Peripheral Vascular DiseaseAzhari GaniThe circulatory system is a network of specialized tubes (known as blood vessels) thatcarry oxygen- and nutrient-rich blood to the organs and tissues of the body There are ! types of blood vessels" arteries# veins# and lymphaticsThe heart is thepumpingorgan of thebody$t pumpsoxygen-andnutrient-richbloodinto theaorta#which is the main artery of the body The branches of the aorta# known as the arteries#carry blood to the organs of the body# such as the kidneys# the liver# and the intestines#as well as to the arms and legs (extremities) The veins return blood from the organsandtheextremitiestotheheart toreplenishthebloodwithoxygenandrestart theprocess This cycle repeats thousands of times each day The lymphatics are the thirdtype of blood vessels of the circulation %ymphatics collect fluid from the tissues of thebody and filter it through the lymph nodes The lymphatics eventually connect with veinstoreturnfluidfromthetissuestothebloodandtheheartThisarticlefocuses onadisorder of the arteries known as peripheral arterial disease (&A')Common Risk Factors for PAD( )moking( 'iabetes( *igh blood pressure( *igh cholesterol( Advanced age (greater than +, years)PAD Is Atherosclerosis of the Extremities &A' is a medical condition caused by blockages of the arteries that provide blood flowto the arms or legs -ou may have also heard of this problem referred to as peripheralvascular disease (&.') or /bad circulation0 $n &A'# the arteries become blocked bycholesterol pla1ue caused by atherosclerosis Atherosclerosis is a common problem in2esternsocieties Atherosclerosiscaninvolvealmostall ofthema3orarteries ofthebody Atherosclerosis of the arteries of the heart is known as coronary artery disease#nDa 1the process that causes chestpain(angina)and heart attack (myocardial infarction)Atherosclerosis of the arteries of the neck and brain# known as cerebrovasculardisease# causes strokes Atherosclerosis of the arteries of the arms and legs# as well asthe aorta# is known as &A' 4any fre1uently occurring conditions place people at riskfordeveloping&A'Theconditionsthat increasetheriskof &A'arethesameriskfactors that increase the risk of heart attack or stroke (see the box titled /5ommon 6isk7actors for &A'0) 5igarette smoking# both tobacco and mari3uana# is the mostimportant correctable risk factor for the development of &A'# whereas age is the mostsignificant nonreversible risk factor 6esearchers are actively working to figure out why&A'specificallyandatherosclerosisingeneral developinsomepeoplebut not inothers )omeof thenewer areasof interest includechronicinflammationof bloodvessels and inherited (genetic) factorsSymptoms of PADThe most common complaint that is caused by &A' is leg pain brought on by walking(seetheboxtitled/)ymptomsof &A'0) Thislegpainisalsoknownasintermittentclaudication 5laudication is a sensation of aching# burning# heaviness# or tightness inthe muscles of the legs that usually begins after walking a certain distance# walking up ahill# or climbing stairs# and goes away after resting for a few minutes The ache can befelt in the buttocks# thighs# or calves $n some patients# particularly patients more than+, years old# the feeling of claudication may be different from this classic or textbookdescription(suchpatientsaresaidtohaveatypical symptoms) -our doctor mustdistinguish leg pain due to claudication from other causes of leg pain# such as painful3oints (arthritis)# tingling or a/pinsand- needles0 sensation (neuropathy)# andpainrunningdownthebackof thethighsduetoarthritisof thespine(sciaticaor spinalstenosis) -our doctor will be able to distinguish claudication from other types of leg painon the basis of your description of the symptoms and a thorough physical examination)ometimes it is difficult to determine the specific cause of the leg discomfort# or youmay have more than one problem# so your doctor may order additional tests# which arediscussed below &atients with severe &A' may have claudication after walking a shortdistance or may have pain in the legs or feet when at rest or when lying in bed at nightnDa 2$n severe cases# patients may develop a sore (ulcer) that willnot healon its own orblackenedskin(gangrene) onthefoot or toe )omepatientscanhave&A'andclaudicationof thearms# althoughthisismuchlessfre1uent than&A'of thelegsThese patients may experience arm discomfort while performing routine housework orbrushing their teeth or hair The diagnosis of &A' of the arms can generally be made bya doctor8s examination &atients with &A' of the arms often have a large difference inthe blood pressure readings between the right and left arms&A' can also cause unusual symptoms $n some men# the only symptom of &A' maybe the inability to have or maintain an erection (erectile dysfunction) 7inally# in manycases# patients who have significant