Peripheral Artery Disease (PAD) - Facts, Diagnosis, and Treatments
- Publish Date: 2009/06/06 - (Rev. 2017/07/26)
- Author: Thomas C. Weiss
- Contact : Disabled World
Outline: Peripheral artery disease (PAD) is a common form of circulatory problem involving a narrowing of the arteries, which reduces the flow of blood to the limbs.
Peripheral artery disease (PAD) is a common form of circulatory problem involving a narrowing of the person's arteries, which reduces the flow of blood the their limbs. When a person develops PAD their extremities do not get enough blood flow to keep up with the demands of their body, causing symptoms such as leg pain when the person walks.
A disease in which plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of fat, cholesterol, calcium, fibrous tissue, and other substances in the blood. P.A.D. usually affects the arteries in the legs, but it also can affect the arteries that carry blood from your heart to your head, arms, kidneys, and stomach.
Known as, 'Claudication.' PAD can also be a sign of widespread fatty deposit accumulation in a person's arteries, referred to as, 'Atherosclerosis,' a condition that can reduce the flow of blood to the person's brain, heart, and legs.
PAD happens when plaque builds up in a person's arteries that carry blood to their limbs, organs, and head; plaque that is made up of cholesterol, fat, fibrous tissue, calcium and additional substances. Plaque that has built up in a person's arteries is referred to as atherosclerosis, and over a period of time the plaque can both narrow and harden the person's arteries, limiting the amount of blood that gets to their organs and additional parts of their body. PAD commonly affects a person's legs, although it can also affect a person's arms, head, kidneys, and stomach.
Blood flow that has been blocked to a person's legs may cause them to experience both numbness and pain, as well as increasing their risk of infection. If the blockage is severe enough, it may cause tissue death, known as, 'gangrene,' that can lead to amputation of the limb. Persons who experience pain when either walking or climbing stairs need to speak with a doctor. What follows are some additional names that PAD is known by:
- Poor circulation
- Vascular disease
- Hardening of the arteries
- Peripheral vascular disease
- Leg cramps from poor circulation
- Atherosclerotic peripheral arterial disease
As people age, their risk for developing PAD increases. Persons older than fifty are at greater risk of developing PAD. Men are at greater risk of PAD than women are. Additional risk factors for PAD include:
- High blood pressure
- High cholesterol or triglycerides
- Weighing over 30 percent more than your ideal weight
- High levels of homocysteine, an amino acid in your blood
- High amounts of sugar in the blood due to insulin resistance or diabetes
Atherosclerosis is the most common cause of PAD. Atherosclerosis involves fatty deposits, or plaque, that builds up in a person's artery walls, reducing blood flow. A person's heart is most often involved in atherosclerosis, although the disease may and does affect arteries throughout a person's body. When the disease affects an individual's arteries that supply blood to their limbs it causes PAD. In less common cases, PAD may be caused by blood clotting in a person's arteries, unusual anatomy of the person's muscles or ligaments, an infection, or an injury to the person's limbs.
Once damage has happened, the person's body begins to heal. The healing process may cause plaque to build up where the person's arteries were damaged. Over a period of time, the plaque that has accumulated may crack; blood platelets may stick to the injured lining of the person's artery, clump together, and form blood clots. Built-up plaque or blood clots can then narrow or even block the person's arteries, limiting the flow of oxygen-rich blood to their body.
Persons with PAD may not experience any symptoms from the disease at all; at first. One of the early symptoms is referred to as, 'Intermittent Claudation (IC).' IC involves either pain or discomfort in the person's legs that occurs when they walk which disappears when they rest. They may not always experience pain, instead feeling cramping, heaviness, weakness or tightness in their leg when they are active. IC happens more quickly when a person's walks uphill, or up a flight of stairs. Over a period of time, the person may begin to experience IC over shorter walking distances. Approximately fifty-percent of persons with PAD experience blockages which are severe enough to also experience IC.
Persons with advanced PAD may experience a symptom referred to as, 'Critical Limb Ischemia.' Critical limb ischemia happens when a person's legs do not receive adequate amounts of oxygen, even while they are at rest. With critical limb ischemia, the person might experience pain in their toes or feet, even when they are not walking.
In persons who experience severe PAD, they may develop sores on their feet or toes that are painful. If the circulation in these persons legs does not improve, the sores could begin as gray, dry, or black sores; eventually becoming gangrenous, or dead tissue. Signs and symptoms of PAD can include the following:
Painful cramping in the hip, thigh or calf muscles after walking or climbing stairs (intermittent claudication)
- Changes in the toenails
- Leg numbness or weakness
- Hair loss on the feet and legs
- A change in the color of the legs
- A pale or bluish color to the skin
- Weak or absent pulses in the legs or feet
- Sores on the toes, feet or legs that won't heal
- Erectile dysfunction, especially among men who have diabetes
- Coldness in the lower leg or foot, especially when compared with the other leg
Should PAD progress, a person may experience pain even while they are at rest or lying down. The pain may be strong enough to disrupt the person's sleep. Half of all persons who have PAD do not exhibit signs of the disease. Persons who should be checked for PAD include persons who are:
- Age 70 or older
- Age 50 or older and have a history of smoking or diabetes
- Younger than 50 and have diabetes and one or more risk factors for atherosclerosis
The more serious and common complications of PAD include both stroke and heart attack. Atherosclerosis causes signs and symptoms of PAD that is not limited to a person's legs alone. Fatty deposits may also build up in a person's arteries that supply their heart and brain, resulting in an increased risk of coronary artery disease and stroke.
