Peripheral Arterial Disease

Aesthetic Medicine Today

Peripheral Arterial Disease (PAD)

What is peripheral arterial disease (PAD)?
Peripheral arterial disease (PAD) -- also known as peripheral vascular disease,
atherosclerosis or hardening of the arteries -- is a disorder that occurs in the arteries
of the circulatory system. Arteries are the blood vessels that carry oxygen and
nutrient-rich blood from the heart to all areas of the body.

PAD occurs in the vessels that carry blood to the arms and legs.
Healthy arteries have a smooth lining that prevents blood from clotting and promotes
steady blood flow. In PAD, the arteries slowly become narrowed or blocked when
plaque gradually forms inside the artery walls. Plaque is made of excessive fat,
cholesterol and other substances floating through the bloodstream, such as
inflammatory cells, proteins and calcium. If the arteries become narrowed or blocked,
blood cannot get through to nourish organs and other tissues, causing damage to
the tissues and eventually tissue death.

The rate at which PAD progresses varies with each individual and depends on many
factors, including where in the body the plaque has formed and the person’s overall
health.

What are the symptoms of peripheral artery disease?
PAD can build up over a lifetime, and the symptoms may not become obvious until
later in life. For many people, the outward symptoms of peripheral artery disease will
not appear until the artery has narrowed by 60 percent or more.

The first noticeable symptom of peripheral artery disease may be intermittent
claudication -- leg discomfort, pain or cramping that develops with activity, is relieved
with rest, and recurs upon resuming activity. The pain is often noticed in the calf, but
may also be felt in the buttocks or thighs. Intermittent claudication symptoms may
also include numbness, weakness, heaviness or fatigue in the leg muscles when
walking that are relieved at rest.

The pain can be severe enough to interfere with normal walking. This type of cyclical
pain is caused by reduced blood flow to the leg muscles and goes away at rest
because the muscles require less blood flow at rest.

Other symptoms of advanced peripheral artery disease may include:
•        A burning or aching pain in the feet and toes while resting, especially at night
while lying flat
•        Cool skin in the feet
•        Redness or other color changes in the skin
•        Increased occurrence of infection
•        Toe and foot sores that do not heal
Many people with peripheral artery disease do not have any symptoms.

What are the risk factors for peripheral artery disease?
An individual is at risk for developing peripheral artery disease when one or more of
these risk factors are present:
•        Smoking
•        Diabetes
•        Age: In the United States, people aged 50 and older have an increased risk for
PAD
•        Race: African Americans have a two-fold higher risk of developing peripheral
artery disease compared to other groups
•        History of heart or blood vessel disease: A personal or family history of heart or
blood vessel disease disease may be an indicator for peripheral artery disease
•        High blood pressure (hypertension)

How is PAD detected?
Talk to your doctor if you are having symptoms of PAD so the cause of your symptoms
can be identified and treatment can be initiated as soon as possible. Early detection
of PAD is important so the right treatments can be provided before the disease
becomes severe enough to lead to complications, such as heart attack or stroke.

Your primary care physician can provide a referral to the Acute Response Testing
Center for a testing to determine the cause of your PAD.

An Ankle Brachial Index (ABI) study is a non-invasive vascular test in which blood
pressure cuffs and a hand-held ultrasound device (called a Doppler or transducer) are
used to obtain information about arterial blood flow in the arms and legs. Non-
invasive means the procedure does not require the use of needles, dyes, radiation or
anesthesia. The blood pressure cuffs and Doppler are used to determine the
presence, severity and general location of peripheral arterial occlusive disease.

During this test, blood pressure cuffs are placed on the arms and legs. The cuffs are
inflated, while a hand-held device (called a Doppler) is used to listen to the blood flow
in the leg and arm. The ABI screening helps evaluate the amount of blood flow to the
legs and feet, which is decreased in a person with PAD. It is a highly accurate method
for detecting PAD.

Your physician will compare the two numbers to determine your ABI. Normally, the
blood pressures in your ankle and arm should be about equal. But if your ankle
pressure is half your arm pressure (or lower), your leg arteries may be narrowed.

A pulse volume recording (PVR) is a noninvasive test that measures the blood volume
changes that occur in the legs. During this test, a blood pressure cuff is placed on the
arm and multiple cuffs are placed on the legs. The cuffs are inflated slightly while the
patient is lying down. As blood pulses through the arteries, the blood vessels
expand, causing an increase or decrease in the volume of air within the cuff. A
recording device displays these pulse volume changes as a waveform on a monitor.
Blood pressures are measured before and after exercise on a treadmill and help
define if the pain is due to PAD or other causes. The PVR test also helps locate the
area of blockages in the legs.

A vascular ultrasound is a noninvasive test used to examine blood circulation. During
a vascular ultrasound, a transducer (small hand-held device) is placed on the skin
over the artery to be examined. The transducer emits sound waves that bounce off
the artery. These sound waves are recorded, and an image of the vessel is created
and displayed on a monitor. This test may be used to detect a blockage in an artery.

Other tests may include angiography, CT scan or MRI.
•        During angiography (also called arteriography), contrast material (dye) is
injected into the blood vessels being examined, and X-ray pictures of the inside of
the blood vessels are produced to evaluate blood flow and detect possible blockages.
•        A CT scan is a technique in which multiple X-rays are taken from different
angles in a very short period of time. The images are collected by a computer and
cross-sectional “slices” of the blood vessel are shown on the monitor.
•        MRI uses powerful magnets to create images of internal organs and blood
vessels.

