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Peripheral Arterial Disease (PAD)

The arteries carry blood rich in oxygen and nutrients from the heart to the rest of your body. When the arteries in the legs become blocked, the legs do not receive enough blood or oxygen, and you may have a condition called peripheral artery disease (PAD)

The arteries are normally smooth and unobstructed on the inside but with age, they can become blocked through a process called atherosclerosis, which means hardening of the arteries. A sticky substance called plaque can build up in the walls of the arteries. Plaque is made up of cholesterol, calcium, and fibrous tissue. As more plaque builds up, the arteries narrow and stiffen. Eventually, enough plaque builds up to reduce blood flow to the leg arteries. When this happens, your leg does not receive the oxygen it needs. You may feel well and still have leg artery disease or sometimes similar blockages in other arteries, such as those leading to the heart or brain. It is important to treat this disease not only because it may place you at a greater risk for limb loss but also for having a heart attack or stroke.

Symptoms

Symptoms

Early in the disease, you may feel pain, cramping, or fatigue in your lower body when you walk or exercise. The pain with walking usually occurs in your buttocks, thighs, and legs. This symptom is called intermittent claudication because it stops when you rest. As the disease worsens, you may find that pain occurs when you walk for shorter distances. Ultimately, as the disease progresses, you may feel pain, usually in your toes or feet, even when you are resting.

PAD may worsen if it is not treated. Signs that it has advanced include:

– Severe pain, coldness, and numbness in a limb
– Sores on your toes, heels, or lower legs
– Dry, scaly, cracked skin on your foot. Major cracks, or fissures, may become infected if left untreated
– Weakened muscles in your legs
– Gangrene (tissue death), which may require amputation

Risk Factors

Atherosclerosis, or hardening of the arteries, causes most cases of PAD.
Risk factors for hardening of the arteries include:

– Smoking
– High cholesterol levels in the blood– High blood pressure
– Obesity
– Having a family history of heart disease

Diagnosis

  • History and Physical Examination
  • Ankle-brachial index (ABI), which compares the blood pressure in your arms and legs
  • Blood tests for cholesterol or other markers for artery disease
  • Duplex ultrasound uses high-frequency sound waves to measure real-time blood flow and detect blockages or other abnormalities in the structure of your blood vessels
  • Pulse volume recording measures the volume of blood at various points in the legs using an arm blood pressure cuff and a Doppler probe
  • Magnetic resonance angiography (MRA) uses magnetic fields and radio waves to show blockages inside your arteries
  • Computed tomographic angiography (CTA) uses specialized CT scans and contrast dye to show blockages inside your arteries
  • Angiography, which produces x ray pictures of the blood vessels in your legs using a contrast dye to highlight your arteries

Treatment

Lifestyle Changes

  • Quit Smoking
  • Healthy weight
  • Exercise
  • Regular monitoring of pressure and compliance with medications
  • Control of blood sugar levels with diet and medications

Medications

  • Cilostazol (Pletal), which may improve the distance you are able to walk without pain.
  • Aspirin or clopidogrel (Plavix), either of which can lower your chances of blood clots.
  • Statins are a class of medications that your physician may use to control your cholesterol levels.
  • None of these medications will "cure" you of the disease, but are important at relieving some of your symptoms, and may help protect your arteries from developing further disease.

Angioplasty and Stenting

During an angioplasty procedure, which is sometimes performed at the same time as an angiogram, a long, thin, flexible tube, called a catheter, is inserted into a small puncture over an artery in your leg and is guided through the arteries to the blocked area. Once there, a special balloon attached to the catheter is inflated and deflated several times. The balloon pushes the plaque in your artery against your artery walls, widening the vessel. In some circumstances, a tiny mesh-metal tube called a stent may then be placed into the narrowed area of your artery to keep it open. The stent remains permanently in your artery. After successful angioplasty, blood flows more freely through your artery.

Atherectomy

During an atherectomy procedure, a wire is passed through the blocked arteries and a special atherectomy device is used to grind away the plaque in the blocked arteries. As the device moves, its diamond-coated crown sands calcium deposits into tiny micro particles (smaller than the size of a red blood cell) that the bloodstream can naturally flush away - restoring blood flow.

Surgery

Bypass surgery, usually done through abdominal and leg incisions depending upon the location of the blockage, creates a detour around the narrowed or blocked sections of your artery. A Y-shaped tube made of synthetic fabric, called a graft, is attached to your aorta above the blockage. The two branches of the graft are then attached to arteries in each leg (called the femoral arteries). Although more invasive, bypass surgery restores blood flow in about 85 percent of patients.

Leg bypass

Bypass surgery creates a detour around a narrowed, or blocked, section of a leg artery. To create this bypass, the vascular surgeon uses one of your veins or a tube made from man-made materials. The vascular surgeon attaches the bypass above and below the area that is blocked. This creates a new path for your blood to flow to your leg tissues and is particularly effective for extensive artery blockages.

Risks of Operation

With endovascular procedures the complications include bleeding, the possibility of distal embolization, the possibility of renal failure from IV contrast dye administration and the need for an open procedure. With open bypass the complications include bleeding, infection, the risk of nerve injury, risk of injury to other organs, risk of retrograde ejaculation with aortic bypasses, prolonged hospitalization, risk of myocardial infarction with a very small risk of death.