- The Samhita-granthas, which guided us from time to time
- "Bhishak-vashyataa" of the pt. who obeyed honestly, each & everything we advised, ( like consuming Eranda-taila daily, preparing quath every day, taking medicines regularly, performing daily asanas and pranayamas, observing the pathya very strictly) and
- The well-wishers like you all.
Actually, we had taken lot of risk to admit the pt. in our clinic, where no major emergency measures were available, there was no 'official' Dr. available in the area of 10 kms. radius, except us two, primary health care center was about 16 Kms. away. So, any emergency situation could have created lot of problems for us. With the blessings of The God Dhanwantari we did not had to face any problem.
To be frank, 'the bye-pass surgery' is a bye-pass to treatment, as the surgeons don't treat the cause. They just give a way to the obstructed flow of blood. They never give guarantee that surgery will prevent further blocks. If this is so, then why not try some other ways like one described here? Perhaps, this, low cost effective remedy, may prove to be an alternative for bypass surgery.
This was possible to accept this kind of case, because the pt. showed full faith with us & he had no other alternative because of his poor financial status.
If this story inspires anybody to try such cases, we will definitely help him/her with our limited capacity. I wished to get attachment to some institute with a large no. of OPD pts., to show positive results in various cases, but I failed to do it. (Dant-Chanak Nyaya).
So friends, I conclude here & wish you all the best in your general practice with Ayurvedic vision.
|| Sarve atra sukhinah santu ||


Contact :
Prof. Vd. M. P. Prabhudesai
Sawantwadi, Dist. - Sindhudurga.
Maharashtra, India. Pin - 416510
Mobile - +919422435323
e-mails - vdmurali13@gmail,com . . . . . . . . . . . . . . . . . . . . . . . . . dr_murali13@yahoo.co.in

Venous ulcers (stasis ulcers, varicose ulcers) are the wounds occurring due to inappropriate functioning of venous valves, usually of the legs. It is one of the most serious chronic venous insufficiency complications.

When a venous valve gets damaged, it prevents the backflow of blood, which causes pressure in the veins that leads to hypertension and, in turn, venous ulcers. Without cleaning and regular dressings, the ulcers usually spread quickly. Venous ulcers can be very painful and may limit mobility and quality of life.

The longer the duration of the venous ulcer, the more is the damage to skin and greater the difficulty in healing. Treating varicose ulcer is a difficult task to the physician and a nightmare for the suffering patient, though different types of treatment modalities are practiced in allied sciences.

In a recent research study ; patients with above conditions provided with Processed castor oil with Neem and Guduchi - 50 ml orally used for Nityavirecana with 50 ml Śunthikashāyam for 3 days. Nityavirecana is the specific therapy in Ayurveda in which the medicine may be processed in oil or as decoction is administered orally for cleansing the bowel and liver system.

This improves the Agni metabolism of the individual. This is the first and necessary step in any enema therapy.On day 4 of management, ManjisthādiBasti karma was started with BalagudūcyādiAnuvāsanaBasti (60 ml) in kālabasti pattern.

Noticeable improvement in the symptoms was seen, it was upto 60% in edematous swelling, burning sensation was reduced up to 40%, and pricking sensation was reduced up to 30% after Nityavirecana. Moreover, Basti karma, edematous swelling was reduced to 95%, Burning sensation to 70%, and pricking sensation was reduced to 80%. Healing of the ulcerous wound started with the proliferative stage by the 3 rd day of the Basti course and the wound got healed up to 90% after the whole course of Basti karma with no adverse event during the entire course of treatment.

Possible action of these therapies-Nityavirecana (bowel and liver system cleansing therapy) Basti karma (medicated drug enema):-
In Ayurveda, this condition is considered as dustavrana and better managed with specific śodhana therapy (Purification therapy).This can be treated successfully with śodhana (purification) and śamana (pacification) therapy. So, the fore mentioned benefits of Nityavirecana (liver and bowel cleansing therapy) and Manjishthābasti (decoction enema therapy) were assessed in alleviating the symptoms and in the healing process of varicose ulcer in the patient.

Digestive and assimilation capacity and enzymatic functions through the liver system was improved by the Nityavirecana. By the laxative actions it created osmotic effects in the gut to suck the extra fluid retained anywhere in the body and is ultimately helpful in the wound healing process. Three days of treatment with Nityavirechana resulted in good appetite, reduction in the edematous swelling around the foot, and starting of granulation tissue formation in the ulcerative wound.

