Peripheral Vascular Disease Worsens Long-term Outcome for Cardiac Patients.
03/11/2004.
Peripheral vascular disease, or PVD, is a condition in which the arteries that carry blood to the arms or legs become narrowed or clogged. This interferes with the normal flow of blood, sometimes causing pain but often causing no symptoms at all.
The most common cause of PVD is atherosclerosis (often called hardening of the arteries). Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called “plaque” that clogs the blood vessels. In some cases, PVD may be caused by blood clots that lodge in the arteries and restrict blood flow. Known risk factors include diagnosed coronary artery disease, tobacco abuse, dyslipidemia, hypertension, diabetes mellitus, obesity, positive family history and a sedentary lifestyle.
PVD affects about 1 in 20 over the age of 50, or approximately 10 million people in the United States. More than half the people with PVD experience leg pain, numbness or other symptoms — but many people dismiss these signs as “a normal part of aging” and don’t seek medical attention. Additionally, only about half of those with symptoms have been diagnosed with PVD and are seeing a doctor for treatment.
In most cases, PVD involves acute muscle pain in the legs while walking which is relieved with rest. This is commonly referred to as “intermittent claudication.” Intermittent claudication is estimated to occur in about 5% of people over 55 years of age and it increases steadily with age. Less types of PVD are suggested by the young age of the patient, involvement of only the upper extremity or digits, or presentation of acute ischemia without a prior history of occlusive PVD. These uncommon types include: thromboangiitis obliterans, giant cells arteritis and PVD due to blunt trauma or arterial entrapment.
PVD usually runs a benign course. Fewer than 30% of patients will require surgical or endovascular intervention. However, PVD is not only a disease in its own right; it’s also an independent
predictor of increased risk of cardiovascular disease, cerebrovascular disease and death. Half of patients presenting PVD also have symptoms of coronary artery disease or EKG abnormality, and 90% have abnormalities on coronary angiography. Symptomatic PVD carries at least a 30% risk of death within five years and almost 50% within 10 years, due to myocardial infarction (60%) and stroke (12%). In a recent analysis of the TARGET study, patients with coronary disease and PVD had a 2.3 times increase in mortality at one year compared to coronary patients without PVD.
Adequate examination of the peripheral arterial circulation in patients presenting intermittent claudication or during screening for PVD should include characterization of the skin color and pulsations of the arteries supplying the limbs: abdominal aorta, femoral, popliteal, dorsal pedis, and posterior tibial; subclavian, brachial, radial, and ulnar; and the cervical carotid.
Skin changes are best evaluated with the elevation-dependency test. The development of skin pallor in an extremity elevated to 60 degrees above the bed in one minute or less indicates significant occlusive arterial disease in this extremity. A bruit is usually indicative of a stenosis upstream, and therefore, auscultation is useful to search for bruits over the large arteries.
An important noninvasive method to confirm a PVD and evaluate the degree of functional impairment is the ankle/arm index (AAI). AAI represents the ratio between the highest pedal systolic pressure in each ankle and the highest brachial systolic pressure. An AAI lower than 0.9 is indicative of PVD. This may require contrast angiography or magnetic resonance angiography to define the PVD further and access treatment options.
Not long ago surgery was the only widely accepted treatment option for PVD. However, medications such as clopidogrel and cilostazol, exercise programs and percutaneous endovascular techniques have shifted the paradigm for the management of PVD. Endovascular revascularizations involve lower risks and incur lower costs than major reconstructive surgery and also make it possible to intervene at an earlier stage of PVD-mediated symptomatic disability. The presence of PVD should also prompt the initiation of aggressive cardiovascular risk factor modification.
The decision to mechanically revascularize a non-diabetic patient with claudication rests not on the anatomic severity or hemodynamic alteration (AAI) but on the degree of functional impairment in that individual. For example, 3-block claudication may be severely limiting to a person with an active lifestyle or a person whose job requires frequent walking. Then again, a 1-block claudication may be well tolerated by an inactive individual. However, the development of rest pain or ischemic skin changes in any patient is an indication for revascularization.
The most common cause of PVD is atherosclerosis (often called hardening of the arteries). Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called “plaque” that clogs the blood vessels. In some cases, PVD may be caused by blood clots that lodge in the arteries and restrict blood flow. Known risk factors include diagnosed coronary artery disease, tobacco abuse, dyslipidemia, hypertension, diabetes mellitus, obesity, positive family history and a sedentary lifestyle.
In diabetic patients, symptoms are not reliable and therefore the decision to revascularize the patient is based on anatomy and hemodynamic alterations alone. Moreover, the absence of reliable symptoms and the high prevalence of asymptomatic disease make foot screening essential.
Cardiology Associates of North Mississippi has adopted an aggressive, highly successful approach in the diagnosis of symptomatic PVD. Incorporating arterial physiologic testing, duplex vascular sonography and magnetic resonance angiography (MRA) into the diagnostic arsenal has allowed the CANM team to diagnose and manage vascular diseases through better patient diagnosis and triage.
PVD Symptoms
- Leg or hip pain during walking
- The pain stops when you rest
- Numbness, tingling or weakness in the legs
- Burning or aching pain in feet or toes when resting
- Sore on leg or foot that won’t heal
- Cold legs or feet
- Color change in skin of legs or feet
- Loss of hair on legs