Living With Peripheral Arterial Disease
Copyright © 2012 Bruce Lashley
Definition of Peripheral Arterial Disease
Peripheral arterial disease (PAD) can be a debilitating disease. It is caused by fatty deposits that accumulate on the inner walls of arteries. These deposits in the arteries of the lower extremity will result in poor blood flow to the legs and feet. If arteries are clogged and narrowed, blood will not be able reach its destination to supply muscles and organs with oxygen and nutrients. Decreased oxygen and nutrients to muscles can result in severe cramping in the legs, especially with increased workload such as walking. Patients with diabetes, high blood pressure, high cholesterol and smokers can be at increased risk of developing PAD. It is also important to note that persons, who have PAD, are also at increase risk of having fatty deposits in the arteries of the heart, which can result in a heart attack or stroke.
Symptoms of PAD
Most people with PAD are non-symptomatic. However, if symptomatic, the most common complaint from patients with PAD is they get severe cramping or burning in the calf muscles when walking. Typically the cramping begins after one or two blocks of walking and will subside after a few minutes of rest. The cramping results from a build up of a waste product produced by exerting muscles called “lactate”. This is produced when there is not enough oxygen getting to the muscles. The cramping can significantly alter a patient’s lifestyle and prevent the patient from enjoying normal daily activities. Aside from physical limitations, severe PAD can lead to non-healing wounds on the leg and foot and black/gangrene in the toes. Some of these patients with PAD may require an amputation of the foot or leg.
Physical Examination for PAD
When a podiatrist evaluates a patient for PAD, there are key signs that are presented on the feet. Patients with PAD tend to have diminished or absent digital hair growth and nails that are brittle and thickened as well as decreased temperature in the feet. The podiatrist may ask the patient to hang their legs over the side of the exam chair, in patients with PAD the legs begin to display a deep purplish color. Patients with PAD will have a white, pale discoloration to the feet if the legs are elevated above the heart for one minute. The podiatrist will also feel the pulses in the feet. If the pulses are weak, it may indicate that there is poor blood flow to the feet. These are important signs that lead to a high suspicion of PAD.
Testing for PAD
The most common and least expensive office test for PAD is called an ankle-brachial index. This is done by taking the blood pressure of the arm (brachial) and comparing that number to the blood pressure in the ankle. This test requires a blood pressure cuff and Doppler ultrasound to hear the pulse. The blood pressure cuff is inflated on both the arm and the leg. Next, the cuff is slowly deflated; the first sound heard in sync with the blood pressure number is recorded and compared by ratio. The normal ankle-brachial index is 1, in other words the arm and the ankle should ideally have the same pressure. Patients with an ankle-brachial index of 0.4-0.9 are considered to have PAD. There are also additional tests that can determine poor blood flow. PAD can also be visualized with an MRI/MRA or angiogram, which requires injecting a dye through the blood vessels and using an imaging system to follow the dye through the arteries in order to visualize artery narrowing.
Conservative Treatment of Peripheral Arterial Disease
The most important goal in treating PAD in the lower extremity is to reduce the risk of amputation. Treatment is usually administered by the primary care or vascular physician. Drugs that thin the blood, such as aspirin, are often prescribed to patients with PAD to prevent the risk of clotting. Smoking cessation programs and good control of cholesterol, blood pressure, and blood sugar levels are also strongly advocated. Foot care is also important in managing peripheral arterial disease to prevent ulceration to the feet. In treating cramping sensations from PAD, exercise therapy has been scientifically shown to increase maximal walking distance because it promotes small vessel formation around the area of the clot.
Surgical Treatment of Peripheral Arterial Disease
If the symptoms of PAD are severe, inhibiting lifestyle or resulting in non-healing wound or gangrene on the feet, surgical treatment may be required by the vascular physician. The goal of surgery is to increase blood flow to the legs and feet. Surgical treatment may include bypassing the area of clot with a vessel graft or vein or opening the artery with a balloon and placing a stent to increase the diameter the artery and attempt to keep it open.
Bruce Lashley, DPM
Dr. Lashley is a podiatrist practicing in midtown Manhattan for the past 28 years. He specializes in the conservative and surgical management of the foot. In October 2009, Dr Lashley moved his office to a new modern facility at 353 Lexington Avenue, in NYC. For more information on Dr. Lashley visit his web site.
Or call 212-949-2901