Peripheral Arterial Disease

What Is Peripheral Arterial Disease (PAD)?

Peripheral arterial disease (also called peripheral artery disease or peripheral vascular disease, PVD), is a disease in which blood flow to your limbs is limited due to narrowed or blocked arteries. Over time, our arteries tend to build up a fatty material that can block blood flow completely. As the lower extremities receive less oxygen, muscle groups and tissue below the blockages may suffer lower bloodstream oxygen. Because of this, patients may experience pain or cramping–called claudication. Imagine holding your breath for two minutes, and then imagine that pain being in your foot every time you take a few steps. Along with pain, however, reduced blood flow over time can lead to the formation of wounds, limited ability to heal, gangrene, and eventually limb loss. This is especially pronounced in smokers, diabetics and patients with renal failure.

What is Critical Limb Ischemia (CLI)?

PAD is often underrecognized and undertreated. Some patients may progress from cramping in their legs while walking, to cramping and pain at rest. Other patients may have no preceding symptoms and still develop this “ischemic rest pain”. In this state, the foot or leg may be in a state of constant, burning pain or numbness, particularly when elevated, and will usually be relieved with the foot put back on the floor (because gravity is able to pull the blood back down into the foot). These patients are in a critical state–their lower limbs are not receiving enough blood even in a resting state. Patients in this category are at significantly higher risk of non-healing wounds, ulceration (hole in the foot), or gangrene (dead or blackened tissue). Unless the underlying disease is managed, many of these people will have an amputation of the affected leg or die of a heart attack or stroke.

If you have rest pain or wounds in your feet (particularly if you are a smoker, diabetic or dialysis patient), contact our vascular specialists NOW.

PAD Causes

Like most diseases, it can be difficult to pinpoint a single, ultimate cause for peripheral arterial disease. Instead, it is typically a combination of genetics, pre-existing illnesses, and lifestyle factors that give way to the buildup of plaque in arterial structures. There are several known risk factors associated with PAD to be aware of:

  • Smoking
  • Over the age of 50
  • High Blood Pressure
  • High Cholesterol
  • Stroke
  • Obesity
  • Diabetes
  • Chronic Kidney Disease
  • Coronary Heart Disease
  • Any family history of the above listed ailments.

PAD Symptoms

Again, the symptoms of PAD often go unnoticed by many patients and physicians alike. Here are some things to look out for:

This is a symptom often overlooked by many of our patients, believing that it is a consequence of age. Intermittent claudication is reproducible--meaning that it recurs over almost the same distance every time--and feels like burning, a cramp, or extreme fatigue in the limb. However, in some patients, particularly those who do not move frequently, the disease may be present but silent.
  • Pain or tiredness in the calf, thigh, or buttock when walking that is relieved with rest (intermittent claudication).
Early in the disease course, some patients will have one foot that is significantly redder than the other, called dependent rubor. That same foot, when elevated, will drain of blood and become completely pale--called elevated pallor.
  • Toes or feet that become discolored when upright.
One of the most recognizable phrases that we hear is that a patient chooses to sleep in their recliner (or somewhere else) because their legs or feet hurt when sleeping on the bed. This is a clear indication of rest pain, and a vascular consult should be made.
  • Leg or foot pain that disturbs your sleep (rest pain).
  • - Sores or wounds on toes or feet that heal slowly, or not at all.
  • - Burning feet (often diagnosed as neuropathy) that do not respond to medication.
  • - Toes that turn black (gangrene).
  • - Changes in the skin on your leg--color, shiny, hair loss.

See the signs of PAD

Hover to view symptoms

How is PAD diagnosed?

According to the CDC, over 8.5 million people over the age of 40 in the U.S. have PAD. To put that further into perspective, one in every twenty people over the age of 50 have PAD–a massive underestimation, given how frequently the disease goes undiagnosed. Every year, there are over 150,000 amputations in the U.S. Perhaps scarier is the fact that 48% of PAD patients that receive an amputation die within the first year. That figure increases to 71% after three years. Because of this, it is critically important that we, as a nation, become better at recognizing and diagnosing end-stage PAD, called critical limb ischemia (CLI).

