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Peripheral Artery Disease
is most common in the arteries of the pelvis and legs. It's a
condition similar to coronary artery disease (CAD) and carotid
artery disease. CAD refers to atherosclerosis in the coronary
arteries, which supply the heart muscle with blood. Carotid artery
disease refers to atherosclerosis in the arteries that supply blood
to the brain.

Atherosclerosis comes from the Greek words athero (meaning
gruel or paste) and sclerosis (hardness). It's a process in which
plaque builds up in the wall of an artery. Plaque is made up of
deposits of fats, cholesterol and other substances. Plaque
formations can grow large enough to significantly reduce the
blood's flow through an artery. When a plaque formation
becomes brittle, it may rupture, triggering a blood clot to form. A
clot may either further narrow the artery, or completely block it.
When that blockage occurs in a coronary artery, it can cause a
heart attack. When it occurs in a carotid artery, it can cause a
stroke. If the blockage remains in the peripheral arteries, it can
cause pain, changes in skin color, sores or ulcers and difficulty
walking. Total loss of circulation to the legs and feet can cause
gangrene and loss of a limb.

It's important to learn the facts about PAD. As with any disease,
the more you understand, the more likely you'll be able to help
your healthcare professional make an early diagnosis and start
treatment. PAD has common symptoms, but many people with
PAD never have any symptoms at all.

Learn the facts, consult your healthcare professional and take
control of your risk factors for heart attack and stroke. You have
the power to improve your heart health.

Peripheral artery occlusive disease
From Wikipedia, the free encyclopedia

In medicine, peripheral artery occlusive disease (PAOD), also
known as peripheral vascular disease (PVD) and peripheral artery
disease (PAD) is a collator for all diseases caused by the
obstruction of large peripheral arteries, which can result from
atherosclerosis, inflammatory processes leading to stenosis, an
embolism or thrombus formation. It causes either acute or
chronic ischemia.

Classification:

Peripheral artery occlusive disease is commonly divided in the
Fontaine stages:[1]

I: mild pain on walking ("claudication")
II: severe pain on walking relatively shorter distances (intermittent
claudication)
III: pain while resting
IV: tissue loss (gangrene)

Symptoms:

Claudication - pain, weakness, or cramping in muscles due to
decreased blood flow
Sores, wounds, or ulcers that heal slowly or not at all
Noticeable change in color (blueness or paleness) or temperature
(coolness) when compared to the other limb
Diminished hair and nail growth on affected limb and digits.

Causes:

Smoking - tobacco use in any form is the single most important
modifiable cause of PAD internationally. Smokers have up to a
tenfold increase in relative risk for PAOD in a dose-related effect

Exposure to second-hand smoke from environmental exposure
has also been shown to promote changes in blood vessel lining
(endothelium) which is a precursor to atherosclerosis.

Diabetes mellitus - increased risk of PAOD 2-4X by causing
endothelial and smooth muscle cell dysfunction in peripheral
arteries. Diabetics account for up to 70% of nontraumatic
amputations performed, and a known diabetic who smokes runs
an approximately 30% risk of amputation within 5 years.
Dyslipidemia - elevation of total cholesterol, LDL cholesterol, and
triglyceride levels each have been correlated with accelerated
PAOD. Correction of dyslipidemia by diet and/or medication is
associated with a major improvement in short-term rates of heart
attack and stroke. This benefit is gained even though current
evidence does not demonstrate a major reversal of peripheral
and/or coronary atherosclerosis.

Hypertension - elevated blood pressure is correlated with an
increase in the risk of developing PAD, as well as in associated
coronary and cerebrovascular events (heart attack and stroke).
Other risk factors which are being studied include levels of
various inflammatory mediators such as C-reactive protein,
homocysteine, and fibrinogen.

Risk of PAOD also increases if the patient is: over the age of 50,
African American, male, obese, or has a personal history of
vascular disease, heart attack, or stroke.

Diagnosis:

Upon suspicion of PAOD, the first-line study is the ankle brachial
pressure index (ABPI/ABI) which is a measure of the fall in blood
pressure in the arteries supplying the legs. A reduced ABPI (less
than 0.9) is consistent with PAOD. Values of ABPI below 0.8
indicate moderate disease and below 0.5 severe disease. It is
possible for conditions which stiffen the vessel walls (such as
calcifications that occur in the setting of chronic diabetes) to
produce incorrect readings and high values(>1.3), meriting further
investigation regardless.

If ABI's are abnormal the next step is generally a lower limb
doppler ultrasound examination to look at site and extent of
atherosclerosis at the femoral artery. Other imaging can be
performed by angiography, where a catheter is inserted into the
femoral artery and selectively guided to the artery in question and
then used to inject radiodense contrast agent whilst an X-ray is
taken. Any stenosis of the arteries can be identified and treated at
the same time by balloon angioplasty if the stenosis is over a
short segment (<3cm). However if the artery is occluded or there
is diffuse disease present, then arterial bypass surgery may be
required.

Modern multislice computerized tomography (CT) scanners
provide direct imaging of the arterial system as an alternative to
angiography. CT provides complete evaluation of the aorta and
lower limb arteries without the need for an angiogram's arterial
injection of contrast agent.