This research concluded that AYURVEDIC THERAPEUTIC PROCEDURES, ŚODHANA (PURIFICATION THERAPY), LIKE NITYA VIRECANA (bowel and liver system cleansing therapy) AND BASTI KARMA (medicated drug enema)ACT ON NON-HEALING ULCERS AND HELP THEM HEAL.

(This research study was conducted by researchers of Department of Panchakarama, KLEU Shri B M K Ayurveda Mahavidylaya, , Belgaum, Karnataka and School of Pharmacy, Faculty of Medical Sciences, University of West Indies, Trinidad & Tobago, West Indies)


(ये सूचना आयुर्वेद विज्ञान के बारे में आपके ज्ञान वर्धन व इसके वैज्ञानिक दृष्टिकोण को समझाने हेतु है.किसी भी रोग से पीड़ित होने पर अपने चिकित्सक के परामर्श अथवा मुझसे drswastikjain@hotmail.com पर संपर्क करने के बाद ही कोई दवा लें.)

India is a developing country and 80% of the population of our country cannot afford expensive healthcare. The facilities provided by the govt are miniscule in front of the giant problem. Shortage of doctors, basic infrastructure, paramedical staff and expensive medicines makes healthcare even more out of reach for a common man. That is the reason we are still struggling with the certain communicable diseases and now added to that is the burden of non- communicable diseases .India is going to be the world capital for heart disease in 2030 as per the WHO report. Diabetes is rampant and there is total lack of awareness about, prevention lifestyle management, hygiene levels, sanitation and the healthy living with the result we have huge load of patients whether it is communicable or non-communicable disease. Added to it is the shortage of man power to treat these patients. As per one study our country has only 20

doctors/10000 population as compared to 650/10000 population in U.S.A. The budgetary provisions for healthcare are so low that even the primary healthcare cannot be delivered efficiently with the result the rural population is the worst sufferers .That is how there is mushrooming of quacks and invaluable lives are at risk.
In such a dismissal scenario only alternative to improve upon the services and making each step in health care delivery more justified and economical we need to look at an evolving healthcare delivery system all over the world and even in developed countries like USA and that is Valve Based Medicine. So far we have been practicing Evidence Based Medicine where in based on the evidence of the disease, we treat it with the most costliest way of treatment. It ignores the logistic of benefit vs cost ratio whether it is concerned with writing costly medicines or adopting the most costliest intervention.
Valve based medicine concept is different from the evidence based medicine concept in the sense that we are treating human being and not symptoms or investigations. The treatment planned has to be based on the effective control of the disease with respect to the perception of the patient and his family in terms

of benefit ratio as compared to the cost involved in it. Let’s say in heart disease a patient having coronary artery disease in two or three vessels can be treated with bypass surgery as well as ballooning and stenting. Now whereas stents will cost him a big money and will also not even be durable so bypass surgery becomes more economical and more durable. So what patient wants here is effective quality of life improvement with an economical and durable procedure .So of course bypass surgery is the best answer here. Similarly a sore throat can be effectively treated with low end antibiotic treatment, supportive therapy instead of expensive and high end antibiotics.
Valve based medicine is a mean to compare all health care interventions on the same scale and a measure that can be combined with the cost of an intervention to arrive at a cost utility ratio . It provides most effective assessment of the patient perceived worth of an intervention. It also measures quality of life and/or length of life. Irony of healthcare industry is that it is one of the few industries where purchasers or the patients are unable to measure the valve of that they purchase.


So Value Based Medicine allows highest quality care, maximization of healthcare rupee and incorporation of patient based perception of quality of life. The goal of Value Based Medicine is to promote what is best for the most important people in healthcare i.e. patients. It provides transparency backed by scientific opinion, communication by personal attention, no scare or fear by involving empathy, economics and 24x7 availability.
Similarly if we come to procedures, Beating Heart Surgery is value based medicine. Minimal invasive surgery goes a step further in that direction as it makes the patient up and about early and patient does not lose productive days of earning and is back to work at the earliest with less stress on the body. Also in terms of logistics there is less ICU stay, less hospital stay, less use of blood products. Value based medicine also incorporates all the forth coming evidence which is percolated to the patient level and helps in decision making for the patients. Now coming to Stent vs Surgery two major trials one in 2009 Syntax trial and the other in Nov, 2012 Freedom trail have clearly established and concluded that is multi-vessel disease and diabetes Bypass Surgery scores over drug coated stents in terms of death, second heart attack and second or repeat intervention.

