According to John W. Hallett, Jr., MD, Clinical Professor, Division of Vascular Surgery, Medical University of South Carolina, in his post here, Peripheral artery occlusive disease is a blockage or narrowing of artery in the legs. It could affect arms due to fat plaque (atherosclerosis). The stenosis of peripheral artery resulting in decreased blood flow.
The symptoms are depend on which artery is blocked and how severe the blockage is, it might be partial or complete blockage. To diagnose peripheral artery occlusive disease, doctors usually measure blood flow to affected areas. The most common treatment for peripheral artery occlusive disease are medicine therapy, angioplasty, and surgery. All of those treatments are used to relieve the blockage and reduce symptoms of peripheral artery occlusive disease.
Peripheral artery occlusive disease is a common disease in older people. It is because they have plaque or disease build up in the wall of the blood vassel (atherosclerosis). This is such a common disease associated with aging.
What is peripheral artery occlusive disease?
“Peripheral artery occlusive disease? What is it? How is it develop?” might be some of common question for those who have it or diagnosed with peripheral artery occlusive disease. This is a common disease among men, people who ever smoked regularly, diabetes, people who have a family history of peripheral artery occlusive disease, including atherosclerosis, high blood pressure, high cholesterol levels, or high blood homocysteine levels, obese people, people who are physically inactive.
Those factors above could contribute development of peripheral artery occlusive disease, even they can worsen it.
Peripheral artery occlusive disease most commonly develops in legs artery, iliac artery, thighs artery (femoral artery), knee artery (popliteal artery, and calf artery (tibia and peroneal artery). In rare case, peripheral artery occlusive disease affects shoulder or arm artery.
In a very rare case, peripheral artery occlusive disease could develop in the part of the largest artery, aorta, that passes through the abdomen (abdominal aorta) or its branches.
Peripheral artery occlusive disease may result from gradual narrowing of an artery or sudden blockage of an artery.
The result of narrowing artery, the part of that body may not receive enough blood. Inadequate blood supply in part of the body leads to insufficient oxygen level in the body tissues. This condition is called ischemia. Ischemia may develop gradually or suddenly. Complete blockage is like a bad news for tissue, the tissue may die.
Gradual artery narrowing
Atherosclerosis is a main cause of gradual artery narrowing in peripheral artery occlusive disease. The cholesterol deposits and other fatty materials develop and stick in the artery wall. Atheromas may gradually narrow the inferior (lumen) of the artery and reduce blood flow. Plus, calcium may also accumulate in the artery wall, this condition make the artery stiff or not elastic.
Ina rare case, artery are gradually narrowed by an abnormal growth of artery wall muscle (fibromuscular dysplasia), inflammation, or pressure from outside the blood vessel by a nearby expanding mass, such as a tumor or fluid-filled sac (cyst).
Sudden blockage of an artery
Sudden blockage or complete blockage is a result of blood clot in blood vessels (thrombus). It is usually initiated with already narrowed artery. It is also as a result of embolus when a clot breaks off from other location of the body. It is usually from the bloodstream, and lodges in an artery downstream. Some conditions can increase the risk of blood clot formation. They include arterial fibrillation, other heart disorders, clotting disorders, and inflammation of blood vessels (vasculitis), which may be due to an autoimmune disorder.
Sometimes atheroma can rupture into the blood vessel and travel to other location. It can trigger the formation of a blood clot that suddenly blocks the artery blood flow. While a piece of fatty material breaks off from an atheroma and suddenly block smaller arteries. Sudden blockage may also result from an aortic dissection, in which the inner layer of the aorta tears, allowing blood to surge through the tear and separate the inner layer from the middle layer of the aorta. As the dissection enlarges, it can block one or more arteries connected to the aorta.
Sign and Symptoms
Symptoms of peripheral artery occlusive disease depend on:
- Which artery is affected
- How completely the artery is blocked
- Whether the artery is gradually narrowed or suddenly blocked
Inferior artery usually has been blocked before symptoms occur. Gradual narrowing of an artery may result in less severe symptoms than sudden blockage. The peripheral artery occlusive disease symptoms may be mild because gradual narrowing allows time for nearby blood vessels to expand or create a new blood vessel (collateral vessels). Thus, the affected tissue can still be supplied with blood well. It is different with complete blockage where there is no blood flow. If the artery is suddenly blocked, there is no time to develop collateral vessel. The symptoms at this condition are very severe.
