Causes and Cure of Peripheral Arterial Disease
By Nik Nikam
Last Updated: April 18, 2008

HOUSTON - A 53 year-old male had been admitted to the hospital for cardiac surgery. He already had a heart attack, bypass in the legs two years earlier. In addition, he had history of diabetes for several years, high cholesterol, and heavy smoking for 20 plus years. He had an uneventful heart surgery and went home. His presentation raises some important questions regarding the generalized nature of the atherosclerosis or arterial blockages. The focus of this article is the arterial blockages in the legs known as Peripheral Arterial Disease or PAD.

What causes PAD?

The arteries in the pelvis and the legs can develop atherosclerosis, leading to the narrowing and blockage, causing symptoms of compromised circulation. The atherosclerosis involves the deposition of cholesterol, platelets, along with proliferation of the smooth muscles. The same process occurs in the heart, the brain, the kidneys, and in the internal organs. When the arterial narrowing approaches 70% of the lumen, patients develop symptoms is ischemia or reduce circulation.

The major risk factors for the coronary arteries also play a significant role in the development of PAD. In fact, people with PAD are twice as likely to have heart disease as compared to those who do not have PAD. Hence, we routinely check the heart circulation for those going for vascular surgery in the legs. Diabetes, high blood pressure, high cholesterol levels are all significant risk factors for PAD. Smoking is a major risk factor for the development of PAD, especially in patients with a history of diabetes or hypertension. Even though the PAD affect people in their fifties and sixties, it is not unusual to see people in their late twenties and early thirties to have PAD if they have history of diabetes, hypertension and smoking.

What are the symptoms of PAD?

Patients with PAD may present with pain in the leg that. gets worse on walking and is relived by rest. This is called the intermittent claudicating. Only 8 to 10% of the people may have this classical intermittent claudicating. As the degree of arterial narrowing gets worse, the patients my experience rest pains. Some patients may not have any symptoms at all.

Others with critical blockages and severely compromised circulation may have unhealing ulceration or gangrene. There may also be discoloration of the skin.

Some may experience aching, pain, tightness, cramping, tiredness, in the thigh and hip region brought on by exercise and relieved by rest.

The legs may feel cold due to poor circulation. There is loss of hair and skin texture. Some patients may have no symptoms at all. Others conditions such as arthritis, sciatica, diabetic neuropathy can produce similar symptoms.
How do we diagnose PAD?

Ankle Brachial Index: A Simple Doppler aided blood pressure measurement at the arms and at the ankle levels could help us diagnose the presence and severity of PDA. This test is known as the Ankle Brachial Index. If the ankle pressure is less than 50% of the of the brachial pressure, it indicates severe arterial disease in the leg. However, it does not help us to establish the level at the arterial blockage is present.

Duplex Scan: In order to determine the exact location and the extent of the disease, we use the ultrasound duplex scan that can not only visualize the anatomic location, the degree of the blockage, but also determine its functional significance by doppler velocity measurements.

The MAR and CTA: They can identify the presence, the extent, and location of the blockage in the arteries above the knee level.

Arteriography: It is a definitive test where we inject contrast and obtain angiograms. The advantage to this approach is that we also can intervene with a balloon or a stent at the same time, if one is needed.

What are the treatment options?

The main purpose here will be to improve the leg circulation, relieve the symptoms, and prevent further worsening of ulcers or gangrene.

Medical: Minor blockages with mild pain can be initially treated with pills (such as Trental) that improve the manner in which the blood travels increasing the blood flow. Other medicines include Aspirin, Plavix, and cholesterol lowering drugs.

Intervention: Localized and critical stenosis can be managed with balloon and or stent. Those people must be on Plavix for 6 to 12 weeks. However, if someone has diabetes, the long term Plavix may be beneficial.

Surgical: In people with multiple or total blockages that are not easily amenable to stent treatment, may be candidates for vascular bypass which involve inpatient stay for 4-5 days and surgery. These surgeries go by different names such as aorto-femoral, Fem-pop, etc., depending on the blockage level.

How can we prevent PAD?

Just as risk factors modification for heart disease leads to improve symptoms and survival rates, similar risk factor modifications can help to reduce the symptoms, and decrease the rate at which the disease progresses. Early detection of the problem and its complications may prevent ulceration, infection, and gangrene. Absolute smoking cessation is essential to prevent any further worsening of the PAD. Exercise also helps to develop collateral circulation and thus improve exercise tolerance.

What is the prognosis?

Early recognition and aggressive risk factor modifications may prevent leg amputation, help in healing of leg ulcers, and prevent the development of gangrene.

Disclosure: Information provided here is for educational purpose only. Please consult with your physician for any medical advice.

(Visit www.sugarlandheartcenter.com for a more information on heart diseases.P: 281-265-7567; email: nikam@alltel.net)