Peripheral Arterial Disease

About

  • Peripheral arterial disease is chronic narrowing of the arteries that supply the legs, due to build-up of plaque (known as atherosclerosis). This often causes no symptoms, but can occasionally be limb-threatening.

  • One-in-four people have peripheral arterial disease.

    By age:

    • It is uncommon in people under the age of 50 years old, affecting less than five percent of people in this age group.

    • Peripheral arterial disease is much more common as we age, impacting 20% of people over the age of 80 years old.

    By symptom:

    • Peripheral arterial disease causes pain when walking in over one in twenty people aged over 65 years.

    • It is limb threatening in more than 1 in 100 adults.

  • Risk factors for peripheral arterial disease include:

    • Smoking

    • Diabetes

    • Hypertension (high blood pressure)

    • Hypercholesterolemia (high cholesterol)

    • Age

    • Being male

    • Kidney disease

  • Peripheral arterial disease results from plaque formation (called atherosclerosis) in the arteries that supply the legs. This can be the arteries in the abdomen that lead to the legs, or arteries in the legs themselves.

    Atherosclerosis occurs due to damage of the innermost layer of the artery by the risk factors listed above. This damaged inner layer then allows inflammatory and cholesterol-carrying cells to get under this layer, causing narrowing or blockage of the vessel and therefore limiting the flow down the vessel to the tissues that need it.

    Often the body will find ways to keep functioning despite narrowings or blockages. As a result, many people with arterial disease have no symptoms.

    However, 5% of people without symptoms will go on to develop pain when walking (claudication – where the calf muscle doesn’t get enough blood when it’s being used). Then, 20% of people with claudication develop rest pain (pain in the toes, a sign that the toes aren’t getting enough blood), which is a sign that gangrene is likely. 25% of people with these symptoms will then undergo amputation.

    • Pain in the calf (or less commonly the thigh) when walking. This often comes on after the same distance every time, and settles after 5-10 minutes of rest, before coming on again at the same distance. This is called claudication

    • Pain in the foot. This often starts in the toes, and mostly at night. This is called rest pain

    • Ulcers – wounds which may occur from minor (or no) trauma, which then are slow to heal, or do not heal.

    • Gangrene – black discolouration of the skin, often beginning in the toes.

  • Assessment begins with a thorough discussion about your medical history, followed by clinical examination.

    An ultrasound (called an arterial duplex) often follows, which is excellent for imaging arteries from the groin to the foot. An arterial duplex is quite good for looking at the arteries in the abdomen, but may not be helpful here in some circumstances.

    A CT scan with intravenous contrast is the best test for imaging the large arteries in the abdomen and pelvis which supply the leg. It is not as good for imaging the small vessels in the lower leg.

    These imaging modalities will determine which arteries are not working properly, and will help determine which type of management is best.

TREATMENT

How do you treat peripheral arterial disease?

There are several treatment options for peripheral arterial disease, depending on the site of the narrowing or blockage, and your symptoms. Most people do not need any intervention for their peripheral arterial disease, but disease in the arteries of the abdomen or legs suggest there may be disease in the arteries that supply the heart, brain or abdominal organs. As a result, if peripheral arterial disease is diagnosed, it is recommended that risk factors for arterial disease are controlled (eg, by stopping smoking, and controlling high cholesterol or diabetes), and potentially starting medications to stop any arterial disease from developing or progressing.

Treatment options include:

  • Conservative measures – there is good evidence that claudication (pain in the calf muscle when walking) responds well to ‘exercise therapy’, which involves walking for 30 to 45 minutes, three to four times per week.

  • Endovascular surgery – also called ‘keyhole surgery’, this involves a small incision in the groin or wrist, and after a wire is passed across the narrowing or blockage, a balloon is inflated to open up the narrowing, and the balloon is then removed. Sometimes a stent (a tubular metal frame) is used to keep the artery open. Endovascular surgery is often preferable to open surgery.

  • Open surgery – before endovascular surgery, open surgery was the traditional way to manage arterial narrowings or blockages. This involves larger incisions, but allows either complete removal of a blockage, or allows implantation of a new vessel to bypass (go around) the blockage.

We will discuss which treatment option may be most suitable for you, with consideration of your preferences and factors such as:

  • The severity of your symptoms

  • Which arteries are affected

  • Your medical history

What are the risks of treatment of peripheral arterial disease?

Any operation requiring a general anaesthetic has risks like stroke, heart attacks, respiratory failure, or death. As such, we avoid general anaesthetics in people who are at high risk of these complications.

The main risks of interventions for peripheral arterial disease are listed below. These are often prevented by careful planning and treatment. While these can be life-threatening, they are actively watched for, and if they occur are immediately managed:

  • Bleeding or bruising

  • Reduction of blood supply

  • Nerve injury

  • Infection

  • Slow-healing wounds

  • Kidney damage

Do I need to follow-up with my Vascular Surgeon after the operation?

Dr Shiraev will want to see you after your operation, to make sure you have recovered well, your wounds are healing, and answer any questions you may have.

In the longer term, people with peripheral arterial disease often benefit from monitoring, which may involve an annual checkup and ultrasound.

Unfortunately, ‘recurrence’ of peripheral arterial disease (where the narrowing or blockage returns) is not uncommon. This may be at the same site, or somewhere else in the artery. This is due to the nature of the damage to the arteries, where the process of arterial damage from atherosclerosis has often been progressing for decades, and so may cause new arteries to narrow, or cause the plaque that was originally treated to regrow.

In addition, any intervention on an artery can cause scarring in that vessel (called ‘neo-intimal hyperplasia’), and formation of this scar in the vessel can cause narrowing. This can be minimized by certain treatments.

This advice is general, and is not intended to replace a formal clinical assessment and discussion with a health professional.