Peripheral Vascular Disease

What is peripheral vascular disease?

Peripheral vascular disease (PVD) is among the most common condition of the blood vessels in North America. Over the past 30 years, the incidence of this condition has increased all over the world. The disorder affects the arteries in most parts of the body. Arteries supply oxygen and blood to the entire body. So when the arteries are diseased, the blood supply and oxygen to the tissues is severely compromised. In North America, the number one cause of disease in the arteries is atherosclerosis. The fatty plaques accumulate in the arteries and over time narrow and completely block the vessels. Arteries anywhere in the body may be affected, but in PVD, it is only the peripheral blood vessels which are affected. In PVD, the blood supply to the legs is compromised.

How common is Peripheral Vascular disease?

Peripheral vascular disease (PVD) is an extremely common condition which has the potential to cause loss of limb, or even loss of life. PVD usually presents because of lack of blood supply (and oxygen) to the tissues. The major cause of PVD is atherosclerosis which may be worsened by emboli (blood clots from elsewhere in the body) or thrombi (blood clots formed at the site of narrowing). Many individuals with PVD often require emergency surgery to save limbs.

What are causes of PVD?

The most common cause of peripheral arterial disease is atherosclerosis. In atherosclerosis, fatty deposits (plaques) build up in your artery walls and reduce blood flow. Other rare causes of PVD include:

- trauma

- surgery

- collagen vascular disease

What is atherosclerosis?

PVD (also known as arteriosclerosis obliterans), is chiefly due to atherosclerosis. The atherosclerotic plaque consists of a core of cholesterol which accumulates in blood vessels. The atherosclerotic process gradually progresses to complete close off the small and medium size blood vessels. Often the atherosclerotic plaques are in different locations in the same blood vessels.

What are risk factors for PVD?

Factors that increase your risk of developing PVD include:

- Smoking, tobacco chewing is not safe either

- Uncontrolled blood pressure

- Diabetes

- Being overweight

- Having high blood cholesterol

- Hyperviscosity (thickened blood).

What disease usually co exist with PVD?

Other medical disorders that often coexist with PVD are

- Heart disease (coronary artery disease)

- Myocardial infarction (MI)

- Abnormal heart rhythms (atrial fibrillation)

- Mini strokes (transient ischemic attack)

- Stroke

- Kidney disease

- Diabetes

- Hypertension

What is intermittent claudication?

Intermittent claudication is a type of PVD characterized by muscle pain or cramping in your legs that is triggered by a definite amount of activity, such as walking, but disappears after a few minutes of rest. The one typical feature of intermittent claudication is that the symptoms are reproducible and the pain always disappears at rest. The location of the pain depends on the site of the narrowed artery. Buttock and calf pain are most common.

The severity of intermittent claudication varies widely. Pain from this condition can range from mildly bothersome to debilitating. Severe intermittent claudication can impair your ability to function and limits one's lifestyle. The majority of individuals with intermittent claudication can be managed conservatively for many years. A good exercise program can help improve circulation and avoid surgery.

where in the leg is PVD most common?

PVD generally occurs in some specific locations but no one area is immune from atherosclerosis. The highest incidence of plaques occurs at the bifurcation (division) of the blood vessels (where turbulence is the highest). These areas include the groin, the neck and just below the knee. If an individual has diabetes, the disease is most severe below the knee.

What are symptoms of PVD?

The symptoms of PVD depend on the degree of blockage. If there is only mild blockage of the blood vessel, most individuals have no symptoms. However, as the disease progresses, the symptoms may include:

- pain while walking (pain may be in the buttock or calf area)

- cramps

- fatigue

- weakness in the legs

- tingling or numbness in the legs

- waking up in the middle of the night with pain in the leg

- leg going numb at night

- cold leg and feet

- ulcers on leg that fail to heal

- hair loss on legs

- deformed toe nails

- failure to achieve an erection

Early diagnosis and treatment of PAD is vital not only to preserve your limbs, but also to decrease your risk of heart disease and stroke.

On examination, what is typical of PVD?

