PERIPHERAL ARTERIAL DISEASE
Peripheral arterial disease (PAD) happens when there is a narrowing of the blood vessels outside of the heart. The main cause of PAD is atherosclerosis which happens when plaque builds up on the walls of the arteries that supply blood to the arms and legs. Plaque is a substance made of fat and cholesterol. It causes the arteries to narrow or become blocked. This can reduce or stop blood flow, usually to the legs. If severe enough, blocked blood flow can cause tissue death and can sometimes lead to amputation of the foot or leg.
The main risk factor for PAD is smoking. Other risk factors include older age and diseases like diabetes, high blood cholesterol, high blood pressure, heart disease, and stroke.
Many people who have PAD don't have any symptoms.
If one has symptoms, they may include;
- A lower temperature in one leg than the other leg
- Pain, numbness, achiness, or heaviness in the leg muscles. This happens especially when walking or climbing stairs
- Erectile dysfunction, especially among men who have diabetes
- Weak or absent pulses in the legs or feet
- Sores or wounds on the toes, feet, or legs that heal slowly, or doesn't heal at all
- A pale or bluish color to the skin
- Poor toe nail growth and decreased hair growth on the legs
- PAD can increase your risk of heart attack, stroke, and transient ischemic attack.
When a person develops peripheral artery disease (PAD), their extremities, (usually the legs) don't receive enough blood flow to keep up with demand. This causes symptoms, most notably leg pain when walking (claudication).
Peripheral artery disease is also likely to be a sign of a more widespread accumulation of fatty deposits in the arteries (atherosclerosis), a condition which may be reducing blood flow to the heart and brain, as well as the legs.
Doctors diagnose PAD with a physical exam and heart and imaging tests. Treatments will include lifestyle changes, medicines, and sometimes surgery. Lifestyle changes will include dietary changes, exercise, and efforts to lower high cholesterol levels and high blood pressure.
Quick facts about PAD
The most common symptoms of PAD involving the lower extremities are cramping, pain or tiredness in the leg or hip muscles while walking or climbing stairs. Typically, this pain goes away with rest and returns when you walk again.
Be aware that:
- People mistake the symptoms of PAD for something else.
- PAD often goes undiagnosed by doctors.
- People with peripheral arterial disease have a higher risk of coronary artery disease, heart attack or stroke.
- If left untreated, PAD can lead to gangrene and amputation.
CAUSES
Peripheral artery disease is often caused by atherosclerosis. In atherosclerosis, fatty deposits (plaques) build up on the artery walls and reduce blood flow.
Although discussions of atherosclerosis usually focus on the heart, the disease can and usually does affect arteries throughout the body. When it occurs in the arteries supplying blood to the limbs, it causes peripheral artery disease.
Less commonly, the cause of peripheral artery disease may be blood vessel inflammation, injury to the limbs, unusual anatomy of the ligaments or muscles, or exposure to radiation.
SIGNS AND SYMPTOMS
Approximately a quarter of people with PAD experience common symptoms of the condition. More sufferers have non-typical symptoms, and about a fifth do not experience any symptoms at all. Yet all of them share high risk of cardiovascular disease. Without treatment, PAD may cause sores, infections and even loss of a limb.
Signs and symptoms of PAD can vary but may include:
- Aching
- Pain,
- Heaviness, or cramping in the legs when walking or climbing stairs that goes away after rest.
This is called intermittent claudication and is the most common PAD symptom. The pain is often in the calf, but you may also feel pain in your buttocks, thigh, or foot.
Other symptoms may be;
- Lack of growth of toenails and leg hair
- One foot feeling colder than the other
- Pale, discolored, or blue leg or foot
- Leg weakness or numbness
- Pain or a feeling of pins and needles in the leg or foot
- Pain while at rest in the leg and foot (critical limb ischemia)
- Sores on your toes, feet or legs that won't heal
- Shiny skin on the legs
- No pulse or a weak pulse in your legs or feet
- Erectile dysfunction in men
PAD RISK FACTORS
Smokers and/or those who have diabetes are at especially high risk. If you have risk factors for peripheral artery disease (PAD), get screened for PAD, even if you're not having symptoms.
Certain risk factors for PAD cannot be controlled. These uncontrollable risk factors include aging, personal or family history of PAD, cardiovascular disease or stroke.
However, you can control the following risk factors:
- Cigarette smoking - Smoking is a major risk factor for PAD. Smokers may have four times the risk of PAD than nonsmokers. It will be in the patient's own interest to quit smoking.
