Peripheral Arterial Disease
Peripheral arterial disease (PAD) is most commonly caused by atherosclerosis or hardening of
the arteries. This common affliction can go unnoticed for many years
because it usually progresses slowly and onset of symptoms is gradual until it is finally diagnosed. The
presence of arterial
insufficiency produces very specific
symptoms and therefore diagnosis can often be made by a careful history and physical examination. Simply feeling
for pulses can alert the physician to the presence of any significant artery blockages. Very often testing may
be indicated to determine the severity and pattern of the disease and establish unequivocally if the symptoms
you experience are due to PAD. Testing can be done non-invasively and consists of a variety of techniques that
can measure the pressure and volume of blood in the affected limb. If this is abnormal, a complete overview of
the circulation in the legs is most often made with ultrasound, a relatively inexpensive, completely safe and
noninvasive technique that obtains pictures of the vessels and information about the blood flow in real time. No
other technique provides both the anatomic and physiologic information which is of prime importance in
How the lower extremity artery system works
arterial system is a series of branching vessels all
originating from the heart—the central pump of the body. Similar to tree branches, the arteries become
smaller and smaller as they extend to the periphery of the body. the aorta is the main artery that arises
from the heart and gives rise to all other arteries. The abdominial aorta branches into the iliac arteries at
the umbilicus or belly button. These in turn branch again and again until vessels course all the away to the
Normally the inner wall of an
artery called the intima is smooth and elastic, allowing blood to
flow freely. In vessels affected by atherosclerosis, the intima becomes thickened and rough by a build up cholesterol or fatty
materials. This build up, much like rust in a pipe, is called plaque. As this plaque increases, it obstructs the
opening or lumen of the blood vessel and may alter or limit the
flow of blood. If the artery is severely narrowed, the amount of blood getting past can be so limited, that
various symptoms can result. However, as long as this is a gradual process, the body is often very good at
developing alternative pathways for blood flow called collaterals.
Claudication - leg pain with exercise is the classical symptom for lack of blood flow to
the legs. An ache or cramp develops in the calf, thigh, or buttocks when the muscle cannot get
enough oxygen, Resting, even for a short time, will allow the blood supply to “catch up” with the
demand and symptoms subside.
Rest pain - severe and steady aching or pain, usually in the toes, heel, or foot,
this suggests severe arterial disease.
Gangrene - blood supply is insufficient to support the tissues and they begin to die
( tissue necrosis).
There are other reasons why a person may experience leg pain
with exertion or even at rest - commonly neuropathy or a nerve compression (neurospinal) syndrome. The testing
equipment at QVI is well suited to determine with a high degree of certainty if pain is from a vascular cause
(vasculogenic) or not.
is typically done with a combination of physiologic testing and
duplex ultrasound (click for more on these testing procedures.) This
non-invasive test can determine if disease is present, its severity, and if it is a likely source of your
symptoms. We can also provide an overview of the arterial tree showing the pattern of disease. For example, it
is important to know specifically where the disease is, if there is an isolated area of narrowing or is there
diffuse disease throughout long segments, and if a vessel is severely narrowed of completely occluded. This
information allows your physician to make specific recommendations as to the best way to treat your
These ultrasound images show tibial arteries in the calf.
The vessel on the left depicted in gray scale with the Doppler information displayed in color is widely patent
and normal. In contrast, the vessel on the right shows a severe narrowing with the resultant flow
The vessel on the left shows a flow limiting narrowing in
the popliteal artery behind the knee - the main blood supply to the lower leg. The popliteal artery on the right
reveals a large aneurysm with thrombus inside. While peripheral artery aneuryms rarely rupture, they
are potentially quite dangerous if they shower this thrombus to the lower leg.
factors - Patients with disease can dramatically lessen the likelihood of the narrowing
becoming worse. Stop smoking, control blood pressure, blood
sugar, and cholesterol levels, maintain proper weight and diet.
Exercise - Most importantly, a regular
exercise regimen can build collaterals and actually reduce the severity of the symptoms. Experience
shows walking a loop is a useful method. Choose a distance where you get the pain a few minutes before you
finish. Remember, you must walk some distance with the pain to get maximum benefit. Then gradually try to
lengthen the loop. Regularly walk short or moderate distances, instead of longer distances sporadically.
Regularity is key!
Follow-up - This can usually be done
clinically. “Are you walking farther without pain?” If necessary, the severity of the plaque buildup can be
followed by ultrasound and / or physiologic testing to determine if there is any progression of
Medicine - While medicine will generally
not lessen the plaque, there are several medications that may be prescribed to aid in modifying risk
factors or reduce symptoms.
Endovascular Intervention - There are a
multitude of “minimally invasive” options to treat blockages. Most common is balloon angioplasty with a
stent inserted to hold the artery open.
Surgery - If blockages are too extensive,
bypass surgery can be done to get blood to the affected area. A vein from the leg or arm or a synthetic
tube can be used to bypass the blocked artery. This is usually done for rest pain or gangrene.
Here is a great link from the Society of Vascular Surgery that thoroughly outlines the all the
options - Society
of Vascular Surgery