Peripheral Arterial Disease

What is Peripheral Arterial Occlusive Disease?

Peripheral Arterial Disease (PAD) is a condition where the arteries become narrowed or blocked (occluded) by a buildup of plaque of fatty deposits called atherosclerosis. This causes a restriction for blood getting to where it needs to go.

We commonly talk about atherosclerosis and how it affects the heart, however it can occur throughout the arteries in the body, including the neck (see carotid artery disease – hyperlink) and when it occurs in the arteries supplying your limbs, this causes peripheral artery disease.

What causes PAD?

There are several things that put you at higher risk of developing atherosclerosis, they are:

• Smoking
• Diabetes
• Obesity (a body mass index over 30)
• High blood pressure
• High cholesterol
• Increasing age, especially after reaching 50 years of age
• A family history of peripheral artery disease, heart disease or stroke
• High levels of homocysteine, a protein component that helps build and maintain tissue

What are the signs/symptoms of PAD?

The signs and symptom syou may experience with PAD are:

• Claudication: Pain in the hip, thigh or calf muscles when walking, particularly walking uphill or up stairs. Claudication feels like a burning and/or cramping sensation that forces you to stop the exercise.
• Rest pain: Painful legs and/or feet when at rest.
• Nocturnal rest pain: Painful legs and/or feet/toes that wakes you up at night, which can be improved when you get up and walk or hang your legs over the side of the bed.
• Change in colour or discolouration of lower legs, feet and or toes
• Diminished or absent pulses in the legs
• Sores that will not heal. This can be called “ulcers” and/or “non-healing wounds”.
• Coldness of your lower leg or foot, especially when compared to the other side.
• Shiny skin on your legs
• Hair loss on your legs
• Slowed toe nail growth

How will PAD affect my health?

Having peripheral arterial disease can be debilitating and painful. It can impact on how active you are, which in turn can prevent you from doing the things you like to do and from exercising and staying fit, which can lead to other health and social problems.

If you have peripheral arterial disease you are also at higher risk of having the same sort of problem in your carotid arteries, which can result in a stroke, and in your heart, which can lead to a heart attack.

Peripheral arterial disease can lead to ischaemia which, in the worst cases and in a very small group of the population this can result in an amputation being required.

What are the stages of PAD?

Peripheral arterial disease can worsen over time and there is a natural progression of the symptoms you would experience in the absence of treatment.

1. First, you might notice that you are getting intermittent claudication, which is when you get pain in your legs when you walk from time to time, which might be worse when you walk up hills or stairs, but it goes away quickly once you rest.
2. Over time you might notice that you can only walk a short distance before you experience this pain, especially when walking up stairs or hills – this is called short distance claudication.
3. If you haven’t gone to see a doctor yet, you might start noticing that when you are sitting in a chair, or are at rest, that you are experiencing pain in your legs, feet and/or toes. This is called rest pain.
4. You are particularly stoic if you have still not gone to the doctor when start getting pain that wakes you up at night. This pain will usually go away if you get up and walk or hang your legs over the side of the bed. This is called nocturnal rest pain.
5. You might also start to notice that your legs, feet, toes are cool to touch and/or that the hair and toenails are not growing like they normally do.
6. At any point you could develop what are known as non-healing wounds. These can occur spontaneously or as a result of minor trauma. These are a sore/ulcer on your legs, feet or toes that will not heal on its own. This can be a difficult problem to manage and usually require a multidisciplinary approach to management, because these wounds are very susceptible to infections that can make you feel extremely sick. See more information about non-healing wounds and how we can help, here.
7. We are very concerned that you have not gone to see your doctor if you get to this next stage, which is called critical limb ischaemia. This is when the blood flow to your leg/s is completely blocked and you can start to develop gangrene. This means that there is not enough blood getting to where it needs to be and the tissues are dying from lack of oxygen and all the other good stuff that your blood supplies. This will be very painful, debilitating and will make you feel extremely sick.

Please note, everyone is different and not everyone will experience the same symptoms. Disease progression is not always linear. Some people will not notice the early stages of the disease. For example, if they do not exercise enough to experience claudication, and sometimes a blockage (occlusion) can occur spontaneously - missing all the early warning signs - going straight to critical limb ischaemia.

I think I have PAD – What should I do?

1. See your GP: Your GP will take a detailed history and perform a physical examination, looking to feel the pulses in the affected leg/s. If they think that your symptoms are caused by a vascular problem they will refer you to a Vascular Surgeon.
2. See a Vascular Surgeon: Your surgeon will probably send you for tests to determine if there are any blockages in your arteries.

