By submitting a question to VascularDoc and selecting “I agree”, I am stating that I agree that all answers from VascularDoc are written in general terms and that this information should be used only as background material for discussions with my own physicians and surgeons. I agree that answers written by VascularDoc are not opinions about my condition or treatment and should never replace consultation with my own physicians. By selecting "I Agree" below, I am also stating that I agree that my question may be used as a source of information and education for other readers. I understand that none of my personal information (including my e-mail address) will ever be published or shared with any other party.
The views and opinions expressed on this website are solely my own and do not reflect the views of the Mount Sinai Health System or any of my colleagues.
PAD is blockage of the arteries in the legs, caused by accumulation of atherosclerotic
plaque. Risk factors associated with development of plaque in the arteries of the
lower extremities include cigarette smoking, high cholesterol levels in the blood,
diabetes, and family history. Peripheral arterial disease usually presents with
the symptom of "claudication," which is pain in the leg, usually in the calf or
thigh, after walking varying distances. Some patients develop "claudication" after
just a few steps, while others can walk up to a half of a mile or more before pain
forces them to stop. Typically, after a rest period of a few minutes, the patient
is able to resume walking again for an equal distance before the pain returns. PAD
is most commonly associated with aging. Approximately 30% of people over the age
of 70 have some degree of PAD. While claudication caused by PAD is not necessarily
a reason to proceed with surgical therapy, evaluation by a vascular surgeon is necessary
when a patient has claudication to ascertain the seriousness of the condition. While
claudication can be extremely painful and lifestyle limiting, it does not necessarily
indicate that limb loss is imminent or even likely. Most patients with claudication
due to PAD do not progress to limb loss. When claudication deteriorates into a condition
of "rest pain" however , limb loss is a distinct probability. Rest pain means that
the patient has pain even when not walking. Typically, rest pain is most intense
when a person is attempting to sleep. When we sleep, our blood pressure tends to
decrease and this blood pressure reduction leads to a decrease in the head of pressure
which is driving blood into the legs around the areas of blockage (see Video #7, Video #8, Video #11).
The patient should been seen by a vascular surgeon. A complete medical history should
be obtained and the surgeon will examine the arterial pulses in the lower extremities
at the level of the groin, behind the knee, and in the feet. An arterial noninvasive
blood flow study may be obtained, which is a noninvasive measurement of the amount
of blood which is being delivered to the legs. If a blockage is suspected on the
basis of the noninvasive arterial blood flow studies (sometimes called a "Doppler
test"), an ultrasound examination of the arteries may be obtained, an MRA (magnetic
resonance angiogram) may be obtained, and finally an angiogram may be necessary
to obtain a "road map" of the circulation.
When PAD is diagnosed, the vascular surgeon will propose a treatment plan. This
plan may involve an exercise program (usually consisting of walking on a daily basis
to the point of claudication to attempt to build "collateral blood vessels" around
the blocked arteries). Other lifestyle changes including cessation of cigarette
smoking, better management of diabetes, weight reduction, and cholesterol-lowering
medications. Medications which have been shown to have some beneficial effect in
patients with claudication caused by PAD include cilostazol (Pletal), which may
improve the walking distance. Other drugs that may be prescribed by the vascular
surgeon include aspirin or clopidogrel (Plavix). If it is the opinion of the vascular
surgeon that the condition has deteriorated to the point where lifestyle changes
and an exercise program are no longer satisfactory treatment options, an angiography
may be obtained. If the angiogram demonstrates localized blockages of the arteries
in the legs, a balloon angioplasty, stenting or bypass surgery may be recommended.
The bypass procedure can be performed either using one of the "extra veins" of the
lower extremities, or an artificial arterial bypass (made of Dacron or Gortex) may
be used. This decision is made by the vascular surgeon and is usually discussed
with the patient prior to operation.
In cases where PAD has progressed beyond the point of claudication and beyond the
point of rest pain to the situation where actual gangrene of the tissues of the
lower extremity has developed, it is sometimes "too late" to salvage the extremity
and amputation may be necessary. More than 50,000 amputations are performed annually
in the United States . The amputation level may be either at the mid foot (transmetatarsal),
below the knee or above the knee. Amputation is the procedure of last resort and
is rarely undertaken prior to an attempt at limb salvage, unless the situation clearly
has progressed to the point where time is of the essence and the amputation must
be performed as a life-saving maneuver.