Peripheral Artery Disease

Imaging & Interventional Specialists

Gethin Williams, MD, PhD

Vascular & Interventional Radiology & Vein Center located in El Paso, TX

Peripheral Artery Disease: A Comprehensive Look

 

Peripheral Artery Disease (or Peripheral Arterial Disease)

What is peripheral arterial disease (PAD)?

Blood vessels can be arteries or veins. The arteries carry blood from the heart to other parts of the body. The veins bring the blood back to the heart and lungs, where it can be oxygenated again before being pumped out into a different part of the body.

Peripheral artery disease (PAD)is a condition described as chronic arterial occlusive disease that causes narrowing or blocking of arteries in the lower limbs, which reduces blood flow to these areas. Usually, the blockage is caused by atherosclerosis (buildup of fat and cholesterol inside arteries), Presence of peripheral artery disease (PAD) in a patient increases his/her risk for future cardiovascular events such as myocardial infarction (heart attack) and stroke.

What causes peripheral artery disease (PAD)?

The main cause of people developing peripheral artery disease (PAD) is atherosclerosis, which is the build-up of fatty deposits on artery walls. This fatty plaque buildup causes narrowing and decreased blood flow. Other common causes are smoking, high blood pressure and high cholesterol. Less common causes are trauma to the arteries caused by an accident or fracture in the bones. PAD also develops as a complication of diabetes. Rarer causes include vasculitis, coagulation disorders, and blood clots.

PAD

What are the risk factors for developing peripheral arterial disease (PAD)?

Risk factors for peripheral artery disease (PAD) include:

  • being over age 50, 
  • smoking, 
  • high blood pressure, 
  • diabetes,
  • lack of exercise, 
  • having had a heart attack
  • high body mass index: being overweight or obese 
  • having high blood cholesterol levels 

How many people are affected?

Peripheral artery disease (PAD) is most common in adults over the age of 50, however it affects all ages. About 8 million people in the United States have PAD. It is estimated that 5% of men and 3% of women aged 40 years and older have PAD. The prevalence of Peripheral artery disease (PAD) increases with age. It is estimated that by 2020 more than 18 million US adults will have the condition. It is more common in men than women and occurs more often in African Americans. In the Hispanic population it is more common in those of Puerto Rican descent, and in the Caucasian population it is more common in those of Scandinavian descent.

What are the symptoms of peripheral artery disease (PAD)? 

A symptom is something felt by a patient and reported to his/her doctor. The most common sign of PAD is pain in leg(s) when walking, also known as intermittent claudication. This is one of the warning signs. The most common complaints in patients have with peripheral artery disease (PAD) are:

  • intermittent claudication (leg pain when walking that goes away when resting)
  • numbness, weakness or tingling in the lower legs and feet 
  • poor wound healing 
  • leg ulcers
  • cold legs or feet
  • leg discoloration
  • shiny skin
  • hairless lower legs
  • weak pulse in legs or foot
  • smaller calf muscle
  • cracked or slow growing nails

Sometimes there will be no symptoms at all, particularly if blood vessel damage remains mild. The condition may not cause any problems for many years before a medical problem develops. 

If untreated though, peripheral artery disease can lead to gangrene of the foot, which may require amputation

Symptoms of PAD

What is intermittent claudication?

Intermittent claudication is the most common symptom of peripheral artery disease (PAD). Intermittent claudication causes leg or hip pain when walking due to reduced blood flow to working muscles. This pain usually goes away after resting for a few minutes and returns with further activity.

What causes intermittent claudication?

The most common cause is atherosclerosis. Atherosclerosis is the build-up of fatty deposits on artery walls, which narrows blood vessels. This leads to poor blood flow in arteries that are narrowed or completely blocked by fatty deposits.

How is intermittent claudication treated?

The goal of treatment is to improve blood flow in the affected artery. This might be done by controlling risk factors such as high cholesterol, high blood pressure and diabetes, or stopping smoking. Medications used to treat PAD include:

  • Beta blockers (these block the effects of adrenaline, which constricts blood vessels, and have a vasodilator effect)
  • Calcium channel blockers 
  • ACE Inhibitors 
  • Statins 
  • Clopidogrel 
  • Cilostazol 

What is gangrene?

Gangrene is the death of body tissue, usually in one or more toes, fingers, or limbs. It is most often due to reduced blood flow, which may be caused by narrowing of arteries.

What causes gangrene?

Gangrene is the end stage of peripheral artery disease (PAD) when arteries are so blocked tissues can't get nutrients and die? 

What are the biggest risk factors for gangrene?

The biggest risk factors for developing gangrene are atherosclerosis, diabetes mellitus, smoking, peripheral vascular disease , neuropathy, trauma to the affected limb (and compartment syndrome ), malnutrition, chronic alcoholism , infection of the soft tissue or bone ( osteomyelitis ), and corticosteroid therapy . 

How is gangrene treated? 

Gangrene is usually treated with antibiotics to fight off any infections associated with it. It can also be treated by surgically removing dead tissue. The rest of the body will heal on its own after this has been done.

What are the symptoms of gangrene?