How is PAD treated?
Lifestyle changes, medications and interventional procedures are the treatments
available
for PAD.

Lifestyle changes.
Initial treatment of PAD includes making lifestyle changes to reduce your risk factors.
to modify your risk factors. Initial treatment of PAD includes making lifestyle changes
to reduce your risk factors. Changes you can make to manage your condition include:
•        Quit smoking. Ask your doctor about smoking cessation programs available in
your community.
•        Eat a balanced diet that is high in fiber and low in cholesterol, fat and sodium.
Limit fat to 30 percent of your total daily calories. Saturated fat should account for no
more than 7 percent of your total calories. Avoid trans fats including products made
with partially-hydrogenated and hydrogenated vegetable oils. If you are overweight,
losing weight will help you lower your total cholesterol and raise your HDL (good)
cholesterol. A registered dietitian can help you make the right dietary changes.
•        Exercise. Begin a regular exercise program, such as walking. Walking is very
important and can aid the treatment of PAD. Patients who walk regularly can expect a
marked improvement in the distance they are able to walk before experiencing leg
pain. Ask your doctor if your hospital or clinic offers a structured, supervised walking
program to help you succeed and maximize your exercise efforts.

Manage other related health problems, such as high blood pressure, diabetes or high
cholesterol. Practice good foot and skin care to prevent infection and reduce the risk
of complications.

Foot Care Guidelines
Every day, examine your legs as well as the tops and bottoms of your feet and the
areas between your toes. Look for any blisters, cuts, cracks, scratches or other
sores. Also check for redness, increased warmth, ingrown toenails, corns and
calluses. Use a mirror to view the leg or foot if necessary, or have a family member
look at the area for you.

Once or twice a day, apply a moisturizing cream or lotion to your legs and soles and
top of your feet to prevent dry skin and cracking. Do not apply lotion between your
toes or on areas where there is an open sore or cut. If the skin is extremely dry, use
the moisturizing cream more often. Care for your toenails regularly. Cut your toenails
after bathing, when they are soft. toenails straight across and smooth with a nail file.
If you have diabetes, it is important to see a podiatrist. Do not self-treat corns,
calluses or other foot problems. Go to a podiatrist to treat these conditions.
Don’t wait to treat a minor foot or skin problem. Follow your doctor’s guidelines.

Medications may be recommended to treat conditions such as high blood pressure
(anti-hypertensive medications) or high cholesterol (statin medications).
•        An antiplatelet medication such as aspirin or clopidogrel (Plavix) may be
prescribed to reduce the risk of heart attack and stroke.
•        Cilostazol (Pletal) may be prescribed to improve walking distance. This
medication has been shown to help people with intermittent claudication exercise
longer before they develop leg pain and to walk longer before they must stop
because of the pain. However, not all patients are eligible to take this medication.
Your doctor will tell you if you are eligible.

Interventional procedures. More advanced PAD can be treated with interventional
procedures such as angioplasty (to widen or clear the blocked vessel), angioplasty
with stent placement (to support the cleared vessel and keep it open), or
atherectomy (to remove the blockage).

In some cases, surgical procedures such as peripheral artery bypass surgery may be
performed to reroute blood flow around the blood vessel blockage.

New therapies are currently being researched. Please ask your doctor if any other
treatment options are available for you.

If any of these procedures are recommended, your health care team will give you
more information about the procedures so you will know what to expect.

What are the conditions associated with PAD?
If left untreated, patients with PAD can develop serious health problems, including:
•        Heart attack: permanent damage to the heart muscle caused by a lack of blood
supply to the heart for an extended time
•        Stroke: interruption of the blood flow to the brain
•        Transient ischemic attack (TIA): a temporary interruption in the blood supply to
the brain)
•        Renal artery disease or stenosis: a narrowing or blockage of the artery that
supplies blood to the kidney
•        Amputation: the removal of part or all of the foot or leg (rarely the arm),
especially in people who also have diabetes

Can PAD be cured?
There is no “cure” for PAD. Quitting smoking, exercising regularly, limiting fat and
following a healthy diet, and managing your risk factors—such as diabetes, high
cholesterol and high blood pressure—can help to reduce the progression of the
disease.

Development of Peripheral Arterial Disease
Your arteries are shaped like hollow tubes. Inside, they are smooth and elastic,
allowing blood to flow freely.

Peripheral arterial disease starts when fatty deposits start streaking the blood vessel
walls. The fatty matter builds up. This causes slight injury to your blood vessel walls.
In an attempt to heal itself, the cells release chemicals that make the walls stickier.
Other substances floating through your bloodstream start sticking to the vessel
walls, such as inflammatory cells, proteins and calcium. The fat and other substances
combine to form a material called plaque or atherosclerosis. The plaque builds up and
narrows the artery.

Over time, the inside of the arteries develop plaques of different sizes. Many of the
plaque deposits are hard on the outside and soft and mushy on the inside. The hard
surface can crack or tear, exposing the soft, fatty inside. When this happens,
platelets (disc-shaped particles in the blood that aid clotting) come to the area, and
blood clots form around the plaque. The artery narrows further. Symptoms occur.
The artery may become completely blocked by plaque or a blood clot that lodges in a
narrowed artery. If this occurs, the tissue below the blockage is permanently
damaged and may die (gangrene). This most often occurs in the toes and feet.