And all patients with multi-vessel disease should be offered Bypass Surgery as the first option for durable economical treatment. So in this scenario Value Based Medicine promotes that when it come to coronary artery disease each and every patient should meet the surgeon with his angiography report to reach to a conclusion whether he needs to go for stents or surgery. The other thing which our country needs to incorporate into VBM is the availability of cost effective medicines, disposables and equipment. Still most of the equipment, disposables used in high end surgeries is being imported and thereby making huge loss and leading to escalation of prices of these essentials. The government has to encourage use of generic drugs availability of which should be free and easy and encourage manufacture of disposables and equipment our own country .It will do away the huge profit margin taken by the multinational companies when middle men and the dealers add to the cost. There are very innovative products available in India and effort should be done to produce them at mass level and promote it at all levels .In fact all hospital should be told to use them as the first priority.
The infrastructure resources for the primary ,secondary and tertiary healthcare delivery are very less so a policy need to be made where in govt. and private

sector should join hands in making the total available infrastructure at the disposal of all the patient population group. There should not be any differentiation and all available beds should be utilized to the maximum by one and all. It will help in reducing the waiting list and huge queues seen in govt. hospitals today. All it needs is rationalization of compensation to private sector .Today also many govt agencies are utilizing the private resources for tertiary care by reimbursing them the subsidized cost of treatment. Why not it can be applied to primary and secondary care? Public private partnership is another good concept of upgrading and brining secondary and tertiary care in all cities and rural areas. To promote health care delivery in rural area the doctor should be encouraged by arranging for them a good housing ,transport ,and good schooling for their children .In fact the concept of rural dispensaries should be abandoned and what we need is a good primary/secondary health care centre within a radius of 20 kilometers and that area on daily basic should be covered for OPD service by mobile vans with fixed hours backed by strong ambulance service which most states have already adopted. This will help getting the medical and paramedical manpower stationed at these centers as they will get basic facility and necessities of life for themselves and their family and doctor will able to deliver better

healthcare with better facility in terms of equipment and beds in an upgraded hospital environment .It will also help in running the various preventive healthcare programs in true earnest. And then these primary/secondary centres are backed by tertiary care centres whether in private or government sectors at treatment cost rationalized by a committee of experts consisting of knowledgeable people from government and private sector. We need to understand that health is the ultimate necessity of life and is very important for the economic growth of this country. Till we get developed this concept of value based medicine will see us through in building a healthy and capable society which in turn will produce a workforce which will work hard to take this country forward and will make it a world leader.

DEEP VEIN THROMBOSIS


What is deep vein thrombosis (DVT)?

The blood circulation system in our body has arteries and veins. The arteries carry pure blood and veins carry impure blood. The vein system in our legs has two groups of veins; superficial veins and deep veins. The superficial veins are ones which we can see under our skin on legs; while deep veins our hidden in the muscles. The thrombosis means blockage of veins by blood clots. So when deep veins forms clot inside it is called “deep vein thrombosis”. This usually happens in the legs. When that happens suddenly; patient develops pain, catch in the muscles and swelling of the leg; depending on the extent of blockage. If the extent of blockage is large you will have pain, swelling, stiffness. If the extent of block is less you may complain only of cramp or stiffness with pain.
In a few cases these pieces of blood clots in veins can break away and deposit into the blood vessels of lungs. When that happens; person may suffer from breathlessness, chest pain, heart failure and sometimes results in death.




Causes of deep vein thrombosis

There are various causes of deep vein thrombosis. It can be due to slowing of blood due to various reasons like prolonged bed rest, long hours of sitting, dehydration, trauma, recent surgery. The “economy class syndrome” is the formation of blood clots in veins deep within the legs occurring during or just after a long airplane flight, especially in economy class due to prolonged immbolisation and lack of space.
Some patients has increased tendency to form clots. It may due to certain deficiency of blood components. These patients tend to form blood clots more than others. Such individuals have repeated attacks of deep vein thrombosis. In certain diseases persons have more frequency of deep vein thrombosis like cancer, obesity and kidney diseases. Pregnancy is one state where chances of deep vein thrombosis are high due to pressure from uterus and hormonal changes. Women who are taking contraceptive pills are again more prone to DVT due to hormonal changes. Old age, persons with severe infections and patients on chemotherapy are also more prone to DVT.




