Dr. K. K. PANDEY
Peripheral Arterial Disease (PAD) used to describe any disease of the peripheral vasculature of the body. PAD causes impairment of blood flow causing a wide spectrum of clinical conditions and diseases. The symptoms vary according to the area affected and degree of obstruction. Most commonly it is used to refer to decreased blood flow to the legs. If not treated, this has the potential of causing limb loss and eventually death.
PAD results from any disease causing narrowing or blockage of the lower limb arteries,with atherosclerosis disease being the most common etiology. Atherosclerosis development commences in the teenage years and then progresses over a period of time (usually decades) to cause significant flow limiting stenosis and obstruction. If not treated in time, it can cause significant discomfort in the legs including your ability to walk and in severe cases gangrene.
When these blockages occur in the heart they cause chest pain called angina and in the brain can cause strokes.
Some of the risk factors for PAD include increasing age, smoking, diabetes mellitus, Hypertension and hypercholesterolemia. If your family members have blockages in the arteries of the legs then you are also at increased risk of PAD. As many as 40% of patients with blockages in the arteries of the heart also have blockages in the arteries of the legs.
Most patients with peripheral artery disease are asymptomatic. The most common complaint is pain or discomfort in the muscles (buttocks, thigh, calves or feet) of the leg on exertion that is relieved with rest. Some patients may also experience heaviness and cramps on walking. The severity of symptoms will depend upon how many arteries are affected, how narrowed your arteries are, how quickly you walk, and whether you walk up an incline or stairs.
As the disease progress and severity of the blockages increases there may be rest pain in the legs, non-healing or slowly healing wound and eventually gangrene that may require amputation of the extremity.
If there is co-existent nerve damage you may feel burning, vibrations and decreased sensation in the feet.
Changes in extremity appearance depend on the duration and severity of PAD. With significantly reduced blood flow, the skin becomes thin with functional loss of the dermal appendages, which is evident as dry, shiny, and hairless skin. As the blockages increase the legs may become cool to touch. Patients with PAD often have diabetes and they may have weakness in the legs.
There are multiple tests that can be done to detect the PAD. The Ankle Brachial Index(ABI) measures the resting blood pressure at the ankle compared with the blood pressure in the arm. The ratio is used to assess the presence of blockages. Usually the ratio is close to 1, but if it low that is a marker of blockages.
Other more advanced testing like ultrasound, CT scan and MRI can also be done to assess for blockages.
Once diagnosed, it is important that the disease be treated aggressively. This includes risk factor modification and treatment of PAD in general. The main risk factors for PAD are cigarette smoking, diabetes mellitus, high blood pressure, and high cholesterol or lipid.
Lowering cholesterol can prevent worsening of PAD and can reduce the symptoms of claudication. Quitting smoking and improving control of diabetes and high blood pressure may also improve claudication symptoms (ie, pain), but even more importantly, it helps to reduce the risk of coronary artery disease. Various medications can also be given to improve the symptoms of claudication.
Exercise programs reduce the symptoms of claudication, including increasing the distance and time that one can walk before developing symptoms. Supervised exercise training involves walking on a treadmill or a track for 45 to 60 minutes at least three times per week.
In selected patients with severe pain and discomfort, particularly if medical therapy has been unsuccessful, your doctor may recommend a procedure to increase the amount of blood flow to the extremities. Revascularization procedures can be generally divided into two general categories: “catheter-based” procedures, such as balloon angioplasty and stenting, or surgery. The selection of revascularization technique depends upon a variety of factors, such as your particular anatomy, severity of symptoms, prior interventions and your overall health and fitness.
Catheter based techniques such as balloon angioplasty and stenting have evolved tremendously and are the default choice for most interventions. The procedure is done under local anesthesia and the patient is send home the next day.
Peripheral artery disease is an important cause of morbidity and mortality and if not treated appropriately and if not treated appropriately and aggressively can lead to amputation and in severe cases even death.
Is a senior cardio thoracic & vascular Surgeon at Indraprastha Apollo Hospitals, New Delhi.