A doctor diagnoses and screens for PAD by asking the person about their medical history, symptoms they have been experiencing, and their general health; they will also conduct a physical examination. Along with the person's history, the doctor will ask if the person smokes, or if they have high blood pressure. The doctor will want to know how often the person experiences the symptoms that they do. Included in the physical examination will be pulse tests, measuring the person's pulse in their arteries behind their knees and feet.
There are a number of tests that a doctor may order in addition to the exam. The tests can help the doctor to both make a diagnosis, as well as to better understand the level of the disease within the person. These tests include the following:
Ankle-brachial index (ABI):
An ABI is one of the most common tests that is used to diagnose PAD, comparing the person's blood pressure I their ankle with that in their arm. A doctor uses a standard blood pressure cuff and an ultrasound device to evaluate the blood pressure and flow. The person might walk on a treadmill while readings are taken both before and after they have exercised.
Using ultrasound imaging techniques such as duplex scanning or Doppler ultrasound, a doctor may be able to evaluate the flow of blood through a person's blood vessels and identify any narrowing or blockages.
Angiography involves injection of a dye into the person's blood vessels, allowing a doctor to view the flow of blood through their arteries. The doctor can then trace the flow of their blood through imaging techniques such as MRI or X-ray imaging, or through Computerized Tomographic Angography (CTA). Catheter Angiography, while more invasive, is also a means of both diagnosis and treatment.
Involves insertion of a catheter through an artery in the person's groin, as well as injection of a dye permitting the doctor to follow the flow of the person's blood flow. With Catheter Angiography, the doctor has the ability to widen a blood vessel with an angioplasty procedure, or administer medication to improve the person's blood flow.
Blood testing may be ordered by a doctor to enable them to measure the person's levels of homocysteine and C-reactive protein, as well as their cholesterol levels.
The kinds of doctors that may become involved in diagnosing and treating PAD include family practitioners, vascular specialists, and cardiologists. Primary care doctors, to include internists and family practitioners, commonly treat persons who have mild PAD. Persons who have more advanced PAD often find themselves involved with a vascular specialist. People who have heart problems such as Coronary Artery Disease (CAD), or have experienced a heart attack, may well find themselves involved with a cardiologist.
Many times, treatment for PAD involves changes in a person's lifestyle. There are a number of lifestyle changes that a person with PAD can make to manage their PAD. These lifestyle changes include:
- Quit smoking
- Lower high cholesterol
- Lower high blood pressure
- Exercising and walking regularly
- Maintaining an ideal body weight
- Eat foods low in saturated fats and calories
- Manage diabetes by maintaining healthy blood sugar levels
A doctor can also prescribe medications to treat PAD that worsens, or complicates leg artery disease. The medications can include drugs to lower the person's cholesterol levels, or ones to lower their blood pressure. A doctor may also prescribe medications to reduce the person's blood clotting with the goal of minimizing the chance of clots that could block the person's arteries. A doctor could prescribe Cilostazol, for person's who do not have heart failure, in order to improve the distance they are able to walk without pain or discomfort. A doctor could ask that a person take simple, over-the-counter Aspirin, or Clopidogrel; these medications also decrease a person's chances of developing blood clots. Regular exercise, in the form of walking at least thirty minutes, three times a week, could help to improve the symptoms persons with PAD experience.
For persons with more severe cases of PAD, lifestyle changes and medications may not improve the symptoms they are experiencing. If this is the case, a doctor may recommend either minimally invasive treatments or surgery. The treatment options depend upon both the pattern and extent of the blockages the person is experiencing, as well as additional factors such as the person's overall health and any other medical conditions the person may have. A vascular surgeon can help to determine which option may be best for the person. What follows is a list of some options:
Angioplasty and Stenting:
Angioplasty and Stenting involves insertion of a catheter into an artery in either the person's arm or groin. The catheter is guided from there to the artery that is blocked. Once the catheter is in place near the blockage, a small balloon is inflated and deflated a number of times, pushing the plaque in the person's artery against the artery walls and widening the artery itself. The surgeon may then place a mesh-metal tube called a, 'stent,' into place in order to widen the person's artery and keep it open. The stent remains in place, allowing blood to flow through the person's artery where the blockage had previously occurred.
Bypass Surgery involves the creation of a detour around the blockage of a section of a person's artery. A vascular surgeon uses a vein or a tube made of man-made materials in order to accomplish the surgery. The surgeon attaches the bypass both above and below the area of the artery that is blocked, creating a new path for the person's blood to flow to their tissues.
Endarterectomy involves removal of the plaque from a person's artery. In order to accomplish this, a vascular surgeon makes an incision and removes the plaque from the lining of the artery. The result is an artery that has a restored ability to allow blood flow through the artery.
Amputation is an option for persons who limb has become gangrenous and is not salvageable; it is a treatment of last resort. A vascular surgeon usually performs this surgery only when the circulation to the limb is so severely reduced that it cannot be improved through other means. Greater than ninety-percent of persons who are seen by a vascular surgeon are able to avoid amputation, or limit the extent of it.