Treatment of deep vein thrombosis

Deep vein thrombosis can be detected by blood test called “D-dimer”. To know the extent of disease sonography of veins (Color Doppler) is done. This Sonography test will confirm the diagnosis and also it will tell us the extent of disease. In some cases MRI scan will be required.
Once detected one should start treatment early to get best results. If your disease is mild, you can be treated as OPD patient. Doctor will give you blood thinning injections two times daily for 5-7 days and start blood thinning medications. You will also need blood tests to see the appropriate level of medication required for blood thinning. It is better to take rest from your work. If your disease is significant doctor will admit and treat you. This would include blockage of veins in pelvis, migration of blood clot into lungs, old age, and other medical diseases.
If there is considerable disease involving major veins in thigh and pelvis; the blood clots can be melted with blood thinning medicines injected directly into affected veins and clots can be aspirated out of the veins. This treatment is called “catheter directed thrombolysis”. This procedure has to be done within two weeks of start of disease. This is a new method of treatment which has significantly improved the results of treatment. If there is increased risk of blood clot migrating into lungs then doctor can put a filter in inferior vena cava (the large vein in lower trunk formed by joining of both leg veins).
Your blood thinning tablet will continue for six months. You will also be investigated to find out if you have certain deficiency of blood components. Besides this you will be required to wear compression stockings in affected leg. These stockings you will have to wear for two years or more.
Discussion will not be complete without long term effects of deep vein thrombosis. In medical term it is called ‘post thrombotic syndrome (PTS)’. Up to half of the patients who had DVT will suffer from PTS. The symptoms of PTS includes swelling of leg, pain, heaviness, itching, discoloration of skin, varicose veins and even ulcer on legs. It is to avoid these symptoms patients are advised to wear compression stockings for two years or more.
Deep vein thrombosis should be detected early and treated appropriately for early recovery, prevention of complications and decrease chances of long term effects.



Dr Sunil Bhargava MD, DNB, MNAMS
Consultant Interventional Radiology and Vascular Sciences
SevenHills Hospital, Andheri (E), Mumbai 400059
E mail drsunil.b@sevenhillshospital.com ,Mobile +919320182803

Dr Sunil Bhargava is an Interventional Radiologist with experience of over 17 years. He is an expert in endovascular treatment of vascular diseases. His areas of interest include venous ailments like varicose veins, deep vein thrombosis and congenital venous malformations.

Introduction

Peripheral arterial disease (PAD) is a common condition in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD).

Although many people with PAD have no symptoms, some people have painful aching in their legs brought on by walking. These aches will usually disappear after a few minutes of resting.

If you experience recurring leg pain with exercise, see Dr B C Shah. PAD is usually diagnosed through a physical examination by Dr B C Shah.

They will also measure the blood pressure in your leg, using the ankle brachial pressure index (ABPI). This involves comparing blood pressure readings from your arm and your ankle. A difference between these readings may indicate PAD.
Why does it happen?

Peripheral arterial disease is a cardiovascular disease, meaning it affects blood vessels. It’s usually caused by a build-up of fatty deposits in the walls of the leg arteries. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.
Who is affected?

Rates of cases of PAD are strongly associated with older age. It is estimated that it develops in:
2.5% of people under 60
8.3% of people aged 60–69
19% of people over 70

Men are more likely to develop the symptoms of PAD earlier in life than women.

There are certain things that can increase your chances of developing PAD and other cardiovascular diseases, including:
Smoking –by far the single most significant risk factor
Diabetes – both type 1 and type 2 diabetes
High blood pressure
High cholesterol
Treating and preventing peripheral arterial disease

PAD is largely treated through medication and lifestyle changes.

Completely stopping smoking and exercising regularly are the main lifestyle changes that can ease the symptoms of PAD and reduce the chances of the condition worsening.

The underlying causes should also be treated, such as reducing high blood pressure and cholesterol and treating diabetes. Medication can be used to improve blood flow. In some cases, surgery may be needed to treat PAD.
Complications of peripheral arterial disease

While PAD is not immediately life-threatening, the process of atherosclerosis that caused it can lead to serious problems.

Having PAD means you have a much higher risk of developing other serious cardiovascular diseases, such as:
coronary heart disease – a condition where the supply of blood to the heart is restricted, putting you at risk of a heart attack
stroke

Also, if the symptoms of PAD worsen, there is a risk that tissue of the lower leg will begin to die (this is known as gangrene), which in severe cases requires the lower leg to be amputated.

If treatment is successful, and lifestyle changes are maintained, your situation will usually improve.

However, if you are unable or unwilling to make lifestyle changes, especially if your leg pain is getting worse, it is estimated there is a:
One-in-five chance you will experience a non-fatal heart attack or stroke
5% chance that one or both of your legs will need to be amputated
One-in-three chance you will die prematurely

Symptoms of peripheral arterial disease

Many people with peripheral arterial disease (PAD) do not have any symptoms. However, you may feel painful aching in your leg muscles triggered by physical activity such as walking or climbing stairs.

