Peripheral arterial disease (PAD) is a chronic disorder that affects 12 million Americans and causes reduction of arterial blood flow to the pelvis, legs or arms. If you have PAD, you have an increased risk for heart attack and stroke. This is a common disorder, usually affecting men over 50. People are at higher risk if they have a personal or family history of heart disease or stroke, diabetes, smoking, hypertension, or kidney disease involving hemodialysis.
What Causes Peripheral Arterial Disease?
PAD, also called peripheral vascular disease (PVD), occurs when blood vessels in the legs are narrowed or blocked by fatty deposits, decreasing blood flow to your feet and legs. Though there are multiple causes for the obstruction to blood flow that causes this condition, atherosclerosis, commonly referred to as hardening of the arteries, is the most common cause.
Most patients who suffer from peripheral arterial disease do not have any symptoms. When the arteries to the arm or leg become narrow enough to reduce nutrient- and oxygen-rich blood to the affected extremity, lactic acid begins to build up in the muscles, leading to pain during exercise. The pain has been called “intermittent claudication” and is described as tiredness in the leg, muscle cramps, or severe pain over the muscles. Though similar symptoms may be found in venous disease, arthritis, neuropathy, or spinal disease, patients with arterial claudication only experience symptoms with exercise, which resolve after several minutes of rest. Patients who have multiple obstructed arteries may have severe enough restriction to blood flow that they feel pain in the extremity even when not exercising, have non-healing ulcers, or get gangrene.
- Leg pain associated with exercise
- Numbness of the legs or feet at rest
- Cold legs or feet
- Muscle pain in the thighs, calves or feet
- Loss of hair on the legs or feet
- Change of color of the legs
- Paleness or blueness
- Pulse, weak or absent in the limb
- Walking or gait abnormalities
Diagnosis can be made after a thorough history and physical examination. Arterial Doppler studies provide a baseline to determine the extent of the vascular blockages. When surgery or endovascular therapy is considered, more detailed imaging will be needed to plan treatment. The gold standard for pre-operative planning is an arteriogram, but other less invasive alternatives include CT angiogram and MR angiogram.
Peripheral Arterial Disease Treatments
Treatments vary and depend on the patient’s health and the severity of the diagnosis. Treatment focuses on the relief of symptoms, and self-care to improve circulation. Medications may be required to control the disorder, including pain relievers, blood thinners, and medications to enlarge or dilate affected arteries.
Surgery is done on patients for whom PAD has affected their ability to work or pursue essential activities. Surgery consists of removing the lining of the artery, or repairing or replacing the vessel. Most commonly, bypass surgery is performed, using a vein or synthetic graft.
Alternatives to surgery include balloon angioplasty, followed by stent implantation, laser treatment or other treatments.
Most patients will not need surgery, but do need counseling on lifestyle modifications that can improve their ability to exercise and prevent atherosclerosis from developing in the heart and brain. Since the four major risk factors for developing atherosclerosis are smoking, high cholesterol, diabetes, and hypertension, we encourage patients to stop use of all nicotine products, and address other medical problems with diet or medications.
Exercise also is an important treatment, since patients with PAD will see an improvement in their claudication symptoms after starting a regimented walking program.
When lifestyle modifications and an exercise program do not result in an improvement in their claudication symptoms, there are medications (Pentoxifylline and Cilostazol) that can help them walk farther before having to stop and rest. If a patient with vascular blockages has severe lifestyle-limiting claudication symptoms that don’t respond to the above treatments, or they have rest pain or non-healing leg ulcers, they may need interventional treatment for their vascular blockages.
Endovascular therapy, including angioplasty and stenting of the peripheral arteries, plays a major role in helping patients with PAD. These less invasive procedures can improve blood flow to the extremities, and lessen claudication symptoms. For patients who are not candidates for endovascular therapy, open surgery can remove the arterial obstruction, or a bypass can improve blood flow to the extremity.