Peripheral Vascular Disease (PVD)

A doctor examines a person with peripheral vascular disease.

• Peripheral vascular disease (PVD) is a circulation disorder that causes narrowing of blood vessels to parts of the body other than the brain and heart.
• Causes of peripheral vascular disease include peripheral artery disease due to atherosclerosis, blood clots, diabetes, inflammation of the arteries, infection, injury, and structural defects of the blood vessels.
• Risk factors for peripheral vascular disease include family history of premature heart attacks or strokes, age over 50 years, being overweight or obese, sedentary lifestyle, smoking, diabetes, high blood pressure, and high blood LDL cholesterol (the "bad cholesterol"), high blood triglycerides and low blood HDL (the "good cholesterol").
• Symptoms of peripheral vascular disease in the legs are dull, cramping pain in one or both calves, thighs, or hips when walking, called intermittent claudication.
• Other symptoms of peripheral vascular disease include
  • buttock pain,
  • numbness or tingling in the legs,
  • weakness, burning or aching pain in the feet or toes while resting,
  • a sore on a leg or a foot that will not heal,
  • one or both legs or feet feel cold or change color (pale, bluish, dark reddish),
  • hair loss on the legs, and
  • impotence.
• Tests to diagnose peripheral vascular disease include the ankle/brachial index (ABI), the treadmill exercise test, angiography (a type of X-ray), ultrasonography, MRI (magnetic resonance imaging),
• Treatment for peripheral vascular disease includes angioplasty, which is a technique for enlarging an artery that is blocked or narrowed without surgery. Stenting may be performed for arteries that are very severely blocked locally or begin to close up again after angioplasty. A procedure called atherectomy is removal of an atherosclerotic plaque.
• Types of medications commonly used to treat peripheral vascular disease include antiplatelet agents, anticoagulants, and "clot-busters" (thrombolytics). Drugs approved to help treat intermittent claudication include pentoxifylline (Trental) and cilostazol (Pletal).
• Lifestyle changes to treat or prevent peripheral vascular disease include quitting smoking, getting regular exercise, eating a low-fat and healthy diet, maintaining a healthy weight, controlling high blood pressure and high cholesterol, and if you have diabetes, keeping blood sugar optimal.
• Complications of untreated peripheral vascular disease include permanent numbness, tingling or weakness in the legs or feet, permanent burning or aching pain in the legs or feet, gangrene  (tissue death caused by lack of blood flow which may require amputation to treat it), and a higher-than-normal risk or heart attack and stroke.
• Other names for peripheral vascular disease include:
  • Atherosclerotic peripheral arterial disease
  • Hardening of the arteries
  • Peripheral arterial disease (PAD)
  • Peripheral vascular disease
  • Poor circulation
  • Vascular disease

Peripheral vascular disease (PVD) is a circulation disorder that causes narrowing, blockage, or spasms of blood vessels to parts of the body other than the brain and heart.

The most common cause of peripheral vascular disease is atherosclerosis, or hardening of the arteries, a gradual process by which cholesterol plaques (material) builds up and causes inflammation in the inner walls of the arteries. This cholesterol plaque builds up over time and may block, narrow, or weaken the blood vessel walls, which results in restricted or blocked blood flow.

Other causes of peripheral vascular disease include:

• Blood clot: A blood clot can block a blood vessel (thrombus/emboli).
• Diabetes: Over the long-term, the high blood sugar level of persons with diabetes can damage blood vessels. This makes the blood vessels more likely to become narrowed or weakened. Plus, people with diabetes frequently also have high blood pressure and high fats in the blood, which accelerates the development of atherosclerosis.
• Inflammation of the arteries: This condition is called arteritis and can cause narrowing or weakening of the arteries. Several autoimmune conditions can develop vasculitis, and, besides the arteries, other organ systems are also affected.
• Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood vessels. Both salmonellosis (infection with Salmonella bacteria) and syphilis have been two infections traditionally known to infect and damage blood vessels.
• Structural defects: Defects in the structure of a blood vessel can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown. Takayasu disease is a vascular disease affecting the upper vessels of the body and affects usually Asian females.
• Injury: Blood vessels can be injured in an accident such as a car wreck or a bad fall.

Risk factors for peripheral vascular disease (and atherosclerotic disease of all arteries throughout the body):

• Positive family history of premature heart attacks or strokes
• Older than 50 years
• Overweight or obesity
• Inactive (sedentary) lifestyle
• Smoking
• Diabetes
• High blood pressure
• High cholesterol or LDL (the "bad cholesterol"), plus high triglycerides and low HDL (the "good cholesterol")

People who have coronary heart disease or a history of heart attack or stroke generally also have an increased frequency of having peripheral vascular disease.

