At a Glance:
1. What is peripheral artery disease (PAD) or peripheral vascular disease (PVD)?
2. What are the types of peripheral artery disease (PAD) or peripheral vascular disease (PVD)?
3. What are the causes of peripheral artery disease (PAD) or peripheral vascular disease (PVD)?
5. What are the symptoms of peripheral artery disease (PAD) or peripheral vascular disease (PVD)?
6. How is peripheral artery disease (PAD) or peripheral vascular disease (PVD) diagnosed?
7. What are the stages of peripheral vascular disease?
9. What is the treatment of peripheral artery disease (PAD) or peripheral vascular disease (PVD)?
Peripheral vascular disease (PVD), also termed as peripheral artery disease is a disorder of blood circulation, seen commonly in the lower limbs. Pathological narrowing down of arteries reduces the blood flow to limbs resulting in the symptoms of the disease.
Peripheral artery disease may also be a sign of accumulation of fatty deposits i.e. atherosclerosis in the arteries all over the body.
In India, peripheral vascular disease is an important cause of morbidity which is often overlooked due to lack of awareness amongst the general population. It is estimated that more than 10 million people in India could be affected by the disease. Amongst the patients affected, an estimated 40% of patients having coronary artery disease also have associated peripheral artery disease. It is further estimated that nearly 14% of these patients may have carotid artery stenosis and 17% have renal artery stenosis. Studies also suggest that the prevalence of the peripheral vascular disease in diabetics in India could be as high as 36%.
Peripheral vascular disease may be of different types depending on the site affected and the underlying pathology. Some of the commonly reported types are:
The most common underlying cause of PVD is ‘atherosclerosis’ where fatty deposits known as plaques accumulate in the walls of the artery walls and reduce blood flow due to constriction.
There is a myth that atherosclerosis is usually present in the blood vessels of the heart. The fact is that the disease affects the arteries throughout the body including the arteries of the limbs thereby causing peripheral vascular disease.
Other less common causes of PAD may include:
Excessive exposure to radiation
Injury to the limbs
Factors that increase the risk of atherosclerosis also increase the risk of PAD. Some of the general factors to be considered are age, sex, and ethnicity. PVD is observed to be twice as common in males as compared to females.
Some of the individual factors that increase a person’s risk of suffering from PVD include (in alphabetical order):
The presence of PVD in many cases may not be evident due to mild or no symptoms. In some persons, it may be reported as leg pain when walking (also called as claudication). Some characteristics of claudication are:
Some of the other commonly reported signs and symptoms of PVD include:
Severe progression of the PVD may lead to pain at rest or while lying down.
A detailed medical history and physical examination can help a doctor to make an initial diagnosis of PVD or PAD.
Physical examination: Presence of weak or absent pulse in the suspected area, bruits (murmur) or whooshing sounds heard with a stethoscope over the affected blood vessel, observation of skin texture, delayed healing of ulcers, etc are made note of.
The initial diagnosis is confirmed by certain specialized tests that include:
A more invasive form of this test is the catheter angiography in which a guiding catheter is advanced through an artery of the groin to the affected area. The dye is injected through the catheter route. Treatment if required can be simultaneously performed in this technique.
There are two most commonly recommended methods to determine the stage of PVD. Introduced by René Fontaine in 1954, the Fontaine stages define the severity of PVD
Stage I: Asymptomatic
Most of the time the person is asymptomatic but have specific, subtle symptoms, like paresthesia. Presence of cold extremities, reduced peripheral pulse or murmurs in the peripheral arteries are noticable upon examination.
Stage II: Presence of Intermittent claudication.
The pain appears at a constant distance
Stage IIa – Intermittent claudication after more than 200 m of walking.
Stage IIb – Intermittent claudication after less than 200 m of walking.
Stage III – Rest pain
Pain may appear at rest, especially during the night while the legs are raised and may disappear during the day.