- Diabetes mellitus - Manage diabetes and blood sugar levels effectively. Having diabetes puts one at great risk of developing PAD as well as other cardiovascular diseases.
- High blood pressure - Blood pressure must also be managed well. It is sometimes called 'the silent killer' because it has no symptoms. The doctor can work with patients to monitor and control blood pressure.
- High blood cholesterol - Managing your cholesterol levels is essential to prevent or treat PAD. High cholesterol contributes to the build-up of plaque in the arteries, which can significantly reduce the blood's flow. This condition is known as atherosclerosis.
- Obesity - People with a Body Mass Index (BMI) of 25 or higher are more likely to develop heart disease and stroke even if they have no other risk factors. People must learn to calculate their BMI and learn healthy ways to manage their weight.
- Physical inactivity - Physical activity increases the distance that people with PAD can walk without pain and also helps decrease the risk of heart attack or stroke. One of the treatments for PAD patients are supervised exercise programs.
WHEN TO SEE A DOCTOR
People should see their doctors if they experience recurring leg pain when exercising. Many people mistakenly think this is just part of growing older. People should learn not to dismiss leg pain, numbness or other symptoms, and not to dismiss them as a normal part of aging. Even if they don't have symptoms of peripheral artery disease, you may need to be screened if they are:
- Over age 65
- Over age 50 and have a history of diabetes or smoking
- Under age 50, but have diabetes and other peripheral artery disease risk factors, such as obesity or high blood pressure
COMPLICATIONS OF PAD
PAD on its own is not immediately life-threatening, but the process of atherosclerosis that causes it can lead to serious and potentially fatal problems.
Coronary heart disease (CHD)
The blockages in the arteries in the legs can also affect other areas of your body, such as the arteries supplying the heart and brain.
This means that having PAD makes you more likely to develop another form of cardiovascular disease (CVD), such as:
- Angina
- Coronary heart disease
- Stroke
- Heart attack
Critical limb ischemia (CLI)
If the blood flow to the legs becomes severely restricted, it could develop into critical limb ischemia (CLI). CLI is an extremely serious complication that can be challenging to treat.
Symptoms of CLI include:
- A severe burning pain in the legs and feet that continues even when one is at rest
- Pale, shiny, smooth and dry skin
- Wounds and ulcers (open sores) on your feet and legs that do not heal
- The loss of muscle mass in the legs
- The toes or lower limbs becoming cold and numb, and/or beginning to swell and produce smelly pus, causing severe pain
DIAGNOSING PAD
PAD diagnosis normally begins with a physical examination. The doctor will ask about symptoms being experienced.
The doctor will check for weak pulses in the legs. The physical examination may include the following:
Ankle-brachial index (ABI): This is a painless exam that compares the blood pressure in the feet to the blood pressure in the arms to determine how well the blood is flowing. This inexpensive test takes only a few minutes and can be performed by the doctor as part of a routine exam. Normally, the ankle pressure is at least 90 percent of the arm pressure, but with severe narrowing it may be less than 50 percent.
If an ABI reveals an abnormal ratio between the blood pressure of the ankle and arm, more testing may be recommended.
Your doctor may recommend one of these other tests.
Doppler and Ultrasound (Duplex) imaging: A non-invasive method which visualizes the artery with sound waves and measures the blood flow in an artery to indicate the presence of a blockage.
Computed Tomographic Angiography (CT): This test is particularly useful in patients with pacemakers or stents. It also is a non-invasive test that can show the arteries in the abdomen, pelvis and legs.
Magnetic Resonance Angiography (MRA): MRS test gives information similar to that of a CT without using X-rays. A non-invasive test.
Angiography: During an angiogram, also called an arteriogram, a contrast agent is injected into the artery and X-rays are taken to show blood flow, arteries in the legs and to pinpoint any blockages that may be present.
PAD that is left untreated can be dangerous because it can lead to severely painful symptoms or loss of a leg, and moreover, patients with PAD have an increased risk of coronary artery disease, stroke and heart attack. Because people with PAD have this increased risk for heart attack and stroke.
TREATMENT
Treatment for peripheral artery disease has two major goals:
- To manage symptoms, such as leg pain, so that patient can resume physical activities
- To stop the progression of atherosclerosis throughout the body to reduce the risk of heart attack and stroke
You may be able to accomplish these goals with lifestyle changes, especially early in the course of peripheral artery disease. In the case of smokers, quitting is the single most important thing they can do to reduce their risk of complications.