Arteries of the legs and arms
If the affected artery is in legs and arms, sudden or complete blockage may cause very severe pain, stiffness, and numbness in the affected limb. During the assessment, the one’s leg or arm is either pale or bluish (cyanotic). There is no pulse or very weak pulse felt below the blockage. the sudden, drastic decrease in blood flow to the limb need medical attention immediately. The absence of blood flow can quickly result in loss of sensation in or paralysis of a limb. If blood flow is absent for too long, body tissue may die, and the worse, the limb may be amputated.
Intermittent claudication, the most common symptoms of peripheral arterial disease results from gradual narrowing of a leg artery. The symptoms are painful, aching, cramping, or tired feeling in the muscle of the leg – not in the joints. Intermittent claudication occurs regularly and predictably during physical activity but is always relieved promptly by rest. The muscles ache when a person walks, and the pain begins more more severe when the person run, the pain usually occurs in the calf, thigh, hip, or buttock, depending on the location of the blockage. In very rarely case, pain occurs in the foot.
If the narrowing artery is in long period of time, the pain is never decrease, even more severe and the leg may still in pain at rest. The location of leg aches are usually in the lower leg or front of the foot, it is more severe while the leg is elevated. The pain sometime interfere sleep. People with peripheral artery occlusive disease usually relieved the leg pain by hang leg. The pain often interferes with sleep. For relief, the person may hang the feet over the side of the bed or rest sitting up with the legs hanging down.
Peripheral Arterial Disease
Large blockages of the arm arteries may cause cramping, fatigue, or pain felt in the arm muscles. It worsens when the arm is used repeatedly.
Doctors are sometime difficult to diagnose peripheral artery occlusive disease if the blood supply is reduced mildly or moderately. When the blood supply to leg is severely reduced, the leg may be palpable cold. Doctors then need special equipment to detect pulses in the leg. Other symptoms in leg such as dry, scaly, shiny, or cracked leg indicate severe blockage. If you inspect the nail, and the leg hair, they show no grow.
Further narrowing artery resulting some serious condition like:
- Chronic leg sore
- Infection occur easily and become serious quickly
- Elongated wounds recovery
- Foot ulcers
- Leg muscle shrink (athrophy)
Someone could be worsening of claudication. For instance, leg pain that occurs after walking 1 kilometer then felt pain after walking 100 meter. The change of this pattern indicates that new clt has formed in leg artery. She or he should seek medical care immediately.
How to diagnose peripheral artery occlusive disease?
There are two ways to diagnose peripheral artery occlusive disease; those are physical examination and blood pressure or blood flow measurement.
The first thing to diagnose peripheral artery occlusive disease is anamnesis. It is based on the sign and symptoms, and the result of physical examination. Doctors usually assess the leg or arm skin color and temperature, including capillary refill time (CTR). To assess the CTR, the doctors measure the blood flow through pressing the suspected peripheral artery occlusive disease location gently to see how quickly color returns after the pressure is removed. These assessments help doctors determine whether circulation is adequate or not. Procedures that directly measure blood pressure or blood flow are also done.
Blood pressure measurement
There is no special procedure for peripheral artery occlusive disease to check the blood pressure. The blood pressure measurement is done using standard blood pressure cuff. The measurement of blood pressure should be done in both arms and both legs. If the blood pressure in one side of arm or leg is lower than the other side (<85%), it means that the blood flow is inadequate, and peripheral artery occlusive disease is diagnosed. If doctors suspect peripheral artery occlusive disease in an arm artery, they tend to measure systolic blood pressure in both arms. Higher pressure in one arm suggests a blockage in the arm with lower blood pressure, and peripheral artery occlusive disease is diagnosed in arm artery.
