About 8 million Americans have peripheral artery disease. Many of them mistake its symptoms for something else. Sometimes there are no symptoms at all. Its prevalence increases with age. Blacks are disproportionately affected, according to the American Heart Association.
Peripheral artery disease, or PAD, is the most common form of peripheral vascular disease, or disease of blood vessels outside the heart. It often affects vessels transporting blood to and from the legs, arms, feet, stomach or kidneys.
The condition results from fatty deposits building up in the inner lining of artery walls. These deposits restrict blood flow to the legs, arms, feet, stomach and kidneys. The condition can cause gangrene and lead to limb amputations.
People with peripheral artery disease often have fatty deposits in heart and brain arteries as well. It is associated with an increased risk of stroke and heart attack. This is because the narrowed arteries can be more easily blocked by a blood clot.
Despite the disease's prevalence and the substantial cardiovascular risk associated with it, public awareness of the disease is alarmingly low. A 2002 study published in the Journal of Vascular and Interventional Radiology estimated that PAD affects 12 to 20 percent of Americans over the age of 65 and that only 25 percent of those afflicted with PAD are undergoing treatment.
Symptoms include pain or fatigue in leg or hip muscles while walking or climbing stairs. Pain is relieved by rest and returns with effort. Physicians refer to this as "intermittent claudication." Claudication comes from a Latin word meaning "to limp."
The pain is caused by an inadequate supply of oxygen to the leg muscles, which in turn is caused by the narrowing of the arteries supplying the leg with blood. During exertion involving the legs, muscles of the calf and thigh increase their demand for oxygen and the circulatory system attempts to increase the flow of blood to the area. Narrowed arteries mean only a portion of the demand can be met, resulting in a temporary shortage of oxygen. When exertion ceases, the pain fades as the circulatory system is once again able to keep pace with demand and oxygen is replenished.
"The one important thing to remember is sometimes there are no symptoms at all," said Joyce Malaskovitz, director of the leg circulation center and diabetes treatment center at Desert Springs Hospital Medical Center.
"Approximately 60 percent of the people who come to us for screening don't have symptoms, and those that do, 90 percent are atypical," she said.
LIFESTYLE CHANGES
Medication and lifestyle changes can improve symptoms or at least keep them from getting worse. Health care professionals agree that the most important lifestyle change is to quit smoking. Smokers are two to 25 times more likely to develop PAD and experience symptoms 10 years earlier than nonsmokers.
"That is the No. 1 worst thing," Malaskovitz said. "We've had patients that quit (smoking) with intervention through our program."
Exercise is essential.
"Our town has a lot of walking clubs in place," Malaskovitz said. "Or join a weight loss support group."
Drugs like cilostazol (marketed as Pletal) and pentoxifilline (sold under the name Trentol) can help improve walking distance. Antiplatelet agents keep platelets from sticking together and reduce the risk of blood clots. Statins, or cholesterol-lowering agents, help keep the fatty buildups from forming.
Dr. Carlos Fonte, a cardiologist at Advanced Cardiovascular Specialists, says patients with some form of peripheral vascular disease make up 35 percent of his practice, and says people over the age of 60 have about a 70 percent chance of having some form of peripheral vascular disease.
Fonte advises patients to be aware of the risk factors for PAD, which include smoking, obesity, diabetes, physical inactivity, high blood cholesterol and high blood pressure. People over the age of 60 or who have any of these risk factors should be screened for PAD.
"The most important things are smoking cessation and a walking program," Fonte said. "And they have to walk through the pain. When they keep walking, they build up the collateral arteries in the legs."
Fonte urges diabetic patients to practice diligent foot care. Examine the feet every day and wash the feet daily with warm soapy water. In addition, to keep PAD from getting worse or leading to other complications, diabetics must keep blood sugar, cholesterol and blood pressure under control.
"The same things we do for the heart," Fonte said.
DRUGS AND OTHER TREATMENTS
Fonte said Pletal is associated with an increase in six-minute walking distance, which is an important benchmark of cardiovascular health, but added that Pletal may not be appropriate for patients with congestive heart failure.
Trentol works by making red blood cells more slippery, and has been helpful in increasing walking distance also. It has the advantage of being less expensive than Pletal and is often covered by formularies.
Plavix, often prescribed for heart attack and stroke patients, can also be beneficial for patients with PAD. Like Trentol, it also works by keeping platelets, or small red blood cells, from sticking together and forming clots that could decrease blood flow.
Another drug Fonte recommends for patients with PAD is good old aspirin. "It's the gold standard," he said.
When medication and lifestyle changes aren't enough, surgery may be necessary. There are a number of options. An expandable metal or plastic tube called a stent can be inserted to hold an artery open, or procedures like angioplasty or atherectomy can be performed.
Angioplasty is done using a special catheter that has an inflatable balloon at one end, which is inflated to compress the fatty material against the artery wall. This procedure is commonly done on coronary arteries, but can sometimes be beneficial for PAD patients.
An atherectomy removes arterial plaque by shaving it off from inside the artery with a special wire-based tool. Fonte compares it to a Roto-Rooter -- a rotating shaver at the end of a catheter, inserted through a small incision and maneuvered to the blockage site.
"Everything I do is under a local anesthetic with the patient awake," Fonte said.
A study conducted from July 2005 to January 2008 by Desert Springs of 1,002 patients screened for PAD found that 63.5 percent had no PAD and 36.5 needed early intervention. Of those studied, 40 percent were male and 57 percent were female. Most patients were over age 50 and the largest segment ranged in age from 61 to 70.
Although diabetes is a reason to test for PAD, only 48 percent of those studied had diabetes or prediabetes while 52 percent did not.
"We had a patient who came to our leg circulation who was going to have back surgery (for his pain)," Malaskovitz said.
A screening at Desert Springs indicated he suffered from PAD, which turned out to be the source of his back pain. He required intervention surgery but did not need the more painful and intrusive back surgery.
Free PAD screening is available through Desert Springs. Call 369-7979 to schedule an appointment.
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