Vascular Health: Millions at Risk for Peripheral Arterial Disease
People who blame old age for their inability to walk short distances without pain may be suffering from peripheral arterial disease, a potentially limb-threatening condition that puts them at greater risk for cardiovascular disease, heart attack and stroke.
"About 1 in every 20 Americans over the age of 50 has peripheral arterial disease," says Dr. Gregory Simonian, executive vice chairman at Hackensack University Medical Center's Heart & Vascular Hospital.
Experts expect the problem to worsen with the nation's burgeoning aging population.
"The number of patients in the United States with PAD is growing rapidly, and it's going to continue as baby boomers get older. We're already seeing an increase," says Dr. Alan Dietzek, chief of vascular and endovascular surgery and director of the Non-Invasive Vascular Lab at Danbury Hospital, part of the Western Connecticut Health Network.
What is PAD?
PAD is a serious but treatable vascular condition that occurs when sticky plaque that builds up in the arteries hardens and blocks the vessels, limiting the flow of oxygen-rich blood to the limbs.
Treatment options include lifestyle changes, medication, minimally invasive procedures to restore blood flow and bypass surgery to create a new passage that goes around the blockage. In severe cases, the lack of blood can cause tissue to die (a condition known as gangrene) and could lead to amputation.
Smokers are four times more likely to develop PAD, according to the National Heart, Lung and Blood Institute, part of the National Institutes of Health. Also at risk are people with high cholesterol, high blood pressure and diabetes. Smokers and people with diabetes are more likely to develop complications, like gangrene. African-Americans are at a greater risk for developing PAD than any other racial or ethnic group, reports the NHLBI.
Diagnosing PAD early is crucial because the condition is a strong marker for heart attack and stroke, says Dr. James Joye, an interventional cardiologist at El Camino Hospital in Mountain View, California.
"Most people are aware of coronary artery disease. But fewer people know about vascular disease. People need to understand that it's not normal for their leg to hurt when they walk. It's not a sign of aging or of being out of shape," Joye says.
One symptom called "intermittent claudication" occurs when pain develops in the calf, thigh or buttock muscles after walking short distances and subsides after rest. In advanced cases, patients experience pain even at rest, greatly limiting their ability to carry out their daily routines.
"The muscles in your legs are like little engines that need oxygen to work effectively," Simonian explains. "Acid builds up in the low-oxygen environment causing pain in the calf, thigh and buttocks muscles depending on the location of the blockage. When you rest, the acid washes out, and in time you're able to walk again without pain."
Ignoring the Warning Signs
Although PAD can be easily diagnosed, the condition may go undetected for years because patients downplay the symptoms, and some physicians fail to routinely assess at-risk patients, experts say. "Many people don't tell their doctors because they assume the pain will go away, or they think it's arthritis," Dietzek says.
Doctors typically check for weak or absent pulses in the leg or feet; non-healing sores or wounds on the toes, feet or legs; decreased hair growth on legs; abnormal nail growth; pale or bluish skin color to the skin; and differences in body temperature in the limbs.
Physicians may recommend tests to pinpoint the problem if they suspect PAD. An ankle-brachial index test compares blood pressure in the ankles and arms. Ultrasound is a painless, non-invasive procedure that converts sound waves into real-time images of blood flow in the arteries and veins. A magnetic resonance angiogram uses magnetic and radio wave energy to take pictures of the blood vessels. With an arteriogram, physicians can get an X-ray that shows the exact location, type and extent of the blockage.
Treatment Options Abound
Treatment options vary depending on the severity. Lifestyle changes such as eating nutritious food, quitting smoking and exercising are the first line of treatment, Simonian says. Medications to improve blood flow and control blood pressure, cholesterol and blood sugar levels may help.
"Most of these issues -- including a sedentary lifestyle -- can be managed," he says. "It's amazing how exercise and weight loss to prevent PAD from getting worse can also help to take care of your diabetes, high blood pressure and high cholesterol."
Some patients find relief with minimally invasive procedures that restore and maintain normal blood supply in the legs.
"There's been a huge increase in the number of interventional procedures that can be used to treat PAD. It has revolutionized the way we approach the disease. The development of less invasive techniques with better results is moving at a rapid pace," says Joye, who is a founding board member of VIVA Physicians. (VIVA stands for Vascular Interventional Advances.)
For example, angioplasty and stenting -- a procedure used to treat blocked vessels to the heart -- can also restore blood flow to the limbs. Physicians use a balloon (attached to the tip of a catheter) to open the blocked artery by pushing the plaque against the vessel's wall. They also may insert stents that work as scaffolds to keep the arteries open.
"We now have drug-coated balloons and stents with medication that tell the cells of the arteries to not produce scar tissue, which could lead to another blockage in the future," Simonian says.
In another procedure known as atherectomy, physicians use a catheter to insert a small cutting device that shaves off the plaque in the blocked area.
In severe cases, patients may need bypass surgery. "With PAD, a vascular surgeon uses a man-made vessel or a blood vessel from another part of the body to create a new passage that goes around the blocked artery to restore blood flow," Dietzek says. Amputation is a last resort in extreme cases where gangrene has developed.
Increased Awareness
Experts advise consumers to find a specialist who is associated with a comprehensive vascular center and certified vascular laboratory. A vascular surgeon can offer the full range of treatments from minimally invasive procedures to bypass surgery. Some interventional cardiologists or specialists perform interventional procedures and refer patients to vascular surgeons, if needed.
"We need to increase awareness about peripheral arterial disease," Joye says. "Legs don't get the same kind of medical attention that the heart and brain gets."