The pain usually develops in your calves, but sometimes your hip, buttock or thigh muscles can be affected. The pain can range from mild to severe.

The pain will usually go away after 5–10 minutes when you rest your legs. Other symptoms of PAD may include:
Hair loss on your legs and feet
Numbness or weakness in the legs
Brittle, slow-growing toenails
Ulcers (open sores) on your feet and legs, which do not heal
Changing skin colour on your legs, turning pale or bluish
Shiny skin
The muscles in your legs may shrink
Men may develop impotence (erectile dysfunction)
When to seek medical advice

If you experience recurring episodes of leg pain, make an appointment with Dr. B C Shah, especially if you are a smoker or have a confirmed diagnosis of diabetes, high blood pressure and/or high cholesterol.

Many people mistakenly think recurring episodes of leg pain are part of growing older. This is not the case. There is no reason why an otherwise healthy person should experience leg pain.
When to seek urgent medical advice

Some symptoms may suggest the supply of blood to your legs has become severely restricted and you may need to see a doctor urgently. These include:
Being unable to move muscles in the affected leg
A sudden loss of normal sensation in the affected leg
Feeling a burning or prickling sensation in the affected leg
Your toes or leg suddenly turns white or blue
The skin on your toes or lower limbs becomes cold and numb, and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain
Causes of peripheral arterial disease

Peripheral arterial disease (PAD) is usually caused by a build-up of fatty deposits on the walls of the arteries inside the legs. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.

People with PAD can experience painful aching in their leg muscles during physical activity because the muscles are not receiving the blood supply they need.

Like all tissue in your body, muscles in your legs need a constant supply of blood to function properly. When you are using your leg muscles, the demand for blood increases four-fold. But if the arteries in your legs are blocked, the supply of available blood cannot meet the demand.

This shortfall between supply and demand causes your muscles to experience painful aches which usually get better when you rest your legs.
Increased risk of PAD

There are some things that cannot be changed which may increase your chances of developing PAD, such as a family history of heart disease and atherosclerosis, or your age.

As you get older, your arteries naturally begin to harden and get narrower, which can lead to atherosclerosis and then PAD.

However, there are many things that can dangerously speed up this process. These are described below.
Smoking

Smoking is the single most important thing that increases your risk of PAD. Smoking can damage the walls of your arteries. Tiny blood cells, known as platelets, will then form at the site of the damage to try to repair it. This can cause your arteries to narrow.

It is estimated that smokers are six times more likely to develop PAD than non-smokers and more than 80% of people who develop PAD are current or former smokers.
Diabetes

If you have poorly controlled type 1 or type 2 diabetes, the excess glucose in your blood can damage your arteries.

People with diabetes are two to four times more likely to develop PAD, and having a combination of poorly controlled diabetes and PAD is a major risk factor for amputation. People with diabetes and PAD are 15 times more likely to need an amputation than people with PAD who do not have diabetes.
High cholesterol

Cholesterol is a type of fat essential for the body to function.

There are two main types of cholesterol:
Low-density lipoprotein (LDL) is the main cholesterol transporter and carries cholesterol from your liver to cells that need it. If there is too much cholesterol for the cells to use, this can cause a harmful build-up in your blood and lead to atherosclerosis. For this reason, LDL cholesterol is known as "bad cholesterol", and lower levels are better.
High-density lipoprotein (HDL) carries cholesterol away from the cells and back to the liver, where it is either broken down or passed from the body as a waste product. For this reason, it is referred to as "good cholesterol", and higher levels are better.

Most of the cholesterol your body needs is made by your liver. However, if you eat foods high in saturated fat, the fat is broken down into LDL ("bad cholesterol").l.
High blood pressure

Your arteries are designed to pump blood at a certain pressure, and if blood pressure is too high (known as hypertension), the walls of the arteries can become damaged. High blood pressure can be caused by:
Being overweight
Drinking excessive amounts of alcohol
Stress
Smoking
A lack of exercise
Homocysteine

Homocysteine is a type of amino acid (molecule that makes up protein) found in the blood. Research has found that 30%–40% of people with PAD have higher-than-average levels of homocysteine in their blood. And one-in-four people who develop leg pain have extremely high levels.

It has been suggested that high levels of homocysteine may damage the walls of the arteries, leading to atherosclerosis, but this has not been proven.