blockages in the arteries supplying blood to thelegs have no symptoms at all and can only be diagnosed by a doctor8s examination andatest knownastheanklebrachial index(A9$)# whichisdiscussedbelow 2earebecoming aware of the fact that for each patient with &A' and claudication# there maybe another patient with &A' who has no symptomsSymptoms of PAD Common( 9uttock# thigh# or calf pain with exertion (claudication)( :o symptoms;diagnosed by abnormal A9$ test( points (&A' ofarms)nDa 3Ho PAD Is Dia!nose"$n most cases# your doctor can diagnose &A' on the basis of a careful medical historyand a thorough physical examination The physical examination focuses on your heartand blood vessels 9ecause atherosclerosis occurs throughout the entire body# patientswith &A' are at high risk for atherosclerosis in the other arteries of the body -our doctormeasures your blood pressure and carefully examines your heart and the pulses of yourneck# arms# legs# andfeet-our doctormayalsouseastethoscopetolistentothepulses in your neck (carotid arteries) and your groin (femoral arteries) $n some cases# adoctor can hear a /whooshing0 or blowing sound (known as a bruit)# which is the resultof blood flow past narrowings in these arteries -our doctor may ask you to remove yoursocks and shoes and will carefully examine your feet and toes to make sure you havenot developed any ulcers caused by poor circulation $f your doctor suspects that youhave &A'# you will likely be asked to undergo the A9$ test# which can be performed byyour doctor#anurse# oramedical assistant (7igure=) -oumayalsobesent toavascular laboratory for the A9$ test 'uring the A9$ test# you will be asked to lie down onastretcher9loodpressureswill bemeasuredinyourarmsandlegswithaspecialultrasound device known as a 'oppler :ormally# the blood pressure in the ankles is thesameor slightlyhigher thanthebloodpressureinthearms 9ecause&A'-relatedblockages in the arteries limit blood flow to the legs# patients with &A' have low bloodpressures in the ankles -our physician will use the ratio of the leg pressure to the armpressure (ankle blood pressure divided by arm blood pressure) to determine whetheryou have &A' $n some cases# the ankle pressures may be near normal# causing thediagnosis of &A' to be hard to make $f this is the case# the arm and leg pressures maybe measured before and after you walk on a treadmill for a short period of time (stresstest) -our doctor may recommend that you undergo the A9$ test even if you do nothavelegdiscomfort or other symptomsof &A' TheA9$ test canbeusedasascreening tool to diagnose &A' in patients without symptoms who have risk factors foratherosclerosis -ou may be asked to undergo the A9$ test if you are older than age ?>#if you have diabetes# or if you are a tobacco smoker older than age >, $n some cases#additional tests may be necessary to confirm the diagnosis of &A' or to determine thelocation of the blockages in the arteries These tests may include an ultrasound of thenDa 4legs# a computed tomogram (5T scan)# or a magnetic resonance angiogram (46$ test)The blood pressures may also be measured at multiple locations along the legs in thevascular laboratory using ! or @ blood pressure cuffs on each legImportance of Dia!nosin! PAD'octorsarerecognizingthat &A'isamuchmorecommonproblemthanoriginallythought According to published research# more than = in > people older than age +,have &A' 7ewer than half of the patients with &A' know they have a problem 2orse#many patients with &A' do not have leg symptoms and can only be diagnosed by adoctor8s examination or by the A9$ test &atients with leg pain caused by &A' may havea limited ability to walk# exercise# perform their 3obs# go shopping# or clean their homes%eg pain from&A'can worsen a person8s 1uality of life 4any treatments forclaudication are available that may greatly improve symptoms of &A' but the first stepin treatment is diagnosis4ost important# patients who have &A' likely have blockages in other arteries of thebody# especially the arteries of the heart and brain &atients with &A' are ! to ? timesmore likely to have a heart attack or stroke than are patients without &A' $f you arediagnosedwith&A'# yourdoctorwill workcloselywithyoutodecreaseyourriskofhaving a heart attack or stroke#reatment $ptions for PADA numberof treatment optionsareavailabletoyouif youhavelegpainfrom&A'(claudication) -ou and your doctor should discuss which treatment is the mostappropriate Allpatients with &A' need to 1uit smoking completely Auitting cigarettesmoking is difficult# but it may save your life $f you have &A' and continue to smoke#you are at increased risk of needing surgery or an amputation &atients with &A' whocontinue tosmokealso havea higher risk of dyingfrom a heartattackorstrokeascomparedwiththosewho1uit -our doctorwill talktoyouabout theimportanceof1uitting tobacco# and