Learn About Your Heart...
Made Simple


By Nicolas Shammas, MD


A new, comprehensive sourcebook for
heart and vascular disease patients

Cardiovascular Health Topics



1.
Statistics about Heart and Blood Vessel Diseases in the United States
2.
Structure and Function of the Heart and Blood Vessels
3.
Diseases of the Blood Vessels of the Heart
4.
Surgical Therapies for the Cardiovascular Patient
5.
Peripheral Vascular Disease
6.
Diseases of the Blood Vessels of the Head and Neck
7.
Strokes: How to Survive Them and How to Prevent Them
8.
Valvular Heart Disease
9.
Heart Rhythms: How to Recognize Them and Treat Them
10.
Congestive Heart Failure
11. Understanding Cardiomyopathy, or Weak Heart Muscle
12. Children and Heart Disease
13. Diseases of the Pericardium
14. Systemic Illnesses, Infections and Drugs that Affect the Heart
15. Erectile Dysfunction: a Vascular Disease
16. Cardiovascular Disease Prevention
17. Heart Healthy Nutritional Tips
18. Cardiac Rehabilitation
19. Medications for Cardiovascular Disorders
20. Heart Tests You Need to Know
21. Learn What to Do in a Medical Emergency
22. How to Choose Your Doctor and Hospital
23. Medical Research and How You Can Get Involved
24. Taking the Next Step — A Few Community Resources to Help You Live More Healthfully
25. How Much Did You Learn from This Book: Take a Simple Test



PERIPHERAL VASCULAR DISEASE

Eric J. Dippel, MD

What is peripheral vascular disease (PVD)?

Peripheral vascular disease (PVD) is a term that describes blockages in the blood vessels that supply blood to the entire body except the neck and head (called cerebrovascular disease) and the heart (called coronary artery disease).

Cholesterol not only clogs the arteries of the heart but also clogs other arteries in the body. All of the arteries in the body are susceptible to this problem. The arteries to the neck are called the carotid arteries, and they supply blood to the head. When the carotid arteries become significantly blocked, patients are susceptible to stroke. This is explained more fully in Chapter 6.

The arteries to the kidneys, known as the renal arteries, also frequently become blocked. Typically, there are no symptoms associated with renal artery narrowing. However, since the kidneys are among the organs that control your blood pressure, any sudden increase in your blood pressure might be a sign that your kidney arteries are becoming blocked.

Blockages can occur anywhere in the arteries to the legs. When this occurs in a mild or moderate degree, the most common symptom is claudication, which is a "tight" or "tired" sensation in the leg muscles that occurs with walking and is relieved with rest (see "What is Claudication?"). When the blockages to the leg arteries become severe enough, tissue in the leg begins to develop ulcers and die. If blood flow is not reestablished promptly, patients may require amputation of part of the leg.

What are the risk factors for PVD?

The risk factors for PVD are identical to the risk factors of coronary artery disease (CAD): high cholesterol, cigarette smoking, diabetes, high blood pressure, obesity, and a family history of peripheral vascular disease. Since arteries in our bodies become blocked over time, PVD typically gets worse as people become older.

Since the risk factors for PVD and CAD are the same, many patients have both problems at the same time. Patients with PVD that is uncontrolled are more likely to die from heart attacks and strokes rather than from blockages in their lower legs.

Among the risk factors, smoking is the most hazardous for patients with PVD. Quitting smoking not only reduces the risk of further disease but also can be one of the most important interventions that can be done to reduce symptoms of pain in the lower legs.

How common is PVD?

PVD is quite common, although it is frequently under-recognized and under-diagnosed. A simple analogy follows: when grandpa walks to the mailbox and gets chest pain, he is referred to the emergency room. However, when grandpa walks to the mailbox and his legs get tired, he simply is told he is "just getting old."

There are millions of Americans who have PVD, yet only a fraction actually receives treatment. Furthermore, there are thousands of amputations performed in this country every year that might be prevented if blockages obstructing the blood flow to the leg were detected and treated early. There are over 12 million people in the United States who live with peripheral vascular disease, but fewer than 25% are being treated. A higher index of suspicion is necessary for both patients and physicians to adequately search for, diagnose, and treat PVD.

What is claudication?

Claudication refers to the symptoms of leg fatigue and cramps that patients with PVD describe when they exert themselves. This is typically described as a "tight" or "cramping" sensation in the calves, thighs, or buttocks that occurs with walking. Typically, this occurs at a very predictable time in walking. For example, after walking 1 to 2 blocks, a patient would have to stop and rest.

Leg cramps at night while sleeping are typically not due to PVD. However, foot pain at night, along with discomfort in the calves with walking a short distance, can be a sign of very advanced PVD that would require immediate attention.

Advanced lack of blood supply to the lower extremities can result in skin ulceration, nonhealing wounds, infection, and ultimately tissue loss and amputations. Dependent rubor and elevation palor are terms that describe advanced blockages in the arteries of the legs. When blockages are very severe, elevation of the legs leads to less blood supply to the foot that turns pale.When the leg is dangled down, the foot turns red (gravity assists the blood in reaching the feet). Patients sometimes complain of their feet and toes turning blue when dangled down. This is generally due to venous stasis, or pooling of the blood to the lower legs, rather than insufficient blood reaching the toes.

What are the causes of leg pain?

Leg pain can be broken down into 3 major categories.

The first category is problems with blocked blood vessels and poor circulation. As previously described, these symptoms of claudication occur with walking or exertion and are alleviated with rest. Patients can develop pain that occurs with rest only if the blockages are severe and the blood flow to the leg is extremely limited. Typically, if this occurs, there are other findings, such as discoloration of the skin or ulcerations of the foot, that go along with resting pain from poor circulation.

The second major type of leg pain is due to problems with the bones and joints, such as arthritis of the knees, ankles, and hips. This type of pain is typically worse with standing and weight bearing on the joint. It may occur at rest and, commonly, is improved with walking.

The third major type of pain is caused by nerve problems. For example, pinched nerves in the low back can cause sciatica pain, which shoots down the hip and buttocks into the lower leg. This pain typically feels sharp and may be worse with certain positions. Another type of nerve pain is numbness and tingling of the feet that is frequently seen in diabetes. This has a sensation of "pins and needles" and may be present 24 hours a day.

What tests can be done to evaluate for PVD?

These tests can be broken down into noninvasive studies versus invasive studies. The simplest noninvasive study is simply measuring the blood pressure in the arms and comparing it to the blood pressure in the legs. This is known as the ankle/brachial index (ABI). The blood pressure in the ankles should be roughly the same as the blood pressure in the arms. If the ankle blood pressure is significantly decreased, this is evidence that there are blockages somewhere in the legs. Pictures of the arteries in the legs can be obtained through either a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan. While these images are similar, for technical reasons, the CT scan probably provides more accurate images. Doppler ultrasound can also be used to measure blood flow into the arteries. This test is most commonly used to monitor the adequacy of blood flow through bypass grafts but also can be utilized to assess blood flow to the native arteries. Invasive studies include the angiogram test. During this test, a catheter is placed in the arm or leg (at the groin level) under local anesthetic and contrast dye is injected through it to visualize the arteries.


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