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Peripheral Arterial Disease
Peripheral arterial disease (PAD) impacts nearly 5 million American’s with at least 1 in 5 of those having diabetes. The true number of PAD in people with diabetes is difficult to determine because many patients are asymptomatic, do not report their symptoms or their pain perception is dulled by neuropathy. Regardless of the actual number or reason(s) for lack of diagnosis PAD is a real problem for people with diabetes and can contribute to the rate of amputations among diabetics.
PAD is a disease in which plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of fat, cholesterol, calcium, fibrous tissue, and other substances in the blood.
When plaque builds up in the body's arteries, the condition is called atherosclerosis. Over time, plaque hardens and narrows the arteries. This limits the flow of blood to your organs and other parts of your body. PAD usually affects the arteries in the legs, but it also can affect the arteries that carry blood from your heart to your head, arms, kidneys, and stomach.
PAD increases your risk of coronary heart disease, heart attack and stroke which are also potential complications of diabetes. If you have coronary heart disease, you have a 1 in 3 chance of having blocked leg arteries.
Risk Factors for Peripheral Arterial Disease
Although the most common cause of peripheral arterial disease (PAD) is atherosclerosis other factors may contribute to development of the disease these include:
Smoking - Smoking is the main risk factor for PAD and your risk increases four fold if you smoke now OR smoked in the past. People who smoke and develop PAD generally exhibit symptoms 10 years earlier than people who don't smoke and develop PAD.
People who smoke and people who have diabetes are at highest risk for PAD complications, such as gangrene and possible amputations in the leg from decreased blood flow.
Quitting smoking slows the progress of PAD. Smoking even one or two cigarettes a day can interfere with PAD treatments.
High Cholesterol or family history of high cholesterol – High cholesterol causes all kinds of problems for people with diabetes and represents the “C” in the diabetes ABC’s. You should know your cholesterol levels and undergo treatment if they rise to abnormal levels. More on cholesterol
High blood pressure or family history of high blood pressure - About 1 in 3 adults in the United States has HBP. The condition usually has no symptoms so knowing your blood pressure numbers is important, even when you're feeling fine. If your blood pressure is normal, you can work to keep it that way. If your blood pressure is too high, treatment may help prevent damage to your body's organs. More on BP
High Glucose Levels – Undiagnosed or poorly controlled diabetes can result in high glucose levels which increases the risk for developing PAD.
Being African American - The disease is more common in African Americans than any other ethnic group.
Age - Plaque builds up in your arteries as you age. About 1 in every 20 Americans over the age of 50 has PAD. The risk continues to rise as you get older.
Many diseases and conditions can raise your risk of PAD, including:
• Diabetes. About 1 in 3 people older than 50 who has diabetes also has PAD
• Coronary heart disease (CHD) or a family history of it.
• Stroke or a family history of it.
Even if you don't have signs or symptoms, ask your doctor whether you should get checked for PAD if you're:
• Aged 70 or older
• Aged 50 or older and have a history of smoking or diabetes
• Younger than 50 and have diabetes and one or more risk factors for atherosclerosis
Although PAD is serious, it's treatable. If you have the disease, see your doctor regularly and treat the underlying atherosclerosis. PAD treatment may slow or stop disease progress and reduce the risk of complications. Treatments include lifestyle changes, medicines, and surgery or procedures.
What Are the Signs and Symptoms of Peripheral Arterial Disease?
Many people who have peripheral arterial disease (PAD) don't have any signs or symptoms. Others may have many signs and symptoms.
Some people who have PAD may experience symptoms when walking or climbing stairs. These symptoms may include pain, numbness, aching, or heaviness in the leg muscles. Symptoms also may include cramping in the affected leg(s) and in the buttocks, thighs, calves, and feet. Calf pain is the most common location.
The severity varies widely, from mild discomfort to debilitating pain. Severe intermittent claudication can make it hard for you to walk or do other types of physical activity. Symptoms may ease after resting but can also return quickly upon resumption of activity.
These symptoms are called intermittent claudication. During physical activity, your muscles need increased blood flow. If your blood vessels are narrowed or blocked, your muscles won't get enough blood, which may lead to the symptoms listed above. When resting, the muscles need less blood flow, so the symptoms will go away.
