PAD Peripheral Arterial Disease

Peripheral Artery Disease results from fatty deposits (plaque) that build up in the arteries outside the heart (peripheral arteries); mainly the arteries supplying the legs and feet. This buildup narrows or blocks your arteries and reduces the amount of blood and oxygen delivered to your leg muscles and feet. The iliac, femoral, popliteal and tibial arteries are commonly affected.

– People with PAD are at higher risk for heart attack and stroke.
– Left untreated, PAD can lead to gangrene and amputation.
– If you smoke, you have an especially high risk for PAD.
– If you have diabetes, you have an especially high risk for PAD.
– People with high blood pressure or high cholesterol are at risk for PAD.
– PAD is easily diagnosed in a simple, painless way.
– You can take control by leading a heart-healthy lifestyle and following the recommendations of your healthcare professional.
– Most cases of PAD can be managed with lifestyle changes and medication.
The most common symptoms of PAD 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.

PAD is most common in the arteries of the pelvis and legs. It’s a condition similar to coronary artery disease (CAD) and carotid artery disease. CAD refers to atherosclerosis in the coronary arteries, which supply the heart muscle with blood. Carotid artery disease refers to atherosclerosis in the arteries that supply blood to the brain.

Atherosclerosis comes from the Greek words athero (meaning gruel or paste) and sclerosis (hardness). It’s a process in which plaque builds up in the wall of an artery. Plaque is made up of deposits of fats, cholesterol and other substances. Plaque formations can grow large enough to significantly reduce the blood’s flow through an artery. When a plaque formation becomes brittle, it may rupture, triggering a blood clot to form. A clot may either further narrow the artery, or completely block it. When that blockage occurs in a coronary artery, it can cause a heart attack. When it occurs in a carotid artery, it can cause a stroke. If the blockage remains in the peripheral arteries, it can cause pain, changes in skin color, sores or ulcers and difficulty walking. Total loss of circulation to the legs and feet can cause gangrene and loss of a limb.

PAD risk factors you can control

Certain risk factors for PAD can’t be controlled, such as aging or having a personal or family history of PAD, cardiovascular disease or stroke. However, you can control many risk factors including:
– Cigarette smoking — Smoking is a major risk factor for PAD. Smokers may have four times the risk of PAD than nonsmokers. – 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. Supervised exercise programs are one of the treatments for PAD patients.
– 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 – High blood cholesterol — 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. Managing your cholesterol levels is essential to prevent or treat PAD.
– Diabetes mellitus — Having diabetes puts you at greater risk of developing PAD as well as other cardiovascular diseases. – High blood pressure — It’s sometimes called “the silent killer” because it has no symptoms. Work with your healthcare professionals to monitor and control your blood pressure.

It’s important to learn the facts about PAD. As with any disease, the more you understand, the more likely you’ll be able to help your healthcare professional make an early diagnosis and start treatment. PAD has common symptoms, but many people with PAD never have any symptoms at all.

Taking care of only one risk factor is not as effective as taking care of all those that you can control. Develop a heart-healthy lifestyle and cooperate with your healthcare professionals. Your heart will thank you by functioning better and lasting longer.
Treatment for PAD focuses on reducing symptoms and preventing further progression of the disease. In most cases, lifestyle changes, exercise and claudication medications are enough to slow the progression or even reverse the symptoms of PAD.

What can you do to help slow the progression of PAD?

Physical Activity

The most effective treatment for PAD is regular physical activity. Your doctor may recommend a program of supervised exercise training for you. You may have to begin slowly, but simple walking regimens, leg exercises and treadmill exercise programs three times a week can result in decreased symptoms in just four to eight weeks. Exercise for intermittent claudication takes into account the fact that walking causes pain. The program consists of alternating activity and rest in intervals to build up the amount of time you can walk before the pain sets in. It’s best if this exercise program is undertaken in a rehabilitation center on a treadmill and monitored. If it isn’t possible to go to a rehabilitation center, ask your healthcare professional to help you plan a program that’s best suited to your situation.

Diet

Many PAD patients have elevated cholesterol levels. A diet low in saturated fat, trans fat and cholesterol can help lower blood cholesterol levels, but medication may be necessary to maintain the proper cholesterol levels.

Smoking Cessation
Tobacco smoke greatly increases your risk for PAD and your risk for heart attack and stroke. Smokers may have four times the risk of developing PAD than nonsmokers. Stop smoking. It will help to slow the progression of PAD and other heart-related diseases.