Prevalence and Incidence:

The prevalence of peripheral arterial disease (PAD) in people
aged over 55 years is 10%–25% and increases with age; 70%
–80% of affected individuals are asymptomatic; only a minority
ever require revascularisation or amputation. [2]

In the USA peripheral arterial disease affects 12-20 percent of
Americans age 65 and older. Despite its prevalence and
cardiovascular risk implications, only 25 percent of PAD patients
are undergoing treatment. [3]

The incidence of symptomatic PAD increases with age, from
about 0.3% per year for men aged 40–55 years to about 1% per
year for men aged over 75 years. The prevalence of PAD varies
considerably depending on how PAD is defined, and the age of
the population being studied. [2] Diagnosis is critical, as people
with PAD have a four to five times higher risk of heart attack or
stroke.

In Western Australia, the prevalence of symptomatic disease at
around 60 years of age is about 5%. [4]

A study from the NHANES 1999–2000 data found that PAD affects
approximately 5 million adults. [3]

The Diabetes Control and Complications Trial and U.K.
Prospective Diabetes Study trials in people with type 1 and type 2
diabetes, respectively, demonstrated that glycemic control is
more strongly associated with microvascular disease than
macrovascular disease. It may be that pathologic changes
occurring in small vessels are more sensitive to chronically
elevated glucose levels than is atherosclerosis occurring in larger
arteries. [5]

Therapy:

Dependent on the severity of the disease, the following steps can
be taken:

Conservative measures include Smoking cessation (cigarettes
promote PAOD and are a risk factor for cardiovascular disease).
Regular exercise for those with claudication helps open up
alternative small vessels (collateral flow) and the limitation in
walking often improves. Medication with aspirin, clopidogrel and
statins, which reduce clot formation and cholesterol levels,
respectively can help with disease progression and address the
other cardiovascular risks that the patient is likely to have.
Angioplasty (PTA or percutaneous transluminal angioplasty) can
be done on solitary lesions in large arteries, such as the femoral
artery.
Plaque excision, in which the plaque is scraped off of the inside
of the vessel wall.
Occasionally, bypass grafting is needed to circumvent a seriously
stenosed area of the arterial vasculature. Generally, the
saphenous vein is used, although artificial (Gore-Tex) material is
often used for large tracts when the veins are of lesser quality.
Rarely, sympathectomy is used - removing the nerves that make
arteries contract, effectively leading to vasodilatation.
When gangrene of toes has set in, amputation is often a last
resort to stop infected dying tissues from causing septicemia.
Arterial thrombosis or embolism has a dismal prognosis, but is
occasionally treated successfully with thrombolysis.

Associations:

Many PAOD patients also have angina pectoris or have had
myocardial infarction. There is also an increased risk for stroke.

Guidelines:

Several different guideline standards have been developed,
including:

TASC II Guidelines[6][7][8]
ACC/AHA Guidelines[9]

References:

^ Fontaine R, Kim M, Kieny R (1954). "Die chirugische
Behandlung der peripheren Durchblutungsstörungen. (Surgical
treatment of peripheral circulation disorders)" (in German).
Helvetica Chirurgica Acta 21 (5/6): 499–533.

^ a b Peripheral arterial disease prevention and prevalence.
Peripheral Arterial Disease (Nov 1 2007). Retrieved on 2007-12-03.

^ a b A. Richey Sharrett, MD, DRPH (Sep 21 2007). Peripheral
arterial disease prevalence. Peripheral Arterial Disease. Retrieved
on 2007-12-03.

^ Hiatt W, Hoag S, Hamman R. (Sep 21 1995). Effect of diagnostic
criteria on the prevalence of peripheral arterial disease. Effect of
diagnostic criteria on the prevalence of peripheral arterial
disease. Retrieved on 2007-12-03.

^ Elizabeth Selvin, PHD, MPH, Keattiyoat Wattanakit, MD, MPH,
Michael W. Steffes, MD, PHD, Josef Coresh, MD, PHD and A.
Richey Sharrett, MD, DRPH (Oct 20 2005). HbA1c and Peripheral
Arterial Disease in Diabetes. The Atherosclerosis Risk in
Communities study. Retrieved on 2007-12-03.

^ Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA,
Fowkes FG; TASC II Working Group, Bell K, Caporusso J, Durand-
Zaleski I, Komori K, Lammer J, Liapis C, Novo S, Razavi M, Robbs
J, Schaper N, Shigematsu H, Sapoval M, White C, White J; TASC II
Working Group. (2007). "Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II)". Eur J Vasc
Endovasc Surg. 33 (Suppl 1): S1-75. doi:10.1016/j.ejvs.
2006.09.024. PMID 17140820.

^ Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA,
Fowkes FG; TASC II Working Group, Bell K, Caporusso J, Durand-
Zaleski I, Komori K, Lammer J, Liapis C, Novo S, Razavi M, Robbs
J, Schaper N, Shigematsu H, Sapoval M, White C, White J; TASC II
Working Group. (2007). "Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II)". J Vasc
Surg. 45 (Suppl S): S5-67. doi:10.1016/j.jvs.2006.12.037. PMID
17223489.

^ Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA,
Fowkes FG; TASC II Working Group, Bell K, Caporusso J, Durand-
Zaleski I, Komori K, Lammer J, Liapis C, Novo S, Razavi M, Robbs
J, Schaper N, Shigematsu H, Sapoval M, White C, White J; TASC II
Working Group. (2007). "Inter-Society Consensus for the
Management of Peripheral Arterial Disease". Int Angiol. 26 (2): 81-
157. PMID 17489079.

^ Hirsch AT, Haskal ZJ, Hertzer NR, et al (2006). "ACC/AHA 2005
guidelines for the management of patients with peripheral arterial
disease (lower extremity, renal, mesenteric, and abdominal
aortic): executive summary a collaborative report from the
American Association for Vascular Surgery/Society for Vascular
Surgery, Society for Cardiovascular Angiography and
Interventions, Society for Vascular Medicine and Biology, Society
of Interventional Radiology, and the ACC/AHA Task Force on
Practice Guidelines (Writing Committee to Develop Guidelines for
the Management of Patients With Peripheral Arterial Disease)
endorsed by the American Association of Cardiovascular and
Pulmonary Rehabilitation; National Heart, Lung, and Blood
Institute; Society for Vascular Nursing; TransAtlantic Inter-
Society Consensus; and Vascular Disease Foundation". J. Am.
Coll. Cardiol. 47 (6): 1239-312. doi:10.1016/j.jacc.2005.10.009.
PMID 16545667.

External links:

Peripheral Arterial Disease: Peripheral Arterial Disorders: Merck
Manual Professional Edition Accessed on 27 March 2007
[hide]v • d • eCirculatory system pathology (I, 390-459)

Hypertension Hypertensive heart disease - Hypertensive
nephropathy - Secondary hypertension (Renovascular
hypertension)

Ischaemic heart disease Angina pectoris (Prinzmetal's angina) -
Myocardial infarction (heart attack) - Dressler's syndrome

Pulmonary circulation Pulmonary embolism - Cor pulmonale

Pericardium Pericarditis - Pericardial effusion - Cardiac
tamponade

Endocardium/heart valves Endocarditis - mitral valve
(regurgitation, prolapse, stenosis) - aortic valve (stenosis,
insufficiency) - pulmonary valve (stenosis, insufficiency) -
tricuspid valve (stenosis, insufficiency)

Myocardium Myocarditis - Cardiomyopathy (Dilated
cardiomyopathy, Hypertrophic cardiomyopathy, Loeffler
endocarditis, Restrictive cardiomyopathy) - Arrhythmogenic right
ventricular dysplasia

Electrical conduction system:

of the heart Heart block: AV block (First degree, Second degree,
Third degree) - Bundle branch block (Left, Right) - Bifascicular
block - Trifascicular block
Pre-excitation syndrome (Wolff-Parkinson-White, Lown-Ganong-
Levine) - Long QT syndrome - Adams-Stokes syndrome - Cardiac
arrest - Sudden cardiac death
Arrhythmia: Paroxysmal tachycardia (Supraventricular, AV nodal
reentrant, Ventricular) - Atrial flutter - Atrial fibrillation (Familial) -
Ventricular fibrillation - Premature contraction (Atrial, Ventricular) -
Ectopic pacemaker - Sick sinus syndrome

Other heart conditions Heart failure - Cardiovascular disease -
Cardiomegaly - Ventricular hypertrophy (Left, Right)

Cerebrovascular diseases Stroke - Transient ischemic attack -
Intracranial hemorrhage/cerebral hemorrhage: Extra-axial
hemorrhage (Epidural hemorrhage, Subdural hemorrhage,
Subarachnoid hemorrhage)
Intra-axial hematoma (Intraventricular hemorrhages,
Intraparenchymal hemorrhage) - Anterior spinal artery syndrome -
Binswanger's disease - Moyamoya disease

Arteries, arterioles and capillaries Atherosclerosis (Renal artery
stenosis) - Aortic dissection/Aortic aneurysm (Abdominal aortic
aneurysm) - Aneurysm - Raynaud's phenomenon/Raynaud's
disease - Buerger's disease - Vasculitis/Arteritis (Aortitis) -
Intermittent claudication - Arteriovenous fistula - Hereditary
hemorrhagic telangiectasia - Spider angioma - Dissection (Carotid
artery, Vertebral artery)

Veins, lymphatic vessels and lymph nodes
Thrombosis/Phlebitis/Thrombophlebitis (Deep vein thrombosis,
May-Thurner syndrome, Portal vein thrombosis, Venous
thrombosis, Budd-Chiari syndrome, Renal vein thrombosis,
Paget-Schroetter disease) - Varicose veins / Portacaval
anastomosis (Hemorrhoid, Esophageal varices, Varicocele,
Gastric varices, Caput medusae) - Superior vena cava syndrome -
Lymph (Lymphadenitis, Lymphedema, Lymphangitis)

Other Hypotension (Orthostatic hypotension) - Rheumatic fever

See also congenital (Q20-Q28, 745-747)