About 10% of people who have PAD suffer from claudication and is more likely in people who also have atherosclerosis in other arteries.
Other Signs and Symptoms
Other signs and symptoms of PAD include:
• Weak or absent pulses in the legs or feet
• Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all
• A pale or bluish color to the skin on your feet or legs
• A lower temperature in one leg compared to the other leg
• Poor nail growth on the toes
• Decreased hair growth or shiny skin on the legs
• Erectile dysfunction, especially among men who have diabetes
PAD is a special problem for people with diabetes. Blocked blood flow to your legs can cause pain and numbness. Diabetic neuropathy can mask some of the symptoms of PAD or make them worse. PAD can raise your risk of getting an infection in the affected limbs. If severe enough, blocked blood flow can cause tissue death and in very serious cases, this can lead to leg amputation.
How Is Peripheral Arterial Disease Diagnosed?
Peripheral arterial disease (PAD) is diagnosed based on your medical and family histories, a physical exam, and test results.
PAD often is diagnosed after symptoms are reported. A correct diagnosis is important because people who have PAD are at higher risk for coronary heart disease (CHD), heart attack and stroke.
That risk is even higher if you have diabetes. If you have PAD, your doctor should also check for signs of these diseases and conditions.
Primary care doctors may treat people who have mild PAD but for more serious or advanced cases a vascular specialist may be consulted. A vascular specialist is a doctor who focuses on treating blood vessel diseases and conditions.
Your doctor may ask:
• Whether you have any risk factors for PAD For example whether you smoke or have diabetes.
• About your symptoms, including any that occur when walking, exercising, sitting, standing, or climbing.
• About your diet.
• About any medicines you take, including prescription and over-the-counter medicines.
• Whether anyone in your family has a history of heart or vascular disease.
Physical Exam and Diagnostic Tests
Your doctor will conduct a physical exam looking for signs of PAD by checking the blood flow in your legs and/or feet to see whether you have weak or absent pulses.
Your doctor also may check the pulses in your leg arteries with a stethoscope checking for an abnormal whooshing sound called a bruit. A bruit may be a warning sign of a narrowed or blocked artery.
Your doctor may compare blood pressure between your limbs to see whether the pressure is lower in the affected limb. They will also check for poor wound healing or any changes in your hair, skin, or nails that may be signs of PAD.
A simple test called an ankle-brachial index (ABI) often is used to diagnose PAD The ABI compares blood pressure in your ankle to blood pressure in your arm. This test shows how well blood is flowing in your limbs. The test can show whether PAD is affecting your limbs, but it won't show which blood vessels are narrowed or blocked (additional tests will be required to determine which vessels are blocked).
The test takes about 10 to 15 minutes to measure both arms and both ankles. This test may be done yearly to measure the progression of the disease.
A Doppler ultrasound examines the blood flow in the major arteries and veins in the limbs. During this painless test, a handheld device is moved back and forth over the affected area. A computer converts sound waves into a picture of blood flow in the arteries and veins. The results show if blood vessels are blocked, which vessels are affected and the severity of the disease.
A treadmill test can measure the severity of symptoms and the level of activity that brings them on. You'll walk on a treadmill for this test which will show whether you have any problems during normal walking.
Your doctor may also schedule an ABI test before and after the treadmill test which will compare blood flow in your arms and legs before and after exercise.
Magnetic Resonance Angiogram
A magnetic resonance angiogram (MRA) uses magnetic and radio wave energy to take pictures of your blood vessels.
An MRA can show the exact location and severity of a blocked blood vessel. Unfortunately, if you have a pacemaker, man-made joint, stent, surgical clips, mechanical heart valve, or other metallic devices in your body, you might not be able to have an MRA. Ask your doctor whether an MRA is an option for you.
An arteriogram is another method of providing a "map" of the arteries. Doctors use this test to find the exact location of a blocked artery particularly if an MRA isn’t possible.
During this test a dye is injected through a needle or tube into one of your arteries. After the dye is injected, an x ray is taken. The x ray can show the location, type, and extent of the blockage in the artery.
A new method of arteriograms uses tiny ultrasound cameras that take pictures of the insides of the blood vessels. This method is called intravascular ultrasound.
