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Peripheral Arterial Disease

This section will concentrate on disorders of arterial system, which includes the arteries of the arms and legs, brain, intestines, kidneys and abdomen. Since these areas are far from the heart they are also known as the peripheral arterial system and disorders of these vessels are grouped under the medical term – Peripheral Arterial Disease or PAD. Some physicians will also use the term Peripheral Vascular Disease or PVD. However, truly speaking this would imply veins as well. However, veins tend to develop very different problems and so will be dealt with in a separate section.

• What is the Circulatory system?
• What are Arteries and Veins?
• What is Peripheral Arterial Disease (PAD)?
• What causes atherosclerosis (PVD)?
• Does atherosclerosis effect other blood vessels?
• Are there other diseases affecting arteries?
• How do I know whether I have PAD?
• What Tests are there for PAD?
• What is an arteriogram?
• Can PAD be prevented?
• Are there medications that can make PAD go away?
• What about Trental® and Pletal®?
• What about Chelation?
• What about Exercise?
• What are Endovascular procedures?
• What Surgical procedures are there for PAD?
• What are the chances that these procedures will be successful?

What is the Circulatory system?

This is the part of the body that carries blood. It includes the heart, which pumps the blood and the blood vessels (arteries and veins), through which the blood circulates.

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What are Arteries and Veins?

The arteries carry the fresh oxygenated blood from the heart and the veins carry the old blood back to the heart and lungs.

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What is Peripheral Arterial Disease (PAD)?

Normally the lining of arteries is smooth. However, as one ages a condition may develop that results in a build up of fat and calcium in the wall of the artery. The lining becomes irregular and ultimately the artery can block off. Also, little pieces of this abnormal fatty build up can break loose and get carried down the artery to lodge elsewhere in the system causing a blockage at that site also. This build up of fat, cholesterol and calcium is called plaque and the condition is called Atherosclerosis or "hardening of the arteries". When it occurs in the arteries outside the heart or brain we may refer to it as PAD. In general PAD refers to all arteries outside of the heart. However, by general common usage it has come to refer to arterial disease of the extremities i.e. the legs and arms and this is what this section will describe.

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What causes atherosclerosis (PVD)?

Plaque starts to build up in arteries when low-density lipoprotein, the bad blood stream fat also known as LDL, gets into the artery wall. Special white blood cells called macrophages ingest the LDL thus becoming bloated and foamy. Muscle cells in the artery wall start to overgrow and fat and calcium build up in the spaces between the cells. Eventually bleeding into the artery wall can also occur which can rapidly result in a blocked artery. At any time, but especially when there is a large build up of plaque, pieces of plaque or blood clot can break loose causing blockage further down the arterial system.

We do not know what causes this condition. However, certain risk factors will increase the probability that it will develop:

• High cholesterol levels 
• High triglyceride levels
• Smoking
• High Blood Pressure (Hypertension)
• Diabetes
• Family History of PAD or heart disease
• Obesity
• Lack of exercise
• Stroke

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Does atherosclerosis effect other blood vessels?

Yes, very much so! Atherosclerosis affects all arteries, although it does seem to effect some more than others. When it affects the heart arteries (coronary arteries) it can lead to angina or heart attack. When it affects the arteries to the brain it can cause strokes. All patients with PAD should seek medical attention to evaluate these other areas.

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Are there other diseases affecting arteries?

Yes, but these seldom begin in the elderly. They usually involve conditions where the body starts fighting its own arteries, much like rheumatoid arthritis is a condition where the body starts fighting its own joints and bones. These conditions are also quite rare and seldom result in major complications such as stroke or limb loss. Some of these conditions are:

• Systemic Lupus Erythematosis
• Polyarteritis Nodosa

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How do I know whether I have PAD?

In most patients PAD is silent and causes no symptoms. However, when the arteries to the legs get significantly narrowed or blocked certain tell tale symptoms will occur. The first and most important symptom is referred to as claudication. This is a cramping pain, dull ache or sense of tiredness in the calves or buttocks when one walks a specific distance and goes away when one stops walking and rests. It comes on again when one resumes walking usually after one reaches the
same distance (provided one walks at the same speed).

