What is peripheral arterial disease (PAD)?
A normal artery is a smooth tube that carries blood from the heart to the other areas of the body. When plaque (atherosclerosis) and calcium builds up in the wall of the artery, it can cause blockages in the circulation to the area supplied by the artery. Outside the brain and heart, those blockages are called peripheral arterial disease (PAD).
What causes PAD?
Several medical conditions cause PAD:
- High cholesterol
- Cigarette smoking
What are the symptoms of PAD?
PAD generally refers to blockages in the arteries to the legs. These blockages can be present without any symptoms, in which case no surgical treatment is recommended. Patients with the medical conditions listed above should be careful to control them with medications. In particular, patients who smoke should stop smoking. However, sometimes these blockages can worsen to produce symptoms such as pain with walking (claudication), pain at rest, or even ulcers or gangrene.
Claudication is pain in the legs when walking that is caused by blockages in the arteries in the legs. This pain usually occurs in the calves but can also occur in the thighs or buttocks. It is usually a gripping, "charley horse"-type pain that goes away when the patient stops walking. Many conditions cause pain in the legs, and claudication is one of them. Other conditions that can cause pain in the legs include arthritis and nerve damage including sciatica and neuropathy. A careful interview and physical examination by a vascular specialist will help determine the cause of pain. If the pain is caused by blockages in the arteries to the legs (PAD), treatment will depend on how severe symptoms are. If the pain does not severely restrict activities (non-disabling), then medical treatment is recommended. Medical treatment consists of smoking cessation and controlling the risk factors (see list above) that can cause PAD to worsen. If the symptoms of claudication are severe (disabling), then evaluation by an arteriogram (see below) is appropriate.
Pain at rest (rest pain) is pain in a foot or both feet that occurs throughout the day. Many conditions can cause pain in the feet, particularly arthritis, bone problems in the foot, and nerve injury due to diabetes (neuropathy). However, lack of blood flow can also cause rest pain and can be dangerous because gangrene can develop under these conditions. A careful history and physical examination by a vascular surgeon can help determine whether rest pain due to lack of blood flow is present, and in that case an arteriogram (see below) is appropriate.
Ulcers or even gangrene in the foot can also develop because the blockages in the arteries in the leg are so severe that the normal tissue in the foot cannot stay alive. This is an urgent situation that requires an evaluation by a vascular surgeon.
How do I know that I have PAD?
A careful history and physical examination are the first steps to determine whether you have significant PAD. Symptoms such as pain with walking and pain in the feet at rest should raise suspicion about the presence of PAD. However, several other medical conditions can cause the same symptoms in the presence of normal blood flow, and the key point is determining that circulation (blood flow) to the legs and feet is abnormal. Examining the pulses at the foot and ankle and examining the foot itself are the next steps.
Ultrasound is usually the first test ordered to look at the arteries of the legs when significant PAD is thought to be present. This also involves measuring the blood pressure in the legs with special blood pressure cuffs, much like taking the blood pressure in the arm.
What is an arteriogram?
An arteriogram is an x-ray of the arteries. It involves numbing the skin over an artery - usually the main artery in the groin which goes to the leg - and inserting a catheter into the artery. A special kind of fluid (dye) is injected into the artery under x-ray, and this "lights up" the artery. The vascular surgeon can then look at the arteries and see where the blockages are.
What are the treatments of PAD?
Medical treatment is appropriate for patients who have no symptoms related to their PAD. The patient is encouraged to work with his or her primary care physician to control the risk factors for PAD, including hypertension, diabetes, etc.
Endovascular (minimally invasive treatment), including balloon angioplasty and stenting, is appropriate for many patients who have significant PAD, such as those who suffer from disabling claudication (see above), poorly healing wounds of the foot or ankle, ulcers, or gangrene. During an arteriogram, a special balloon can be used to open the blockage in the artery, and a stent (small metal scaffold placed inside the artery) can be placed to keep the artery open. This is an outpatient procedure that requires only topical anesthesia and possibly sedation, and recovery is quick. Angioplasty and stenting are appropriate for some but not all patients with severe PAD. In some patients, it is not technically possible to perform angioplasty and stenting, and bypass surgery is required.
Bypass surgery is surgery where a vein from the leg or an artificial vein is used to bypass the blockages in the legs, thereby increasing blood flow to the foot. Small incisions are made in the leg, and a general anesthesia is required. Recovery in the hospital usually lasts a few days.
Testing for Peripheral Vascular Disease can be done in our Vascular Lab Appointment Request