Peripheral Arterial Disease (PAD)
What is Peripheral Arterial Disease (PAD)?
Peripheral arterial disease (PAD) is a very common condition that affects between 12 to 20 percent of Americans over age 65. PAD occurs most often in the arteries of the legs but can also affect the arteries that carry blood to the brain, the arms, the kidneys and other vital organs. When blockages affect the arteries to the heart, this is called coronary artery disease. The buildup of plaque in arteries causes the arteries to harden and narrow and this significantly reduces blood flow. This serious condition is called atherosclerosis. Other names for PAD include:
- Hardening of the arteries
- Poor circulation
- Leg cramps from poor circulation
People with hardening of the arteries in the legs also frequently have hardening of the arteries to the heart and brain. This is why PAD is considered a significant marker for increased risk of having a heart attack or stroke. When the blockages in the legs are mild or moderate, treatment for the leg blockages may not be necessary but it is very important to know so you can reduce the risks of heart attack, stroke and disease progression. More serious blockages cause further reductions in blood flow which causes pain during walking and can lead to disabling symptoms that seriously affect quality of life. As further reductions in blood flow occur, some people will develop non-healing ulcers, gangrene and may even risk possible amputation. They tend to have rest pain, which is pain at rest that is relieved by sitting or standing and letting the legs hang down. The legs normally develop redness (rubor) when the legs hang down.
While PAD usually affects the arteries in the legs, atherosclerosis affects all the arteries in your body and can affect the arteries that carry blood from your heart to your head, arms, kidneys, and stomach. Here our focus will be on PAD that affects blood flow to the legs.
How does PAD happen?
As we age, our arteries tend to thicken, get stiffer and narrow. Narrowing of the arteries in the legs can cause peripheral arterial disease or PAD. Peripheral arterial disease occurs when plaque (fat, cholesterol and other substances in the blood) builds up in the arteries that carry oxygen-rich blood to your legs, arms and pelvis.
Although the heart is usually the focus for discussion of atherosclerosis, this disease can and usually does affect arteries throughout your body. When it occurs in the arteries supplying blood to your limbs, it causes peripheral artery disease.
Less commonly, the cause of PAD may be blood vessel inflammation, injury to your limbs, unusual anatomy of your ligaments or muscles behind your knee, or radiation exposure.
What are the risk factors for PAD?
Factors that increase your risk of developing peripheral artery disease include:
- High blood pressure
- High cholesterol
- High triglycerides
- Increasing age, especially after 50 years of age
- A family history of peripheral artery disease, heart disease or stroke
- Excess levels of homocysteine, which can trigger premature vascular disease
People who smoke or have diabetes have the greatest risk of developing peripheral artery disease due to already reduced blood flow. And if you have diabetes AND smoke, this is the worst possible combination for risk you can have.
What are the symptoms of PAD and what should I do?
Many people who have peripheral arterial disease do not have any signs or symptoms while others may have many signs and symptoms.
It is important first to distinguish between PAD and other causes of leg pain since most leg pain is not caused by circulation problems. Night cramps and leg pain while you are sitting, lying or standing is usually not caused by PAD but can be. Pain in your joints, feet or back while walking is most frequently related to one of many musculoskeletal disorders.
Symptoms of PAD are usually very specific. The most common signs include calf or thigh or buttock muscle pain that occurs while walking (not night cramps) and is usually relieved with only 2 to 5 minutes of rest allowing you to walk painfree and normally again until the pain returns and you can rest and repeat this cycle over and over. This is called claudication and occurs when blockages prevent the additional flow of blood and oxygen needed by the muscles for the extra work of walking. The severity of claudication varies widely from mild discomfort to debilitating pain.
If you have leg pain, numbness or other symptoms, do not dismiss this as a normal part of aging. Call your doctor and make an appointment.
Even if you do not have signs or symptoms, ask your doctor whether you should get checked for PAD if you are:
- Age 70 or older
- Age 50 or older and have a history of smoking or have diabetes
- Younger than 50 and have diabetes and one or more risk factors for atherosclerosis
- A strong family history of severe vascular disease requiring surgery for carotid arteries (stroke) and heart attacks
Other signs and symptoms of PAD include:
- Weak or absent pulses in the legs or feet
- Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all
- A pale or bluish color to the skin
- Leg pain that when you sit up and let your legs hang down your feet turn red over the toes and foot (dependent rubor)
- A lower temperature in one leg compared to the other leg
- Poor nail growth on the toes and decreased hair growth on the legs
- Erectile dysfunction, especially among men who have diabetes
If PAD progresses, pain may even occur when you are at rest or when you are lying down (ischemic rest pain). It may even be intense enough to disrupt your sleep and you find that hanging your legs over the side of your bed or walking around your room temporarily relieves the pain. Usually when you let your legs hang down, the affected toes and foot turn red (dependent rubor). You need to see your physician if you have these symptoms because your feet are not getting enough blood flow even at rest.
