Peripheral Arterial Disease

Do your legs hurt when you walk? You could have PAD.

PAD is narrowing of the arteries in the body that can lead to inadequate blood flow to the tissues "downstream." Many people do not experience the symptoms of peripheral arterial disease. However, if you experience symptoms, you should take action. If you have one or more of the following signs, notify your physician immediately.

§ Dull pain in the buttocks, thighs, calves, or feet following exercise or walking

§ Numbness or tingling in the leg, foot, or toes

§ Changes in skin color (paleness or a bluish color) in the leg, foot, or toes

§ Foot or toe pain at rest that often disturbs your sleep.

§ Skin wounds or ulcers on the foot or toes that heal slowly

"For the first time, we are seeing an increasing number of younger patients, mostly women in their 40s and 50s, being diagnosed with PAD." --Merrill R. Krolick, DO

"More than 40 percent of the patients seen at HAVI have some element of PAD." --Patrick A. Cambier, MD

Peripheral arterial disease - Detecting and treating restricted blood flow in patients

Peripheral arterial disease (PAD) is a common circulatory problem in which narrowed arteries reduce the blood flow to your limbs. It is often related to a number of other factors including obesity, smoking, high blood pressure, high cholesterol, inactivity and diabetes.

PAD often goes unrecognized and untreated and the consequences can be devastating. The disease can respond well to early detection and treatment. Unfortunately, many patients are not aware of the presence of the disease.

The pain associated with PAD is in the muscles, not the joints as with arthritis. The pain usually goes away shortly after you stop exercising. Individuals with undiagnosed PAD can have a significantly reduced quality of life due to their restricted mobility. Too many people ignore their pain thinking it is just a sign of getting older.

Prevalence and profile

PAD affects people of all ages. More than eight million people in the United States have PAD. The prevalence of the disease increases with age. Besides those over 50, individuals at highest risk are smokers, diabetics, and those who are overweight, do not exercise, or have high blood pressure and high cholesterol. The combination of established PAD and diabetes seems to confer a worse prognosis. PAD can be stealthy – aches and pains associated with PAD can often be perceived as a sign of aging. Therefore, it often goes undiagnosed.

"More than 40 percent of the patients seen at HAVI have some element of PAD," says Patrick A. Cambier, MD, a HAVI cardiologist. "Our staff is one of the most experienced in the Tampa Bay area at treating this grossly under diagnosed problem."

Merrill R. Kolick, DO agrees that PAD is under diagnosed and reports a rising trend in its prevalence. "For the first time, we are seeing an increasing number of younger patients, many women in their 40s, and 50s, being diagnosed with PAD," he says. "Most of these women are smokers, have high cholesterol, and are overweight. This new trend of young women with PAD is most likely due to a combination of lifestyle changes and the increasing prevalence of obesity in the U.S."

Diagnostic testing for PAD

We promote the early diagnosis of peripheral arterial disease by offering several painless, noninvasive, precise diagnostic tests.

Ankle-brachial index (ABI): The ABI is one of the easiest and most reliable tests for the diagnosis of peripheral arterial disease. This painless exam measures blood pressure at the ankle and in the arm, first while a person is at rest and again while walking on a treadmill. This test uses a regular blood pressure cuff and a special Doppler ultrasound stethoscope. By comparing the blood pressure in your ankle and in your arm, we can get a good idea of the level of blood flow to your legs. (The American Diabetes Association recommends ABI screening in everyone with diabetes over age 50.)

Based on the results of the ABI, as well as symptoms and risk factors for PAD, the cardiologist can decide if additional testing is needed. These tests might include imaging diagnostic procedures such as magnetic resonance angiography (MRA), angiography, ultrasound, or contrast-enhanced MRA.

Ultrasound Doppler test: This noninvasive test uses sound waves to determine blood flow in the legs. With this test, we can diagnose if a specific artery has plaque buildup or blockage in a very precise fashion.

The incidence of PAD is increasing along with the aging of the population and expanding number people with obesity. As Dr. Krolick notes, "Cardiologists will be working overtime caring for patients with PAD well into the future. It is just as clear that PAD will impose a personal health challenge for a growing share of the population."

Treatment options for PAD

If the symptoms are mild, your doctor may only recommend periodic check-ups. However, if the symptoms are more severe, treatment may be required. Several options follow.