The Society for Vascular Surgery introduced the Rutherford classification after the Robert B. Rutherford, an American vascular surgeon
The Rutherford classification describes seven stages of peripheral artery disease:
Undiagnosed and untreated peripheral artery disease can lead to serious and sometimes even life-threatening complications. The presence of PVD in a specific site can also be a warning sign of the presence of generalized vascular disease.
Some of the common complications of untreated peripheral artery disease are:
The treatment for peripheral artery disease has two major objectives:
These goals can be achieved by a combination of lifestyle changes, medications, and surgical management depending on the severity.
Medication management: Any existing medical conditions should be managed with medications and periodically reviewed by treating physicians. These may include but are not limited to the following categories of medications :
Surgical management: Cases, where claudication and ischemia are not relieved by conservative management, patient may be considered for revascularization with angioplasty and bypass by a vascular or endovascular surgeon.
Angioplasty: A catheter which is essentially a hollow tube with a balloon at the tip is inserted through a blood vessel into the affected artery. Once the affected site is reached, the balloon is inflated. The inflation of the balloon reopens the artery and flattens the blockage into the wall of the artery. The blood flow increases due to the simultaneous stretching and opening up of the artery. A mesh framework known as a stent is placed in the artery to maintain the opening, a procedure similar to angioplasty of the heart arteries.
Bypass surgery: If the blockage is not amenable to angioplasty, the surgeon may create a bypass for the blockage site using a graft from a vessel in another part of the person’s body. Sometimes a synthetic graft may be used. Following this technique, the flow of the blood “bypasses” the affected area and normal circulation are restored.
Atherectomy: Sometimes, normal blood flow from the affected site in the blood vessel may be restored by surgically scraping off the plaque off of the inside of the vessel wall
Amputation: Severe cases where gangrene has set in beyond repair, the limb may have to be surgically cut off to prevent the infection from spreading into the body
Thrombolytic therapy: If an artery gets blocked due to a clot, an injection of a clot-dissolving drug may be administered into the artery at the point of the clot to break it up into smaller fragments.
Maintaining a healthy lifestyle is by far the most important way to prevent PVD since many of its risk factors are related to a person’s lifestyle. Some of the important preventive measures are:
With the advancement in medical technology, newer treatment options have emerged for PVD in the field of peripheral intervention. A marked increase in the understanding of the disease dynamics and treatment methodologies has also led to a dramatic improvement in the quality of consumables and devices like balloons, stents, devices for atherectomy, etc. Newer consumables like drug-eluting stents and balloons help in durable and long-term treatment outcomes. As a result, the recurrence rate and postoperative complications decrease. Alternative techniques like atherectomy in cases where stents are not recommended are proving to be of benefit in many cases. Drug-eluting balloons combined with atherectomy have also shown satisfactory results in many reported studies. Considering the difference in the anatomy and physiology of the limbs and heart where the angioplasty procedure is now the proven standard of care, advanced technology stents that are suitable to the peripheral vessels are now available. However, it should be emphasized that the management of PVD is an intensive team effort that requires a multidisciplinary approach consisting of specialists from areas of vascular surgery, interventional cardiology, radiology, endocrinology, diabetologists, and trained paramedical staff. Further advanced medical infrastructure also must provide comprehensive care for the limbs at risk. Hence it is recommended that care for PVD should be considered at a multispecialty centre of excellence.
References:
https://www.healthline.com/health/peripheral-vascular-disease#prevention
Mayo Clinic. Peripheral artery disease. Available at: https://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/symptoms-causes/syc-20350557. Accessed on December 17, 2019
Johns Hopkins Medicine.Peripheral Vascular Disease. https://www.hopkinsmedicine.org/health/conditions-and-diseases/peripheral-vascular-disease Accessed on December 17, 2019
Society for vascular surgery. Peripheral Arterial Disease. Available at: https://vascular.org/patient-resources/vascular-conditions/peripheral-arterial-disease. Accessed on December 17, 2019
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