Another useful assessment for peripheral artery occlusive disease is pulse assessment. All of medical team often assesses pulse in certain location; armpits, elbows, wrists, groin, ankles, feet, and an area behind the knees. The artery pulse in peripheral artery occlusive disease may be weak or even absent. The pulse assessment is the most often assessment for peripheral artery occlusive disease. If doctors suspect a blockage leg artery blockage, they will check the pulse below a certain point in the leg. For inaccessible artery such as like renal artery which is inside the body and not palpable, procedures that provide images of blood flow are done. A stethoscope usually can listen abnormal sounds of the artery such as a turbulent blood flow through a narrowed artery. This turbulent sounds of the blood flow called bruits.
Tissue Oxygen Measurements
Transcutaneous oxygen tension testing measures of the oxygen level of the tissue beneath the skin. Because blood carries oxygen to the tissue, this is an indirect measurement of blood flow blockages. This test is unpainful; the test is done by placing sensors on the skin of the affected leg or arm and the upper chest. Electrodes in the sensors heat the area underneath the skin to temporarily widen the blood vessels so that the oxygen level can be easily measured by the sensor.
Doppler ultrasonography is one of the best imaging equipment that can directly measure blood flow and can confirm the diagnosis of peripheral artery occlusive disease. This diagnosis imaging can detect narrowing or blockage of blood vessels correctly. Doppler ultrasonography to measure blood flow also may be done during exercise stress testing, because some problems appear only during exercise.
Angiography. It is an invasive procedure in which a flexible plastic catheter is inserted into one of the large arteries in the upper thigh. This imaging diagnosis is done only when surgery or angioplasty (opening up a blockage by inflating a small balloon with the artery) is required. The purpose of this diagnosis is to provide doctors clear images of the affected arteries before surgery is done. Angiography is like a dye agent, a radiopaque contrast agent, which can be seen on x-rays, is injected into artery via the flexible plastic catheter. The result of angiography shows an outline of the inside of the artery when x-rays are done. It means that angiography shows precise diameter of the artery. This diagnosis procedure is much more accurate than Doppler ultrasonography.
CT angiography or Magnetic Resonance Angiography (MRA). Those are the most recent diagnosis for peripheral artery occlusive disease. This is such a favorite diagnosis for doctors because it does not need flexible catheter into a major artery. It just need a small amounts of a contrast agent that are injected into the bloodstream by vein using a standard intravenous catheter in the arm.
Other tests for diagnosing occlusive peripheral arterial disease
For those who have atherosclerosis, doctors usually perform some test such as blood tests to measure cholesterol, sugar, and homocysteine level, including blood pressure.
Blood test can also identify other causes of narrowed or blocked arteries, such as inflammation of blood vessels due to an autoimmune disorder. The blood test includes measuring the erythrocyte sedimentation rate (ESR), and level of C-reactive protein, which is produced only when inflammation is present.
Doctors also may be performed magnetic resonance imaging (MRI) diagnosis to rule out spinal stenosis, which can cause pain during physical activity. However, this pain, unlike intermittent claudication, is not relieved by rest.
How to prevent the development of peripheral artery occlusive disease is to modify or eliminate the risk factor of atherosclerosis. You may prevent it with these following measures:
- Stop smoking
- Control diabetes
- Lowering high blood pressure, high cholesterol levels, and high homocysteine level.
- Losing weight
- Engaging in regular physical activity
- Good control of diabetes helps delay or prevent the development of occlusive peripheral arterial disease and reduces the risk of other complications.
The purpose of peripheral artery occlusive disease treatment are:
- To prevent the disease from progressing
- To reduce the risk of heart attack, stroke, and death
- To prevent amputation
- To improve the quality of life by relieving symptoms (such as intermittent claudication)
peripheral artery occlusive disease treatment cause clots to dissolve (thrombolytic, or fibrinolytic), angioplasty, surgery, and other measures; exercise and foot care. All of those treatments are used depend on:
- Whether the blockage developed suddenly or gradually
- The severity of the symptoms
- The severity of the blockage
- The location of the blockage
- The risks related to the treatment (particularly for surgery)
- The person’s overall health
Beside the specific treatments above, patient with peripheral artery occlusive disease still need to treat disorder that are risk factors for atherosclerosis such as like high blood pressure, diabetes, smoking, and high cholesterol level.
