Peripheral Arterial Disease (PAD)
What is peripheral arterial disease (PAD)?
Arteries carry blood rich with oxygen and nutrients away from your heart to the rest of your body. When the arteries that carry blood to your legs become narrowed or blocked, your leg muscles may not receive enough of the blood and oxygen they need to support physical activity. Ischemia occurs when there is not enough oxygen/blood for the muscles during physical activity. Your legs may receive enough blood while you are at rest so that you do not experience any discomfort without activity. This condition is known as peripheral arterial disease (PAD).
However, your muscles need more oxygen when you walk or increase physical activity. Therefore, if the arteries in your legs are narrowed to the point that too little blood reaches your muscles, you may feel leg pain when you walk. Claudication, which physicians also call intermittent claudication because it happens off and on, is a serious warning symptom because people who have it are also at increased risk for heart attack and stroke.
PAD can cause discomfort or pain when you walk. The pain can occur in your hips, buttocks, thighs, knees, shins, or upper feet. Leg artery disease is considered a type of peripheral arterial disease because it affects the arteries, blood vessels that carry blood away from your heart to your limbs. You are more likely to develop PAD as you age. One in 3 people age 70 or older has PAD. Smoking or having diabetes increases your chances of developing the disease sooner.
The aorta is the largest artery in your body, and it carries blood pumped out of your heart to the rest of your body. Just beneath your belly button in your abdomen, the aorta splits into the two iliac arteries, which carry blood into each leg. When the iliac arteries reach your groin, they split again to become the femoral arteries. Many smaller arteries branch from your femoral arteries to take blood down to your toes.
Your arteries are normally smooth and unobstructed on the inside but, as you age, they can become blocked through a process called atherosclerosis, which means hardening of the arteries. As you age, a sticky substance called plaque can build up in the walls of your arteries. Plaque is made up of cholesterol, calcium, and fibrous tissue. As more plaque builds up, your arteries narrow and stiffen. Eventually, enough plaque builds up to reduce blood flow to your leg arteries. When this happens, your leg does not receive the oxygen it needs. Vascular surgeons call this leg artery disease. You may feel well and still have leg artery disease or sometimes similar blockages in other arteries, such as those leading to the heart or brain. It is important to treat this disease not only because it may place you at a greater risk for limb loss but also for having a heart attack or stroke.
What are the symptoms?
You may not feel any symptoms from peripheral artery disease at first. The most common early symptom is claudication. Derived from the Greek word “claudio” meaning “to limp”, claudication is the sensation of pain, cramping, tiredness or weakness in your legs, usually during activity such as walking. The symptoms typically begin when you start to exercise, and go away a short time after you rest. Primarily in the calves, it can also occur in the thighs and buttocks. Claudication often occurs more quickly if you walk uphill or up a flight of stairs. Over time, you may feel claudication at shorter walking distances, as the degree of artery blockage worsens.
Significant peripheral arterial disease may result in something called critical limb ischemia. This occurs when your legs do not get enough oxygen even when you are resting. With critical limb ischemia, you may experience pain in your feet or in your toes even when you are not walking. This is also known as rest pain. In other words, pain at rest; commonly at night in the feet, that is only relieved with either dangling your foot over the side of the bed or else getting up and walking around to allow gravity to help deliver blood to your feet. In severe peripheral artery disease, you may develop painful sores on your toes or feet. If the circulation in your leg does not improve, these ulcers can start as dry, gray, or black sores, and eventually become dead tissue (called gangrene).
What causes peripheral artery disease (PAD)?
Atherosclerosis causes peripheral artery disease. As you get older, your risk of developing leg artery disease increases. People older than age 50 have an increased risk of developing the disease, and men have a greater risk than women. Additionally, smoking, diabetes, high blood pressure (hypertension), high cholesterol, being overweight and lack of exercise are some other risks factors associated with the development of atherosclerosis.
What tests will I need?
First your vascular surgeon asks you questions about your general health, medical history, and symptoms. In addition, your vascular surgeon conducts a physical exam. Together these are known as a patient history and exam. As part of your history and exam, your vascular surgeon will ask you if you smoke or have high blood pressure. Your vascular surgeon will also want to know when your symptoms occur and how often.
After your exam, if your vascular surgeon suspects peripheral artery disease, he or she may order tests, such as an ankle-brachial index (ABI), which compares the blood pressure in your arms and legs. To better understand the extent of your leg artery disease, your vascular surgeon may also recommend duplex ultrasound, pulse volume recording, magnetic resonance angiography (MRA), or angiography.
- Duplex ultrasound uses high-frequency sound waves to measure real-time blood flow and detect blockages or other abnormalities in the structure of your blood vessels.
- Pulse volume recording measures the volume of blood at various points in the legs using an arm blood pressure cuff and a Doppler probe.