Symptoms of gangrene include:

  • abnormal color to skin (red, blue, black) 
  • deep pain at site
  • warmth at site of infection
  • sudden swelling of the affected limb

How is gangrene treated? 

If gangrene occurs, it may require amputation of a toe, foot or leg. Prevention of PAD and treatment of the peripheral arterial disease reduces the risk of developing dry gangrene and improves quality of life. For example putting on compression stockings to improve blood flow to the arteries in lower legs.

How do I prevent developing peripheral arterial disease (PAD)?

The following lifestyle changes may help prevent or stop the progression of PAD:

  • smoking cessation,
  • eating a healthy diet, 
  • exercising regularly,
  • maintaining a normal weight with a BMI less than 25.0.
  • controlling diabetes
  • controlling hypertension
  • controlling hypercholesterolemia

Controlling diabetes by managing blood sugar levels and taking medication as prescribed if needed. It is important to regularly check feet for any cuts or injuries that can lead to infection. Patients should also be aware of changes in the color or temperature of their feet that could indicate an underlying problem. Peripheral arterial disease (PAD) is a progressive disease with no cure unless treated early on before permanent damage occurs to the arteries which may require surgery. Treatment includes medications such as prescription strength nonsteroidal anti-inflammatory drugs (NSAIDs) which reduce pain and improve mobility. 

PAD

 

How do Imaging & Interventional Specialists diagnose peripheral artery disease (PAD)?

The diagnosis of peripheral arterial disease (PAD) begins with a history and physical exam. Important questions include:

  • Where is the pain? (i.e. calves, thighs, groin)
  • Any prior history of smoking
  • History of diabetes and/or hypertension
  • Is there a family history of PAD or early cardiovascular disease?
  • Do you have risk factors?

Risk factors include:

  • diabetes, 
  • high blood pressure, 
  • heart disease
  • smoking history

During the physical exam the Imaging & Interventional Specialist will look for signs such as: 

  • Coolness to the touch of the feet and legs (this could indicate poor circulation
  • Gait abnormalities – due to claudication (pain down one leg when walking) or paralysis (loss of movement in one leg)
  • Skin changes (shiny skin, loss of hair)
  • Muscle atrophy (thinning of the muscles)
  • Limited movement in one or both legs
  • Swelling and leg ulcers
  • your ankle and foot pulses chracter
  • critical limb ischemia

What tests do Imaging & Interventional Specialist use to diagnose peripheral arterial disease (PAD)?

Tests that may be ordered by your Imaging & Interventional Specialist include:

  • Ankle brachial index (ABI) – this helps determine how much blood is flowing in the vessels of the leg. A higher number means there is more blood flow and a lower one means there is less or no blood flow.
  • Doppler Ultrasound to measure pressure in the legs. 
  • CT Angiogram, MRI angiography, DSA (Digital Subtraction Angiography) which can produce pictures of blood vessels when injected with contrasting dye 
  • Pulse Volume Recording or PVR Scan which measures the blood pressure in the feet and ankles
  • Treadmill test
  • Lower extremity angiogram (LEA) is usually required to confirm diagnosis of peripheral arterial disease.
  • Other imaging tests including CT angiography, MR angiography

What is an Ankle brachial index (ABI) and how is it performed?

Ankle brachial index (ABI) is a simple and non-invasive test that compares the blood pressure in your ankles to the blood pressure measured at your arms. It can be used as a screening test for those who have symptoms of peripheral arterial disease (PAD). A low ABI may indicate the presence of PAD, but it does not give conclusive results: further tests such as treadmill exercise testing and ultrasound imaging may be recommended by your doctor.

The ankle brachial index (ABI) uses a machine similar to an or blood pressure monitor which has been validated or calibrated specifically for this purpose. The measurement is recorded as the systolic blood pressure at both the ankle and arm divided by the higher of the two readings. A ratio higher than 0.9 is considered normal, a ratio of 0.8 to 0.89 is diagnosed as PAD Stage 1 or "claudication" and a reading below 0.8 is said to represent severe arterial obstruction ("critical limb ischemia"). If you have any symptoms at all of pain when walking it is advisable to get these checked out by a medical professional who specializes in vascular medicine or cardiac rehabilitation (preferably both). This can help determine how severe your disability might be if left untreated and also what treatment options are available

* A normal result reading above 0.7 at both the ankle and arm.

* A result below 0.5 is considered severe and requires further investigation to ensure you don’t have other life-threatening conditions such as an abnormal heart rhythm, coronary artery disease or congestive heart failure (CHF); 

* If PAD is suspected, your doctor will likely recommend an imaging study such as x-ray, ultrasound or angiography. This type of imaging can show how much blockage there is in your arteries.

How are the measurements taken?

The patient sits down with their back supported and legs uncrossed. The blood pressure cuff for the upper arm should be wrapped around bare skin above the elbow on the same side as your tested leg (so if you are testing your left leg it goes on your right arm). After 5 minutes rest, this cuff will measure your systolic blood pressure at that arm. You will be given a blood pressure cuff to wrap around your ankle on the same

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