Lower extremity ischemia, commonly referred to as Peripheral Arterial Disease or PAD, is caused by a decrease in blood flow (circulation) to the legs. Typically, this occurs over time as the arteries narrow due to plaque buildup thus limiting the flow of blood to the leg muscles.
In a normal leg, that is, in a person who does not have PAD, as the leg requires more oxygen (for example as you go from sitting to walking to jogging to sprinting) the body is able to open (dilate) the arteries—much like turning on a faucet—to provide increasing amounts of blood and oxygen to the muscles. Thus, the increasing demand of the leg muscles is met by increasing the supply of blood by, among other things, regulating the size of the arteries that supply the blood.
However, in the patient with PAD, the ability to dilate the arteries is diminished due to their hardening (atherosclerosis) thus giving rise to symptoms of PAD. Initially, PAD may start out as soreness or fatigue in the legs when walking a significant distance. If this is not addressed, this can progress to pain or cramping at rather short distances. Rarely, if left untreated, will this progress to gangrene or the need for an amputation. More commonly, people’s lifestyles will be altered to the point of having to eliminate many activities they enjoy doing.
Some people with rather severe PAD develop wounds on their legs that will not heal or pain that is present constantly—not simply with walking. These people are in need of urgent treatment to avoid the possibility of an amputation.
PAD is very similar to heart disease in terms of the risk factors with which it is associated. In fact, almost all patients with PAD also have underlying heart disease—even if it has not been diagnosed prior to finding out that someone has PAD.
Risk factors for PAD include
- Family history of PAD or heart disease
- High cholesterol
- Diabetes Mellitus
- Smoking
- Sedentary lifestyle
- Kidney failure
The most important aspect in the treatment of PAD is to make the correct diagnosis! Once diagnosed, treatment options will depend on the severity of symptoms, the associated medical problems one might have and the severity of the disease.
Diagnosis
The diagnosis of PAD can usually be made with a detailed history and physical examination. An experienced examiner knows the right questions to ask and how to perform a proper physical examination. Typically, this is all that is needed to make the diagnosis of PAD.
Claudication is one of the more common types of presentations of PAD. Claudication is pain that occurs after a specific walking distance—usually present in the calf muscles but may also appear in the foot, thigh or hip. It is important to distinguish claudication from arthritis pain or back pain radiating to the legs (e.g., sciatica or spinal stenosis) as these diseases typically occur together in the over 60-year-old patient!
Once the diagnosis is suspected, based on the history and physical examination, confirmation can be made in the Noninvasive Vascular Laboratory.
Noninvasive testing using blood pressure cuffs and ultrasound technology are used to determine the location of the disease in the legs and the severity. Utilizing these methods, the experienced vascular specialist can plan an appropriate course of treatment.
More complex testing, such as Magnetic Resonance Imaging (MRI), Computed Tomography Scanning (CT Scan) or diagnostic angiography might be utilized to aid in the diagnostic process.
Once the diagnosis is confirmed, the appropriate treatment plan can be constructed.
Treatment Overview
Treatment options for PAD vary from lifestyle modification for mild claudication to bypass surgery for limb-threatening problems such as gangrene or pain that occurs without any exertion (pain at rest.) The large majority of patients can be treated without invasive therapy—lifestyle modification, lipid (cholesterol) management and exercise. However, there are some patients whose claudication will not improve with even the strictest adherence to these recommendations. Many of these patients are younger and are not willing to resort to a lifestyle limited by their PAD.
Our success with those patients has been remarkable and quite gratifying. While these patients are not in danger of losing their legs, their PAD has adversely affected their lives. They can no longer do the activities—social, physical or personal—that they were able to do just several years ago. The cramping pain in their calves or thighs limits them in their lifestyle. Walking the boardwalk or chasing their young grandchildren is no longer possible.
We, at The Cardiovascular Care Group, have cared for thousands of patients with these problems. Minimally invasive techniques, such as balloon angioplasty, stent placement and atherectomy have allowed our patients to return to a healthy, enjoyable and vibrant life. Many of the treatment options are available in our office obviating the need for a hospital admission. Patient walk in in the morning and leave that same day feeling years younger without the burden of leg pain and cramping they experienced for years that limited their active lifestyle to one of an individual decades older!
Equally important is that many patients come in for a second opinion only to find out that the best treatment option is that of medicine and lifestyle modification. Our walking exercise program has saved many patients from undergoing surgery or minimally invasive angioplasty. Decades of experience have allowed us to recognize those patients who need intervention and those who need simple noninvasive alternatives.
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