Your physician or vascular specialist can review your history and risk factors and examine the pulses in your feet and legs. If your pulses are normal, you do not have PAD and appropriate recommendations will be made to your family physician or other specialists. If your pulses are weak or absent, you may well have PAD and require further diagnostic studies.
How is PAD diagnosed?
Peripheral arterial disease is often diagnosed after you report symptoms to your primary care physician or other doctor. It can also be detected or suspected during a regular physical exam. Your primary care physician may check the pulses in your leg arteries by feeling for a pulse to see if it is a strong pulse, if it is weak or if it is absent. Your doctor may also listen with a stethoscope for an abnormal whooshing sound called a bruit which may be a warning sign of a narrowed or blocked artery. He or she may also check whether or not you have any changes in your hair, skin, nails or any poor healing or nonhealing skin that may be signs of PAD.
A correct diagnosis is important because people who have PAD are at higher risk for carotid artery disease, heart attack, TIA (mini-stroke) or a stroke. For that reason you may be referred to a vascular specialist—a doctor who specializes in treating blood vessel diseases and conditions.
Your doctor may ask:
- Whether you have any risk factors for PAD. For example, do you smoke or do you have diabetes.
- Do members of your family have a history of PAD or any history of heart disease or other blood vessel diseases.
- Do your symptoms occur when walking, exercising, sitting, standing, or climbing.
- About your diet.
- About any medicines you take, including prescription and over-the-counter medicines, supplements and anything from the health food store.
During the physical exam, your doctor will look for signs of PAD. Your doctor may compare blood pressure between your limbs to see whether the pressure is lower in the affected limb. He or she also may check for slow-healing or nonhealing wounds to your skin as well as any changes in your hair, skin, or nails that may be signs of PAD.
Non-invasive diagnostic tests
A simple test called an ankle-brachial index (ABI) often is used to diagnose PAD. The ABI compares blood pressure in your ankle to blood pressure in your arm. This test shows how well blood is flowing in your limbs.
Multilevel segmental pressures and index is a simple test that not only compares arm and ankle pressures but arm, thigh and calf pressures as well as toe pressures. This includes Doppler waveform analysis and segmental plethysmography (the volume change under the loose blood pressure cuff that occurs with each heartbeat).
ABI can show whether PAD is affecting your limbs, but it won't show which blood vessels are narrowed or blocked.
A normal ABI result is between 0.96 to 1.20. An ankle to brachial index greater than 1.20 usually indicates blood vessels under the blood pressure cuff that will not compress and are thus yielding falsely elevated pressures ususally from atherosclerotic disease or calcification of the artery from diabetes. The test takes about 10 to 15 minutes to measure both arms and both ankles. This test may be done yearly to see whether PAD is getting worse. If an ankle pressure is too high (calcified vessels), a toe pressure may be more accurate.
Duplex Doppler ultrasound
A duplex Doppler ultrasound looks at blood flow in the major arteries and veins in the limbs. This is much like a fish-finder or submarine detector. This makes pictures of narrowed areas and a directed Doppler takes samples of the blood flow. Color flow can detect turbulence at a site of narrowing and direct to the best area for taking a Doppler sample. During this test, a handheld device is placed on your body and passed back and forth over the affected area. A computer converts sound waves into a picture of the arteries.
The results of this test can show whether a blood vessel is blocked. The results also can help show the severity of a narrowed area.
A treadmill test can demonstrate the severity of symptoms and the level of exercise that produces symptoms. It also helps you understand whether the pain in your calves, thighs, buttocks, or back are secondary to PAD (claudication) or a back ailment. You will walk on a treadmill for this test.
You will have an ABI test before and after the treadmill test. This will help compare blood flow in your arms and legs before and after exercise. A person with normal arteries will have normal ankle pressures within 2 minutes and not longer than 4 minutes after completing the exercise.