If one has signs or symptoms of peripheral artery disease, they most likely will need additional medical treatment. The doctor may prescribe medicine to prevent blood clots, lower blood pressure and cholesterol, and control pain and the other symptoms.
Medications
Cholesterol-lowering medications. A cholesterol-lowering drug called a statin may be prescribed to reduce the risk of heart attack and stroke. The goal for people who have peripheral artery disease is to reduce low-density lipoprotein (LDL) cholesterol, the 'bad' cholesterol. The goal is even lower if the patient has additional major risk factors for heart attack and stroke, especially diabetes or continued smoking.
High blood pressure medications. If the patient also have high blood pressure, the doctor may prescribe medications to lower it. A blood pressure reading, given in millimeters of mercury (mm Hg), has two numbers. The top number in the reading measures the pressure in your arteries when your heart beats (systolic pressure). The bottom number in the reading measures the pressure in your arteries between beats (diastolic pressure). Normal blood pressure treatment goal should be less than 130/80 mm Hg, which is the guideline for anyone with coronary artery disease, diabetes or chronic kidney disease. Achieving 130/80 mm Hg is also the goal for healthy adults age 65 and older and healthy adults younger than age 65.
Medication to control blood sugar. If patient also has diabetes, it becomes even more important to control blood sugar (glucose) levels. A chat with the doctor about blood sugar goals and what steps needs to be taken to achieve these goals will be necessary.
Medications to prevent blood clots. Because peripheral artery disease is related to a reduced blood flow to your limbs, it may be important to improve that flow. In that effort, the doctor may prescribe daily aspirin therapy or some other medication.
Symptom-relief medications. Cilostazol, is a drug that increases blood flow to the limbs both by keeping the blood thin and by widening the blood vessels. It specifically helps treat symptoms of claudication, such as leg pain, for people who have peripheral artery disease.
Common side effects of this medication include headache and diarrhea. An alternative to cilostazol is pentoxifylline. It's generally less effective than cilostazol, but side effects are rare with this medication.
Angioplasty and surgery
In some cases, angioplasty or surgery may be necessary to treat peripheral artery disease that's causing claudication:
- Thrombolytic therapy. If you have a blood clot blocking an artery, the doctor may inject a clot-dissolving drug into the artery at the point of the clot to break it up.
- Angioplasty. To perform this procedure, a small hollow tube (catheter) is threaded through a blood vessel to the affected artery. There, a small balloon on the tip of the catheter is inflated to reopen the artery and flatten the blockage into the artery wall, while at the same time stretching the artery open to increase blood flow. The doctor may also insert a mesh framework called a stent in the artery to help keep it open. The same procedure is what doctors use to open heart arteries.
- Bypass surgery. The doctor may create a graft bypass with a vessel from another part of the patient's body or a synthetic blood vessel. This technique allows blood to flow around, or bypass the blocked or narrowed artery.
LIVING WITH- PERIPHERAL ARTERY DISEASE
PAD is a lifelong medical condition. Once a person is diagnosed with PAD, they will need to see a doctor who specializes in vascular (blood vessel) diseases regularly. Steps will need to be taken to prevent complications.
A team of healthcare professionals can help with the management of PAD and treat any complications. The patient may need;
- A specialist in vascular (blood vessel) medicine,
- A cardiologist to treat heart disease,
- A radiologist to do imaging tests,
- A vascular surgeon to perform procedures to improve blood flow, infectious disease specialist to treat infections,
- A physical therapist to serve as guide to the exercise program,
- A podiatrist to provide foot care, and
- A nutritionist to help plan healthy meals.
Manage the condition
It is important to get routine medical care and to take all medicines as the doctor prescribes.
Patient must talk with the doctor about the frequency of doctors office visits, blood tests or other tests.
Patients must also call their doctors between visits if they develop leg pain that does not go away after a few minutes of rest or if any other PAD symptoms get worse. Changes in symptoms could be a sign of PAD complications.
Get recommended vaccines, including the pneumococcus and influenza (flu) shots, every year at the start of flu season. Anyone who lives with you or whom you see often should also get regular vaccines.
Patients should also follow up with their doctors regularly to check on risk factors, monitor symptoms, and assess the legs and feet.
Take care of the feet
If a foot sore develops, there will be the need for regular care to help the sore heal and prevent infection. Foot problems are a common complication of PAD.
A lot of people who have PAD also have diabetes. This raises the risk of complications that may lead to amputation (surgery to remove all or part of a foot or leg). Diabetes may also cause nerve problems that make it hard to sense when a foot is injured.
One can reduce your risk for foot ulcers and infections by taking care of the feet.