Those treatments could improve the peripheral artery occlusive disease prognosis. Angioplasty and surgery are only mechanical measures for correcting the immediate problem. They do not control or reverse the process that caused the disease in the first place.
peripheral artery occlusive disease medicine such as pentoxyfylline or cilostazol may relieve claudication of blood vessels. Other medicine such as medicine for high blood pressure, diabetes, and high cholesterol may be prescribed. Other drugs may be given to dissolve clots or prevent new clots from forming. The most common medicine for peripheral artery occlusive disease are aspirin and clopidogrel which can decrease the risk of blood clot formation.
Angioplasty is a treatment that performed immediately after angiography. Angioplasty is like a first treatment before surgery. Sometimes it is used in combination with surgery. Angioplasty consists of inserting a catheter with a balloon at its tip into the narrowed part of the artery and then inflating the balloon to clear the blockage. doctors may insert a permanent wire mesh (a stent) into the artery. Nowadays, the stent contain medicines that are slowly released (drug-eluting stents) and it can prevent regrowth of the artery blockage. angioplasty is for outpatient procedure. It is rarely painful but it can be uncomfortable because the person has to lie still on a hard table. The patient is given sedative, but no general anesthetic.
The success of angioplasty varies, depending on the location of the artery blockage and the severity of peripheral artery occlusive disease. Doctors are often prescribed a medicine (aspirin or clopidogrel) to prevent clots formation in the arteries of the limb and to prevent a subsequent heart attack and stroke. Doppler ultrasonography is done regularly for patient to monitor blood flow through the artery and thus detect whether the artery is narrowing again.
If patient has many areas of artery blockage, angioplasty cannot be done well, also if the narrowed section is too long. After angioplasty, surgery may be needed if a blood clot fomrs in the narrowed are, if a piece of the clot breaks off and blocks an artery downstream, if blood seeps into the lining of the artery causing bulge inward that blocks blood flow (a disorder called dissection), or if severe bleeding occurs.
Other devices such as lasers, mechanical cutters, ultrasonic catheters, and rotational sander can be used instead of balloon catheter during angioplasty but none appear to be more effective.
A last treatment for peripheral artery occlusive disease called thromboendarterectomy can be performed when thrombolytic drugs are ineffective or too dangerous. Surgery to remove atheromas (endarectomy) may also be performed. Alternatively, bypass surgery may be performed.
Bypass surgery is a graft consisting of a tube made of synthetic material or part of vein from another part of the body. Those material and part of the vein is joined to the blocked artery above and below the blockage. Then blood is rerouted around the narrowed or blocked artery.
Another approach is to remove the narrowed or blocked section and insert a graft in its place. This is a serious surgery, the doctors usually assess the heart function and blood flow through the heart to determine the safety of surgery. It is because patient with peripheral artery occlusive disease may have coronary artery disease too.
Amputation should be avoided. Amputation of a limb may be necessary if part of a limb died or if there is no good way to restore blood flow to the area.
Arteries of the legs and arms
Angioplasty is a first treatment for peripheral artery occlusive disease in legs and arms arteries to widen a blood vessel, sometimes with a procedure to remove a blood clot, or surgery to bypass a blockage is performed as soon as possible to prevent irreversible loss of limb function or amputation in arteries that are suddenly and completely blocked.
Surgery to remove the blockage or bypass surgery may be done if other treatments do not relieve claudication. Surgery is usually done to avoid amputation of a leg when blood flow is greatly reduced—that is, when claudication is incapacitating or occurs during rest, when wounds do not heal, or when gangrene develops.
Intermittent claudication can be relieved by regular exercise. Exercise is the most effective treatment for peripheral artery occlusive disease. It may be appropriate for motivated people who can follow a prescribed daily exercise program. Till today, the understanding of how exercise relieves claudication is unknown. Probably exercise improve muscle function. There is no evidence that exercise improves blood flow or causes new blood vessels to grow (collateral). People with peripheral artery occlusive disease should walk at least 30 minutes a day, and 3 times a week.
This regular exercise could increase the distance they can walk comfortably. If you have discomfort feeling during walking, it is not dangerous. You just need to stop walking until the discomfort subsides and then walk again. The total walking time (excluding rest periods) must be at least 30 minutes to improve walking distance.