he or she may offer you a 1uit-smoking program# nicotine patchesor gum# or a medication called bupropion (BybanC Glaxo)mithDline) Auitting smoking isthehardest thingyouwill beaskedtodo# but it iscritical -our doctor will likelynDa 5recommend that you start an exercise program $n many studies# patients withclaudication can more than double their walking distance in supervised exerciseprograms -our doctor may suggest that you participate in a structured exerciseprogramfor patientswith&A'or that youexerciseonyour own 2alking# whetheraround your neighborhood# at the mall# or on a treadmill# is the best exercise for patientswith leg pain from &A' $f you do not have access to a supervised program# we suggestthat you walk @ to > times per week for !, minutes (excluding rest stops) each time $t isimportant that all patients with &A' take good care of their feet &atients with &A' mustavoid developing ulcers on the feet# as these may not healproperly because of poorcirculation Eften# patients with ulcers that do not heal re1uire a procedure to restore thecirculation(seediscussionabout revascularizationbelow) &atientswith&A'shouldwear comfortable and appropriately fitting shoes 2omen with &A'should avoidhighheeled shoes# as this type of ootwear puts too much pressure on certain areas ofthe feet 5are of the toenails is especially important# and your physician mayrecommend that you make an appointment with a podiatrist -ou should also examineyour feet regularly to make sure you have not developed an ulcer $f you find an ulcer ononeof your feet or toes# youshouldnotifyyour doctor -our doctor mayconsiderprescribing a medication to improve your ability to walk There are two medications thathave been approved by the 7ood and 'rug Administration for the treatment ofclaudication" pentoxifylline (TrentalC Aventis) andcilostazol (&letalC EtsukaAmerica&harmaceutical) 6esearch studies have suggested that cilostazol is more effective thanpentoxifyllinefor thetreatment of claudication Thesideeffectsof cilostazol includepalpitations# headache# anddiarrhea Enlyasmall number of patients takingthismedication will experience a side-effect 5ilostazol cannot be prescribed to patients whohavehadfluidintheir lungsbecauseof heartpumpingproblemscongestiveheartfailure)Althoughcilostazol orpentoxifyllinemayimproveyourabilitytowalkfarther#neither of these medications can cure the symptoms of &A' entirely There are manyclinical trials of new medical therapies for claudication 7or some patients with severeclaudication that has not improved with smoking cessation# exercise# and a course ofmedication# their doctors may consider referring themto a vascular specialist forrevascularization 6evascularization refers to a procedure that restores blood flow in anDa 6limb that is supplied by blocked arteries &atients with leg pain at rest caused by &A'andthosewith ulcersthatwillnot heal shouldbereferredforrevascularizationThevascular specialist may be a vascular internist# cardiologist# vascular surgeon# orradiologist The vascular specialist typically re1uests an additional imaging test# such asanultrasound# 46$# orangiogramtodeterminethelocationof theblockagesinthearteries andthebest approachfor revascularization Anangiogramis atest thatinvolves in3ecting dye into the arteries while taking x-rays $t is an invasive test that mayinclude an overnight stay in the hospital 6evascularization can be accomplished by twoapproaches $n some cases# it may be possible to directly open the blockages in thearteries at the time of the angiogram The blockages are opened with specialballoontipped catheters $n most cases# a special metal scaffolding# known as a stent# isplaced within the artery that has been ballooned open This procedure is similar to thecoronary angioplasty and stenting procedures that are performed on the heart for therelief of chest pain 7or blockages that cannot be opened with angioplasty# the vascularspecialist may recommend surgery 'uring vascular surgery# blocked arteries arebypassedwithsegmentsof asurfaceveinfromthelegorfromtubesof manmadematerials (grafts) The vascular specialist will decide which revascularization approachis appropriate for each patient# after reviewing the case in detailPre%entin! Serious Vascular E%ents in Patients &ith PAD$n addition to prescribing a treatment plan to improve claudication# your doctor will workclosely with you to improve your overall cardiovascular health and decrease your risk ofhaving a heart attack or stroke This preven prevention strategy will likely involve takingmedications to prevent serious cardiovascular problems -our doctor may prescribe acholesterol-lowering medication (typically a statin drug)# aspirin or clopidogrel(&lavixC9ristol-4yers)1uibbF)anofi&harmaceuticals&artnership)to reducethestickiness ofplatelets# andamedicationtoloweryourbloodpressure(suchasan A5