DID YOU KNOW... Peripheral Artery Disease (PAD) is often without symptoms & has a High Mortality rate?

Prepared by John. A. Sawdon M.Sc. Public Education & Special Projects Director,
Cardiac Health Foundation of Canada

What is Peripheral Artery Disease (PAD)?

Peripheral artery disease (can be referred to as peripheral vascular disease) is when your arteries begin to narrow or occlusion forms by atherosclerotic plaques of arteries outside of the heart and brain. It’s a common problem that will affect 9 % of the population, but will only cause problems for about a quarter of those people. 1 It has a particularly high prevalence rate in people over 70 years of age.2 Lower extremity peripheral artery disease symptoms will affect 30 to 40% of those patients presenting with claudication symptoms, thus it is difficult to predict with accuracy the actual prevalence of this disease. Of patients with known PAD, 30 to 50% have evidence of coronary artery disease and approximately 15 to 25% have significant ceratoid artery disease.3 Individuals with peripheral artery disease have a 3 to 5 fold higher mortality risk compared to those without PAD. Increased mortality is associated with cardiovascular risk and reflects the higher incidence of atherosclerosis in persons with PAD. 4

How does it Develop?

The Heart pumps oxygenated blood along with nutrients through the arteries to every part of your body. The artery is a hollow tube with a smooth interior for the blood to travel through. When the blood travels through the arteries it can leave behind deposits known as plaque. This plaque referred to as LDL-C cholesterol along with lipoprotein (a) which forms as a sticky particle that then attaches itself to the intima of an inflamed spot within the arterial wall builds up over time and narrows the artery. The name health-care professional’s call this process is occlusive disease. Peripheral artery disease is the name when occlusive disease occurs in the peripheral or outer arteries of the body. PAD can occur in any blood vessel but it is more common in the legs than the arms. Peripheral artery disease is more common in people over 65 but can occur at any age.


Figure 1: Comparison of plaque buildup in arteries within the heart & leg Risk Factors for PAD

Some of the causes of peripheral artery disease include smoking, atherosclerosis, high cholesterol or high triglycerides, high blood pressure, diabetes, kidney failure, over age 60, physical inactivity and obesity. Vascular disease can also be a heredity condition however genetics are not well understood. If any of your family members have histories of vascular disease tell your Doctor.5


Figure 2: Risk factors for Peripheral Artery Disease (PAD)

Although peripheral artery disease is slightly more common for men than women, Afro Americans/Afro Canadian/Afro Caribbean’s and other ethnic groups have higher prevalence rates. 6

Symptoms of Peripheral Artery Disease

The severity of the peripheral artery disease, the location of the plaque and the activity of the muscles determines severity of symptoms and pain. Many patients do not have any symptoms associated with peripheral artery disease, making this condition difficult to diagnose and treat. Often individuals over 60 experience arthritis, degenerative joint disease, herniated discs and spinal stenosis which can mimic PAD. The classic symptom of PAD is pain in the legs; this may follow a period in which the legs feel heavy and weak.


Figure 3: Progressive development of the stages & symptoms associated with Peripheral Artery Disease

This weakness in the legs area is a sign of the lack of oxygen to the lower limbs. Although this occurs most commonly in the calf muscle, it can also occur in the thigh or buttock muscles usually after walking or climbing stairs. This symptom is called claudication. As the disease progresses, and the blood is not able to get nutrients and oxygen to the feet, individuals even when lying down will experience pain in their feet or calves. Without nutrients and oxygen the skin will break down into ulcers. If an individual has resting leg pain or ulcers they are at risk of developing gangrene and losing their foot and or leg to amputation. 6 Other symptoms which may occur with PAD include:

  • Leg numbness or weakness
  • Coldness in your lower leg or foot, especially when compared with the other side
  • Sore on your toes, feet or legs that will not heal
  • A change in the colour of your legs
  • Hair loss or slower hair growth on your legs and feet.
  • A change in colour of your legs
  • Slower growth of toenails
  • Shiny skin on your legs
  • No pulse or a weak pulse in your legs or feet
  • Erectile dysfunction in men

Depression which impacts quality of life often occurs in individuals with claudication along with increasing concerns about balance and potential for falling.


