Peripheral Vascular Disease (PVD)

Peripheral Vascular Disease, or PVD, is a disease of the blood vessels (outside the brain and heart) that affects tens of thousands of people. In this condition, the arteries that carry blood to the arms or legs become narrow or clogged, slowing or stopping the flow of blood. In the majority of patients, PVD is caused by generalized atherosclerosis - a gradual process in which cholesterol and scar tissue build up inside the artery. The disease most often affects the legs, but sometimes PVD occurs in the arms or in the neck affecting the arteries supplying blood to the brain. In some cases the renal artereries may also be narrowed, resulting in untreatable hypertension and kidney damage.

Many people live with the symptoms of PVD - such as numbness or pain in the legs or arms, believing it is arthritis or part of the normal aging process. The condition can often be treated successfully with exercise and medications or invasive procedures (angioplasty or surgery).

Symptoms of Peripheral Vascular Disease

The symptoms of PVD of the lower extremities usually begin gradually. People who have PVD are often unaware of subtle symptoms and do not seek medical advice until the disease is advanced. Approximately 50% of patients do not experience any symptoms, 45% have intermittent claudication (see definition below) and about 5% experience pain at rest, ulceration or gangrene.

Intermittent claudication: This is the most common symptom of PVD, and is characterized by a progressive aching or cramping sensation which is triggered by walking and relieved by rest, even simply standing in one place. This symptom typically occurs in the muscles distal (opposite) to the occlusion site (place where the artery is obstructed). The typical location of the occlusion in patients younger than 40 years is the aorta (the main "trunk" from which the arterial system proceeds) and the iliac arteries which serve the mid-section of the body. In those over 40, the obstruction is predominantly located in the arteries that serve the lower extremities. Intermittent claudication must be differentiated from so-called pseudoclaudication, which is caused by lumbar spinal canal stenosis.

Pain at rest: This is a sign of ischemia (lack of blood flow) in the leg when blockage in the artery progresses to critical level. Most commonly it occurs at night when the patient is lying in bed. Very often dangling of the affected foot over the side of the bed or getting up and walking brings relief.

Ulcers: As ischemia progresses, patients with rest pain may develop ischemic necrosis, or the death of cell due to lack of oxygen. Feet are most frequently affected. Non-healing ulcers after minor trauma are another typical presentation of severe PVD.

Muscular atrophy: This is a result of the combination of chronic limb ischemia and reduced physical activity secondary to pain. This form of musclular atrophy often causes difficulty with rehabilitation after revascularization and can compromise physical therapy.

How is PVD Diagnosed?

Clinical history and detailed physical exam taken by your physician is the first method of diagnosis

The ankle-brachial index: A simple test in which the ratio of blood pressure in a pedal artery (artery in the foot) and the blood pressure in the brachial artery (artery in the arm) is calculated.

Duplex ultrasound: A non-invasive method of visualizing the arteries of the legs and detecting blood flow in the arteries. Lack of flow or increased blood velocity indicate blockage and gives approximate estimate of its severity.

Magnetic resonance angiography: Another non-invasive method
utilizing magnetic resonance technology to detect flow of the magnetic contrast in the arteries. It may show relatively precisely location of the stenosis but it is not very reliable estimating its severity.

X-ray angiography: The most precise method to visualize leg arteries. The severity and the location of stenosis is seen very clearly. Digital subtraction technology can give high-quality images using a small amount of contrast material. It is the prerequisite of an interventional procedure (angioplasty or bypass surgery). As an invasive procedure it carries some risk of complications (usually very low).

Treatment

Modification of risk factors.

Hypertension: The higher the blood pressure the greater the risk of claudication. It is imperative to control it adequately to slow the progression of PVD and reduce cardiovascular events.

High cholesterol: It doubles the incidence of intermittent claudication and affects up to 50% of patients with PVD. Angiographic studies have confirmed that that lipid lowering stops the progression of femoral and carotid atherosclerosis. Target LDL level in patients with PVD should be < 100mg.

Smoking: The progression of PVD is significantly greater in patients who continue to smoke. They also have higher chances of heart attack and death. Complete cessation of smoking should be the goal. It can reduce the 5-year amputation risk tenfold and decrease the mortality by 50%.

Control of diabetes: Of utmost importance, since diabetics with PVD have much higher risk of death and amputation. Progression to ischemic pain at rest and ulceration is frequent and fast. Diabetic education is critical to successful management of diabetes. Despite that large-scale studies didn�t demonstrate that optimal glycemic control has any influence on macrovascular complications such as PVD, it seems prudent to attempt to achieve that goal.

Walking program:

A regular walking exercise is extremely beneficial. Patients should walk at least three times weekly and preferably every day. 30-45 min daily walking continued for at least 6 months helps in new blood vessel formation. Patients should walk as far as possible using near maximal pain as a signal to stop. Patients can enroll into rehabilitation programs in a supervised setting or exercise home on their own. Regularity and persistence are the most important.

Pharmacological therapy:

There are several medications that are helpful but none of them alone or in combination stops or reverses PVD.

Antiplatelet agents: reduce both the risk of limb loss and the need for surgical revascularization in patients with intermittent claudication. All patients should take aspirin unless contraindicated. Plavix also has beneficial effect.

Pentoxifylline (Trental): is helpful in only about 20% of patients. A trial of 2 to 3 months in most patients is reasonable.

Cilostazol (Pletal): a newer vasodilating and antiplatelet agent. It significantly increases the distance patients with claudication could walk. Unfortunately this medication is contraindicated in congestive heart failure (it could increase mortality).

Revascularization: is indicated for lifestyle-limiting claudication like pain at rest, ischemic ulceration, and gangrene. It is also indicated in diabetic patients with moderately severe or severe claudication. A lower threshold for performing revascularization in that group of patients is indicated since they have much higher risk of limb loss.

Angioplasty: is favored because of lower morbidity and shorter hospital stay (very often done as an outpatient procedure). Reocclusion of a blood vessel after angioplasty is more frequent than after surgery and repeated angioplasties are not unusual. In general shorter occlusions and larger arteries are preferably treated with angioplasty and sometimes stenting. Very often is chosen as an initial treatment since if it fails, surgery may be done almost always.

Bypass surgery: provides more complete revascularization- higher patency rates after 3-5 years. Requires at least several days stay in hospital and carriers higher morbidity. Surgery is sometimes technically impossible, where angioplasty may be done. Vascular surgery in general is a high risk procedure, especially that many patients with PVD also have coronary artery disease.

Are You at Risk for Peripheral Vascular Disease ?

Your answers to these questions will help you know.

Do you have heart problems like hypertension or heart attack?
Do you have an inactive (sedentary) lifestyle?
Do you have diabetes?
Do you smoke or have you ever smoked?
Do you have a family history of heart problems or diabetes?
Are you more than 25 pounds overweight?
Do you eat fried or fatty foods three times a week or more?
Do you have pain in your toes or feet at night?
Do you have any ulcers or sores on your feet or legs that are slow in healing?
Do you have aching, cramping or pain in your legs when you walk or exercise, but the pain goes away when you rest?

The more "Yes" answers you have, the more important it is for you to see your doctor.

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