Peripheral Arterial Disease

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Peripheral Arterial Disease (PAD)

What is peripheral arterial (vascular) disease?

Peripheral arterial disease (PAD) is a common circulatory problem in which narrowed arteries reduce the blood flow to your extremities (most often the legs). The most common cause of this narrowing is fatty deposits (atherosclerosis) accumulating in the walls of the arteries. As deposits continue to build within the arterial wall, the internal diameter of the vessel decreases, blockage results, and the blood flow to the extremity is jeopardized. Once the artery becomes narrowed, the sluggish flow of blood may result in clots forming completely shutting off the blood flow to an area. This may become an emergency situation. Another concern is that peripheral arterial disease is likely to be a sign of widespread accumulation of fatty deposits in your other arteries. This condition may also be reducing blood flow to your heart and brain, and result in heart attack or stroke.

About half of people with peripheral arterial disease have mild or no symptoms. About one-third to one-half develops more severe symptoms, including intermittent claudication. Intermittent claudication is characterized by muscle pain or cramping in your legs or arms that is triggered by a certain amount of activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is the most common area of intermittent claudication. The severity of pain varies widely. Pain from this condition can range from mildly bothersome to debilitating. Severe intermittent claudication can impair your ability to function and engage in any physical activity. It may interfere with the ability to do your job. Risk factors are similar to those for coronary artery disease and include family history, age over 50, smoking, high blood pressure, hyperlipidemia, diabetes, and smoking.

Other signs and symptoms of peripheral arterial disease include:

  • Leg numbness or weakness
  • Cold legs or feet
  • Sores on your toes, feet or legs that won't heal
  • A change in the color of your legs
  • Hair loss on your feet and legs
  • Changes in your nails

As peripheral arterial disease progresses pain may begin to occur when you're at rest or when you're lying down. This is called ischemic rest pain. This is a more serious condition and suggests a higher risk of limb loss due to gangrene. Rest pain may be intense enough to prevent sleep or to wake you from sleep. You may be able to temporarily relieve the pain by hanging your legs over the edge of your bed or by walking around your room. If you are worried about peripheral arterial disease, contact your physician. Rest pain should lead you to seek more urgent medical attention. Early diagnosis and treatment of PAD is important not only to preserve the health of your limbs, but also to decrease your risk of heart disease, stroke, and other medical conditions.

What is a peripheral vascular angiography?

A vascular angiogram is similar to heart catheterization done for heart, where dye is injected to see how the blood flows through the vessels in the legs, kidneys, neck or other different organs of the body. X-ray pictures are taken and a treatment plan is developed with your doctor if blockages are seen. It is important to tell your doctor if you are allergic to x-ray contrast dye. Your doctor can give you medication to prevent an allergic reaction, like a rash, difficulty breathing or nausea and vomiting.

A full vascular angiogram is usually completed in 30-40 minutes. The catheters the doctor uses are similar to a large IV. You should not feel pain once the catheter is placed, and you will not feel the catheter moving inside your body. When the catheter is in position, a dye is used to form a picture of your arteries. You may feel some warmth in your neck, arms, legs and abdomen for a few seconds as the dye is injected. At this time the doctor and radiology technologist may ask you to hold very still or take a deep breath as the table and camera move to take pictures from different angles.

The x-ray picture of the dye injection creates a map of your arteries called an angiogram. The doctor will be able to see blockages in your arteries and will discuss with you several methods of treatment. You may require vascular bypass surgery. This will be determined after consultation with your vascular surgeon. You may also be a candidate for angioplasty, which can be performed at the same time as your angiogram. You and your doctor will decide on the best treatment for you.

Angioplasty and stenting

An angioplasty may be done to treat blockages within your arteries. An angioplasty is performed when a very thin wire and a small balloon is passed across the blockage in your vessel. The balloon is inflated to compress the cholesterol plaque. While the balloon is inflated, you may feel some cramping pain. This is only temporary and will go away once the balloon is deflated. After the balloon is deflated, the blockages will improve and blood flow in the artery will be restored.

“Stenting” refers to the method by which a small metal slotted or coil tube is placed against the artery wall to hold the artery open. Balloon angioplasty is usually done before and after the stent is placed. These stents remain permanently in the artery after the procedure.

Occasionally, in the case of a particularly dense blockage, a small mechanically driven cutter shaves the plaque from the artery wall. This is referred to as atherectomy. The catheter is placed over a guide wire to the narrowed segment. Balloon angioplasty may be done after the atherectomy. The different types of atherectomy catheters that may be used:

  • Rotational atherectomy uses an abrasive diamond coated burr at the tip of the catheter. The catheter is rotated rapidly (like a dental drill) to grind or sand the plaque into tiny particles that float away in the blood stream.
  • Extraction atherectomy uses a rotating blade inside the tip of the catheter to cut the plaque. The plaque is then vacuumed into the catheter and removed.

When the procedure is completed an intravascular ultrasound may be performed. A sonogram (ultrasound) catheter is placed in the diseased artery and pictures of the interior of the vessel are made as the catheter is slowly removed. This is used to determine the level of blockage and the size of the artery.

Most procedures are done on an outpatient basis or may require a one-night stay in the hospital. Patients recover quickly and can resume normal activities sooner than with traditional surgery.

What are the risks of the procedure?

Because this is an invasive test there are certain grave risks that you need to be aware of. Fortunately we encounter these extremely rarely. The risk of death, heart attack or stroke is less than 1 in 1000. Bruising at the access site occurs in many people but very few of these will have enough bleeding into the groin that we have to surgically address this. The IV contrast can rarely cause an allergic-type reaction in people with a history of iodine allergy and can be harmful to patients with poor kidney function.