Peripheral artery disease
|Peripheral artery disease|
|Synonyms||Peripheral vascular disease (PVD), peripheral artery occlusive disease, peripheral obliterative arteriopathy|
|An arterial insufficiency ulcer in a person with severe peripheral artery disease|
|Symptoms||Leg pain when walking which resolves with rest, skin ulcers, bluish skin, cold skin|
|Causes||Atherosclerosis, artery spasm|
|Risk factors||Cigarette smoking, diabetes, high blood pressure, high blood cholesterol.|
|Diagnostic method||Ankle-brachial index < 0.90, duplex ultrasonography, angiography|
|Treatment||Stopping smoking, supervised exercise therapy, surgery|
|Medication||Statins, ACE inhibitors, cilostazol|
|Frequency||155 million (2015)|
Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular disease. Peripheral artery disease most commonly affects the legs, but other arteries may also be involved. The classic symptom is leg pain when walking which resolves with rest, known as intermittent claudication. Other symptoms include skin ulcers, bluish skin, cold skin, or abnormal nail and hair growth in the affected leg. Complications may include an infection or tissue death which may require amputation; coronary artery disease, or stroke. Up to 50% of people with PAD do not have symptoms.
The greatest risk factor for PAD is cigarette smoking. Other risk factors include diabetes, high blood pressure, kidney problems, and high blood cholesterol. The underlying mechanism is usually atherosclerosis. Other mechanisms include artery spasm, thrombosis, and vasculitis. PAD is typically diagnosed by finding an ankle-brachial index (ABI) less than 0.90, which is the systolic blood pressure at the ankle divided by the systolic blood pressure of the arm. Duplex ultrasonography and angiography may also be used. Angiography is more accurate and allows for treatment at the same time; however, it is associated with greater risks.
It is unclear if screening for disease is useful as it has not been properly studied. In those with intermittent claudication from PAD, stopping smoking and supervised exercise therapy improves outcomes. Medications, including statins, ACE inhibitors, and cilostazol also may help. Aspirin does not appear to help those with mild disease but is usually recommended in those with more significant disease. Anticoagulants such as warfarin are not typically of benefit. Procedures used to treat the disease include bypass grafting, angioplasty, and atherectomy.
In 2015, about 155 million people had PAD worldwide. In the developed world, it affects about 5.3% of 45- to 50-year-olds and 18.6% of 85- to 90-year-olds. In the developing world, it affects 4.6% of people between the ages of 45 and 50 and 15% of people between the ages of 85 and 90. PAD in the developed world is equally common among men and women, though in the developing world, women are more commonly affected. In 2015 PAD resulted in about 52,500 deaths, which is an increase from the 16,000 deaths in 1990.
Signs and symptoms
The signs and symptoms of peripheral artery disease are based on the part of the body that is affected. About 66% of patients affected by PAD either do not have symptoms or have atypical symptoms. The most common presenting symptom is intermittent claudication, which causes pain and severe cramping when walking or exercising. The pain is usually located in the calf muscles of the affected leg and relieved by rest. This occurs because during exercise the muscles of the leg need more oxygen and in an unaffected leg, the arteries would be able to increase the amount of blood and oxygen going to the exercised leg. However, when there is a narrowing, the artery is unable to meet the increased demand for oxygen by the muscles.
In individuals with severe PAD complications may arise, including critical limb ischemia and tissue death. Critical limb ischemia occurs when the obstruction to blood flow in the artery is compromised to the point where the blood is unable maintain oxygenation of tissue at rest. This can lead to is pain at rest, feeling of cold, or numbness in the affected foot and toes. Other complications of severe PAD include tissue loss, arterial insufficiency ulcers, and gangrene. Many of these severe complications are irreversible.
- Decreased or absent pulses
- Muscle atrophy or wasting
- Noticeable blueness of the affected limb
- Decreased temperature (coolness) in affected limb when compared to the other
- Thickened nails
- Smooth or shiny skin and hair loss
- Buerger's test can check for pallor when the affected limb is in an elevated position. The limb is then moved from elevated to sitting position and is checked for redness, which is called reactive hyperemia. Buerger's test is an assessment of arterial sufficiency, which is the ability of the artery is to supply oxygenated blood to the tissue that it goes to.