Vitamin B supplements and eating foods high in folic acid, such as green leafy vegetables or wholegrains, are known to lower homocysteine levels. However, researchers found no significant reduction in risk of cardiovascular disease when people with PAD increased the amount of vitamin B and folic acid in their diet.
Diagnosing peripheral arterial disease

If Dr. B C Shah suspects a diagnosis of peripheral arterial disease (PAD), he will carry out a physical examination of your leg.

PAD can cause a number of noticeable signs and symptoms, such as:
Shiny skin
Brittle toenails
Hair loss
The pulse in your leg being very weak or undetectable
Leg ulcers

Dr B C Shah may also ask about your symptoms and personal and family medical histories.
The ankle brachial pressure index

The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assessing how well you are responding to treatment.

While you rest on your back, Dr B C Shah will measure the blood pressure in your upper arm and your ankle. These measurements are taken with a Doppler probe, which uses sound waves to determine the flow of blood in your arteries.

They then divide the second result (from your ankle) by the first result (from your arm).

If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same and the result of your ABPI would be 1.

But if you have PAD, the blood pressure in your ankle will be lower due to a reduction in blood supply, so the results of the ABPI would be less than 1.

In some cases, ABPI may be carried out after getting you to run on a treadmill or cycle on an exercise bike. This is a good way of seeing the effect of physical activity on your circulation.
Further testing

In most cases, Dr B C Shah will be able to confirm a diagnosis of PAD by doing a physical examination, asking about your symptoms and checking your ABPI score.

Further testing is usually only required if:
There is uncertainly about the diagnosis – for example, if you have symptoms of leg pain but your ABPI score is normal.
You do not fit the expected profile of somebody with PAD; for example, you are under 40 and have never smoked.
The restriction of blood supply in your leg is severe enough that treatment may be required.

Additional hospital-based tests that can be used include:
Ultrasound scan – where sound waves are used to build up a picture of arteries in your leg. This can identify exactly where in your arteries there are blockages or narrowing.
Angiogram – a special liquid known as a contrast agent is injected into a vein in your arm. The agent shows up clearly on a computerised tomography (CT) scan or magnetic resonance imaging (MRI) scan and produces a detailed image of your arteries.

In some cases, the contrast agent may be injected directly into the arteries of your leg and X-rays may be used to produce the images.
Treating peripheral arterial disease

There are two main types of treatment used in the management of peripheral arterial disease (PAD).

These are:
Making lifestyle changes to improve symptoms and reduce your risk of developing a more serious cardiovascular disease (CVD), such as coronary heart disease
Taking medication to address the underlying cause of PAD and reduce your risk of developing another CVD. For example, a statin can be used to lower your cholesterol levels.

Surgery may be used in some cases. For example, if you experience pain in your leg while resting or if there is tissue loss. These treatment types are discussed in more depth below.
Lifestyle changes

The two most important lifestyle changes you can make if you are diagnosed with PAD are:
If you currently smoke, you should stop.
Take regular exercise.
Smoking

Quitting smoking will reduce your risk of PAD getting worse and another serious cardiovascular disease developing.

Research has found people who continue to smoke after receiving their diagnosis are five times more likely to have a heart attack and seven times more likely to die from a complication of heart disease than people who quit after receiving their diagnosis.

People who stop smoking usually notice an improvement in their symptoms and an improvement in their ankle brachial pressure index (ABPI) score.
Exercise

Evidence suggests regular exercise helps reduce the severity and frequency of PAD symptoms, while at the same time reducing the risk of developing another CVD.

Research has found that after six months of regular exercise, a person can::
Walk for two to three times longer before experiencing pain
Walk a lot further before experiencing pain
see a 20% improvement in their ABPI score

If you are diagnosed with PAD, it is likely you have not taken part in regular exercise for many years (although this is not true for everyone, such as previously fit people with type 1 diabetes).

The exercise programme usually involves two hours of supervised exercise a week for three months. But ideally, over time, you should be aiming to exercise daily for the rest of your life, as the benefits of exercise are quickly lost if it is not frequent and regular.

The preferred exercise is walking. It is normally recommended you walk as far and as long as you can before the symptoms of pain become intolerable. Once this happens, rest until the pain goes and begin walking again until the pain returns. Keep using this "stop-start" method until you have spent at least 30 minutes walking.

You will probably find the exercise course challenging, as the frequent episodes of pain can be upsetting and off-putting. But if you persevere, you should gradually notice a marked improvement in your symptoms and you will begin to go longer and longer without experiencing any pain.
Medication

Different medications can be used to treat the underlying causes of PAD while reducing your risk of developing another CVD.