Always wear socks and shoes. People should wear socks that does not have any seam. They should wear comfortable shoes that fit well and protect their feet. The shoes should have low heels and shock-absorbing soles to reduce pressure on the bottom of the foot. Shoes that have fasteners to prevent rubbing.
Check your feet every day for injuries or sores. If someone has PAD and diabetes, they should have their doctor examine their feet two times a year.
Do walk barefoot. This will be to prevent foot injury that can lead to ulcers and infections, which are more likely when you have poor circulation.
Follow the doctor's instructions. Care for incisions that are made in the skin of your legs or feet during surgery or a procedure for treating PAD.
See your doctor for any foot problems. Treating corns, calluses, long or ingrown nails, or other foot problems yourself could lead to sores or infections.
WOMEN AND PAD
Certain conditions during pregnancy (e.g. pre-eclampsia - a high-blood pressure disorder, or gestational diabetes - high blood sugar during pregnancy), can raise a woman's risk of developing PAD later in life.
PAD affects women and men differently. Women's symptoms for PAD may be worse than that of men. Women who have PAD often cannot walk as far or as fast as men who have PAD. Women also report lower quality of life than men, perhaps because of the difficulty in walking and taking part in daily activities. Depression is also more common in women who have PAD than in men who have PAD.
Diseases linked with PAD
People who have PAD have lifestyle habits and other factors, such as a family history, that make it more likely that they will develop other diseases related to atherosclerosis, including the under listed:
- Heart attack
- Coronary heart disease (i.e. when plaque builds up in the arteries of the heart)
- Sleep apnea
- Diseases that affect the arteries of the brain, including stroke and vascular dementia
- Chronic kidney disease
- Heart failure
- Carotid artery disease, which affects the arteries in the neck
- Atrial fibrillation, a type of irregular heart rhythm
Control blood pressure
It is important to continue with the treatment plan if one has high blood pressure, it is important as well to get regular follow-up care, and learn how to monitor the condition at home. It may be necessary to let the doctor know if there are plans to become pregnant. Attention to these steps can help prevent or delay complications that high blood pressure can cause.
The doctor may adjust the treatment plan as needed to lower or control the high blood pressure.
Follow the diabetes care plan
If the patient has diabetes, the doctor will recommend lifestyle changes, including a special eating plan, and may prescribe medicines to manage blood sugar levels. Managing diabetes carefully can lower the risk of complications.
Be alert for sores on the feet or legs, and people should call their doctor if they see signs of a sore getting infected, such as redness, swelling, pain, or pus, or if you have a fever or chills. To treat sores, the doctor may prescribe antibiotics, clean the sores, remove dead tissue with surgery and apply medicines and bandages to the area.
Manage blood cholesterol levels
If you have unhealthy levels of blood cholesterol, it is important to continue with the treatment. Follow-up care depends on the cholesterol levels, the risk of complications such as a heart attack or a stroke, and the body's response to treatment.
Take care of your mental health
Living with PAD may cause fear, anxiety, depression, and stress. A person may worry about having heart problems or making lifestyle changes that are necessary for good health. Some people become depressed because of problems with walking and daily activities. PAD might also lead to concerns about the risk of amputation.
Patients should talk with their healthcare team about how their persistent feelings. Their doctors may recommend the following steps:
- Seek support from family and friends. Letting loved ones know how the exact situation and what they can do to help can help relieve stress and anxiety.
- Lowering stress levels and learning some coping skills. A patient may be able to live longer and improve their quality of life if they adapt such skills.
- Join a patient support group. This may help one adjust to living with PAD. Patient can find out how other people manage similar symptoms.
- Talk to a professional counselor. The doctor may also recommend medicines or other treatments that can improve your quality of life. However, if the patient has depression or anxiety they might be referred to a professional counselor.
LOWERING THE RISK OF PAD
The more risk factors, the higher the overall risk. Depending especially on age, lifestyle, and other medical conditions, the doctor may recommend the following to help lower a person's risk:
- Getting regular physical activity
- Eating a heart-healthy diet
- Medicines to help control diabetes, cholesterol level, and blood pressure
- Having regular screenings to check blood sugar, cholesterol, and blood pressure levels, weight, and any symptoms of PAD
PREVENTION
The best way to prevent claudication is to maintain a healthy lifestyle. That means:
- Maintain a healthy weight.
- Lower cholesterol and blood pressure levels
- Quit smoking
- Keep blood sugar in good control.
- Exercise regularly with the doctors involvement
- Eat foods that are low in saturated fat.