- Smoking – tobacco use in any form is the single most important modifiable cause of PAD internationally. Smokers have up to a 10-fold increase in relative risk for PAD in a dose-response relationship. Exposure to second-hand smoke from environmental exposure has also been shown to promote changes in blood vessel lining (endothelium), which is a precursor to atherosclerosis. Smokers are two to three times more likely to have lower extremity PAD than coronary artery disease. More than 80%-90% of patients with lower extremity peripheral arterial disease are current or former smokers. The risk of PAD increases with the number of cigarettes smoked per day and the number of years smoked.
- Diabetes mellitus causes between two and four times increased risk of PAD by causing endothelial and smooth-muscle cell dysfunction in peripheral arteries. The risk of developing lower extremity peripheral arterial disease is proportional to the severity and duration of diabetes.
- Dyslipidemia – a high level of low-density lipoprotein (LDL cholesterol) and a low level of high-density lipoprotein (HDL cholesterol) in the blood) - elevation of total cholesterol, LDL cholesterol, and triglyceride levels have been correlated with accelerated PAD. Correction of dyslipidemia by diet and/or medication is associated with a major reduction in rates of heart attack and stroke.
- Hypertension – elevated blood pressure is correlated with an increase in the risk of developing PAD, as well as in associated coronary and cerebrovascular events (heart attack and stroke). Hypertension increased the risk of intermittent claudication 2.5- to 4-fold in men and women, respectively.
- Risk of PAD increases in individuals who are over the age of 50, male (male to female ratio is 2:1), obese, with history of a heart attack, or stroke or with a family history of vascular disease.
- Other risk factors which are being studied include levels of various inflammatory mediators such as C-reactive protein, fibrinogen, hyperviscosity, and hypercoagulable state.
High risk populations
- All people who have leg symptoms with exertion (suggestive of claudication) or ischemic rest pain
- All people aged 65 years and over regardless of risk factor status
- All people between 50 and 69 and who have a cardiovascular risk factor (particularly diabetes or smoking)
- Age less than 50 years, with diabetes and one other atherosclerosis risk factor (smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)
- Individuals with an abnormal lower extremity pulse examination
- Those with known atherosclerotic coronary, carotid, or renal artery disease
- All people with a Framingham risk score of 10%-20%
- All people who have previously experienced chest pain
As previously mentioned, the most common cause of peripheral artery disease, especially in patients over 40 years old, is atherosclerosis. Atherosclerosis is a narrowing of the arteries caused by lipid or fat build up and calcium deposition in the wall of the affected arteries. The most commonly affected site occurs at arterial branch points, because there is an increase in turbulence and stress on the artery at these areas where the artery branches to supply distant structures. Disease of distant structures, including feet and toes, are usually caused by diabetes and seen in the elderly population.
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Upon suspicion of PAD, the first-line study is the ankle–brachial index (ABI), which is the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the upper arm. When the blood pressure readings in the ankle are lower than those in the arm, blockages in the arteries that provide blood from the heart to the ankle are suspected. An ABI range of 0.90 to 1.40 is considered normal. A person is diagnosed with PAD when the ABI is ≤ 0.90. ABI values of 0.91 to 0.99 are considered borderline and values >1.40 indicate noncompressible arteries. PAD is graded as mild to moderate if the ABI is between 0.41 and 0.90, and an ABI less than 0.40 is suggestive of severe PAD. These relative categories have prognostic value.
In people with suspected PAD with normal resting ABIs, exercise testing of ABI can be done. A baseline ABI is obtained prior to exercise. The patient is then asked to exercise (usually patients are made to walk on a treadmill at a constant speed) until claudication pain occurs (for a maximum of 5 minutes), after which the ankle pressure is again measured. A decrease in ABI of 15%-20% would be diagnostic of PAD.
Conditions which stiffen the vessel walls (such as calcifications that occur in the setting of long term diabetes) can produce false negatives, usually indicated by abnormally high ABIs (> 1.40). Such results and suspicions merit further investigation and higher-level studies.
