Peripheral Vascular Disease is a disorder which affects 8-12 million Americans. People with PVD have arteries in their extremities that are narrower, harder, and are filled with plaques on the walls of the blood vessel. The plaques are comprised of fats, cholesterol (hard, waxy substance), calcium, and other blood products. This is commonly called atherosclerosis or hardening of the arteries.
While both men and women can have PVD, it occurs more often in men. It is generally thought to be a disease of the aging, as it is not uncommon for men over 50 years old to have peripheral vascular disease. Symptoms may affect only one limb, but if both; the symptoms are generally different in both legs. The early symptom of PVD is leg pain or intermittent claudication. This pain is increased with exercise, and subsides with rest. It generally occurs in the calves of the leg. It is estimated that half of the people with PVD have no symptoms; however, intermittent claudication strikes about one third of those with this disease. Although calf pain is the symptom that may get the person to the doctor; the physician will also question pain or fatigue in the foot, thigh or buttocks, as that too is related to peripheral vascular disease. One symptom that is rarely mentioned, but may be the most common of PVD is erectile dysfunction (i.e. a man can no longer obtain an erection and/or maintain an erection). A very small number of people with PVD progress to the severest form, or ischemic stage. Ischemia causes death to the surrounding tissue, as oxygen is no longer available.
The ultimate outcome of PVD was brought home to me recently when my husband was hospitalized for an elective surgery. His room mate was suffering from the late stages of PVD, and groaned in pain constantly. The pain was so intense it prevented sleep or any rest for this poor, suffering patient. Despite on going pain medications from the nurses, the pain was relentless. It was so distressing, that we finally requested transfer to another room for my husband. The following day, this patient was taken to surgery to amputate his leg, below the knee.
For years now, we have been able to prevent above the knee amputations through the placement of stents (i.e. hollow tubes or catheters which allow blood flow) in the large arteries of the thigh or performing a bypass around the diseased artery through a graft of a vein. However, blockages below the knee had one recourse for treatment only: amputation.
Thankfully, times have changed. We now have stents which are small enough to fit through the smaller arteries of the lower leg (i.e. 3 mm) and flexible enough. It is estimated that almost 85% of patient’s undergoing this surgery still have a patent artery after one year (i.e. artery remain opened, unblocked). Additionally, 77% have unblocked arteries after 2 years. As recurrences are not uncommon after surgery for PVD, these numbers for the severest form of the disease, are significant.
Patients, who need this type of surgery, don’t have a lot of other options. Grafting their own arteries is not an option, as their arteries are too stiffened and corrupt due to the disease progression. As hardening of the arteries never strikes only one part of the body, other blood vessels throughout the body, including those in the heart, kidneys, brain, etc. are also diseased; therefore, these patients are too sick to withstand the rigors of general anesthesia. Stent placement, however, is accomplished through conscious sedation, which decreases anxiety and pain; but does not render the patient completely unconscious as general anesthesia does.
Patients requiring amputation from ischemic disease caused by peripheral vascular disease (PVD) are not common, affecting only 1-2% of the population. However, peripheral vascular disease is common. Fifty percent or more of men 50 or older have peripheral vascular disease. These men may suffer with cramps in their calves when walking, but rarely have other symptoms. The cramps are caused from mild tissue ischemia, as oxygen demands increase when walking which can not be met due to diseased arteries. However, this mild cramping does not compare to the excruciating pain of severe disease or the associated ulcers or gangrene which can develop from PVD.
Atherosclerosis, as indicated by PVD, occurs throughout the body. If one has PVD, one is 6-7 times likelier to have coronary artery disease (CAD), heart attack, or a stroke. And, if a person has coronary artery disease, one is 3 times more likely to also have PVD.
One can significantly reduce the natural progression of peripheral vascular disease, delay its occurrence for decades, and minimize the affects of atherosclerosis throughout the body by:
• Not smoking. Smoking not only constricts blood vessels, and contributes to clotting; but also leaves actual cuts in the arterial wall, which subsequently develop scars and/or plaques. Smokers have a five times higher risk of having PVD, and develop PVD 10 years earlier than non-smokers. Even one to two cigarettes a day can compromise the vascular system. Some surgeons will not operate on a person for PVD if they smoke. The risk from smoking drops dramatically when one quits, so in 5 years, the risk has decreased by 40%.
• Exercise. Exercise consists of walking to the point of pain, resting till the pain subsides, and then walking again. Walking forces the blood flow through the arteries; thereby, maintaining its patency (i.e. openness). Additionally, exercising promotes the growth of collateral circulation.
• Management of cholesterol. Cholesterol causes arterial plaques on the walls of the blood vessel and decreases blood flow. Remember, your magic numbers of total cholesterol below 200, HDL above 50, and LDL below 100 (below 70 if high risk). While medications will help maintain good lipid numbers, diet is also critical.
• Maintenance of a healthy blood pressure. The targeted blood pressure is 120/80, but those with certain risk factors may even be lower.
• Maintenance of a healthy weight. The body-mass-index or BMI can be used to calculate what is healthy for you. This number is based on calculations relating to your height and weight. A good BMI is anything below 25. Excessive weight will contribute exponentially to the pressure on the arteries in your extremity; thereby, exacerbating the symptoms of PVD.
• Maintenance of good control, if diabetic. The hemoglobin A1C test—a test that gives an estimate of how well blood sugar has been controlled over the past 3 months, should be below 6.5. Excess sugar will deteriorate the walls and composition of your blood vessels. It is estimated that one in three people with diabetes will also have PVD.
Finally, a word to the wise! If you think you have the symptoms of PVD, run don’t walk to your physician. This disease is treatable, but the consequences are grave if you wait too long.
Circulation, American Heart Association, 2006
http://circ.ahajournals.org/cgi/reprint/113/11/1474
National Heart, Lung and Blood Institute
http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_causes.html
Mayo Clinic
https://www.mayoclinic.com/health/peripheral-arterial-disease/DS00537/DSECTION=4
Society of Interventional Radiology meeting, 2007
http://www.medpagetoday.com/MeetingCoverage/SIRMeeting/dh/5211
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