Peripheral vascular disease

How common is PVD
What are the symptoms of PVD
Who is at risk for PVD
How is PVD diagnosed
How can PVD be treated
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Peripheral vascular disease, or PVD, is the narrowing or blockage of arteries that carry blood throughout the body. The most common cause of PVD is atherosclerosis (often called hardening of the arteries). Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called "plaque" that narrows the blood vessels. Eventually, if an artery becomes very narrow, clot can form within it and prevent any blood from flowing beyond the blockage.

Arteries anywhere in the body can be involved with this process, and the symptoms may range from high blood pressure or abdominal pain to difficulty with walking. In this discussion, we will focus on the arteries of the legs, and the problems associated with blockage of these arteries. Decreased circulation to the legs can be caused by narrowing of arteries anywhere from the region of the navel (belly button) to the ankles. Mild to moderate disease is usually well tolerated, and may even be unnoticed. More advanced disease leads to difficulty with walking and may threaten the entire limb.

How common is PVD?

PVD affects about 1 in 20 people over the age of 50, or 10 million people in the United States. More than half the people with PVD experience leg pain, numbness or other symptoms — but many people dismiss these signs as "a normal part of aging" and don't seek medical help. Only about half of those with symptoms have been diagnosed with PVD and are seeing a doctor for treatment.

What are the symptoms of PVD?

The most common symptom of PVD is a cramping pain in the calf, thigh, hip, or buttock that comes on with walking. This symptom, also known as "intermittent claudication", occurs because there is not enough blood flowing to the leg muscles during exercise. The pain typically goes away after several minutes of resting, but returns predictably after exercise is resumed. Some people describe this as a heaviness, weakness or tingling in their legs. These symptoms may be present for quite some time before a diagnosis is made. If the pain is occurring near the hip, it is frequently mistaken for arthritis.

The blood flow to the leg can become so restricted that pain develops at rest. This type of pain typically occurs in the foot or toes with elevation and is referred to as “ischemic rest pain”. People with this severe degree of disease have difficulty sleeping through the night because of this pain. Often, they get relief by hanging the foot from the bed, or by walking around. The pain is usually described as a burning sensation, and some people are intolerant of having the bedclothes lying on their foot. When sitting or standing, the foot may be very red in color, and then turn pale with elevation. These types of symptoms signify very advanced compromise in circulation, and require medical attention. Left untreated, this may progress to gangrene and amputation. In some cases, sores may develop on the toes or heel of the foot, which will not heal because of the poor blood flow.

Who is at risk for PVD?

Peripheral vascular disease is very common among older adults. While this process can develop in anyone, some of the more common risk factors include smoking, diabetes, obesity, high blood pressure or cholesterol, and a family history of heart disease. While slightly more common in men, this occurs in many women as well.

How is PVD diagnosed?

The presence and severity of PVD can usually be accurately assessed with non-invasive vascular studies. These are simple, painless exams designed to compare the blood pressure in your legs with your arms. By taking measurements in the thigh, calf and ankle, the location and severity of blockage can be determined.
An ankle-brachial index (ABI) is derived by comparing the ankle pressure to the arm pressure. In the normal setting, these pressures should be about equal (ABI = 1). As the blockages progress, the ABI decreases. ABIs in the 0.7 to 0.8 range are usually well tolerated, and result in leg pain only with strenuous activity. Once ischemic rest pain develops, the ABI is typically less than 0.4.

Based on the results of your ABI, with comparisons to your symptoms and risk factors for PVD, your care provider can decide if further tests are needed. Before any intervention to improve the circulation to the leg can be planned, some sort of direct picture of the blood vessels will be obtained. This can be accomplished by a computed tomography (CT) angiography or catheter based angiography.

How can PVD be treated?

Treatment of PVD has three aims, some of which overlap. The first important aim is to treat the systemic disease of atherosclerosis, which involves all of the arteries in the body, including those of the heart (coronary artery disease). People with PVD are at increased risk of developing ischemic heart disease (heart attack). Treatment for this purpose consists of lifestyle modifications and medication. Quitting cigarette smoking, maintaining a healthy diet and increasing activity levels are important first steps. Medications designed to inhibit platelets (aspirin) and control cholesterol are frequently recommended. Other medications to control high blood pressure and diabetes are sometimes necessary and need to be carefully monitored.

The next aim in treating PVD is to increase the ability to walk. Smoking cessation alone usually increases pain free walking distance. Exercise programs have also been effective. There are medications that can improve the walking distance as well, and these may be recommended by your doctor in certain instances. In the most severe cases, or in otherwise young healthy individuals, your doctor may recommend repair or bypass of blocked arteries to improve the circulation and increase exercise tolerance.

The final aim in the treatment of PVD is to increase the circulation to the extremity by either addressing the blockages directly or by performing bypass procedures around the blockage. These types of treatment are generally reserved for those with more severe degrees of blockage, or for otherwise healthy patients who are very limited by their circulation. Two general options are available to increase the circulation of the leg. The first approach is called endovascular or percutaneous therapy. This is a minimally invasive procedure where catheters and other devices are used to treat the blockages directly without the need for open operation. These types of procedures can frequently be done as an outpatient, or with an overnight stay. When feasible, this approach is well tolerated and can provide durable relief of symptoms.

Not all patients can be treated with endovascular therapy. In those individuals, open surgical approaches to remove or bypass the blockages in the arteries are necessary. These are major surgical procedures, and are usually only performed when the disease is advanced and there are no other alternative to save the limb. These types of procedures are generally very successful however, and long term durability is quite good.

Treatments for PVD are chosen carefully for the individual patient. In those with minimal symptoms, lifestyle modification and medication are typically all that is required. You should be sure to discuss all options with your doctor and understand why a particular course of action has been planned for your situation.