Only about half of the individuals with peripheral vascular disease have symptoms. Almost always, symptoms are caused by the leg muscles not getting enough blood. Whether you have symptoms depends partly on which artery is affected and to what extent blood flow is restricted.

The most common symptom of peripheral vascular disease in the legs is pain in one or both calves, thighs, or hips.

• The pain usually occurs while you are walking or climbing stairs and stops when you rest. This is because the muscles' demand for blood increases during walking and other exercise. The narrowed or blocked arteries cannot supply more blood, so the muscles are deprived of oxygen and other nutrients.
• This pain is called intermittent (comes and goes) claudication.
• It usually is a dull, cramping pain. It may also feel like a heaviness, tightness, or tiredness in the muscles of the legs.
• Cramps in the legs have several causes, but cramps that start with exercise and stop with rest most likely are due to intermittent claudication. When the blood vessels in the legs are completely blocked, leg pain at night is very typical, and the individual almost always hangs his or her feet down to ease the pain. Hanging the legs down allows for blood to passively flow into the distal part of the legs.

Other symptoms of peripheral vascular disease include the following:

• Buttock pain
• Numbness, tingling, or weakness in the legs
• Burning or aching pain in the feet or toes while resting
• A sore on a leg or a foot that will not heal
• One or both legs or feet feel cold or change color (pale, bluish, dark reddish)
• Loss of hair on the legs
• Impotence

Having symptoms while at rest is a sign of more severe disease.

There are two types of peripheral vascular disease (PVD):

1. Functional PVD: This type of PVD does not involve defects in the blood vessel structure, as the vessels are not damaged and the blood vessels are affected by external factors such as stress, temperature, or drugs. The diseases of this type often have symptoms that come and go.
2. Organic PVD: This type of PVD is caused by structural changes to the blood vessels, such as inflammation or tissue damage, including:
   • Atherosclerosis
   • Buerger's disease
   • Chronic venous insufficiency
   • Deep vein thrombosis (DVT)
   • Raynaud's phenomenon
   • Thrombophlebitis
   • Varicose veins

When you have symptoms of peripheral vascular disease in a leg or a foot (or in an arm or a hand), see your health-care professional for an evaluation.

Generally, peripheral vascular disease is not an emergency. On the other hand, it should not be ignored:

• Medical evaluation of your symptoms and effective treatment, if indicated, may prevent further damage to your heart and blood vessels.
• It may prevent more drastic events such as a heart attack or stroke or loss of toes and feet.

If you have symptoms of peripheral venous disease along with any of the following, go to the nearest hospital emergency department:

• Pain in the chest, upper back, neck, jaw, or shoulder
• Fainting or loss of consciousness
• Sudden numbness, weakness, or paralysis of the face, arm, or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden dizziness, difficulty walking, loss of balance or coordination
• Sudden severe headache with no known cause

Do not try to "wait it out" at home. Do not try to drive yourself. Call 911 right away for emergency medical transport.

Physical examination

The classic symptom of leg pain on walking that stops with rest is a good indication of peripheral vascular disease. However, only about 40% of people with peripheral vascular disease have intermittent claudication. Upon hearing the patient's symptoms, the health-care professional will formulate a list of possibilities.

• Several other conditions may be suspected.
• The patient's risk factors for peripheral vascular disease.
• The absence of a pulse in the legs or the arms will immediately result in a workup to rule out peripheral vascular disease.

The American College of Cardiology and the American Heart Association guidelines recommend screening for peripheral artery disease (PAD) using the ankle-brachial index (ABI) in patients at increased risk, including adults 65 years and older, adults 50 years and older with a history of smoking or diabetes, and adults of any age with leg symptoms on exertion or wounds that do not heal.

Tests for peripheral vascular disease

Rose criteria: A test used by many medical professionals to screen for peripheral vascular disease is a series of 9 questions called the Rose criteria. The answers to these questions indicate whether you have peripheral vascular disease and how severe it is.

Ankle/brachial index: One of the most widely used tests for a person who has symptoms suggesting intermittent claudication is the Ankle/Brachial Index (ABI).

• This test compares the blood pressure in the arm (brachial) with the blood pressure in the legs.
• In a person with healthy blood vessels, the pressure should be higher in the legs than in the arms.
• The blood pressure is taken in both arms in the usual way. It is then taken at both ankles.
• The pressure at each ankle is divided by the higher of the 2 pressures from the arms.
• An ABI above 0.90 is normal; 0.70-0.90 indicates mild peripheral vascular disease; 0.50-0.70 indicates moderate disease; and less than 0.50 indicates severe peripheral vascular disease.

Treadmill exercise test: If necessary, the ABI will be followed by a treadmill exercise test.

