Peripheral Vascular Disease

The most common cause is atherosclerosis. Atherosclerosis means the hardening of the arteries and formation of plaques or clots in these vessels. This can be due to old age and high lipid levels/cholesterol levels or due to smoking.

Risk factors for atherosclerosis/PVD include:

• Advanced age
• Smoking/Tobacco chewing
• Diabetes
• High blood pressure
• Uncontrolled lipids/cholesterol
• Sedentary lifestyle
• Raised BMI/Obesity
• Males are more prone
• Women after menopause are at a greater risk

• PAD or PVD may be diagnosed incidentally during routine check for another cause, eg vessel wall calcification detected on Ultrasound or CT. Or it may be detected during a coronary angiogram. Such patients may be asymptomatic and may have no symptoms.
• If the PAD is severe, the patient may have pain while walking. The pain may be in the form of cramps, especially in the thigh. This is a classical symptom of PVD called “claudication”. The pain classically starts after walking a few steps and is relieved on rest.
• Sometimes the PVD may be so severe that the pain may even be present at rest. This is called “rest pain” and it is a sign of severe advanced PVD.
• While the above two conditions are life style limiting, in extreme cases, PVD may also pose an increase in morbidity and mortality. This happens when a patient with wound develops an ulcer, due to no blood flow, the wound does not heal. This typically presents as a non-healing wound in diabetics and is colloquially called “Diabetic Foot”. The condition is scientifically called “Critical Limb Ischemia (CLI)”.
• Sometimes, the blockage in the arteries can be fresh or happen suddenly, and the limb may suddenly turn cold, pale with extreme pain and often numbness or paralysis. This is a medical emergency called “Acute Limb Ischemia or ALI”. It often poses a risk of loss of limb and poses a risk to life due to complications including infection/sepsis etc. if not treated on time.

• A clinical examination is key. Screening tests for detection include a test called ABI - Ankle Brachial Index, where blood pressures in your arm and leg are compared.
• Confirmatory tests include a Colour Doppler - to confirm the diagnosis.
• For confirmation of the extent of blockage, the percentage and number of involved vessels an angiography is done. This can be either a CT angiography, MR Angiography or a conventional invasive angiography also called DSA or Digital Subtracted Angiography.
• Since PVD is a multi-system systemic problem, other vessels of your body may be blocked. 1/3rd patients may have blockages in the heart vessels. Therefore, an ECG and a 2D echo for heart function may be requested.
• A quick arterial assessment called arterial Screening may be suggested. This would include a Carotid Doppler (to look for blockages in your arteries supplying the brain) as well as an Aortic Screening (to look for any associated aortic aneurysms AAA or aortic blockages).

Asymptomatic PVD patients may not require any treatment. Blood thinners and a few medications may have to be added to make sure there is no disease progression. This would ideally include Ecosprin and sometimes a low dose anticoagulant like Rivaroxaban may be added.

Claudicants (pain in the legs or arms that occurs while walking or using the arms) may be treated in two ways. For lifestyle non limiting claudicants, conservative management may be tried with blood thinners and exercise programs.

For lifestyle limiting claudication, intervention may be suggested depending on the level of blockage. For short blockages stenting or drug coated balloon angioplasty may be advised. For more complex lesions and blockages, bypass surgery may be suggested. This varies from case to case and treatment is tailored depending on multiple clinical parameters.

Sometimes both surgery and stenting may be combined called “hybrid procedures.” For critical or acute limb ischemia, revascularization to improve the blood flow is essential. This generally involves angioplasty and/or stenting and sometimes combined with a bypass. This requires admission and is followed by a surgical clean up of the wound or ulcer and in extreme cases also require an amputation.

Angioplasty/Stenting for Peripheral Vascular Disease

• Just like the heart, stents can be placed in any blood vessel of your body by an interventional radiologist.
• To open the blockages of your lower limb, opening of the block with a balloon may be done - this is called angioplasty.
• A stent may then be placed to keep the blockage open.
• These stents are placed commonly in your iliac arteries (present in the pelvis) or in the femoral artery (in the thigh).
• Now drug coated stents and balloons (DES or DEB) are also available, which have better patency.
• For below knee small arteries, generally stents are not placed since they get blocked easily. Here, only balloon angioplasty is done to keep the vessel open.

Reduction of the risk factors for PVD is key

• Maintain a healthy lifestyle
• Keep diabetes under check
• Sugars to be controlled
• Quit tobacco
• Lipid profile under control
• Daily physical activity
• Weight reduction

For patients with PVD, you may require to continue your blood thinners life long. It is important for correct foot wear. Wear closed shoes at all time. Socks to be worn at home to prevent wound or hurt to the leg. Prevent extreme hot or cold temperature to the legs to prevent boils and blisters. Any wound to the leg may not heal due to poor blood supply and may end up turning black due to “gangrenous” changes. A dedicated Foot Care regime needs to be followed as a lifestyle modification.