Your surgeon will take a detailed history and perform a physical examination, which will include listening to your heart, examining your abdomen and assessing the pulses in your neck, arms and legs both by hand and with a stethoscope. Your surgeon will then either recommend more tests or recommend a course of treatment, often in this order:

1. Initial test: Ultrasound: Tests are important and SVS recommends ultrasound in the first instance. Ultrasound is good at measuring the rate at which blood is flowing through your arteries and at detecting narrowing of the vessel and/or blockages. These ultrasounds are usually of the affected leg and may include a scan of the vessels in the abdomen, as blockages in the aortic vessels can cause symptoms in the legs. Your doctor may also recommend that other areas be scanned if they think you are at risk of disease in other vessels.
2. CT, CT Angiogram, MRI and Diagnostic Angiogram: Sometimes you need more tests because your surgeon might think that your symptoms don’t match the kind of disease that is identified on ultrasound. In this instance they may refer you for a CT, CT angiogram, MRI or diagnostic angiogram. These tests also help to exclude other problems such as blockages in the legs, heart or carotid arteries.

Your treatment plan will be discussed with you once the results of your ultrasound/s and tests are known by your surgeon. They are now in a great position to advise you on treatment. Based on your consultation and the results of your scans, they will then recommend an appropriate treatment regimen for you, which could include surgery, surveillance, adjustment of lifestyle factors and addition of medications.

What if I don’t have my Peripheral Arterial Disease treated?

Some people with peripheral arterial disease can be managed conservatively (with adjustment of lifestyle factors and medication) and their condition may never deteriorate. However, in many cases the disease does progress and this can result in:

• Worsening of symptoms
• Development of/deterioration of non-healing wounds and associated infections
• Development of gangrene requiring protracted multi-disciplinary care
• Development of critical limb ischaemia
• Limb amputation (very rare)

What treatments does Sydney Vascular Surgery offer for PAD?

Treatment options are tailored for each patient depending on where the plaque that is causing the problem is located, what shape it is and how severe the blockage is. Your surgeon will also take into account your medical history and comorbidities when recommending treatment. Your surgeon will discuss with you why they have decided on your treatment and if you ever have questions about it you should always ask. The treatment options we offer are:

Conservative management

If you do not want surgical intervention or if your PAD is not severe enough to warrant the risk of intervention, you would likely be commenced on blood thinning medication and be advised about adjusting lifestyle factors like optimising weight, keeping blood pressure and cholesterol under control, exercising regularly and not smoking! You would then be asked to attend regular, ongoing surveillance consultations and ultrasounds to monitor disease progression. Of course, if you noticed your symptoms getting worse you would contact your doctor.

Endovascular Treatments

Endovascular treatments are minimally invasive procedures that usually require a day of surgery admission and an overnight stay. These procedures are usually done under a local anaesthetic with sedation and take about 90 – 120 minutes.

Angioplasty

A balloon is used to push open the walls of the vessel and is removed once the vascular surgeon is satisfied that the vessel has been opened sufficiently to improve blood flow. Sometimes the balloon is coated with a drug that will be administered to the area of plaque buildup, to try and prevent it from recurring in the same area.

Stent

A stent will remain in the vessel and open it up, so that the blood can flow more freely. In order to place the stent and get it to the right size, it is common for an angioplasty balloon to be used to open the vessel and then to expand the stent. Sometimes the stent has a drug component to it, which is designed to reduce the chance of recurrence of plaque in the stent.

Atherectomy

An atherectomy device is used when the blockage in the vessel is so tight that a balloon and/or stent will not fit through the length of it. The atherectomy device “drills” through the plaque in the vessel so that an angioplasty balloon or stent can be used as well.

Open Surgical Techniques

These are open procedures that require a day before admission and 3-5 days stay in hospital with an ICU admission following the procedure. These procedures are used when the vessel is too badly blocked for stenting, ballooning or atherectomy, or are completely blocked.

These procedures are done under a general anaesthetic and usually take 180 minutes.

Endarterectomy

An endarterectomy is a procedure where the vessel itself is cut open and the Dr cleans out the blockage of plaque manually. This will normally occur for tight blockages in the iliac, femoral and profunda segments (which are in the upper part of the leg going into the abdomen).

Bypass Graft

A bypass is where the doctor will either harvest one of your veins (from your leg or arm) or use a prosthetic tube to connect the artery above the blockage to the artery below the blockage, restoring the blood flow.

Helpful Links:

For more detailed information please visit: Angiograms and Angioplasty - http://www.anzsvs.org.au/patient-information/angiograms-and-angioplasty/