- Magnetic resonance angiography (MRA) uses magnetic fields and radio waves to show blockages inside your arteries.
- Computed tomographic angiography (CTA) uses specialized CT scans and contrast dye to show blockages inside your arteries.
- Angiography, which produces x ray pictures of the blood vessels in your legs using a contrast dye to highlight your arteries.
How is leg artery disease treated?
If your peripheral artery disease is detected early, you can make lifestyle changes to help you manage your disease. Things that could help delay or prevent progression of atherosclerosis and peripheral arterial disease include STOP SMOKING, controlling diabetes, lowering high blood pressure and high cholesterol and maintaining an ideal body weight. Additionally, eating foods low in saturated fat and sodium as well as a regular exercise/walking program should also be a part of a healthy lifestyle.
Your vascular surgeon may also recommend medication to treat conditions that worsen or complicate leg artery disease. These medications may include cholesterol-lowering drugs (statins) or blood pressure-lowering medications. You may also need to take medications that reduce blood clotting to minimize the chances of clots blocking your narrowed arteries. If you do not have a disqualifying medical condition, such as heart failure, your vascular surgeon may also prescribe cilostazol (Pletal), which can improve the distance you are able to walk without discomfort or pain. Other drugs your vascular surgeon may prescribe include aspirin and clopidogrel (Plavix), either of which can decrease your chances of developing blood clots.
Exercise therapy is the initial treatment for claudication. Therapeutic exercise recommendations for claudication generally consist of walking for periods of thirty minutes, three or more times per week, for at least 3 to 6 months, ideally under medical supervision. The aim is to increase the amount of time that you can walk without reproducing severe pain in your legs. You will gradually accomplish this by walking for longer and longer periods. At first, you should walk until you experience claudication pain, usually between 3 and 5 minutes after you begin walking. You should then continue walking until the pain becomes moderate (on a scale of 1 to 5, the pain is 3), which is usually at around 8 to 10 minutes of walking. Then you should stop walking and rest until the pain goes away, at which point you should begin walking again. Repeat this cycle of exercise and rest for approximately 35 minutes at the beginning and gradually increase the time until you can walk up to a total of 30 minutes. A sign that you are making progress in your walking program is that you will be able to walk for longer periods without pain. Once you have been able to walk for thirty minutes without significant pain, then gradually increase the speed or intensity of your walking.
Angioplasty and stenting
In some cases of peripheral artery disease, your vascular surgeon may recommend angioplasty and stenting. This procedure is considered to be minimally invasive in comparison to open surgery. It is most effective for more localized blockages in the larger arteries. In an angioplasty, your vascular surgeon inserts a long, thin, flexible tube called a catheter into a small puncture over an artery in your arm or groin. The catheter is guided through your arteries to the blocked area. Once in place, a special balloon, which is attached to the catheter, is inflated and deflated several times. The balloon pushes the plaque in your artery against your artery walls, widening the vessel. In some circumstances, your vascular surgeon may then place a tiny mesh-metal tube, called a stent, into the narrowed area of your artery to keep it open. The stent remains permanently in your artery. After this procedure, blood flows more freely through your artery. Other devices, such as atherectomy catheters (small devices that act like a “roto-rooter” in a clogged pipe) may be deployed as well to help improve blood flow to your legs.
Bypass surgery creates a detour around a narrowed, or blocked, section of a leg artery. To create this bypass, your vascular surgeon uses one of your veins or a tube made from man-made materials. Bypass is considered when it is felt that a blockage is either too severe or in a place (such as the groin or knee joint) that a stent or balloon would not be feasible. Your vascular surgeon attaches the bypass above and below the area that is blocked. This creates a new path for your blood to flow to your leg tissues and is particularly effective for extensive artery blockages.
An endarterectomy is a way for your surgeon to remove the plaque from your artery. To perform an endarterectomy, your vascular surgeon makes an incision in your leg and removes the plaque contained in the inner lining of the diseased artery. This leaves a wide-open artery and restores blood flow through your leg artery. The effectiveness of this method depends upon the particular location and extent of the arterial blockage.
In extreme cases, especially if your leg has gangrene and is not salvageable, your surgeon may recommend amputating your lower leg or foot. Amputation is a treatment of last resort. Vascular surgeons usually only perform it when the circulation in your leg is severely reduced and cannot be improved by the methods discussed already. More than 90 percent of patients with gangrene who are seen by vascular specialists can avoid amputation or have it limited to a small portion of the foot or toes.
This information is intended to be informational for our patients and in no way is meant to be an exhaustive understanding of peripheral arterial disease. We fully recommend you discuss your situation with your physician here at Las Vegas Surgical Associates. Additional information may be found on the Society of Vascular Surgery website at vascularweb.org.
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