Accumulation of “plaque” within the walls of the arteries affecting the legs is commonly referred to as peripheral arterial disease [PAD].

Similar to the situation that occurs with a narrowed pipe, when plaque accumulates within the walls of the arteries it becomes difficult for oxygenated blood to flow from the heart to the legs.

Peripheral arterial disease [PAD] is a common (and under-diagnosed) condition. In the United States, an estimated 10 million people are affected with PAD.

diagram of peripheral arterial diseaseSymptoms

Somewhat surprisingly, many patients with PAD are asymptomatic. In this situation plaque accumulation has developed within the walls of the arteries, however, the degree of reduction of arterial blood flow to the legs has not yet reached a critical level and blood is still able to flow through (or around) the narrowing in the artery.

As the burden of plaque increases, it becomes increasingly more difficult for oxygenated blood to be delivered to the muscles and tissues of the legs.

In general PAD is a slowly progressive condition, however, occasionally the condition will present suddenly (acutely).

With low-grade levels of PAD patients typically experience pain or cramping in their legs when walking. Although the pain can occur anywhere in the leg calf cramping is particularly common.  The medical name for this symptom complex is “claudication.”

With more severe levels of PAD patients can experience pain in their legs with minimal activity or even when at rest (“rest pain”).

In severe cases of PAD patients can develop ulcers (wounds), discoloration of the skin of the feet and toes, and are at risk for developing gangrene of the toes/foot.

Diagnostic Workup

Initial diagnostic testing for PAD often involves a simple test known as the “ABI” test.  “ABI” is an acronym that stands for “Ankle-Brachial Index”. In this test blood, pressure cuffs are used to compare the pressure of arterial blood flow in your legs compared to your arms.

Another commonly utilized form of diagnostic study used in the evaluation of PAD is a specialized form of ultrasound testing known as duplex ultrasound.

In some situations, additional diagnostic tests such as CT-scans and MRI scans may be required.

Treatment

Nearly all patients with confirmed PAD will benefit from medications that are intended to reduce further plaque accumulation, reduce the risk of “plaque rupture”, or decrease the risk of blood clot formation.

In many patients, blood flow to the legs can be improved using “minimally-invasive procedures”.

One of the most common procedures performed to improve the blood flow to the legs is called “angiography” or “angiogram”.  In this procedure, a thin piece of flexible tubing is used to inject dye directly into the artery. As the dye is injected x-ray images allow real-time evaluation of blood flow through the area of concern, and can accurately delineate the location and the degree of narrowing in the artery.

In many situations, it is possible to treat the narrowing or blockage at the same time the angiogram is performed. The catch-all phrase used to describe vascular procedures done with the guidance of angiography is “endovascular therapy”.

A wide variety of treatment options can be performed at the time of angiography:

  • Balloon angioplasty (dilating the narrowing with a balloon)
  • Stent deployment (insertion of cylindrical metallic lattice that acts as a structural scaffold; allows blood to flow through a previously narrowed area.
  • Atherectomy procedures (procedures designed to directly remove plaque from the wall of the artery). Common atherectomy options include devices that rotate or spin rapidly within the artery and laser devices.

In some situations, a surgical bypass around the arterial blockage may be the best option. In this situation, a length of the vein (or artificial tubing) is surgically attached to an area above the blockage, tunneled around the blockage, then re-connected to the artery below the blockage.  Blood is then able to flow through the new flow channel to the leg.

Increasingly, the aforementioned techniques are used in combination.  It is not uncommon for patients with PAD to undergo a variety of procedures, which may include both endovascular and surgical modalities of care.

Vascular surgeons specialize in the endovascular and surgical care of peripheral arterial disease.

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