Peripheral Arterial Disease (PAD) is a disease causing narrowing of the blood vessels of the lower extremities, resulting in impaired blood flow to the legs. PAD is caused by atherosclerosis, or deposits of cholesterol rich plaque lining the wall of the arteries. This is the same disease process that involves the arteries of the heart (resulting in chest pain or heart attack) or brain (resulting in stroke).

According to the Centers for Disease Control and Prevention (CDC), an estimated 8 million people in the U.S. suffer from PAD. Twelve to 20% of these individuals are aged 65 year or over. Men and women are equally susceptible, although women face a greater risk of loss of limb from the condition.

Symptoms

Many people with PAD are unaware of their condition because they do not have any symptoms or mistake the symptoms for something different. When symptoms do occur, the most common is achiness or cramps of the thigh or calf muscles. This usually occurs with walking, exercise or climbing stairs, and resolves with rest. When PAD becomes more severe, patients may experience pain or tingling in the feet or toes at rest, weakness of the calf muscles or painful non-healing ulcers on the feet or toes. Other manifestations of advanced PAD can include hair loss over the legs, thick toenails or shiny, tight skin. Left untreated, patients may suffer gangrene, limb loss, heart attack and stroke.

Risk factors

Risk factors for PAD are the same as those for coronary artery disease (heart disease) or stroke. They include smoking, diabetes, high blood pressure, high cholesterol and advanced age.

Smoking is the most important risk factor for PAD. 80 to 90 percent of patients with PAD are current or former smokers. Patients who continue to smoke are more likely to progress to a more critical state of the illness.

People with diabetes have three to four times the normal risk for PAD, tend to develop PAD at an earlier age and have more severe disease. Poor blood sugar control increases the risk and its progression.

High cholesterol level is also an important risk factor. Research shows the risk of PAD increases by five to 10 percent for each 10 mg/dL increase in total cholesterol. Low levels of HDL, the “good” cholesterol, and high levels of triglycerides and LDL, the “bad” cholesterol, further increase the risk.

Diagnosis

Early diagnosis and management of the condition is crucial. Diagnosis of PAD begins with inspection of the legs and pulse by a health care provider. The ankle-brachial index, a simple test, is commonly used to diagnose PAD by calculating the ratio of blood pressure in the lower extremity and the arms. Advanced imaging such as ultrasound, computed tomographic (CT) or magnetic resonance (MR) imaging of the arteries of the lower limbs are used to determine the location, severity and management of disease.

Treatment

Lifestyle change is the first and most important component of management. Smoking cessation, meticulous control of diabetes and control of blood pressure and cholesterol are very important.

Regular physical activity is also an effective treatment strategy. Supervised exercise training can lead to reduced symptoms and increased distance and time patients can walk before symptoms begin. Regular use of aspirin or aspirin-like medications, as recommended by the health care provider, can reduce the risk of local complication as well as heart attack. Other medications have been used to improve blood flow in the legs with variable success.

For patients with severe symptoms that do not respond to medical and exercise therapy, surgical treatment may be necessary. Options include open bypass surgery or endovascular therapy, such as balloons or stents.

For more information regarding PAD or other cardiovascular issues, contact Clarkson Heart Center at (402) 552-2320.  Clarkson Heart Center is affiliated with The Nebraska Medical Center.

by M.Z. Hoque, MD, Clarkson Heart Center