When the blockage becomes severe pain may occur even at rest. This usually is noticed at night when one lies down to go to sleep. In bed we no longer have gravity helping the blood get down to the feet and so they start to pain. Patients will often remark that the pain eases somewhat when they get out of bed and stand. This is an important symptom since it implies very severe impairment to blood flow. If untreated, gangrene or death of the toes or feet can eventually
result. Similarly, cuts or scrapes may not heal and also lead to loss of part of the limb.

When the doctor examines patients with PAD/PVD certain findings may be discovered:

• Absent pulses in the foot or leg
• A noise in the artery caused by turbulent blood flow. This is called a bruit.
• Cool temperature of the foot or leg
• Pale color when the foot is elevated
• Decreased hair or tissue fat
• Open sores or black areas of gangrene

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What Tests are there for PAD?

Nowadays simple painless tests can be performed to diagnose PAD. These tests do not involve needles or dye. These tests are usually performed in a Vascular Lab. Since the quality of these labs is variable it is important to request that your test be performed in a lab that is accredited by the Intersocietal Commission on the Accreditation of Vascular labs (ICAVL). Our lab was the first to be accredited in Sarasota in 1993 (see the Vascular lab).

• Blood Pressure or Plethysmography tests: The simplest test is called the Ankle/brachial Index or ABI. Using a Doppler that is a special hand held device much like an electronic stethoscope, the blood pressure in the ankle is compared to that in the arm. In normal legs the ankle pressure and the arm pressure should be the same and the ABI should equal 1. When the patient has PAD the leg arteries are blocked and so the pressure at the ankle falls. This results in an ABI of less than 1.
• Duplex ultrasound: In order to get a picture of where the blockage is, very advanced machines using ultrasound can painlessly and noninvasively produce pictures showing the blood vessels and the blood flowing through them. This process is a little like radar. The test is called a duplex or ultrasound scan.
• Magnetic Resonance Scans: High-powered magnets can be used to produce pictures of body parts and blood vessels. These tests are expensive but completely safe. There is hope that at some time in the future they may replace the need for arteriograms. However, they cannot be used in patients who have steel implants such as pacemakers. Some patients also become claustrophobic in the scanners.

When some form of invasive treatment is planned, an arteriogram may be performed.

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What is an arteriogram?

Blood vessels do not show up on regular X-rays. Accordingly, in an arteriogram the doctor will insert a needle into the artery and inject a special dye. This will allow detailed pictures of the inside of the arteries. The needle is usually inserted via the groin or femoral artery. A sensation of heat often accompanies the dye injection however, local anesthesia and sedation is used to eliminate pain. The procedure usually takes about half an hour. After it has been completed the patient is required to lie flat for about 4 hours in order to prevent bleeding. The procedure is performed in an X-ray facility usually in a hospital. It is rare that an arteriogram is necessary for diagnosis since this can usually be achieved by noninvasive tests. The arteriogram is usually reserved to help plan some form of intervention.

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Can PAD be prevented?

We cannot completely prevent or cure atherosoclerosis but limiting the risk factors is important in slowing down its progress and in some cases actually reversing the blockages.

• Smoking: All forms of Tobacco products are harmful and should be avoided. Ask us about our Quit Smoking Program.
• Diet: Reduce the intake of cholesterol and saturated fats found in meat, shell fish and dairy products as well as certain plant oils such as coconut, palm oil and cocoa (chocolate).
• High Blood Pressure: Hypertension aggravates PAD. It is important that you keep your blood pressure well controlled. Your family doctor, internist or cardiologist usually does this.
• Medications to decrease cholesterol: These include Statins, Niacin and Fibrates.
• Diabetes should be well controlled. Also, diabetics are prone to developing infections and open sores in the feet. With poor circulation this can become an even more serious problem. Accordingly it is imperative that a diabetic takes special care of their feet.
• Prevent foot injuries:
  • Avoid going barefoot even in the house
  • Wear well fitting shoes
  • When using new shoes wear them for a short time only and reassess to make sure that they are not casing blisters
  • Wash and dry feet thoroughly but do not soak the so much that they wrinkle
  • Do not expose your feet to extreme temperatures or harmful chemicals
  • Inspect your shoes to make sure that there are no harmful objects in the shoe
  • Inspect feet daily for sores or injuries. Diabetics often have decreased sensation and so they may not realize that there is a problem area in the foot.
  • Treat your feet as if they were made of fine crystal. Seek good podiatric acre on a regular basis. Whenever possible have your podiatrist be responsible for cutting your nails. If you must cut them yourself cut them straight across no shorter than the length of the toe. Do not treat calluses or bunions yourself.

