Most people are familiar with the potential health problems of coronary artery disease, such as heart attack or heart failure, and most can name at least one or two of its risk factors, such as high blood pressure or high cholesterol. But not nearly as many can list the problems or risk factors associated with peripheral arterial disease, or PAD — or for that matter, even know it exists.
Like coronary artery disease, PAD is caused by a build-up of plaque in arteries, but in this case this involves the arteries leading to the peripheral areas of the body — the arms, legs, kidneys, or intestines — rather than the heart. The plaque slows or even blocks the flow of blood to these areas, depriving them of oxygen and vital nutrients normally carried through the bloodstream.
PAD is a very common disease, especially among older people and those who already have coronary artery disease or carotid artery disease (blockages in the vessels leading to the brain). People who have PAD are at four to six times greater risk of suffering from a heart attack or stroke, and the more severe their symptoms are, the higher their overall risk of health problems.
Patients with PAD may suffer from claudication, which refers to pain or discomfort in the legs during exercise, such as a feeling of heaviness or cramping. It usually occurs in the calves but can also affect the thighs or buttocks; rest helps relieve the discomfort. In advanced form, PAD can lead to a condition called critical limb ischemia, which occurs when blood flow to the lower extremities is so restricted that vital nutrients cannot reach the muscles, skin or nails. Often, this leads to gangrene, sores on the feet or legs that don’t heal, or constant, extreme foot and leg pain. These patients are at imminent risk of losing their legs, and perhaps their lives.
However, many people with PAD have no symptoms at all, and often don’t even know they have the disease. Even without any symptoms, patients with PAD are at much higher risk for developing serious health problems like heart attack and stroke. That’s why diagnosing PAD is so important. At Scripps, our goal is to improve PAD awareness amongst both the general population and health care providers, and increase screening for the disease. This can be as basic as having a physical exam and an evaluation of the pulses in the extremities. We can also perform a simple test called an ABI which measures and compares blood pressure in the upper and lower extremities to determine the percentage of blood flow that is reaching the lower extremities. The ABI can diagnose PAD with very high certainty and thereby identify patients at increased risk of heart attack, stroke, and other complications so they can be treated early and aggressively.
If we determine that someone has PAD, the next step is identifying and addressing any risk factors such as smoking, diabetes, high blood pressure, high cholesterol, family history, or an existing diagnosis of heart attack or stroke. Even if the patient has no symptoms, risk factors need to be treated aggressively with medication, lifestyle changes, or a combination of the two to reduce the chances of developing future health problems.
Patients who have claudication often can be successfully treated with intensive exercise, lifestyle changes, and medication. If claudication symptoms persist and substantially limit someone from doing what they want they want to do, a procedure to restore blood flow to the lower limbs called revascularization may be necessary. For patients with critical limb ischemia, an expeditious evaluation with consideration for revascularization is vitally important; for very advanced cases amputation may unfortunately be the only option, thus reinforcing the need for early detection and treatment.
There are two types of revascularization commonly used to treat patients with advanced PAD. The first is known as bypass surgery whereby incisions are made above and below the blockage in the vessel, and a new channel is created around the blockage using either a vein as a “spare part” from another part of the body or a synthetic tube. This is stitched into place to “bypass” the blockage and restore blood flow. This type of traditional operation has been used for many years, but requires hospitalization and can be associated with potentially serious complications.
In many cases we can now treat PAD far less invasively. Just as minimally invasive techniques have evolved for the treatment of heart disease, similar techniques are now being utilized in the treatment of PAD. During these procedures, a small tube called a catheter is first inserted into the blocked artery using a needle; dye is injected to locate the blockage (this is known as an angiogram), which can then be cleared by a variety of techniques such as dilating the artery with a balloon, using a catheter to “grind out” the blockage, or inserting a thin expandable metal tube called a stent to expand and hold the artery open to restore blood flow.
We are now using these less invasive procedures routinely to treat PAD at Scripps. In general they are much easier on the patient and are associated with minimal recovery time and a low risk of complications. In addition, these procedures are frequently done on an outpatient basis, with patients often going home the same day.
The first step to treating PAD is detecting it as early as possible. Scripps offers PAD screenings; if you have any risk factors such as diabetes, smoking, a history of heart disease or related problems, or suspicious leg pain, you should be screened as soon as possible.
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