Leg Arteries

Peripheral Arterial Disease (PAD):

PAD is blockage of the arteries in the legs, caused by accumulation of atherosclerotic plaque. Risk factors associated with development of plaque in the arteries of the lower extremities include cigarette smoking, high cholesterol levels in the blood, diabetes, and family history. Peripheral arterial disease usually presents with the symptom of "claudication," which is pain in the leg, usually in the calf or thigh, after walking varying distances. Some patients develop "claudication" after just a few steps, while others can walk up to a half of a mile or more before pain forces them to stop. Typically, after a rest period of a few minutes, the patient is able to resume walking again for an equal distance before the pain returns. PAD is most commonly associated with aging. Approximately 30% of people over the age of 70 have some degree of PAD. While claudication caused by PAD is not necessarily a reason to proceed with surgical therapy, evaluation by a vascular surgeon is necessary when a patient has claudication to ascertain the seriousness of the condition. While claudication can be extremely painful and lifestyle limiting, it does not necessarily indicate that limb loss is imminent or even likely. Most patients with claudication due to PAD do not progress to limb loss. When claudication deteriorates into a condition of "rest pain" however , limb loss is a distinct probability. Rest pain means that the patient has pain even when not walking. Typically, rest pain is most intense when a person is attempting to sleep. When we sleep, our blood pressure tends to decrease and this blood pressure reduction leads to a decrease in the head of pressure which is driving blood into the legs around the areas of blockage. 

Testing for PAD:

The patient should been seen by a vascular surgeon. A complete medical history should be obtained and the surgeon will examine the arterial pulses in the lower extremities at the level of the groin, behind the knee, and in the feet. An arterial noninvasive blood flow study may be obtained, which is a noninvasive measurement of the amount of blood which is being delivered to the legs. If a blockage is suspected on the basis of the noninvasive arterial blood flow studies (sometimes called a "Doppler test"), an ultrasound examination of the arteries may be obtained, an MRA (magnetic resonance angiogram) may be obtained, and finally an angiogram may be necessary to obtain a "road map" of the circulation.

Treatment Options for PAD:

When PAD is diagnosed, the vascular surgeon will propose a treatment plan. This plan may involve an exercise program (usually consisting of walking on a daily basis to the point of claudication to attempt to build "collateral blood vessels" around the blocked arteries). Other lifestyle changes including cessation of cigarette smoking, better management of diabetes, weight reduction, and cholesterol-lowering medications. Medications which have been shown to have some beneficial effect in patients with claudication caused by PAD include cilostazol (Pletal), which may improve the walking distance. Other drugs that may be prescribed by the vascular surgeon include aspirin or clopidogrel (Plavix). If it is the opinion of the vascular surgeon that the condition has deteriorated to the point where lifestyle changes and an exercise program are no longer satisfactory treatment options, an angiography may be obtained. If the angiogram demonstrates localized blockages of the arteries in the legs, a balloon angioplasty, stenting or bypass surgery may be recommended. The bypass procedure can be performed either using one of the "extra veins" of the lower extremities, or an artificial arterial bypass (made of Dacron or Gortex) may be used. This decision is made by the vascular surgeon and is usually discussed with the patient prior to operation.

In cases where PAD has progressed beyond the point of claudication and beyond the point of rest pain to the situation where actual gangrene of the tissues of the lower extremity has developed, it is sometimes "too late" to salvage the extremity and amputation may be necessary. More than 50,000 amputations are performed annually in the United States . The amputation level may be either at the mid foot (transmetatarsal), below the knee or above the knee. Amputation is the procedure of last resort and is rarely undertaken prior to an attempt at limb salvage, unless the situation clearly has progressed to the point where time is of the essence and the amputation must be performed as a life-saving maneuver.