Saturday, October 25, 2014

Peripheral Vascular Disease


Peripheral Vascular Disease usually refers to atherosclerosis (development of fatty deposits that narrow arteries) in the peripheral arteries (often the legs).


Mention blocked arteries and most people think of the heart. But blockages can affect other areas of the body as well - and certain types of leg or foot pain can be an important warning sign of potentially serious circulatory problems.

When leg pain occurs with exercise and is relieved promptly by rest, chances are that blockage has invaded the vessels of the legs or feet. Doctors call this condition lower-extremity peripheral vascular disease.

Leg pain severe enough to prevent a person from working, walking the golf course, or even crossing the street may be a symptom of advanced peripheral vascular disease, also known as atherosclerosis of the extremities. Late in life, fatty, fibrous plaques are likely to narrow the body's large and medium-sized arteries, impeding the flow of blood.

As the plaques grow larger, the arteries lose elasticity and their once-smooth inner linings crack and roughen, making them more likely to snag clots and other material. This does not happen uniformly from one person to the next or throughout the arterial system: in some individuals atherosclerosis clogs the channels that supply blood to the heart muscle or brain; in others, plaques accumulate mainly in the vessels leading to the extremities - almost always the legs.


Some degree of narrowing due to peripheral atherosclerosis occurs in about 12 percent of individuals between the ages of 65 and 70 and about 20 percent of those over 75, with only a fraction of these people experiencing symptoms.

When a stenosis, or narrowing, occurs in an artery that normally supplies blood to the leg, small collateral vessels try to compensate by rerouting blood around the obstruction. This strategy will eventually fail, however, because these secondary conduits simply do not have the carrying capacity of a large artery.

The deficit may go unnoticed until the disease is well advanced if the only exercise a person gets is walking around the house or from the parking lot to the store and back. But when walking time is extended or there is a need to move faster, the collateral system's inability to supply enough oxygen-carrying blood becomes all too apparent.

Starved for the oxygen that is their fuel, the muscles almost literally cry out in pain. Such discomfort - which may also be felt as numbness or fatigue - is called intermittent claudication (a term derived from claudicare, the Latin verb "to limp").

Smoking is an important risk factor.


The classic symptom of peripheral arterial disease is crampy leg pain while walking - intermittent claudication. Pain may worsen when a person walks faster or uphill. The pain usually stops when he or she rests. The cause is ischemia in the working muscles, a sort of "leg angina." (Angina pectoris, or chest pain, is usually caused by inadequate blood supply to heart muscle.)

The pain of claudication is most often triggered by exercise, but may be brought on by other factors, including exposure to cold or certain medications, such as some beta blockers, that constrict blood vessels and decrease peripheral blood flow.

The location of the blockage determines the symptoms. If the obstruction is relatively low in the arterial branches supplying the legs, calf pain may be the result; higher blockage may cause thigh pain; and blockage higher than the groin (in the blood vessels in the abdomen) may also cause buttock pain and impotence.

When arteries are badly narrowed - or blocked altogether - leg pain may be noticed even when resting. At this point, the legs may look normal, but the toes may appear pale, discolored, or bluish (especially when the legs are dangling). Feet will feel cold to the touch. Pulses in the legs may be weak or absent.

In the most severe cases, blood-starved tissues may actually begin to die. Lower-leg, toe, or ankle ulcers may occur, and in the most advanced cases, gangrene may result and necessitate the amputation of toes or feet. However, such serious complications of peripheral arterial disease are uncommon.


Diagnosis is made by medical history and physical examination as well as additional tests to determine the extent of blood flow - doppler ultrasound, arteriography, or MRA (magnetic resonance angiography).


Depending on the patient's overall health and the extent of his or her peripheral atherosclerosis, treatment options include taking good care of the feet, following a daily walking program, having the blockage eliminated or reduced nonsurgically, or having bypass surgery to shunt blood around the clogged area.

Smoking must be discontinued.

Pentoxifylline (Trental), which makes blood less viscous so that it flows more easily through smaller blood vessels, is helpful in some patients.

Experts are divided over the benefits of low-dose aspirin. Proponents say it may slow the progression of arterial narrowing and perhaps reduce the need for surgery, even though it doesn't relieve pain. Others say that the only peripheral vascular disease patients who should routinely take aspirin are those who are having clotting problems in grafted arteries.

Depending on the site and extent of peripheral vascular disease, surgery may include an arterial bypass surgery with an arterial graft, thromboendarterectomy (clot removal from the artery), and endovascular (within the blood vessel) surgery (angioplasty or atherectomy).


Could it be just a leg cramp? stretched ligaments?

What type of treatment do you recommend for this condition?

a. (if drug treatment) What are the side effects of the drug?

b. (if aspirin) Will you combine aspirin with other methods of treatment?

c. (if exercise) Besides walking, are there are special exercises that should be done?

Do you recommend surgery?


When inadequate amounts of blood reach the feet, they become susceptible to trauma or infections that can linger and develop into ulcers. If possible, people with peripheral atherosclerosis should wash their feet every day and immediately apply moisturizing lotion or baby oil.

They should tuck cotton or lamb's wool between the toes if cracks threaten to develop, and wear comfortable, breathable shoes that protect the feet, avoiding footwear made of plastic or other synthetic materials.

Keeping the feet warm is also important. Wool socks work well, as does a combination of wool over white cotton socks or polypropylene sock liners.

Patients should not wear garters, support stockings, or socks with elastic tops because they can impede blood flow.