Your doctor may recommend blood tests to check for PAD risk factors such as diabetes and high cholesterol and triglycerides
If your vascular specialist determines that you do have PAD and feels it needs further advanced testing, one of the following may be recommended to you:
Magnetic resonance angiogram (MRA)
Using MRI to look at blood vessels and the flow of blood through them is called magnetic resonance angiogram (MRA) and uses magnetic and radiowave energy rather than x-ray. It can find problems of the arteries and veins, such as an aneurysm, a blocked blood vessel, or the torn lining of a blood vessel (dissection). Sometimes contrast material is used to see the blood vessels more clearly. If you have a pacemaker, man-made joint, stent, surgical clips, mechanical heart valve, or other metallic devices in your body, you might not be able to have an MRA. Ask your doctor whether an MRA is an option for you.
CT angiography (CTA)
During this test contrast media is injected into a blood vein, usually in your arm, and a CT scan takes pictures as this flows through your body. This will demonstrate if there is a blockage and help plan for any future procedure if needed.
This is the gold standard. By injecting a dye (contrast material) through a catheter into your arteries, this test allows your doctor to view blood flow through your arteries as it happens. Your doctor is able to trace the flow of the contrast material using X-ray imaging techniques. Catheter angiography is a more invasive procedure that involves guiding a catheter through an artery in your groin to the affected area and injecting the dye that way. Although invasive, this type of angiography is the most accurate and allows for simultaneous diagnosis and treatment — finding the narrowed area of a blood vessel and then widening it with an angioplasty and possibly stenting procedure or administering medication to improve blood flow.
What happens next?
Once the condition of your blood vessels is determined, your vascular specialist will discuss your findings with you and make further recommendations. Recommendations can include any of the above or the following treatments, procedures or preventative measures or a combination.
What is the treatment for PAD?
Treatment for peripheral artery disease has two major goals.
- To manage symptoms, such as leg pain, so that you can resume physical activities.
- To stop the progression of atherosclerosis throughout your body to reduce your risk of heart attack and stroke.
You may be able to accomplish these goals with lifestyle changes including an exercise program. If lifestyle changes are not enough, you need additional medical treatment.
Your doctor may prescribe medicines to:
- Stop smoking. There is medication that may help you stop smoking.
- Treat unhealthy cholesterol levels, unhealthy triglyceride levels and high blood pressure
- Prevent blood clots from forming due to low blood flow
- Help ease leg pain that occurs when you walk or climb stairs
- Cholesterol-lowering medications. You may take a cholesterol-lowering drug called a statin to reduce your risk factor 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 may be to get this even lower if you have additional major risk factors, especially diabetes, or if you continue smoking.
- High blood pressure medications. If you also have high blood pressure, your doctor may prescribe medications to lower it. The goal is to reduce your systolic blood pressure (the top number of the two numbers).
- Medication to control blood sugar. If you have diabetes, it becomes even more important to control your blood sugar (glucose) levels. Talk with your doctor about your blood sugar goals and what steps you need to take to achieve these goals.
- Medications to prevent blood clots. Because peripheral artery disease is related to reduced blood flow to your limbs, it is important to reduce your risk of blood clots. A blood clot can completely block an already narrowed blood vessel and cause tissue death. Your doctor may prescribe daily aspirin therapy or another medication that helps prevent blood clots, such as Plavix.
- Symptom-relief medications. The drug Pletal increases blood flow to the limbs by widening the blood vessels, particularly the ones that go around a blockage. It specifically helps the symptom of claudication (leg pain) for people who have peripheral artery disease. An alternative to Pletal is Trental. However, Trental is generally considered to be ineffective. Both Pletal and Trental have specific side effects. Pletal you may not be able to take if you have congestive heart failure and the Trental causes nausea and your body to feel flush. Trental is used more to stabilize the white blood cells around an open ankle ulcer to promote healing.
Procedures to open blocked arteries
The majority of patients with symptomatic PAD can be treated conservatively with medical and non-interventional management. The most important non-interventional management is a daily walking program. However, in patients with severe PAD symptoms, more aggressive treatment measures may be necessary.
There are a number of ways that vascular specialists can open blood vessels at the site of blockages and restore normal blood flow. In many cases, these procedures can be performed without surgery using modern, interventional radiology techniques. Interventional radiologists, cardiologists or vascular surgeons are highly trained physicians who use tiny tubes called catheters and other miniaturized tools and X-rays to do these procedures.
Sometimes, open vascular surgery is required to remove blockages from arteries or to bypass an occluded area. These procedures are performed by vascular surgeons.
The treatment of PAD can be complex and require the expertise of several overlapping specialists. At the Vascular Center of Wichita Falls, Dr. Brazil will work closely with your other doctors to help you achieve an outcome that gives you the best quality of life.
Prior to performing any intervention most patients will require angiography.
