Peripheral Arterial Disease (PAD)
Peripheral arterial disease (PAD) is a common arterial problem in which narrowed arteries reduce the blood supply to your limbs. Thus the decreased blood supply to the extremity cannot cope up with the demand. This leads to leg pain mainly on walking (Claudication).
Peripheral arterial disease is also a warning sign of reduced blood supply to other organs due to the generalised disease called atherosclerosis which is the deposition of fat, cholesterol, calcium, fibrous tissue in the wall of the arteries. This reduced flow may affect your brain and heart.
PAD may be successfully be treated by giving up smoking, walking and eating a healthy diet.
Symptoms of Peripheral Arterial Disease
- Many are asymptomatic while some have pain on walking – intermittent claudication
- Intermittent Claudication is a pain in the leg muscles on exercise and relieved by a few minutes of rest.
- The location of the pain depends on the location of the narrowed or blocked artery. The commonest site is calf pain.
Other symptoms of PAD
- Pain in the leg initially on walking and later at rest
- Numbness or weakness of the legs
- Cooler leg than the other side
- Sores on the toes, foot or leg that refuse to heal.
- Change in colour of the legs
- Hair loss or slower growth of hair on legs
- Slower growth of nails
- Shiny skin on legs
- Weak pulse or no pulse on the legs.
- Erectile dysfunction in men.
Leg pain worsens as the disease progresses and becomes rest pain which disrupts sleep and the patient has to hang the foot out of the bed Norwalk about at night to get temporary relief.
Blocked flow in your legs cases pain and numbness. It also increases the risk of infection which may be difficult to eradicate. If the blockage is severe enough and long enough it can cause the death of the tissue leading to gangrene. This is an important cause of amputation. If you have pain in your legs on walking or climbing stairs talk to your doctor and do not put it down to ageing. If you smoke or have given up, you have a 4 times higher chance of PAD.
PAD increases the chances of your having Coronary artery disease (CAD), heart attack, stroke and transient ischemic attack. If you have CAD you have a 1:3 chance of having a blocked artery in the leg. PAD is a serious condition but treatable. The treatment is of the underlying cause which is atherosclerosis. Treatment slows or stops the progression of atherosclerosis, reducing the chances of serious complications. Treatment includes lifestyle changes, medicines and surgery or procedures.
When to see a doctor?
If you have leg pain, numbness or other symptoms do not dismiss it as an ageing process but consult your doctor.
Even if you are asymptomatic, you need a consultation if:
- over 70 years
- over 50 with a history of diabetes and smoking
- Under 50 but with diabetes and another of the risk factors like obesity or hypertension.
Causes of Peripheral Artery Disease
- The most common cause if atherosclerosis which is deposition of fat within the arterial wall and is a generalised disease.
- Inflammation of the arteries
- Injuries to the limbs
- Unusual anatomy of the limb ligaments and muscles
- Radiation exposure
Risk factors of Peripheral Artery Disease
- High blood pressure (140/90 mmHg or higher)
- Obesity (body mass index > 30)
- High cholesterol (total blood cholesterol > 240 mg % or 6.2 millimoles/ litre)
- Increasing age > 50 years.
- A family history of heart disease or stroke or PAD.
- High levels of homocysteine, a protein that helps build and maintain tissue.
The greatest risk is smoking and diabetes.
Complications of Peripheral Artery Disease
If you have PAD due to atherosclerosis then you are also at risk of developing:
- Critical limb ischemia (CLI). In this condition, sores do not heal, and injury or infection of the leg may progress to tissue loss (gangrene) which may progress to amputation.
- Stroke and heart attack are due to narrowing of the vessels of the heart or the brain due to generalised atherosclerosis.
Tests and diagnosis for Peripheral Artery Disease
The diagnosis is based on medical, family history, physical examination and test results. A correct diagnosis is very important because people with PAD are at higher risk of heart attack and Stroke.
To be sure you have PAD your doctor may ask for the following tests:
- Physical Examination – Your doctor may find your foot pulses absent of weak. He may find a bruit with a stethoscope placed over the artery or reduced blood pressure in the affected limb.
- Ankle-brachial index (ABI). This is commonly performed and compares your blood pressure in the ankle with that of the arm. This test may be performed after exercising on the treadmill.
- Ultrasound – this helps evaluate blood flow through the arteries and identify blocked arteries or narrowed arteries.
- Angiography – It is performed by injecting a dye into the artery and seeing the flow through the vessel.
The tracing of the dye and the visualisation of the arteries can be done by:
- X-Ray imaging
- Magnetic resonance imaging (MRA)
- Computerised tomography imaging.
- Conventional angiography which is more invasive as a catheter is placed in the vessel and advanced to the groin and affected area. However, in this form, it is the only modality that is diagnostic and therapeutic. Angioplasty and stenting or insertion of the drug can be done simultaneously to improve the blood flow.
- Blood cholesterol, triglycerides and sugar should be tested.
Treatment and Drugs
The treatment of PAD has two major goals:
- Relief from pain so that patient can resume normal activity
- Stop the progression of atherosclerosis throughout the body to reduce the risk of heart disease and stroke
It is likely that you achieve these goals by lifestyle changes like quitting smoking which is the most important thing one can do reduce the risk of complications.