• Blood pressures in your arms and legs will be taken before and after exercise (walking on a treadmill, usually until you have symptoms).
• A significant drop in leg blood pressures and ABIs after exercise suggests peripheral vascular disease.
• Alternative tests are available if you are unable to walk on a treadmill.
• If the leg pulses are not palpable, the use of a portable Doppler flow probe will quickly reveal the absence or presence of an arterial flow.

Imaging tests for peripheral vascular disease

To help locate blockages in your blood vessels, any of several tests, such as angiography, ultrasonography, or MRI (magnetic resonance imaging), can be used. Angiography, or arteriography, is a type of X-ray.

• An X-ray dye is injected into the arteries in question; the dye highlights blockages and narrowing of arteries on an X-ray. This is an invasive study performed in a catheterization or interventional radiology laboratory. The X-ray dye must be excreted by the kidneys. If you have diabetes or already have kidney damage, the dye may precipitate further damage to your kidneys and, rarely, cause acute renal or kidney failure requiring dialysis.
• Some people describe the angiogram (X-ray obtained from angiography) as a "road map" of the arteries.
• Angiography has for many years been considered the best test available and has been used to guide further treatment and surgery.
• Certain treatments for blocked arteries can be performed at the same time, such as angioplasty. A specialist called an interventional radiologist or an invasive cardiologist can perform these treatments.
• Imaging techniques, such as ultrasonography and MRI, are preferred more and more because they are less invasive and work just as well. With either of these two techniques, angioplasty cannot be done.

Ultrasonography uses sound waves to find abnormalities.

• A handheld device that emits ultrasound waves is placed on the skin over the part of the body being tested. It is noninvasive and painless.
• You cannot hear or see the waves; they "bounce" off structures under your skin and give an accurate picture. Any abnormalities in the vessels or obstruction of blood flow can be seen.
• This safe technique is the same method used to look at a fetus in pregnancy.

MRI is a type of X-ray. Rather than radiation, MRI uses a magnetic field to obtain an image of internal structures. It gives a very accurate and detailed image of blood vessels. This technique is also noninvasive.

Several other tests are used under certain circumstances. Your health-care professional can explain why he or she recommends that certain tests be performed.

Whether medication is a good choice for you depends on the underlying cause of your peripheral vascular disease. Medications used to treat peripheral vascular disease and intermittent claudication include those that aim to lower the risk and progression of atherosclerosis throughout the body, such as those to help stop smoking, lower blood pressure, lower cholesterol, and optimize the blood sugar in people with diabetes.

Two medications have been approved by the United States Food and Drug Administration (FDA) for direct treatment of the symptom of intermittent claudication.

• Pentoxifylline (Trental): How this drug helps in intermittent claudication is not completely understood. It is believed to improve blood flow by making red blood cells more flexible. With these alterations, the blood can move more easily past obstructions in the blood vessel.
• Cilostazol (Pletal): This drug keeps platelets from clumping together. This clumping promotes formation of clots and slows down blood flow. The drug also helps dilate, or expand, the blood vessels, encouraging the flow of blood.

Sudden blockage of an artery by a blood clot (thrombus) has been treated with medication for many years. Choices include antiplatelet agents, anticoagulants, and "clot-busters" (thrombolytics).

• Antiplatelet agents include aspirin, ticlopidine, and clopidogrel. These agents do not get rid of an existing clot. They prevent further clots from forming by keeping blood cells and platelets from clumping together.
• Anticoagulant agents include heparin, warfarin (Coumadin, Jantoven), or low-molecular-weight heparin such as enoxaparin (Lovenox). These agents also do not remove an existing clot. They interfere with the sequence of blood clotting factors that causes a clot to form.
• Thrombolytics are powerful drugs that can actually dissolve an existing clot. They can be used only under certain circumstances and are given only in the hospital. They can be injected directly into the blocked artery under angiographic guidance. To be effective, they have to be administered intravenously within the first 4-8 hours after a patient develops symptoms.

The most effective medications are those that help prevent the development and progression of atherosclerosis.

Beta-blockers were not recommended in the past for treatment of peripheral arterial disease (PAD) because it was believed they would worsen intermittent claudication. However, more recent reviews have concluded they are safe for use in patients with PAD, except in the most severe of cases and in those with Raynaud's phenomenon.

Percutaneous (through the skin) balloon angioplasty, or just "angioplasty," is a technique for enlarging an artery that is blocked or narrowed without surgery.

• A diagnostic angiogram is done first to locate the blockage or narrowing and determine the severity, because, for instance, minor blockages are treated medically.
• A thin plastic tube called a catheter is inserted into the affected artery through a needle under local anesthesia. X-ray dye or contrast is injected, X-ray films are taken and studied by the doctor. If the obstruction is significant, especially in a larger more proximal artery, angioplasty may be reasonable. The angioplasty catheter has a tiny balloon attached to the end. The balloon is inflated, pushing aside the plaque and widening the artery so that it no longer restricts blood flow.
• The balloon is then deflated and removed from the artery.