Figure 4: advanced signs of peripheral artery disease which can lead to gangrene and potential amputation

Diagnoses of Peripheral Artery Disease

Your Doctor may consider a number of the following tests in determining whether you have PAD. This can include 7:

  • Physical Exam: your Doctor may discover a weak or absent pulse below the narrowed or blocked artery. This might include a whooshing sound through the stethoscope, evidence of poor wound healing in area of blockage or narrowed artery, and decreased blood pressure in your affected limb.
  • Ankle-brachial index, (ABI) this test compares the systolic blood pressure in your ankle with the systolic blood pressure in your arm. In individuals with significant PAD in the legs, the blood pressure in the ankles will be lower than in the arms (Brachial Blood Pressure). The ankle brachial index is a number derived from dividing the ankle blood pressure by the brachial blood pressure. An ABI of .9 to 1.3 is normal; an ABI less than .9 indicates presence of peripheral artery disease in the arteries of the legs. An ABI below .5 indicates severe arterial occlusion in the legs. In using an ankle-brachial index to get your blood pressure the Doctor uses a regular blood pressure cuff and may also use a special ultrasound device to evaluate blood pressure and flow. Your Doctor may also ask you to walk on a treadmill and have readings taken before and after exercising in capturing the degree of blockage in the narrowed arteries.
  • Ultrasound: these imaging techniques help your Doctor to evaluate blood flow through the blood vessels while identifying blocked or narrowed arteries. The Doppler Ultrasound measures high frequency sound waves that are bounced off your tissues. This is used to measure blood pressure behind the knees and in the ankles. The Duplex ultrasound is an non-invasive technique to study the arteries. Ultrasound probes can be placed on the skin over the arteries in accurately detecting artery stenosis, including the degree of obstruction.
  • Angiography: an angiography is an imaging procedure to study the blood vessels of the extremities similar to a coronary angiogram. It is the most accurate way to detect occlusions or blockages within the arteries. Small hollow tubes (catheters) are advanced through the skin in the groin area to the aorta and arteries. Dye (iodine) is then injected into the arteries while x-ray video is recorded. An angiogram gives the Doctor an accurate picture of the narrowed arteries including severity of blockages. The angiogram dye can be damaging for anyone with kidney disease, thus it is not usually used during the initial assessment.
  • A number of other techniques including x-rays, magnetic resonance imaging and computed tomography scans are also used. Magnetic resonance imaging angiography uses magnetism radio waves and a computer to produce images of the body structures.

Treatment and Treatment Goals for Peripheral Artery Disease

The treatment of peripheral artery disease is usually centred on aggressive management of the risk factors through lifestyle change and medications. In doing so, the following goals create the framework for action:

  • Relieving the pain of intermittent claudication
  • Improving exercise tolerance through walking, and cycling

  • Preventing critical artery blockages that can lead to foot ulcers, gangrene and amputation
  • Prevention of heart attacks and strokes

Supervised exercise can increase blood oxygen within the muscles and reduce claudication. Ideally you should be prescribed an exercise prescription from your Doctor and or enrolled in a cardiovascular rehabilitation program. In Canada fees vary for these programs. In Ontario most programs are free with a Doctors referral, in other provinces fees are charged for materials and can range from a few dollars per session to over $300 for a 12 week program. Ideally your exercise program that will help build tolerance before claudication occurs should be 3 times a week lasting between 30 to 45 minutes. Ideally you will begin walking on a treadmill and be monitored including oxygen levels, blood pressure, heart rate and any potential arrhythmias. 8

Lifestyle stage may include stopping smoking if you smoke, adjusting your diet in reducing trans fats, salt and sugars. Smoking is the one critical risk factor that increases progression of PAD including increased pain frequency and potential for gangrene and amputation. A healthy diet can help lower blood cholesterol, triglycerides, and blood pressure. Controlling diabetes, cholesterol levels and blood pressure through lifestyle change and medications is important in reducing impact of peripheral artery disease. This includes cholesterol-lowering medications. The Mayo clinic suggests that the goal for people with peripheral artery disease is to reduce low density lipoprotein LDL-C to less than 100 milligrams per deciliter or 2.6 millimoles. The goal is even lower if you have diabetes, chronic kidney disease, are a current smoker or have previously had a heart attack or stroke.