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Are there medications that can make PAD go away?

There are no medications that can totally reverse PAD. However in some people lowering cholesterol with medications can improve some of the blockages. Usually your internist, family doctor or cardiologist will prescribe these. However, we will be happy to assess your medications and help you receive optimal care. In some cases we may advise an advanced Berkeley lab test of the blood factors that can cause atherosclerosis. We can give you information on this when you come to the office. There are also medications, which may improve the symptoms of PAD such as Trental® and Pletal®.

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What about Trental® and Pletal®?

None of these medications makes plaque go away nor do they help new arteries to grow. They may, however, have some beneficial effects in some people.

Trental® is a medication that has been used for many years. We are not sure how it works although it is suggested that it makes the red blood cells slippery. This allows them to go through blockages more efficiently and this may be why people may be able to walk further when they are on this medication. It is taken 3 times a day with meals.

Pletal® is a new medication. Again we do not know why it works but clinical trials suggest it may be more effective than Trental® in improving walking distance. Serious side effects can happen in patients with heart failure, so they should not be on it. Pletal can also interact with other medications especially Prilosec® (a heart burn medication), some antifungals and erythromycin. Grape fruit is also contraindicated with this medication. It is taken twice a day before meals. We are currently prescribing this medication under close supervision. If you think you are a candidate for it, call our Physicians Assistant, Rick Morales and he will evaluate you to see if you are a candidate for these medications.

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What about Chelation?

This chemical "treatment" has been around for a long time. It involves intravenous injection of a chemical that supposedly will take calcium out of the plaque. However, there is so much calcium in bones that there will always be calcium in the body to go into the plaque. Clinical studies have failed to show any benefit from this chemical and insurers will not pay for its use.

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What about Exercise?

Many studies have shown the benefit of exercise. Not only can it improve your walking distance but also it can reduce the risk of heart attack and stroke. It is important that you consult with your medical doctor before embarking on increased exercise.

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What are Endovascular procedures?

In some patients PAD must be treated invasively. This implies surgery or some of the minimally invasive procedures where the artery is treated from inside or endovascularly. It should be realized that these procedures are still invasive in that a needle, wire or balloon has to be inserted into the artery. Furthermore, complications can occur that may be serious. On the other hand these are usually rare and most patients can go home within 24 hours of the procedure.

• Balloon Angioplasty: This procedure can be performed for short areas of narrowing. A balloon is threaded into the artery and inflated thus breaking the plaque and widening the artery. The balloon is then removed.
• Stents: after balloon angioplasty some arteries will tend to collapse again. A stent is a small metal scaffold that is placed in the artery to prevent this narrowing. Unfortunately, in some patients the body forms scar tissue around the stent and this scar can also block the artery again.
• Thrombolytic therapy: Sometimes blood clot can form on plaque causing a sudden worsening of the circulation. In some patients the doctor can pass a catheter into the clot and clean the clot out with a special medication.

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What Surgical procedures are there for PAD?

Endarterectomy: The simplest surgical procedure is known as an endarterectomy. Here the surgeon cores out the plaque from the artery wall and stitches the artery back together again. This is the procedure of choice to clean out the carotid arteries for the prevention of stroke.

Embolectomy: When a piece of the artery or a blood clot from the heart breaks loose and gets carried down the blood stream, it can block an artery. The surgeon can sometimes remove this by passing a catheter with a balloon down through the clot and then pulling the clot out again with the balloon inflated.

Bypass: This is the commonest form of surgery performed for PAD involving the legs. The surgeon may use an artificial artery or take the persons own vein and use it as an artery replacement. Incisions are made in the leg and the new artery sewn above the blockage and then around the blockage to a good portion of artery beyond the blockage. The original artery is left in place.

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What are the chances that these procedures will be successful?

This chemical "treatment" has been around for a long time. It involves intravenous injection of a chemical that supposedly will take calcium out of the plaque. However, there is so much calcium in bones that there will always be calcium in the body to go into the plaque. Clinical studies have failed to show any benefit from this chemical and insurers will not pay for its use.

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