How Is Peripheral Arterial Disease Treated?
Treatment for peripheral artery disease has three major goals. The first is to manage symptoms, such as leg pain, so that you can resume physical activities. The second is to stop the progression of atherosclerosis throughout your body to reduce your risk of heart attack and stroke. The final goal is to improve your quality of life.
Treatments for peripheral arterial disease (PAD) include lifestyle changes, medicines, and surgery or procedures.
Treatment often includes making long-lasting lifestyle changes, such as:
• Quit smoking. Talk with your doctor about programs and products that can help you quit smoking. Also, try to avoid secondhand smoke.
• Lower blood pressure. This lifestyle change can help you avoid the risk of stroke, heart attack, heart failure, and kidney disease.
• Lower high blood cholesterol. Lowering cholesterol can delay or even reverse the buildup of plaque in your arteries.
• Lower blood glucose levels if you have diabetes. You should request an A1C test to show how well you have controlled your blood sugar level over the past 3 months.
• Be physically active. Talk with your doctor about taking part in a supervised exercise program appropriate for your condition. This type of program has been shown to reduce PAD symptoms.
Success in treatment of PAD is often measured by how far you can walk without pain. Proper exercise helps condition your muscles to use oxygen more efficiently.
• Follow a healthy eating plan that's low in total fat and salt. Include fruits, vegetables, and whole grains as part of a heart healthy diet. [link to my plate]
• If you're overweight or obese, work with your doctor to create a reasonable weight-loss plan.
These same lifestyle changes are also the means by which you can prevent PAD thereby avoiding the potential complications of the disease.
Your doctor may prescribe medicines to:
• Treat unhealthy cholesterol levels and high blood pressure
• Prevent blood clots from forming due to low blood flow. A blood clot can completely block an already narrowed blood vessel and cause tissue death. Your doctor may prescribe daily aspirin therapy or another medication that helps prevent blood clots, such as clopidogrel (Plavix).
• Help ease leg pain that occurs when you walk or climb stairs. The drug cilostazol increases blood flow to the limbs both by preventing blood clots and by widening the blood vessels. It specifically helps treat symptoms of claudication, such as leg pain, for people who have peripheral artery disease.
• If you also have diabetes, it becomes even more important to control your glucose levels.
• Avoid certain cold medications. Over-the-counter cold remedies that contain pseudoephedrine such as Advil Cold & Sinus, Aleve Sinus & Headache, Claritin-D, Sudafed, Tylenol Cold, Zyrtec-D, etc. constrict your blood vessels and may increase your PAD symptoms.
Surgery or Procedures
Your doctor may recommend bypass grafting surgery if blood flow in your limb is blocked or nearly blocked. For this surgery, your doctor uses a blood vessel from another part of your body or a man-made tube to make a graft. The graft goes around the blocked part of the artery and allows blood to flow around the blockage.
This surgery doesn't cure PAD, but it may increase blood flow to the affected limb.
Angioplasty and Stenting
Your doctor may recommend angioplasty to restore blood flow through a narrowed or blocked artery.
During this procedure, a thin tube with a balloon at the tip is inserted into a blocked artery. The balloon is then inflated, to reopen the artery and flatten the blockage into the artery wall, while at the same time stretching the artery open to increase blood flow. A stent (a small mesh tube) may also be placed in the artery during angioplasty. A stent helps keep the artery open after angioplasty is done. Some stents are coated with medicine to help prevent blockages in the artery.
Atherectomy is a surgical procedure that removes plaque buildup from an artery. During the procedure, a tube is used to insert a small cutting device into the blocked artery. The device is used to shave or cut off plaque.
The bits of plaque are removed from the body through the tube or, if they are small enough, allowed to wash away in the bloodstream. A newer technique uses a special laser that dissolves the blockage.
If you have a blood clot blocking an artery, your doctor may inject a clot-dissolving drug into your artery at the point of the clot to break it up.
People with peripheral artery disease, particularly those with diabetes, are at risk of slow healing which can impact the lower legs and feet. Poor blood circulation can postpone or prevent proper healing and increases the risk of infection. Here’s a few Rules for Survival when it comes to caring for your your feet.
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