PAD diagnosis begins with recognizing the symptoms. Often, our patients experience classic PAD symptoms, but attribute them to aging or another ailment. Others, like diabetics, may remain clinically silent with severe disease until a wound appears. By being mindful of PAD risk factors & symptoms, our patients may be able to better communicate to their physicians what they’ve been experiencing, and the medical diagnosis can begin.

Several diagnostic tests exist for diagnosing and confirming PAD / CLI. Physicians may rely on a simple ankle-brachial index (ABI), where they compare blood pressure readings in the leg and arm, looking for lower readings in the leg, which may indicate blockages are present. To better localize the blockages, your physician may request for a doppler ultrasound–which uses sound waves to help visualize the flow of blood through your arteries. Magnetic resonance angiography (MRA) and computerized tomography angiography (CTA) are also non-invasive ways of imaging the arteries in order to gain an understanding of where blockages may be.

Finally, there is the minimally invasive procedure of angiography, where–by using a series of small catheters and wires–the arteries can be seen live under x-ray, and endovascular intervention can occur on site if disease is found (read more about this in our treatment options). In this case, treatment can occur immediately if there is disease present in the arteries.

PAD Treatment

PAD is a chronic, progressive, and systemic disease. This means that once present, it will not go away completely, regardless of therapy. The goal of treatment is to relieve the pain associated with the disease so that you as a patient can remain active and return closer to your normal lifestyle–and lessen the likelihood of greater complications (like tissue loss or amputation). Treatment type depends largely on the stage of the disease at diagnosis in addition to patient risk factors, but generally follows a pattern:

  1. Lifestyle modifications. This may include adding in a bit of walking to your daily routine, making changes to your diet, the addition of certain medications, and of course–if you smoke, you should stop.
  2. Minimally invasive procedures for vascular reconstruction. Click here to learn more about these options.
  3. Invasive surgical procedures. This can include bypass surgery and amputation*.
 

*Although we list amputation for the sake of education, we at Palm Vascular Centers do not see amputation alone as a form of treatment for PAD. Amputation may be a life-saving surgery, but we believe should generally be a last-resort, if you as the patient are invested in keeping your limbs attached. Additionally, without proper vascular reconstruction, amputations may not heal and can resort in a vast array of postoperative complications. If you or a loved one have been diagnosed with PAD and are facing amputation, we encourage you to look for another opinion.

Lifestyle Changes

P.A.D. treatment often includes making long-lasting lifestyle changes. If you have P.A.D., or are aiming to lower your risk, your health care provider may prescribe one or more of the following:
  • Quit smoking. Don’t smoke, and if you do, quit. Lower your numbers.
  • Work with your health care provider to correct any high blood pressure, cholesterol, and blood glucose levels.
  • Follow a healthy eating plan. Choose foods that are low in saturated fat, trans fat, and cholesterol.
  • Get moving. Make a commitment to be more physically active. Aim for 30 minutes of moderate-intensity activity on most, preferably all, days of the week.
  • Aim for a healthy weight. If you are overweight or obese, work with your health care provider to develop a supervised weight loss plan.

Medication for Peripheral Arterial Disease

In addition to lifestyle modifications, your health care provider may prescribe one or more medications that help:

  • Lower high blood pressure and cholesterol levels and treat diabetes
  • Prevent the formation of blood clots that could cause a heart attack or stroke
  • Help reduce leg pain while walking or climbing stairs
  • Peripheral Arterial Disease Clinical Treatments
  • For people suffering from Peripheral Arterial Disease (PAD), the buildup of plaque in the arteries of the legs often leads to severe and even debilitating leg pain. When the plaque becomes “calcified,” limited options have been available to successfully treat the problem – until now.

Minimally Invasive Surgical Treatment Options for PAD

Angiograms​

Angiograms are minimally invasive diagnostic procedure used to confirm the presence of disease.

Angioplasty​

An Angioplasty can be performed at the time of the angiogram and is the expansion of a balloon in the area of the blockage in order to re-establish blood flow.

Stent Placement​

A stent is a small metal mesh tube that may accompany balloon angioplasty that helps the vessel remain open.

Atherectomy​

There are many forms and devices, but all Atherectomy allows for the removal of plaque (cholesterol, fat, and calcium deposits) in order to return the elasticity of the blood vessel.