Peripheral Vascular Disease – Diagnosis, Symptoms and Treatment

What is Peripheral Vascular Disease?

Peripheral vascular disease is characterized by fatty plaque formation in the peripheral arteries - arteries that do not include the heart or its major branches.  This condition usually affects the arteries in the legs and results in leg cramping (claudication) with physical activity.

The peripheral vascular disease typically occurs in patients with cardiovascular risk factors such as advanced age, high blood pressure, elevated cholesterol, smoking history, and diabetes mellitus.  One of the most problematic complications is foot gangrene, which may necessitate foot or lower extremity amputation.  This condition is also very closely associated with heart disease.

What Causes Peripheral Vascular Disease?

Peripheral vascular disease is caused by the buildup of fatty plaques in the lower extremities' arteries (legs).  This results in reduced blood flow in the legs, especially during physical activity and exercise.  When you exercise, the muscles in your legs require more blood flow and oxygen - when this blood flow is decreased – you develop symptoms of peripheral vascular disease.

The most important risk factors for fatty plaque buildup in the arteries of the lower legs include:

•         Smoking history
•         High blood pressure
•         Elevated cholesterol
•         Advanced age
•         Diabetes mellitus

These are the same risk factors responsible for heart disease – in other words, these risk factors cause a fatty buildup in arteries all over your body (including the heart).

How Common is Peripheral Vascular Disease?

Peripheral vascular disease is a prevalent condition.  It affects approximately 8 to 12 million Americans. About 15% to 20% of adults over the age of 70 have peripheral vascular disease.  This is likely due to the Western diet and lack of physical activity.

Signs and Symptoms

The most common symptom of peripheral vascular disease include:

•         Pain in the legs or calves (claudication)
•         Weakness in the legs
•         Decreased leg stamina
•         Numbness or tingling in the legs

All of these symptoms typically occur with prolonged walking or exercise and improve with rest.  Improvement with rest is a crucial characteristic of this condition because as you rest, your leg muscles do not require as much oxygen.

Signs may include reduced pulses in the feet, hair loss in the legs/feet, and a shiny appearance to the lower legs' skin.

Some patients with the severe peripheral vascular disease develop necrosis and gangrene in the lower extremities – this occurs because tissues in the feet and lower legs do not receive enough oxygen and die.

Diagnosis

Peripheral vascular disease is diagnosed based on symptoms, physical examination, and laboratory tests.

Your doctor will likely screen for the condition with a study called an ankle-brachial index (ABI).  During this test, blood pressure in the ankles is compared to blood pressure in the arms.  If there is a large difference between these two values – this suggests that you are receiving less blood in your legs and likely have peripheral vascular disease.  Occasionally, your doctor may also order vascular studies that use arterial duplex ultrasound to assess for adequate blood flow in your legs.

If the tests mentioned above are positive, your cardiologist or vascular surgeon will likely confirm the diagnosis with an angiogram.  During this test, they will insert a catheter in the groin and advance it to the arteries in your legs.  They will then inject dye to see if there are any significant blockages in the arteries – and if they see any – they may deploy a balloon or stent to open the artery up.

In addition to these interventional studies, your doctor will usually check blood tests such as a comprehensive metabolic panel, complete blood count, and cholesterol.  They will also typically screen you for diabetes with a test called hemoglobin A1c.

Peripheral Vascular Disease Treatment

Peripheral vascular disease is treated with dietary and lifestyle changes, as well as medications.  Your doctor will likely recommend a low-sodium, low-cholesterol diet rich in fruits and vegetables.  If you smoke, they will encourage tobacco cessation, as this is a significant risk factor.

Pharmacologic treatment usually includes at least one medication in each of the following categories:

•         Antiplatelet agents
•         Aspirin
•       Plavix (Clopidogrel)
•         Cholesterol-lowering therapy
•       Lipitor (Atorvastatin)
•       Pravachol (Pravastatin)
•         Antihypertensive agents
•         Diuretics - Microzide (hydrochlorothiazide)
•         Angiotensin-converting enzyme (ACE) inhibitors - Zestril (Lisinopril)
•         Angiotensin receptor blockers (ARBs) - Cozaar (Losartan)
•         Calcium channel blockers - Norvasc (Amlodipine)

Occasionally your doctor may recommend a medication called Pletal (Cilostazol), as long as you do not have heart failure.

If you have diabetes, they may also recommend drugs such as Glucophage (Metformin), Glucotrol (Glipizide), Januvia (Sitagliptin), or even insulin.

Besides lifestyle changes and medical therapy, your doctor may also recommend interventional treatment such as balloon angioplasty or arterial stents placement to open up blockages in the arteries in your leg.  If your condition is very severe and not amenable to stent placement, they may recommend arterial bypass surgery.  Amputation is usually indicated if you have dead tissue or gangrene in the lower extremities.

References:

1.     Kullo I, Rooke T. Peripheral Artery Disease. N Engl J Med. 2016 March 3;374:861-871. - https://mfprac.com/web2019/07literature/literature/Surgery/PAD_Kullo.pdf
2.     Peach G, Griffin M, Jones KG. Diagnosis and management of peripheral arterial disease. BMJ. 2012 Aug 14;345:e5208. - https://www.bmj.com/content/345/bmj.e5208/rr/598794
3.     Hennion DR1, Siano KA. Diagnosis and treatment of peripheral arterial disease. Am Fam Physician. 2013 Sep 1;88(5):306-10 - https://www.ncbi.nlm.nih.gov/pubmed/24010393