Peripheral arterial occlusive disease (PAOD)

Peripheral arterial occlusive disease (PAVD) is a common vascular disease affecting the extremities, especially the legs. PAOD causes progressive narrowing of the arteries, resulting in a lack of oxygen to the affected limbs. This can lead to severe pain, limited mobility, ulceration and, in the worst case, amputation of the affected limb *. Up to 30% of the population is affected * *. In severe cases, spinal cord stimulation can relieve pain and improve circulation.

How is PAOD classified?

According to Fontaine, PAOD is divided into 4 stages from I to IV.

StageSymptoms
Ino symptoms
IIintermittent limping (claudicatio intermittens)
II awalking distance without pain > 200 m
II bwalking distance without pain < 200 m
IIIpain at rest with horizontal position of the affected limbs
IVtrophic disorders, functional tissue changes, necrosis (tissue destruction), ulcer (tissue ulcer), gangrene

What are the treatment options?

Classical therapy

Peripheral arterial occlusive disease is usually treated by specialists in cardiology, angiology or vascular surgery. Classic therapy includes:

  • modification of risk factors
  • lifestyle changes
  • medications
  • interventional procedures (angioplasty and stenting)
  • surgical procedures (bypass surgery) *

Spinal cord stimulation (SCS)

In patients with persistent pain, mostly patients in stage III or IV, but better in patients who are still in stage II b, spinal cord stimulation (SCS) can be a therapeutic option. SCS is mainly used after conventional therapy options have been exhausted. It not only relieves pain, but can even improve blood flow to the extremities and heal ulcers * and possibly save patients from amputation *.

Spinal cord stimulation

How does spinal cord stimulation work?

Spinal cord stimulation involves implanting electrodes in close proximity to the spinal cord. A neurostimulator sends electrical impulses through these electrodes to the spinal cord.

The exact mechanisms of SCS are not yet fully understood. Due to the anatomical location close to the posterior cord tracts (in the dorsal region of the spinal cord), a cascade of molecular reactions is triggered, which eventually release nitric oxide (NO). Nitric oxide is a potent vasodilator molecule.

There also appears to be a modulation of the fibers of the autonomic nervous system (sympathetic nervous system).

Overall, the effects lead to vasodilatation and consequently to increased blood flow to the tissues *.

Studies on research into spinal cord stimulation for PAOD

According to the Neuromodulation Appropriateness Consensus Committee (NACC) guidelines, spinal cord stimulation is recommended for the treatment of nerve disorders caused by inadequate blood flow, known as ischemic neuropathies *.

  • As early as 1995, Jivegard et al. were able to demonstrate a significant reduction in the amputation rate in a randomized study based on 51 patients *.
  • In 1999, Ubbink et al. showed a significantly reduced rate of amputations by treatment with SCS in a subgroup of 120 patients with critical leg ischemia *.
  • In another study with 71 patients, the amputation rate after 12 months of conservative therapy was compared with that after SCS. The SCS group performed 33% better. In addition, pain was significantly reduced in this group *.
  • Horsch et al, in a retrospective study of 258 patients who were not eligible for revascularization, found a significantly reduced amputation rate with improved blood flow and a significant reduction in pain *.
  • Patients who did not undergo vascular surgery showed significant pain reduction and improvement in quality of life after a 12-month follow-up in a small study *.
  • In 2009, a large retrospective cohort study of 98 patients showed good pain reduction in 85% of cases *.

References

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  2. Newman AB, Shemanski L, Manolio TA et al. Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. The Cardiovascular Health Study Group. Arterioscler Thromb Vasc Biol. 1999;19:538-545.

  3. Murabito JM, Evans JC, Nieto K, Larson MG, Levy D, Wilson PW. Prevalence and clinical correlates of peripheral arterial disease in the Framingham Offspring Study. Am Heart J. 2002;143:961-965.

  4. White C. Clinical practice. Intermittent claudication. N Engl J Med. 2007;356:1241-1250.

  5. Klomp HM, Spincemaille GH, Steyerberg EW, Habbema JD, van Urk H. Spinal-cord stimulation in critical limb ischaemia: a randomised trial. ESES Study Group. Lancet. 1999;353:1040-1044.

  6. Deogaonkar M, Zibly Z, Slavin KV. Spinal cord stimulation for the treatment of vascular pathology. Neurosurg Clin N Am. 2014;25:25-31.

  7. Deer TR, Mekhail N, Provenzano D et al. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee. Neuromodulation. 2014;17:515-50; discussion 550.

  8. Jivegård LE, Augustinsson LE, Holm J, Risberg B, Ortenwall P. Effects of spinal cord stimulation (SCS) in patients with inoperable severe lower limb ischaemia: a prospective randomised controlled study. Eur J Vasc Endovasc Surg. 1995;9:421-425.

  9. Ubbink DT, Spincemaille GH, Prins MH, Reneman RS, Jacobs MJ. Microcirculatory investigations to determine the effect of spinal cord stimulation for critical leg ischemia: the Dutch multicenter randomized controlled trial. J Vasc Surg. 1999;30:236-244.

  10. Amann W, Berg P, Gersbach P et al. Spinal cord stimulation in the treatment of non-reconstructable stable critical leg ischaemia: results of the European Peripheral Vascular Disease Outcome Study (SCS-EPOS). Eur J Vasc Endovasc Surg. 2003;26:280-286.

  11. Horsch S, Schulte S, Hess S. Spinal cord stimulation in the treatment of peripheral vascular disease: results of a single-center study of 258 patients. Angiology. 2004;55:111-118.

  12. Brümmer U, Condini V, Cappelli P et al. Spinal cord stimulation in hemodialysis patients with critical lower-limb ischemia. Am J Kidney Dis. 2006;47:842-847.

  13. Reig E, Abejón D. Spinal cord stimulation: a 20-year retrospective analysis in 260 patients. Neuromodulation. 2009;12:232-239.