The same thing applies to medication for High Blood Pressure. The ideal goal is to reduce blood pressure to 140 millimeters of mercury (mmHg) over 90 millimeters of mercury as a maximum unless you have diabetes or chronic kidney disease. The goal is these cases are to reduce it 130 mmHg over 80 mmHg. If you have Diabetes, it is important to keep your blood glucose levels under control. This may mean a discussion with your Doctor if you are having problems with wildly fluctuating blood sugar readings.

Because peripheral artery disease is related to reduce blood flow in your lower arteries, it’s important to increase that flow and to prevent blood clots from occurring. Your Doctor may want you to take aspirin daily or other medications such as clopidogrel or Plavix. The drug cilostazol (Pletal) may also be considered to treat symptoms of claudication including leg pain.

Depending on the severity of the peripheral artery disease and the lack of success of lifestyle and medications, your Doctor may recommend angioplasty and surgery.

  • Angioplasty: this procedure includes threading a small hollow tube (catheter) through a blood vessel to the affected artery. A small balloon on the tip of the catheter is inflated to reopen the artery and flatten the blockage into the artery wall, while stretching the artery to increase blood flow. If required a Doctor may insert a metal stent which is medicated into the blocked portion of the artery to keep this open in allowing increased blood flow.

  • Bypass Surgery: Your vascular surgeon may create a graft bypass using a vessel from another part of your body or a synthetic fabric. This procedure allows the blood to flow around or bypass the blocked artery.
  • Thrombolytic Therapy: If you have a blood clot blocking the artery the surgeon may inject a clot dissolving drug into your artery at the point of the clot to break it up.

Summary: Peripheral Artery Disease can be frustrating and debilitating because any type of exercise usually results in pain. This makes believing that by walking you will increase the distance you walk and eventually lower the pain you are feeling, difficult to comprehend. Above all if you smoke quit smoking, get help and do what you can to reduce this burden. Additionally take care of your feet, wash them thoroughly, inspect them for sores that do not seem to heal and see your Doctor right away. At night time elevate your head above your feet, this may reduce the pain you might be experiencing in your calves. Also avoid cold temperatures as much as possible or alternatively dress warmly layering your clothing.

If you suspect you have peripheral artery disease, prepare yourself for your first visit with your Doctor. Write down any questions you have and any symptoms you have been experiencing. Tell the Doctor where you experience pain, when you experience it and how often. If you haven’t shared your family history be prepared to do so during your next visit. Peripheral Artery Disease is serious and likely will affect the majority of people over 70 years of age. It is also a sign of atherosclerosis and should be checked out and treated by Doctor as soon as possible.

We have provided this article to raise awareness of peripheral artery disease and to alert you to seek help if you are experiencing any of the symptoms identified within this paper. If you have other topics you wish to learn more about in terms of cardiovascular disease, please let us know. If we have piqued your curiosity and you enjoyed this topic, we also hope to hear you. Remember as we age it’s important to see your Doctor on annual basis for a full checkup.

References:

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  17. What are some treatments for peripheral artery disease? https://www.reference.com/health/treatments-peripheral-artery-disease-27aeaf52cae0161
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The articles, on the Cardiac Health Foundation of Canada website, are presented with the understanding that the Foundation is providing information only and not rendering medical advice. Please check with your family physician, specialist or health care professional before implementing any of the ideas expressed in these articles.