While Peripheral Vascular Disease (PVD) can affect the arteries, the veins or the lymph vessels, the most common and important type of PVD is Peripheral Arterial Disease or (PAD) which affects about 8 million Americans. It becomes more common as one gets older and by age 65, about 12 to 20% of the population has it. Diagnosis is critical, as people with PAD have a four to five time’s higher risk of heart attack or stroke.
Claudication is a term derived from the Latin word meaning “to limp”. Intermittent claudication (vascular claudication) describes the pain that develops in the muscles of the legs when exercising, such as walking. Commonly, the calf muscles are the most affected, and patients described a cramping discomfort, as characteristic of the pain. Initially patients may be able to walk through the pain, but as the disease progresses further, this is not possible and the claudication pain causes limping and can only be relieved by resting. Most patients find that their claudication symptoms are worse on walking uphill. They can also be worse when walking barefoot or wearing flat shoes. Any situation in which the muscles of the legs have to work harder will worsen claudication symptoms.
Pain develops because there is a narrowing or blockage in the main artery taking blood to the leg due to hardening of the arteries (atherosclerosis). Over the years cholesterol and calcium build up inside the arteries. This occurs much earlier in people who smoke and those who have diabetes or high levels of cholesterol in the blood.
The blockage in the arteries means that the blood flow is reduced. At rest there is enough oxygen in the blood reaching the muscles to prevent any symptoms. When walking the calf muscles need more oxygen, but because the blood flow is restricted the muscles cannot obtain enough oxygen from the blood and cramping occurs.
Critical Limb Ischemia (CLI)
Critical Limb Ischemia or CLI is a severe obstruction of the arteries which seriously decreases blood flow to the extremities (hands, feet and legs) and has progressed to the point of severe pain and even skin ulcers or sores. Critical Limb Ischemia (CLI) is often present in individuals with severe peripheral arterial disease (PAD). The pain caused by CLI can wake up an individual at night. This pain, also called “rest pain,” can be relieved temporarily by hanging the leg over the bed or getting up to walk around.
Treatment for CLI can be quite complex and individualized, but the overall goal should always be to reduce the pain and improve blood flow to save the leg. A treatment plan will likely include:
- Medications: Several medications may be prescribed to prevent further progression of the disease and to reduce the effect of contributing factors such as high blood pressure, high cholesterol and diabetes, and most certainly to reduce the pain. Medications that prevent clotting or fight infections may also be prescribed.
- Ulcer Care: Treatment will likely include medications and dressings for ulcers.
- Surgery or Endovascular Procedures: Surgical or endovascular procedures can be highly successful methods that restore oxygenated blood flow to the areas of skin breakdown. An endovascular procedure consists of a small incision through which a catheter is inserted to where the blockages occur. A balloon may be inflated (angioplasty) or the plaque may be scrapped off the artery, or the clot may be removed or broken up (thrombolysis). A wire-reinforced stent may be left in the artery to keep it open.
A bypass graft may be performed in more serious cases. This surgical procedure uses either an artificial tube or one of your veins as a new artery to bring improved blood flow to the needed area. The place where the blood flow is constricted is bypassed. In a few cases, the surgeon may cut open the artery and scrape out the plaque keeping the artery usable. The last recourse would be amputation of a toe, part of the foot, or leg. Amputation occurs in about 25 percent of all CLI patients.
Since treatment depends on the severity of the disease and many individual parameters, it is essential that someone with ulcers, or pain in the legs or feet when walking or at rest, see a vascular specialist as soon as possible. The earlier a diagnosis can be made, the earlier treatment can be started with less serious consequences.
Complete or partial arterial blockage may lead to tissue necrosis and/or ulceration. Signs on the extremity that one should look for include:
- Pulselessness of the extremity
- Painful ulceration
- Small, punctuate ulcers that are usually well circumscribed
- Cool or Cold skin
- Delayed capillary return time (briefly push on the end of the toe and release, normal color should return to the toe in 3 seconds or less)
- Atrophic appearing skin (shiny, thin, dry)
- Loss of digital and pedal hair
- Can occur anywhere, but is frequently seen on the dorsum (top) of the foot.
Utilize noninvasive vascular tests such as doppler, waveform, Ankle Brachial Indices (ABI) and Transcutaneous Oxygen Pressure measurements (TCP02) to aid in your diagnosis. Duplex scanning and arteriograms may also be performed if indicated.
Large vessel disease must be differentiated from small vessel disease. A blockage in a large artery may be removed or bypassed. Narrowing of smaller arterial vessels is more difficult to address.
Treatment of an arterial ulcer has many goals. The primary goal is to increase the circulation to the area in question. This can be done surgically or medically (with oral pills) depending on the cause of the ulcer and the patient’s overall medical condition.
Many clinicians like to keep an arterial wound somewhat dry, as they have found that too much moisture can lead to problems. Usually, topical treatment is very conservative.
All of these diseases are considered “Indications for Use” for the BioArterial Plus, Model IC-BAP high pressure, rapid inflation, arterial pneumatic compression therapy device for arterial blood flow enhancement.