Peripheral Vascular Disease

“My new shoes fit kind of tight and they rubbed some skin off the top of my big toes. Can you take a look at them?” Normally that question would be no big deal. But when the patient has weak to non-existent pulses in their feet, diabetes, and smokes, it can be a huge deal. That was the case with Mrs. Brown, and a culture of the abrasions showed that they were already infected as well. Her future will almost certainly hold visits to a wound care center, vascular studies and possibly MRI’s to be sure the infection hasn’t spread to the bones.

One of the main underlying problems for her and many others is something called peripheral arterial disease (PAD). PAD is generally a result of atherosclerosis, the build-up of plaque that slowly blocks arteries. The end result of atherosclerosis can be a blocked coronary artery causing a heart attack, a blocked cerebral artery causing a stroke, a blocked artery in the gut causing intestinal problems, or blocked arteries in the limbs causing PAD.

Who gets PAD? Generally the same folks who are at risk for heart attack or stroke may get PAD. So the risk factors would include smoking, diabetes, high blood pressure, high cholesterol, obesity, age over 50, and a positive family history of PAD, heart disease or stroke.

How would you know it if you were getting it? That can sometimes be a little tricky. Only 10% of people with PAD get the classic symptom of intermittent claudication (IC). IC refers to a symptom where people’s legs (usually the calves) predictably begin to cramp after a certain distance of walking. The cramping or muscle pain resolves after 2-5 minutes of rest.

But 90% of the time people with PAD have less obvious symptoms. They have subconsciously limited their walking and have more vague leg pains, a sensation of heaviness in the legs, poor healing of wounds or, in 40% of patients with PAD, no symptoms are reported at all. So the diagnosis can sometimes be difficult. One clue is sometimes the new onset of ED (erectile dysfunction), although the majority of men with ED don’t have significant PAD.

A test called the ankle-brachial index (ABI) is the most common initial test to sort out whether PAD is the problem. More involved tests such as types of vascular MRI’s or cat scans may follow if a substantial problem is found.

If PAD is confirmed, non-surgical treatment is initially tried unless a critical, limb-threatening blockage is already present. Quitting smoking has the biggest impact on preventing PAD from worsening. Beyond that, certain meds and lifestyle changes to manage high cholesterol, high blood pressure, diabetes and obesity can be helpful. There are also a small number of meds that have a modest effect on opening up (dilating) the arteries or reducing the tendency to form unwanted clots. Regular walking up to the point of claudication (muscle pain) is also helpful to maintain and sometimes regain circulation.

PAD is also a red flag for other blockages that can lead to heart attack or stroke so that an overall evaluation for these is wise when PAD is found. This connection explains why the mortality for patients with claudication is approximately 30% at 5 years, 50% at 10 years, and 70% at 15 years.

As is so often the case, prevention is the best approach. But if symptoms of PAD seem to be sneaking up on you, have your physician check you for it and start to battle this threat to life and limb.