Regular exercise is effective when there is a supervision from trained therapist in rehabilitation program. But before undergo a regular exercise, doctors should perform exercise stress test before. It is important because you should know the adequacy of blood supply to heart muscle.
Medicine like pentoxifylline or cilostazol are to treat claudication. These medicines have a function, it can increase blood flow and supply the muscles with oxygen. Either medicine must be taken for 2 – 3 months to determine whether it is effective or not. But now usefulness of pentoxifylline is in doubt. Many experts no longer recommend its use. In contrast, cilostazol could increase the walking distance without pain. Cilostazol must not be taken by people with heart failure.
Ramipril (angiotensin-converting enzyme inhibitors) could help blood vessels dilate and improve blood flow.
Aspirin or clopidogrel is usually prescribed because this medicine help prevent clot formation and reduce the risk of heart attack and stroke. This medicine modifies platelets so that it does not adhere to blood vessel walls. Normally, platelets which circulate in the blood, gather and form a clot to stop minor or mayor bleeding when blood vessel in injured.
Amputation of the leg is required to remove infected tissue, relieve unrelenting pain, or stop worsening gangrene. Surgeons remove as little of the leg as possible. Preserving the knee is particularly important if the person plans to wear an artificial leg. Physical rehabilitation after leg amputation is important.
The injection of stem cells into the legs of people peripheral artery occlusive disease is currently being studied. Stem cells may be alternative treatment, it can stimulate the growth of new blood vessels, thereby reducing the need for amputation.
Foot care is important for peripheral artery occlusive disease in leg or arm. It helps prevent wound or foot ulcer (gangrene). Good foot care is as important as curing, it can prevent amputation. Gangrene need meticulous care. Foot care is needed to treat infection, to protect the skin from damage, and to enable the patient to continue to walk.
Foot care should be done to keep the foot clean. Foot should be washed daily with a mild soap or antibacterial solution and covered daily with clean and dry dressings. The foot should be below the heart, it help improve blood flow into leg. People with diabetes must control blood sugar level. You must check the foot ulcer to doctor if there is no healing after 7 days. Often, doctors prescribe an antibiotic ointment.
If foot ulcers are not healing, you may need complete bed rest. Bed rest requires bandages with heel pads to prevent bedsores (pressure ulcer) from developing on the feet. The head of bed should be raised about 15-20 cm and let legs below heart level. It helps blood flow through the leg arteries because of gravity. If the ulcer is infected, doctors will prescribe antibiotic to be taken, and you may need to be hospitalized.
How to Prevent Foot Ulcer in Peripheral Artery Occlusive Disease
Foot care is essential for people with peripheral arterial disease of the leg arteries. The following self-care measures and precautions can help:
- Inspect the feet daily for cracks, sores, corns, and calluses.
- Wash the feet daily in lukewarm water with mild soap, and dry them gently and thoroughly.
- Use a lubricant, such as lanolin, for dry skin.
- Use unmedicated powder to keep the feet dry.
- Cut toenails straight across and not too short. (A podiatrist may have to cut the nails. Tell the podiatrist that peripheral arterial disease is present.)
- Have a podiatrist treat corns or calluses.
- Do not use adhesive or harsh chemicals to remove corns or calluses.
- Change socks or stockings daily and shoes often.
- Wear loose wool socks to keep the feet warm.
- Do not wear tight garters or stockings with tight elastic tops.
- Wear shoes that fit well and have wide toe spaces.
- Do not wear open shoes or walk barefoot.
- Ask the podiatrist about a prescription for special shoes if the feet are deformed.
- Do not use hot water bottles or heating pads.
- Do not soak feet in hot water or chemical solutions.
- Avoid cold weather, which can cause blood vessels to narrow (constriction).
- Avoid medicine that cause blood vessels to narrow. These medicine are like ephedrine, pseudoephedrine, and phenylephrine, which are components of some sinus congestion and cold remedies.
Bypass Surgery in the Leg
Bypass surgery may be performed to treat peripheral artery occlusive disease. Bypass surgery in leg, the blood is rerouted around the affected artery. This procedure is like making another way of artery to reach the certain tissues. A graft consisting of a tube made of synthetic material or part of a vein from another part of the body is joined to blocked artery above and below the blockage.