Angioplasty and stenting
Your doctor may recommend angioplasty to restore blood flow through a narrowed or blocked artery. During this procedure, a catheter (a thin tube) with a balloon at the tip is inserted into a blocked artery. The balloon is then inflated, which pushes plaque outward against the artery wall. This widens the artery and restores blood flow.
A stent (a small mesh tube) may be placed in the artery during angioplasty. A stent helps keep the artery open after angioplasty is done. Some stents are coated with medicine to help prevent blockages in the artery. The stents without medication also work well and, in some cases, better.
This is a minimally invasive treatment that does not require major surgery, just a nick in the skin approximately 1/4 inch in length, or about the size of a pencil diameter.
Atherectomy is a procedure that removes plaque buildup from an artery. During the procedure, a catheter is used to insert a small cutting device into the blocked artery. The device is used to shave or cut off plaque. The bits of plaque are then removed from the body through the catheter or washed away in the bloodstream if they are small enough.
Doctors also can do atherectomy using a special laser that dissolves the blockage.
Your doctor may recommend bypass grafting surgery if blood flow in your limb is completely blocked or nearly blocked. For this surgery, your doctor uses a blood vessel from another part of your body or a man-made tube to make a graft.
This graft bypasses (that is, goes around) the blocked part of the artery. The bypass allows blood to flow around the blockage.
This surgery does not cure PAD but it may increase blood flow to the affected limb.
Supervised exercise program
In addition to medications or surgery, your doctor may prescribe a supervised exercise program to increase the distance you can walk pain-free. Regular exercise improves symptoms of PAD by a number of methods, including helping your body use oxygen more efficiently and helping you develop collateral (new small arteries) around the blocked area.
Taking personal action to control your risk factors can help prevent or delay peripheral arterial disease and its complications. Many people can manage the symptoms of peripheral artery disease and stop the progression of the disease through lifestyle changes. To stabilize or improve PAD the following are recommended:
- Stop smoking. Smoking contributes to constriction and damage of your arteries and is a significant risk factor for the development and worsening of PAD. If you smoke, quitting is the most important thing you can do to reduce your risk of complications.
- Exercise. This is a key component. Success in treatment of PAD is often measured by how far you can walk without pain. Proper exercise helps condition your muscles to use oxygen more efficiently. Your doctor can help you develop an appropriate exercise plan. He or she may refer you to a claudication exercise rehabilitation program.
- Eat a healthy diet. A heart-healthy diet low in saturated fat can help control your blood pressure and cholesterol levels, which contribute to atherosclerosis. Diets rich in nutrients — such as vitamins A, B-6, B-12, C and E; folate; fiber; and omega-3 fatty acids — are associated with a lower incidence of peripheral artery disease.
- Avoid certain cold medications. Over-the-counter cold remedies that contain pseudoephedrine constrict your blood vessels and may increase your PAD symptoms. Talk to your pharmacist. He or she can assist you in making an appropriate selection.
Careful foot care
In addition to the above suggestions, take good care of your feet. People with peripheral artery disease, especially those who also have diabetes, are at risk of poor healing of sores on the lower legs and feet. Poor blood circulation can lead to slow healing or not healing and increases the risk of infection. Infection will be much more aggressive with PAD and particularly diabetes and one can have loss of part of the extremity or the extremity with the first infection if this is not immediately managed. The following are recommendations for protecting your feet and reducing risk:
- Wash your feet daily, dry them thoroughly and moisturize often to prevent cracks that can lead to infection. Don't moisturize between the toes, however, as this can encourage fungal growth.
- Visually inspect your feet twice a day. If you are a diabetic, elderly or have severe peripheral arterial disease and you have a neuropathy (loss of feeling), you may never know you have a problem unless you visualize your feet.
- Wear well-fitting shoes and thick, dry socks.
- Promptly treat any fungal infections of the feet, such as athlete's foot.
- Take care when trimming your nails or better still have a podiatrist (foot doctor) trim your toenails for you. NEVER trim your own toenails with a pocket knife or let any one else trim them with a pocket knife.
- Have a podiatrist treat bunions, corns or calluses.
- Avoid walking barefoot even in the house.
- See your doctor at the first sign of a sore or injury to your skin.
We hope the information on these pages is both informative and helpful, but it is intended for education only. Please do note that no web site, no matter how much information is shared, can replace a consultation with your doctor and a vascular specialist. Medical technology and treatment are continually improving and evolving so before making any decision on treatment, it is always advisable to see your doctor first for a comprehensive evaluation of your vascular disease and other medical conditions.
At the Vascular Center of Wichita Falls, we work closely with your other physicians. If you have concerns about your arteries or veins, contact us. A referral is not necessary to make an appointment.