Peripheral Arterial Disease (PAD)

Azadeh Beheshtian | Apr 22, 2024

Peripheral arterial disease, or as it’s more commonly known — PAD, has many causes and is also one of the most under-diagnosed forms of vascular disease. PAD is caused by atherosclerosis — or the build-up of plaque within the arteries inside one’s legs. Atherosclerosis manifests when “the blood vessels that carry oxygen and nutrients from your heart to the rest of your body (arteries) become thick and stiff — sometimes restricting blood flow to your organs and tissues.” Although “healthy arteries are flexible and elastic,” plaque build-up can result in hardening of the arteries over time.  Moreover, atherosclerosis can cause difficulties for patients when walking or performing any physical activity. In more severe cases, PAD can lead to tissue loss, infection, and even limb amputation.  Fortunately, PAD is also easily tested for in the care of a trained vascular surgeon.  Dr. Beheshtian has performed over a thousand PAD cases of varying complexity over her medical career.

Furthermore, patients with PAD are at increased risk for cardiovascular disease. In fact, PAD is often cited as “the major cause of cardiovascular disease.” This is due to the fact that atherosclerosis is a systemic disease that also causes coronary and cerebrovascular problems. The build-up of plaque “narrows the arteries, making it harder for blood to flow through.” The formation of a blood clot can block blood flow and consequently result in a heart attack or stroke.

According to the most recent data from the National Health and Nutrition Examination Survey, 6% of the US population 40 years or older has a low ABI (Ankle-brachial index) of ≤0.9, which indicates the presence of PAD. This translates into approximately 7,000,000 people in the US. ABI is a “simple test that compares the blood pressure in the upper and lower limbs.” By calculating the ratio between “the blood pressure in an artery of the ankle by the blood pressure in an artery of the arm,” medical professionals can determine a patient’s ABI.

The true number of PAD cases has historically been tough to establish. “Even though the American Heart Association estimates that approximately 8 to 12 million Americans have PAD,”  more than half of individuals with a low ABI are asymptomatic (show no symptoms) or express unusual or atypical symptoms.  Population screening methods are done by a wide range of professionals, but it is highly recommended that patients are tested by a doctor with endovascular training to ensure that they’re receiving the best and most accurate diagnosis possible.

PAD Risk Assessment and Symptoms

In addition to older age, major risk factors for PAD include diabetes, smoking, high blood pressure, high cholesterol levels, obesity, and physical inactivity. Currently, smoking and diabetes have shown the strongest association with PAD.  Some signs of disease are:

• Painful cramping in one or both of your hips, thighs or calf muscles after certain activities, such as walking or climbing stairs
• Leg numbness or weakness
• Coldness in your lower leg or foot, especially when compared with the other side
• Sores on your toes, feet or legs that won’t heal
• A change in the color of your legs
• Hair loss or slower hair growth on your feet and legs
• Slower growth of your toenails
• Shiny skin on your legs
• No pulse or a weak pulse in your legs or feet
• Erectile dysfunction in men

Even if you don’t have any of the above symptoms, you should see a doctor — specifically a peripheral vascular specialist — if you are:

• Over the age of 65
• Over the age of 50 and have a history of diabetes or smoking
• Under the age of 50, but have diabetes and other peripheral artery disease risk factors, such as obesity or high blood pressure

Screening Tests by Qualified Doctors

Resting ABI is the most commonly used measurement for the detection of PAD in clinical settings. However, variation in measurement protocols may lead to differences in the ABI values obtained.  This test can often be completed in 10-15 minutes and is best done by a physician with specific training in Peripheral Vascular Disease treatment.

The ankle-brachial index is calculated as the systolic blood pressure obtained at the ankle divided by the systolic blood pressure obtained at the brachial artery while the patient is lying down. A ratio of less than 1 (typically defined as <0.9) is considered abnormal. ABI is typically used to both “diagnose PAD and prevent its progression and [any future] complications.” Moreover, ABI often serves to help “identify people who have a high risk for coronary artery disease.”

PAD Treatment and Interventions

Due to the fact that PAD is a result of systemic atherosclerosis in the lower limbs, treatment of PAD is primarily targeted at (1) reducing morbidity and mortality from lower limb ischemia and (2) preventing cardiovascular disease due to systemic atherosclerosis.

But there is hope for mitigation and/or management of this disease. A patient has the best hope for preventing their condition from worsening if PAD is diagnosed early enough and a treatment plan is adhered to.

In mild cases, there are several ways that an individual can lower their risk of or even reverse PAD. The best remedy is to maintain a healthy lifestyle, which means:

• Quit smoking if you’re a smoker.
• If you have diabetes, keep your blood sugar under control (in normal range).
• Exercise regularly. Aim for 30 to 45 minutes 3-4 times a week after you’ve gotten your doctor’s OK.
• If you have varicose veins in your legs or feet, have them examined beyond their cosmetic considerations
• Lower your cholesterol and blood pressure levels, if applicable.
• Eat foods that are low in saturated fat.
• Maintain a healthy weight (for your age and gender)

In more serious cases of PAD, there are many advanced methods of minimally invasive procedures that, when performed, may reduce or eliminate the instance of PAD.  These cases are best performed by an interventional cardiologist who can give patients a total cardiovascular health solution and help to manage overall risk factors over time.

Dr. Beheshtian is an interventional cardiologist who has trained and performed on over a thousand PAD cases — ranging from mild to extremely complex.  In addition, she has also counseled an abundance of patients on ways to manage their lifestyle — with or without the aid of medication — in an effort to minimize the impacts of PAD on their health and daily life.

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