If ABIs are abnormal, the next step is generally a lower limb Doppler ultrasound examination to look at the site and extent of atherosclerosis. Other imaging can be performed by angiography, where a catheter is inserted into the common femoral artery and selectively guided to the artery in question. While injecting a radio-dense contrast agent, an X-ray is taken. Any flow-limiting stenoses found in the X-ray can be identified and treated by atherectomy, angioplasty, or stenting. Contrast angiography is the most readily available and widely used imaging technique.Modern multislice computerized tomography scanners provide direct imaging of the arterial system as an alternative to angiography.
Magnetic resonance angiography (MRA) is a noninvasive diagnostic procedure that uses a combination of a large magnet, radio frequencies, and a computer to produce detailed images of blood vessels inside the body. The advantages of MRA include its safety and ability to provide high-resolution, three-dimensional imaging of the entire abdomen, pelvis and lower extremities in one sitting.
There are various ways to classify severity and define treatment of peripheral artery disease. The first classification system, The Fontaine stages, was introduced by René Fontaine in 1954 to define severity of chronic limb ischemia:
- Stage I: Asymptomatic, incomplete blood vessel obstruction
- Stage II: Mild claudication pain in limb
- Stage IIA: Claudication when walking a distance of greater than 200 meters
- Stage IIB: Claudication when walking a distance of less than 200 meters
- Stage III: Rest pain, mostly in the feet
- Stage IV: Necrosis and/or gangrene of the limb
A second classification by the Society for Vascular Surgery and International Society of Cardiovascular Surgery, introduced in 1986 and revised in 1997 (and known as the Rutherford classification after the lead author, Robert B. Rutherford), consists of four grades and seven categories:
- Grade 0, Category 0: Asymptomatic
- Grade I, Category 1: Mild claudication
- Grade I, Category 2: Moderate claudication
- Grade I, Category 3: Severe claudication
- Grade II, Category 4: Rest pain
- Grade III, Category 5: Minor tissue loss; ischemic ulceration not exceeding ulcer of the digits of the foot
- Grade IV, Category 6: Major tissue loss; severe ischemic ulcers or frank gangrene
The TASC (and TASC II) classification suggested PAD treatment by severity of disease seen on angiogram. More recently classifications, such as the Society for Vascular Surgery "Wound, Ischemia and Foot Infection" (WIFI) classification, take into account that ischemia and angiographic disease patterns are not the only determinants of amputation risk.
The necessity to screen individuals for peripheral artery disease is based on an individual's risk of complications. PAD is a known risk factor for abdominal aortic aneurysms (AAA) and for the presence of narrowed vessels in the heart (coronary arteries), the neck (carotid arteries), and the kidneys (renal arteries). However, there is no data on screening individuals with asymptomatic PAD for abdominal aortic aneurysms. In people with symptomatic PAD they should be screened by ultrasound for AAA.
Depending on the severity of the disease, these steps can be taken, according to these guidelines:
- Smoking cessation (cigarettes promote PAD and are a risk factor for cardiovascular disease)
- Management of diabetes
- Management of hypertension
- Management of high cholesterol, and medication with antiplatelet drugs, and medication with aspirin, clopidogrel, and statins reduce clot formation and cholesterol levels, respectively, can help with disease progression, and address the other cardiovascular risks that the affected person is likely to have.
- Regular exercise for those with claudication helps open up alternative small vessels (collateral flow) and the limitation in walking often improves. Treadmill exercise (35 to 50 minutes, three or four times per week) has been reviewed as another treatment with a number of positive outcomes, including reduction in cardiovascular events and improved quality of life. Supervised exercise programs increase pain-free walking time and the maximum walking distance in people with PAD.
Cilostazol can improve symptoms in some. Pentoxifylline is of unclear benefit. Cilostazol may improve walking distance for people who experience claudication due to peripheral artery disease, but no strong evidence suggests that it improves the quality of life, decreases mortality, or decreases the risk of cardiovascular events.