Angioplasty is not a permanent solution for most people. Stenting is a technique for arteries that are very severely blocked or begin to close up again after angioplasty.

• Generally, after the stent is placed, angioplasty is carried out. Stenting and angioplasty are very useful if the obstructive lesions are localized and involve a small portion of the vessel. The majority of peripheral vascular lesions can be managed by placement of a stent, a small metal mesh sleeve that is fixed inside the narrowed artery.
• The stent holds the artery open.
• Eventually, new tissue grows over the stent. A bare metal stent was the initial approach. However, development of restenosis or fibrous scar tissue growth inside the stent leads to recurrent obstruction.
• A new generation of drug-eluting stents is especially exciting, since a drug is attached to the metal sleeve that dissolves into the blood and prevents growth factors acting to develop scar tissue. The rate of restenosis has decreased.
• Atherectomy is removal of an atherosclerotic plaque. A tiny cutting blade is inserted into the artery to cut the plaque away.

When the obstructive lesions are long and involve most of the vessel, surgery is the best alternative. The most widely used operation for a blocked or damaged artery is called a bypass. This is similar to the artery bypass operation done on the heart.

A piece of vein, harvested from another part of your body, or a piece of synthetic artery is used to bypass or detour the obstructed segment of disease, therefore restoring blood flow to the downstream or distal portion of the artery.

Surgery is required less often today, as better preventative anti-atherosclerotic medications and techniques have become available for treating blocked or damaged arteries. With modern treatments, surgery is required only for very severe atherosclerosis unresponsive to medications and angioplasty.

Treatment depends on the underlying cause of your peripheral venous disease, the severity of your condition, and your overall health. Your health-care professional will recommend ways that you can reduce your risk factors for atherosclerosis and peripheral vascular disease. Not all risk factors can be changed, but most can be reduced. Reducing these risk factors can not only prevent your disease from getting worse but can also actually reverse your symptoms..

• Quit smoking. Quitting smoking reduces symptoms and lowers your chance of having your peripheral artery disease (and arteries elsewhere) get worse.
• Get active. Regular exercise, such as walking, can reduce symptoms and increase the distance you can walk without symptoms.
• Eat nutritious, low-fat foods and avoid foods high in cholesterol.
• Maintain a healthy weight.
• Follow your healthcare professional's recommendations for controlling high blood pressure and high cholesterol.
• If you have diabetes, follow your healthcare professional's recommendations for controlling your blood sugar and taking care of your feet. Trimming your own toenails and injuring skin could lead to skin breakdown, gangrene, and loss of toes, if blood flow is impaired.

You may initially see your primary care provider (PCP) such as a family practitioner or internist for your symptoms of peripheral vascular disease.

You may be referred to a vascular medicine specialist, who specializes in disorders of the circulatory system or a vascular surgeon if surgery is needed. Depending on the cause of your PVD, you may also see a cardiologist, a specialist in disorders of the heart.

The best way to prevent peripheral vascular disease is to reduce your risk factors. You cannot do anything about some of the risk factors, such as age and family history. Other risk factors are under your control.

• Do not smoke.
• Eat nutritious, low-fat foods; avoid foods high in cholesterol.
• Maintain a healthy weight.
• Engage in moderately strenuous physical activity for at least 30 minutes a day. At least walk briskly for 20-30 minutes daily.
• Control high blood pressure.
• Lower high cholesterol (especially LDL cholesterol or the "bad cholesterol") and high triglyceride levels, and raise HDL or "the good cholesterol." If exercise fails to lower your cholesterol, certain medications (statin drugs) can be taken to decrease the bad cholesterol.
• If you have diabetes, control your blood sugar level and take scrupulous care of your feet. Ask your doctor what your HbA1C is, a measure of how well your blood sugar is controlled; it should be less than 7.0. If it is greater than 8.0, it is not controlled, and your risk of blood vessel complications (eyes, heart, brain, kidneys, legs) escalates.

Smoking is a very strong risk factor for developing peripheral vascular disease and can significantly worsen the disease, especially in diabetics. Quitting smoking can reduce the symptoms of peripheral vascular disease and lower your chance that the disease will get worse.

Follow the recommendations of your health-care professional for risk factor reduction. If he or she recommends medication, take the medication as directed. Report changes in your symptoms and any side affects you experience.

If untreated, peripheral vascular disease can develop complications:

• Permanent numbness, tingling, or weakness in legs or feet
• Permanent burning or aching pain in legs or feet
• Gangrene, which is a very serious condition and is the result of a leg or foot or other body part not getting enough blood. The tissues die and begin to decay. The only treatment is amputation of the affected body part.

People with peripheral vascular disease are at higher-than-normal risk of heart attack and stroke.