Peripheral artery disease

Peripheral artery disease (PAD) is also sometimes referred to as peripheral vascular disease (PVD) is a common disease of the circulation where the arteries to the legs are narrowed or completely blocked. This is a result of atherosclerosis. Plaque, a fatty deposit, can build up in the blood vessels and this build up causes the narrowing and when severe enough it can completely plug the artery. This decreases the amount of blood flow lower down the leg and can result in symptoms. Because of collateral blood flow which improves with time, there is still blood flow getting beyond the blocked areas which is what keeps the leg alive even though the main channels are plugged. In some cases this collateral blood flow can be strong enough to where there are no or minimal symptoms. When symptoms do develop they fall into a few categories: claudication, rest pain, and tissue loss.

Sketch of a blockage in a blood vessel

Claudication is cramping or discomfort that develops in the leg with walking. With rest the symptoms will improve. Rest pain is pain that is typically in the foot. The classic description is that it develops when laying down flat at night. It can come on after a few hours and wake you up from sleep. It then gets better with standing up. It is fairly common to hear that someone has started sleeping in a recliner because of it. Rest pain can also get to the point where it just hurts all the time, however. Tissue loss relates to sores or ulcerations that develop on the feet or fail to heal because of poor circulation. Infection can also develop.

Rest pain and tissue loss are grouped together into a category called chronic limb threatening ischemia (CLTI). This is also sometimes called critical limb ischemia. This refers to the fact that these symptoms represent more advanced disease and there is a risk of amputation if the symptoms are ignored and better blood flow is not obtained. Patients with CLTI will usually need a procedure to restore blood flow. This can either be traditional surgery or a catheter based procedure to open the affected vessels in a minimally invasive fashion.

Claudication represents less advanced disease. In general, patients with claudication have a very low risk of progressing to where they are at risk of amputation. Because of this, the treatment for claudication is based on how bad the symptoms are and we start with conservative measures. Conservative measures include quitting tobacco products, daily walking for exercise, and sometimes medications that can help with the symptoms. If conservative measures fail to improve the symptoms and the symptoms are severe enough to cause a significant impact on quality of life, an intervention can be considered. The interventions to improve blood flow in claudication are the same as those used for CLTI.

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