Treatment with other drugs or vitamins are unsupported by clinical evidence, "but trials evaluating the effect of folate and vitamin B12 on hyperhomocysteinemia, a putative vascular risk factor, are near completion".
After a trial of the best medical treatment outline above, if symptoms persist, patients may be referred to a vascular or endovascular surgeon. The benefit of revascularization is thought to correspond to the severity of ischemia and the presence of other risk factors for limb loss such as wound and infection severity.
- Angioplasty (or percutaneous transluminal angioplasty) can be done on solitary lesions in large arteries, such as the femoral artery, but may not have sustained benefits. Patency rates following angioplasty are highest for iliac arteries, and decrease with arteries towards the toes. Other criteria that affect outcome following revascularization are length of lesion and number of lesions. There does not appear to be long term advantages or sustained benefit to placing a stent following angioplasty in order to hold the narrowing of the superficial femoral artery open.
- Atherectomy, in which the plaque is scraped off of the inside of the vessel wall (albeit with no better results than angioplasty)
- Vascular bypass grafting can be performed to circumvent a diseased area of the arterial vasculature. The great saphenous vein is used as a conduit if available, although artificial (Gore-Tex or PTFE) material is often used for long grafts when adequate venous conduit is unavailable.
- When gangrene has set in, amputation is required to prevent infected tissues from causing sepsis, a life-threatening illness.
- Thrombolysis and thrombectomy are used in cases of arterial thrombosis or embolism.
An updated consensus guideline from the American College of Cardiology and American Heart Association for the diagnosis and treatment of lower extremity, renal, mesenteric, and abdominal aortic PAD was compiled in 2013, combining the 2005 and 2011 guidelines.
Individuals with PAD have an "exceptionally elevated risk for cardiovascular events and the majority will eventually die of a cardiac or cerebrovascular etiology"; prognosis is correlated with the severity of the PAD as measured by an ABI. Large-vessel PAD increases mortality from cardiovascular disease significantly. PAD carries a greater than "20% risk of a coronary event in 10 years".
The risk is low that an individual with claudication will develop severe ischemia and require amputation, but the risk of death from coronary events is three to four times higher than matched controls without claudication. Of patients with intermittent claudication, only "7% will undergo lower-extremity bypass surgery, 4% major amputations, and 16% worsening claudication", but stroke and heart attack events are elevated, and the "5-year mortality rate is estimated to be 30% (versus 10% in controls)".
The prevalence of PAD in the general population is 12–14%, affecting up to 20% of those over 70; 70%–80% of affected individuals are asymptomatic; only a minority ever require revascularisation or amputation. Peripheral artery disease affects one in three diabetics over the age of 50. In the USA, it affects 12–20 percent of Americans age 65 and older. Around 10 million Americans have PAD. Despite its prevalence and cardiovascular risk implications, only 25% of PAD patients are undergoing treatment.
The incidence of symptomatic PAD increases with age, from about 0.3% per year for men aged 40–55 years to about 1% per year for men aged over 75 years. The prevalence of PAD varies considerably depending on how PAD is defined, and the age of the population being studied. Diagnosis is critical, as people with PAD have a four- to five-fold higher risk of heart attack or stroke.
The Diabetes Control and Complications Trial, and the U.K. Prospective Diabetes Study trials, in people with type 1 and type 2 diabetes, respectively, demonstrated that glycemic control is more strongly associated with microvascular disease than macrovascular disease. Pathologic changes occurring in small vessels may be more sensitive to chronically elevated glucose levels than is atherosclerosis occurring in larger arteries.
Only one randomized controlled trial has been conducted comparing vascular bypass to angioplasty for the treatment of severe PAD. The trial found no difference in amputation-free survival between vascular bypass and angioplasty at the planned clinical endpoint, but the trial has been criticized as being underpowered, limiting endovascular options, and comparing inappropriate endpoints. As of 2017, two randomized clinical trials are being conducted to better understand the optimal revascularization technique for severe PAD and critical limb ischemia (CLI), the BEST-CLI (Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia) Trial, and the BASIL-2 (Bypass Versus Angioplasty in Severe Ischaemia of the Leg – 2 )Trial. 
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