Vascular Diseases of the Lower Extremity

Peripheral arterial disease (PAD)

Peripheral arterial disease or PAD is a condition in which blood flow to the legs is slowed or stopped by blockages in the arteries. If the condition is found in the legs then its possible that it exists in other areas of the body.

What are the symptoms?

Claudication or cramping in the legs while sitting or walking can be mild or severe. Some patients have difficulty walking and are forced to take breaks frequently in order to subdue the pain. Other symptoms include numbness, weakness, coldness in the feet, open wounds to the toes, a change in color of the legs, hair loss, shiny skin, no pulse in the foot, and slow toenail growth.

If the arterial disease becomes severe enough then pain will occur even at rest or when lying down. This is called resting pain. The patient will typically sit up and let their legs dangle off the side of the bed to have the blood get down to the lower extremity. If the blood flow is not restored to the extremity then gangrene can occur. Gangrene is when the skin and structures become necrotic because of the lack of blood flow. Early detection is crucial to prevent gangrene from occurring.

What are the risk factors of PAD?

Smoking, diabetes, obesity, high blood pressure, high cholesterol, age 50+, and a family history of PAD. Smoking is by farina of the greatest risk factors in developing PAD. Stopping smoking can help to prevent the disease.

How is PAD diagnosed?

When you go to see your podiatrist he will perform a physical exam and will feel your legs and feet for palpable pulses. Depending on this clinical exam he/she will determine whether further testing is needed. If the pulses are non-palpable then an ultrasound machine can be used to listen for the pulse and also measure the strength of the pulses with a computer. ABIs or ankle brachial index is a test that is used to measure the ratio of the blood pressure in the arm compared to the ankle. If the number is abnormal then further testing is required. A vascular surgeon may be involved to complete the more advanced testing. Visual ultrasound can be used to check the flow of the arteries and also veins of the legs. Angiography using contrast dye and x-ray is a very easy way to determine where the narrowing of the arteries occur in the lower extremity. This testing is usually performed by a vascular surgeon because if the problem is identified it can be fixed using several angioplasty techniques.

How do you treat PAD?

Treatment of PAD can start with lifestyle changes. Quitting smoking, exercise, weight loss, controlled diabetes, and medication can all help with reducing symptoms and reversing the disease. If the symptoms are severe then a vascular surgeon may perform surgical procedures to open up the blocked arteries of the legs. The vascular surgeon may use such surgical techniques as angioplasty, stents, bypass, grafts, and arterectomy. All these techniques have different indications and the surgeon will choose the most effective and least invasive technique to provide the best outcome for the patient.

What is venous disease?

Veins are the blood vessels that return blood back to the heart. They are very flexible and have valves within the vessel that open and allow blood to flow. The valves keep the blood from flowing backwards (away from the heart). Sometimes the vessels get damaged and the valves then cannot function properly. This leads to retrograde flow of the blood and results in venous disease.

What is chronic venous insufficiency?

This disease is when blood pools into the leg due to faulty veins and causes chronic swelling. The chronic swelling leads to increased pressure, discoloration of the skin, openings in the skin, and engorged visible skin veins.

What is a deep vein thrombosis or DVT?

A DVT is a clot in a vein that may develop in the upper or lower extremities. The DVT can be life threatening since the possibility of the clot traveling to the lungs resulting in a pulmonary embolism. This type of clot can lead to acute death so a DVT is very serious and should be taken care of quickly.

What is venous phlebitis?

This is when the superficial veins develop a clot and become painful. This clot is superficial and therefore the clot if dislodged does not travel to the lungs. Therefore this type of clot does not pose any life threatening risks.

What are the treatment options for venous disease?

There are both surgical and non-surgical treatment options for any of the various types of venous disease. DVTs for instance are treated with blood thinners and exercise. Venous insufficiency can be treated with compression stockings and also ablation of the veins if the symptoms are serious. The vascular doctor will determine the best option so that the optimum outcome can be achieved.

What are varicose veins?

Varicose veins are typically superficial veins that are engorged due to the compromised veins. Vascular surgeons can treat them by performing various procedures such as vein stripping, ablation, sclerosing, and laser therapy. These should only be performed by a valid vascular surgeon who has had extensive training in vein diseases. Complications can be painful so choosing the right procedure is crucial for a good outcome.

What is lymphedema?

This condition results in swelling to the arms and legs. Its caused by damage to the lymph nodes of people who receive cancer treatments. The lymphatic system is a vessel system that involves the lymph nodes. When these vessels are damaged then blockages can occur and stops the flow of lymph fluid and this leads to the swelling in the legs. There is no cure for lymphedema but the symptoms can be reduced with early detection of the disease.

What are the symptoms of lymphedema?

Swelling of part or all of the legs and arms including the fingers and toes. Patients often complain of heaviness or tightness in their extremities. Range of motion is slowed due to the heaviness of the legs. Hardening of the skin is a result of chronic swelling secondary to the lymphedema.

What are the causes of lymphedema?

Surgery or removal of the lymph nodes can result in lymphedema. Radiation treatment for cancer can cause blockages within the lymph nodes if they are damaged. Cancer itself can cause blockages in the lymphatic system if the tumor is large enough to place pressure on the vessels. Infection of the lymph nodes can occur and lead to damage. This damage can then lead to blockages and poor flow of lymph fluid.

What are the risk factors for lymphedema?

Factors that may increase your risk of lymphedema is old age, obesity, and rheumatoid or psoriatic arthritis.

How do you diagnose lymphedema?

Advanced imaging such as MRI, CT, ultrasound, and lymphoscintigraphy can be used to help diagnose lymphedema. The doctor’s physical exam and history of the patient is also crucial when determining the diagnosis. The imaging studies can be use to identify where the blockages are and also if there are soft tissue masses pressing on any of the lymphatic structures.

How do we treat lymphadema?

As stated before there is no cure for lymphedema. Exercise encourages the excess fluids in the extremities to be pumped out and back into circulation. Compression wraps and stockings can help to keep fluid out of the extremities and again pumped back into circulation. Massage therapy can be utilized to milk the excess fluid out of the extremities. Pneumatic compression with mechanical pumps can help to also pump the fluid out of the legs with minimal effort. All these therapies help to limit excess fluids in the extremities and by doing this it can prevent ulcerations and chronic infections to the legs.

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