Procedures

For a minority of patients the above recommendations and treatments aren’t enough, and minimally invasive treatment or surgery may be needed. Minimally invasive procedures consist of angioplasty or stent placement (as is done in the heart for CAD) or clot-removal treatment. They are nonsurgical and are performed by making a small incision through which a catheter is inserted to reach the blocked artery. A tiny balloon is inflated inside the artery to open the clog. A stent — a tiny wire mesh cylinder — may also be implanted at this time to help hold the artery open. Sometimes a medicine can be given through the catheter or a special device can be inserted through it to remove a clot that’s blocking the artery.

If there’s a long portion of artery in your leg that’s completely blocked and you’re having severe symptoms, surgery may be necessary. A vein from another part of the body can be used to “bypass” and reroute blood around the closed artery. Your healthcare professional will discuss your options and help choose the best procedure for your situation.

How Is Peripheral Arterial Disease Diagnosed?
Peripheral arterial disease (P.A.D.) is diagnosed based on your medical and family histories, a physical exam, and results from tests.

P.A.D. often is diagnosed after symptoms are reported. An accurate diagnosis is important, because people who have P.A.D. are at increased risk for coronary artery disease (CAD), heart attack, stroke, and transient ischemic attack (“mini-stroke”). If you have P.A.D., your doctor also may want to look for signs of these conditions.

Primary care doctors, such as internists and family practitioners, may treat people who have mild P.A.D. For more advanced P.A.D., a vascular specialist may be involved. This is a doctor who specializes in treating blood vessel problems.

A cardiologist also may be involved in treating people who have P.A.D. Cardiologists treat heart problems, such as CAD and heart attack, which often affect people who have P.A.D.

Medical and Family Histories
To learn about your medical and family histories, your doctor may ask:
– Whether you have any risk factors for P.A.D.
– About your symptoms, including any symptoms that occur when walking, exercising, sitting, standing, or climbing
– About your diet
– About any medicines you take, including prescription and over-the-counter medicines
– Whether anyone in your family has a history of cardiovascular disease

Physical Exam
During the physical exam, your doctor will look for signs and symptoms of P.A.D. He or she may check the blood flow in your legs or feet to see whether you have weak or absent pulses.
Your doctor also may check the pulses in your leg arteries for an abnormal whooshing sound called a bruit (broo-E). He or she can hear this sound with a stethoscope. A bruit may be a warning sign of a narrowed or blocked section of artery.

During the physical exam, 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 poor wound healing or any changes in your hair, skin, or nails that may be signs of P.A.D.

Diagnostic Tests

Doppler Ultrasound and Ankle-Brachial Index
Intermittent claudication caused by peripheral artery disease is typically diagnosed using a procedure called Doppler ultrasound and a calculation called the ankle-brachial index. This method is also proving to be a helpful way to diagnose PAD in patients without symptoms of intermittent claudication.

The procedure is done as follows:
– The doctor measures the systolic blood pressure of both arms while the patient is lying down. (The systolic pressure is the “top” number in a blood pressure measurement. It is the force that blood exerts on the artery walls as the heart contracts to pump out the blood. For example, in a blood pressure reading of 120/80, 120 is the systolic number.)
– The doctor then puts blood pressure cuffs on four different locations on each leg. An ultrasound probe is passed over arteries in the foot. The signal emitted from the strongest artery is recorded as the cuffs are inflated and deflated. This is the ankle’s systolic pressure.
The doctor divides the systolic pressure in the ankle by the systolic pressure in the arm. The result is called the ankle-brachial index (ABI), also called ankle-arm pressure index (API).
What the results mean:
– ABI over 0.90. This result often rules out PAD, but if the patient has specific risk factors for artery disease, the doctor may still suspect PAD. In such cases, the patient takes a treadmill test and another ABI measurement. If the API index drops, then the doctor makes a diagnosis of peripheral artery disease.
– ABI below 0.90. This is usually sufficient information to diagnose PAD. The lower the index the greater the risk for heart attack, stroke, or other serious circulatory or heart events. (In patients with diabetes, the doctor may perform additional tests, which may include ultrasound, pressure measurement in the first toe, or others that might confirm or dismiss a diagnosis of PAD.)
– ABI less than 0.50. These measurements are highly associated with impaired leg function.
– ABI less than 0.40. These measurements indicate very severe blockage in the leg arteries and a risk for gangrene.