Some people may only need to take one or two of the medications discussed below, while others may need all of them.
Statins

If blood tests show that your levels of LDL cholesterol ("bad cholesterol") are high, you will be prescribed a type of medication called a statin.

Statins work by helping to reduce the production of LDL cholesterol by your liver.

Common side effects of statins include:
Digestive disorders, such as constipation and diarrhoea
Difficulty sleeping (insomnia)
Pain in the muscles and joints
Feeling sick (nausea)
Antihypertensives

Antihypertensives are a group of medications used to treat high blood pressure (hypertension).

It is likely you will be prescribed an antihypertensive drug if your blood pressure is higher than 140/90mmHg if you do not have diabetes, or 130/80mmHg if you do have diabetes.

A widely used type of antihypertensive is an angiotensin-converting enzyme (ACE) inhibitor.

ACE inhibitors block the actions of some hormones that help regulate blood pressure. They help to reduce the amount of water in your blood and widen your arteries, which will both decrease your blood pressure.

Side effects of ACE inhibitors include:
Dizziness
Tiredness or weakness
Headaches
A persistent dry cough

Most of these side effects pass in a few days, although some people find they still have a dry cough.

If side effects become particularly troublesome, a medication that works in a similar way to ACE inhibitors, known as an angiotensin-2 receptor antagonist, may be recommended.

ACE inhibitors can cause unpredictable effects if taken with other medications, including some over-the-counter ones, so check with Dr B C Shah before taking anything in combination with this medication.
Antiplatelets

One of the biggest potential dangers if you have atherosclerosis is a piece of fatty deposit (plaque) breaking off from your artery wall. This can cause a blood clot to develop at the site of the broken plaque.

If a blood clot develops inside an artery that supplies the heart with blood (a coronary artery) it can trigger a heart attack. Similarly, if a blood clot develops inside any of the blood vessels going to the brain, it can trigger a stroke.

You will probably be prescribed an antiplatelet medication to reduce your risk of blood clots. This medication reduces the ability of platelets (tiny blood cells) to stick together, so if a plaque does break apart, you have a lower chance of a blood clot developing.

Low-dose aspirin (usually 75mg a day) is usually recommended.

Common side effects of aspirin include:
Irritation of the stomach or bowel
Indigestion
Nausea (feeling sick)

If you are unable to take aspirin (for example, if you have a history of stomach ulcers or you are allergic to aspirin), an alternative antiplatelet called clopidogrel can be used.

Side effects of clopidogrel include:
Diarrhoea
Pains in your stomach and bowel
Nosebleeds
Bruising
Blood in your urine
Blood in your stools
Naftidrofuryl oxalate

Naftidrofuryl oxalate improves blood flow in the body, and is often used if you prefer not to have surgery or your supervised exercise programme has not led to satisfactory improvement in your condition.

Side effects of naftidrofuryl oxalate include:
Dizziness
Headache
Stomach pains
Diarrhoea
Rashes
Surgery

There are two main types of surgical treatment for PAD:
Angioplasty – where a blocked or narrowed section of artery is widened by inflating a tiny balloon inside the vessel
Bypass graft – where blood vessels are taken from another part of your body and used to bypass the blockage in an artery
Angioplasty vs bypass surgery

Both types of surgery have their own set of pros and cons.

An angioplasty is less invasive (it does not involve making major incisions in your body). It is usually performed under a local anaesthetic as a day procedure. This means you will be able to go home the same day you have the operation. You also feel less pain after an angioplasty. However, the improvement in symptoms varies from person to person and may only last for around 6-12 months.

Bypass surgery, which is usually only used when angioplasty is not suitable or if it has failed, has a longer recovery time (around two to three weeks). However, the improvement in symptoms usually lasts for longer than a year.

However, after two years, both techniques have broadly the same success rate of improving symptoms.

Both techniques carry a risk of causing serious complications such as a heart attack, stroke and even death. One study found that the risk of death for angioplasty was around one person in every 200, and the risk for bypass graft was slightly higher – around two to three people in every 100.

Before recommending treatment, a team of specialist surgeons, doctors and nurses will discuss the options with you – including the potential risks and benefits.

Surgery is not always successful in treating PAD and is usually only recommended under the following circumstances:
Your leg pain is so severe it prevents you from carrying out everyday activities.
Your symptoms have failed to respond to treatments discussed above.
The results of tests, such as ultrasound scans, show surgery is likely to improve symptoms.

Both techniques are discussed in more detail below.
Angioplasty

A tiny hollow tube known as a catheter is inserted into one of the arteries in your groin. The catheter is then guided to the site of the blockage.