A systematic examination of the peripheral vasculature is critical for proper evaluation. The classic features of PVD include the "5 P's":

- Lack of pulses in the legs

- Paralysis of the leg (may be indicative of severe PVD)

- Paraesthesia (may be indicative of severe PVD)

- Pain

- Pallor (bluish discoloration of the feet and legs)



What does it mean if I have pain in my legs at rest or at night?

If PVD progresses, pain may occur when you are at rest or when you are sleeping. This is called ischemic rest pain. The pain occurs because the leg is not receiving any blood and indicates severe PVD. Some individuals will wake up in the middle of the night and relieve the pain by either hanging the legs over the edge of the bed or by walking around (standing up causes more blood to passively flow to the legs).

What are complications of PVD?

If PVD is allowed to progress, then the resulting complications include:

- Failure to heal leg wounds

- Open leg wounds

- Repeat infections of the leg

- Gangrene

- Cold extremities

- Amputation

- Severe Pain

Because PVD is a systemic disease, other organs are also involved. These individuals can also develop strokes, heart attacks, kidney failure and dead bowel- all of which are complications of systemic vascular disease.



Is there a cure for PVD?

Todate, we have no cure for PVD and the best treatment today is prevention. A change in diet, active lifestyle, quitting smoking and controlling diabetes are the key to preventing PVD.



How is diagnosis of PVD made?

To make the diagnosis of PVD, a physical exam is very important. Your physician may examine your body for the following:

a. Presence/absence of pulses in the extremities

b. Any noises (bruits) in the groin area

c. Presence of any ulcers or open wounds on the foot

d. Presence of hair (in PVD there is little blood and hair fails to grow)

e. Loss of muscle- because of a chronic lack of oxygen, the legs are thin and appear bottle shaped

f. Blood pressure in the legs (normally BP is higher in the legs than in the arms)

Blood: Routine blood tests generally are indicated in the evaluation of patients with suspected serious compromise of vascular flow to an extremity. The blood work will assess your kidneys, lipid profile and the presence of an infection.

ECG: The ECG may reveal evidence of any heart disease or abnormal rhythms. Abnormal heart rhythms (esp. atrial fibrillation) are notoriously associated with throwing blood clots (emboli) and blocking blood supply to the legs or brain.

To confirm the diagnosis of PVD, other tests may include:

Ankle-brachial index (ABI). In this test, the blood pressure in the calf is compared to the blood pressure in the arms. If the ratio is less than 0.7, there is mild-moderate disease. If the ratio is less than 0.5, you have severe disease. Normal value is around 1.

Angiography. Angiogram is an invasive test which requires the use of a dye and radiation. The test is the gold standard to determine the presence of vascular disease in the extremities. The test can determine where the lesion is, the extent of the lesion and whether it may be amenable to a balloon (angioplasty).

Others: Other radiological tests that are sometimes used to assess for PVD include MRI and CT angiogram. However, these tests are not very sensitive in identifying PVD in the extremities. They are also quite expensive.

What is treatment of PVD?

Treatment for PVD has two major goals. The first is to manage symptoms, such as leg pain, so that one can resume physical activities. The second is to arrest the progression of atherosclerosis throughout your body to reduce your risk of heart attack and stroke. In both cases, a drastic change in lifestyle is imperative if one wants to prevent surgery.

If lifestyle changes are not enough, you will need additional medical treatment. Your doctor may prescribe drugs to prevent blood clots, control your blood pressure, diabetes and cholesterol.

What medications can be used to treat PVD?

Cholesterol: The majority of individuals have high cholesterol levels and need treatment.

Exercise should be the first treatment but if that fails, cholesterol lowering drugs can help. All individuals should make an effort to reduce the low-density lipoprotein cholesterol (the "bad" cholesterol), to less than 100 milligrams per deciliter (mg/dL).



Blood pressure: The majority of individuals with PVD have a high blood pressure. This must be treated with medications. It is imperative that the blood pressure be within normal. Continued high blood pressure worsens the damage to the blood vessels and even the heart.

Diabetes: If you have diabetes, it becomes even more important to control your blood sugar (glucose) levels. Diabetics frequently end up with amputation of their toes, feet or legs. Thus, blood sugar control is vital.

Blood thinners: Today, PVD is treated with anti platelet drugs (e.g. aspirin). These medications have been found to prevent clogging up of the blood vessels and reduce the chance of a heart attack and stroke.