If lifestyle changes are inadequate then additional medical treatment is needed – to prevent blood clots, lower blood pressure and cholesterol, control pain and other symptoms.
Cholesterol-lowering medications – These are statins reduce your risk of developing heart attack and stroke. The goal is to reduce Low-Density Lipoprotein (LDL) cholesterol or the ‘bad’ cholesterol to less than 100mg%. This should be further reduced if you have additional factors for heart attack and stroke, especially diabetes or continued smoking.
High blood-pressure medications – It is necessary as it is a risk factor. The goal is to reduce the systolic blood pressure to 140 mmHg and the diastolic or lower pressure to 90 mmHg or lower. With diabetes, the blood pressure target should be 130/80 mmHg.
Medication to control blood sugar – If you have diabetes it is vital you control your blood sugar levels and consult your doctor regularly.
Medication to prevent blood clots – Since PAD is associated with reduced blood flow due to arterial disease, a small blood clot may block an already narrowed artery causing tissue death and gangrene. To prevent this your doctor may prescribe aspirin or clopidogrel (Plavix) to prevent clots from forming.
Symptom relief medications – Cilostazol (Pletal) increases the blood flow by preventing clots and widening arteries. It improves claudication. The side effects are a headache and diarrhoea. The alternative medicine is pentoxifylline (Trental). It is less effective than cilostazol but has fewer side effects.
Angioplasty and surgery
Rarely is this required for intermittent claudication?
Angioplasty – A small hollow tube called catheter is passed through an artery to the problem site. There is a small balloon at the tip of the catheter which is dilated by inflation to flatten the blockage into the arterial wall thus dilating the narrowed artery and increasing the blood flow. If needed a mesh framework may be inserted (stent) to keep the blockage open.
Bypass surgery – This involves the usage of the patients owns vein or a synthetic tube to pass around the blockage.
Atherectomy – this is a procedure to remove plaque built up within the narrowed or blocked artery. Here a catheter is inserted within the artery with a cutting device which shaves off the plaque.
Thrombolytic therapy – if you have a clot blocking your artery then a clot-dissolving drug is inserted into the clot using a catheter and the clot is dissolved and broken up to allow blood to flow.
Supervised exercise program
This helps to increase the distance you can walk pain-free. Regular exercise increases the symptoms of PAD by using oxygen more efficiently.
Lifestyle and home remedies
By lifestyle changes, many people reduce the symptoms from PAD and stop the progression of the disease.
To stabilise or improve PAD the following lifestyle changes are advised:
- Stop smoking – smoking causes constriction and damage to the arteries and is a risk factor for worsening of PAD. Quitting is the best thing you could do for yourself. If you are having problems your doctor could prescribe medicines that would help you quit the habit.
- Exercise – This is a key component. Success in the treatment of PAD is measured by improvement in the distance you walk pain-free. Proper exercise helps condition your muscles to use oxygen more efficiently.
- Eat a healthy diet – A diet low in cholesterol and saturated fats could help you control blood pressure and atherosclerosis.
- Avoid certain cold medications – over the counter cold medications contain pseudoephedrine which constrict your blood vessels worsening symptoms by increasing PAD.
Take good care of your feet especially if you have diabetes. Poor blood supply can delay or prevent proper healing of ulcers and the patient is at risk of infection.
Follow the advice to take care of your feet:
- Wash feet daily, dry them completely and then moisturise them often to prevent infection between cracks. Never moisturise between toes as this leads to fungal infection.
- Well, fitting shoes and dry socks.
- Treat any fungal infection of the foot immediately
- Take care while trimming your nails
- Avoid walking barefoot
- Get bunions, corns or calluses treated by a foot doctor (podiatrist)
- See your doctor immediately at the first signs of sore, or injury to the foot skin.
Coping and support
It is very frustrating when you want to walk but cannot due to pain. Just try to continue walking because the pain-free walking distance has to increase.
You could increase the head of your bed by 4-6 inches because keeping feet below the heart level will lessen the pain
Avoid cold temperatures as far as possible – by going to a warm place or wearing many layers of clothing to prevent cold.
Prevention of Peripheral Arterial Disease
The best way to prevent claudication is to maintain a healthy lifestyle and this is done by:
- Quit smoking
- If you have diabetes control it.
- Exercise regularly – 30 mins thrice a week
- Lower blood cholesterol and blood pressure levels
- Eat foods low in saturated fats
- Maintain a healthy weight.
Living with the peripheral arterial disease
If you have PAD you are likely to have CAD, heart attacks, strokes and TIAs. You can take steps to control PAD and lower the risk of these other conditions.
Living with peripheral arterial disease symptoms
With PAD you may feel pain in the leg or calf on walking. Take a break and walk again when the pain subsides. Over time this helps you increase the distance of walking. Take part in a supervised walking program which reduces PAD symptoms
- Check your feet and toes daily for sores and infection.
- Wear comfortable shoes that fit well.
- Maintain good food hygiene.
- Have professional medical treatment for corns, bunions and calluses.
Ongoing healthcare needs and lifestyle changes
See the doctor regularly and take the prescribed medicines. Lifestyle changes may prevent or delay PAD and other related problems. One must be active, eat a healthy diet and regular exercises.