On the tip of the catheter is a balloon which is inflated when the catheter is in place. This helps widen the vessel. Sometimes a hollow metal tube known as a stent may be left in place to help keep the artery open.

Read more about angioplasty.
Bypass graft

If angioplasty is unsuccessful or unsuitable, a bypass graft may be performed. During surgery a length of a healthy vein in your leg is removed. The vein is then joined (grafted) above and below the blocked vein so the blood supply can be rerouted, or bypassed, through the healthy vein. Sometimes a section of artificial tubing can be used as an alternative to a grafted vein.
Complications of peripheral arterial disease

The build up of fat in the arteries (atherosclerosis) that causes peripheral arterial disease (PAD) can also lead to other serious conditions.
Critical limb ischemia (CLI)

Critical limb ischemia (CLI) is a condition that occurs when blood flow to the limbs is severely restricted from atherosclerosis.

Symptoms of CLI include:
A severe burning pain in your legs and feet even when you are resting; the pain often occurs at night and episodes of pain can last several hours. You may find you have to hang your legs out of bed to get relief.
Your skin turns pale, shiny, smooth and dry.
You may develop wounds and ulcers (open sores) in your feet and legs that show no sign of healing.
The muscles in your legs begin to waste away.
The skin on your toes or lower limbs becomes cold and numb and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain.

If you think you are developing the symptoms of CLI, contact Dr. B C Shah immediately.

CLI is treated using an angioplasty or bypass graft (Read about treating peripheral arterial disease for more information on these operations). However, these may not always be successful and you may be advised to have an amputation below the knee. Around one-third of people with CLI will require an amputation.

CLI is an extremely serious complication that can be challenging to treat. Around one in four people will die from a complication of CLI, such as infection.
Heart attack and stroke

The build up of fat in the arteries in the legs that causes PAD can also affect other areas of your body too, such as the arteries supplying the heart and brain.

Blockages in these arteries can cause a heart attack or a stroke
Preventing peripheral arterial disease

The most effective way to prevent peripheral arterial disease (PAD) or stop your symptoms of PAD worsening is to tackle the build up of fat in your arteries (atherosclerosis).

There are five main ways you can achieve this:
Stop smoking
Eat a healthy diet
Take regular exercise
Lose weight (if you are overweight or obese)
Moderate your consumption of alcohol

These lifestyle changes are discussed in more detail below.
Smoking

If you smoke, it is strongly recommended you quit as soon as possible. T

It is recommended you use an anti-smoking treatment such as nicotine replacement therapy (NRT) or bupropion (a medication used to reduce cravings for cigarettes). People who use these treatments have a much greater success rate in permanently quitting than people who try to quit using willpower alone.

It is recommended you eat two to four portions of oily fish a week. Oily fish contains a type of fatty acid called omega-3, which can help lower your cholesterol levels.

Good sources of omega-3 include:
Herrings
Sardines
Mackerel
Salmon
Trout
Tuna

If you are unable or unwilling to eat oily fish, Dr B C Shah may recommend you take an omega-3 food supplement. However, never take a food supplement without first consulting Dr B C Shah. Some supplements, such as beta-carotene, can be harmful.

It is also recommended you eat a Mediterranean-style diet. This means you should eat more bread, fruit, vegetables and fish and less meat. Replace butter and cheese with products that are vegetable and plant-oil based, such as olive oil.
Weight management

If you are overweight or obese, aim to lose weight and maintain a healthy weight by using a combination of regular exercise and a calorie-controlled diet.
Alcohol

If you drink alcohol, do not exceed recommended daily limits (three to four units a day for men and two to three units a day for women).

A unit of alcohol is roughly half a pint of normal-strength lager, a small glass of wine or a single measure (25ml) of spirits. Regularly exceeding recommended alcohol limits will raise your blood pressure and cholesterol level, which will increase the risk of your PAD symptoms worsening and increase your risk of developing another more serious type of cardiovascular disease.

Contact Dr. B C Shah if you find it difficult to moderate your drinking. Counselling services and medication can help you reduce your alcohol intake.
Regular exercise

If you do not have PAD, then a minimum of 150 minutes of vigorous exercise a week is recommended. The exercise should be strenuous enough to leave your heart beating faster, and you should feel slightly out of breath afterwards.

Activities that you could incorporate into your exercise program include:
Brisk walking
Hill climbing
Running
Cycling
Swimming

If you find it difficult to achieve 150 minutes of exercise a week, start at a level you feel comfortable with. For example, you could do 5–10 minutes of light exercise a day and then gradually increase the duration and intensity of your activity as your fitness begins to improve.