Miscellaneous: Newer medications are available which can not only prevent blood clots but also improve blood flow to the legs. These medications have been around for decades and are helpful in some people. The two most common medications are cilostazol (Pletal) and Pentoxifylline.



What is the cause of an acutely cold leg?

There are some patients with PVD who suddenly develop a cold leg which is painful and discolored. The reason for this is an emboli (a blood clot from somewhere else in the body has broken off and blocked off the narrowed blood vessel in the leg). This is a surgical emergency and all patients need urgent treatment to save the leg.



What is the treatment of an acutely cold leg?

All patients with an acutely cold leg need to be admitted to the hospital. The site of the blocked artery can be determined by a radiological test. The treatment includes:

Blood thinner: Heparin is immediately started and pain medication is administered. Heparin does not dissolve the clot but prevents further clot formation.

Thrombolytics: There are some medications which can dissolve the clot. However, these medications have serious side effects and can cause bleeding. They are only administered in a hospital setting. Those individuals with active internal bleeding may not be candidates for this therapy

Surgery: The procedure usually involved inserting a small catheter with a balloon and sucking out the blood clot. The procedure known as thromboembolectomy is frequently done in patients with PVD. The emergency surgery is life and limb saving.



What is the role of angioplasty in PVD?

Recent advances in radiology have made angioplasty and stenting the first choice for treatment of PVD. Most lesions can be ballooned and stented. PVD in most large vessels is preferably treated with angioplasty. It is far safer than surgery and there is little downtime.



What is the Role of surgery in treating PVD?

Sometimes the PVD is severe and not amenable to angioplasty and surgery may be the only option. Surgery for PVD usually requires replacement of the diseased vessel with a plastic graft. There are numerous surgical procedures available for PVD and all of them are done for limb salvage.

What is the role of Exercise program in PVD?

A daily exercise program is a must for all individuals who want to avoid surgery. Numerous studies have shown that a supervised exercise training program can help one increase the walking distance pain-free. Exercise is the best treatment for any one with a diagnosis of intermittent claudication.



What preventive steps can one take?

The progression of PVD can be stopped in some cases. To stabilize or improve the PVD one should:

Exercise: Anyone with a diagnosis of PVD must continue to be active. By walking, the muscles remain active and it is believed that this may improve collaterals (additional bloods vessels) to develop. A standardized exercise program should be undertaken. Your doctor should enroll you into an exercise therapy program.

Quit smoking: Smoking is the universal evil and it can worsen PVD. In most individuals who are diabetic and smoke, the chances of a leg amputation are very high. You should ask your physician to help you quit smoking with drug patches or just quit cold turkey.

Eat healthy: A complete lifestyle change with a low fat diet is a key to prevention of PVD. A heart-healthy diet can help control your diabetes, blood pressure and cholesterol levels, which contribute to atherosclerosis. Eat foods with low fat. Omega 3 fatty acids have been postulated to help with PVD. Foods containing omega 3 fatty acids include fish, salmon, mackerel and herring. Lesser amounts are found in flaxseeds, walnuts and soybeans.



What home care is required for PVD?

For individuals with compromised blood supply to the foot, it is absolutely vital that good foot care is maintained. Diabetics are especially prone to foot infections and have extremely poor healing. To avoid developing foot infections one should:

Clean and wash the feet daily

Wear proper shoes

Rapidly treat any fungal infection

Take great ca e with trimming of the nails and avoid injury

Never walk barefoot

See your physician at the first sign of any injury to your skin

Always go to a reputable vascular surgeon if a diagnosis of PVD has been made

What is role of alternative medicine in treatment of PVD

There are numerous herbs and nutrients postulated to treat or cure PVD. The most commonly cited herb is ginkgo. It has blood thinning properties and there are claims that individuals who ingest this product have less pain and are able to walk further. There are no scientific data to back these claims and all reports remain anecdotal. In addition, this herb may react adversely with the commonly prescribed medications for PVD. Before you embark on alternative care, you should discuss this with your physician. One should be aware that many of these herbs and nutrients are often contaminated with real pharmaceutical medications to trick the customer. Buyer Beware.