Risk factor modification: Your doctor may recommend changes in your lifestyle to treat your PAD, including decreasing the amounts of fat and cholesterol in your diet, exercising regularly, and, most importantly, smoking cessation. People with diabetes should strictly control their blood glucose (blood sugar) levels. When combined, these measures can help retard or reverse plaque buildup, relieve symptoms, and improve quality of life.

Medical management: Your physician may also prescribe specific medicines to improve the blood flow in your arteries or to lower the cholesterol in your blood. Simple dedication to a daily walking program can make a big difference. Your doctor can advise you of a plan. Additionally, recent clinical trials using lipid-lowering drugs show promise for improving symptoms and reducing PAD-induced vascular events such as heart attacks or strokes.

Angioplasty: Before your doctor can make a final diagnosis, you may be asked to undergo an angiogram. This test uses a special dye injected into the arteries to take X-rays, which show any narrowed or blocked arteries. During angioplasty, the physician threads a balloon-tipped catheter (a thin, plastic tube) to the site of a narrow or blocked artery and then inflates a small balloon to open the vessel. Stenting, often performed at the same time as an angioplasty, places a small mesh tube called a stent in the newly opened artery. This may be necessary with the angioplasty procedure. The stent is a permanent device left in the artery to help it heal and remain open after the angioplasty.

Atherectomy: This is a newer, less common procedure that removes plaque from arteries. The laser sends bursts of ultraviolet light through a catheter to clear away blockages in arteries that are cutting off circulation to the limbs. Balloon angioplasty or stenting may be used after atherectomy.

Dr. Krolick has performed more than 200 of these laser procedures at HAVI. He reports that most vessels remain open after two years, assuming risk factor modification and regular use of medications that helps keep blood platelets from sticking together and forming clots. "I have found lasers work very well in the lower extremity vessels, and in some cases, it can be an alternative to more invasive surgery," he says.

What you need to know

Symptoms of PAD are often confused with the signs of degenerative aging or arthritis. This disorder can also lead to the loss of sensation in the lower part of the extremity. If you discover symptoms suggestive of PAD, or you if you feel that you are at risk, consult your doctor. Early treatment in many cases can prevent the disease from progressing further. Aggressive treatment of risk factors may actually result in regression of symptoms and plaque buildup.

The physicians at Heart & Vascular Institute of Florida believe dialogue with you, the patient, remains the best approach to a healthy quality of life.

Patrick A. Cambier MD, FACC, FSCAI, graduated from Hahnemann University School of Medicine in Philadelphia. After taking a commission in the U.S. Army Medical Corps, he completed residency in internal medicine, cardiology, and peripheral vascular diseases at Walter Reed Army Medical Center, Washington, D.C., and was on the clinical faculty of the Uniformed Health Services University in Bethesda, Maryland. Dr. Cambier received certification in interventional cardiology at Madigan Army Medical Center, Tacoma, Washington, and was associate faculty at the University of Washington. He assumed the directorship of the cardiac catheterization laboratory for the cardiology training program and received the Surgeon General's National Physician Recognition Award before completing his military obligation. Dr. Cambier joined the Heart and Vascular Institute of Florida in 1996. He has held a seat on the Morton Plant Mease (MPM) Board of Directors. Presently Dr. Cambier managing partner and is the chairman of the Baycare Health System cardiology technology task force and the MPM Physician Advisory Council. He is active in clinical research, has been involved as a principal investigator in more than 40 trials, and presented research at American College of Cardiology, American Heart Association, and Transcatheter Coronary Therapeutics meetings. Dr. Cambier is board certified in Internal Medicine, Cardiology, and Interventional Cardiology.

Merrill A. Krolick, DO, FACC, FACP, brings more than 18 years of experience. After graduating cum laude from Rensselaer Polytechnic Institute in Troy, New York, Dr. Krolick earned his DO from New York College of Osteopathic Medicine in Old Westbury, New York. After his cardiology fellowship at the University of South Florida in Tampa, he became an attending physician in cardiology at Fairfax Hospital in Fairfax, Virginia. He now is affiliated with Largo Medical Center, Largo Indian Rocks Hospital, Morton Plant Hospital in Clearwater, and Mease Dunedin and Countryside Hospitals.