Peripheral Artery Disease (PAD) refers to a decrease in the circulation to the feet and legs. It is also associated with a decrease in the circulation to the hands, but this is less common than the circulation loss below the knees. The most common causes of Peripheral Artery Disease (PAD) by far are Smoking and Diabetes Mellitus. Peripheral Artery Disease or PAD is usually not localized to the feet and legs. In those patients that undergo a full work-up for decreased circulation to the feet and legs, we usually find that the circulation to the various heart vessels also show some degree of blockage. In addition, when further testing of those vessels is performed, blockages or potential blockages of the vessels of the brain can sometimes be seen.
Blockage of the vessels of the legs can lead to decreased circulation to the feet. This is usually an indicator of more generalized decrease in circulation in the entire body. When there is loss of circulation to the heart and the brain there are very serious implications. The risk of heart attack (myocardial infarction) or stroke (cerebrovascular accident) is extremely high.
Decreased circulation to the lower extremities as seen in PAD will lead to various symptoms including but not limited to generalized foot pain that is worsened with activity, calf pain when walking that is relieved when you stop or take a break, pain in the feet and legs at night when you go to bed, coldness and pain in the feet with activity, coldness in the feet in the evening and pain in the toes when the sheets rub on them at night. Some patients also relay burning in the toes and balls of the feet. These symptoms can be complicated or masked by the symptoms of Diabetic Neuropathy.
Findings in Peripheral Artery Disease (PAD) can usually include discoloration of the toes, generalized pain in the feet, hair loss in the feet that may extend up into the legs, dry, scaly changes to the skin, nail changes including decreased growth rate, thickening of the nail, development of nail fungus, etc.
The pain in the calf muscles felt when walking is called Intermittent Claudication. It is easily described by the following scenario. The vessels of the feet and legs are smaller (decreased in size from plaque and cholesterol deposits as well as deposits of the plaques seen in diabetics) than they should be. The patient goes for a walk and the muscles of the feet and legs require a certain amount of Oxygen in order to function properly. As the circulation is decreased, the amount of Oxygen needed is not met and there is an Oxygen Deficit. This is felt as a burning/cramping pain in the calf muscles and sometimes in the muscles in the bottoms of the feet.
The discoloration in the feet and toes can be easily identified. If your feet are the usual color when you are sitting with the feet down and they turn very white (blanched) or a purplish color when you elevate them, there is a possibility that the circulation to the feet is decreased. If you have pain in the calf and foot when you walk distances or if you have pain in the feet and calf when you go to bed at night, you may be experiencing symptoms of Peripheral Artery Disease (PAD).
Diagnosis is best made by Non-invasive and Invasive Vascular Studies. The Non-Invasive studies include Segmental Pressures and Arterial Doppler Exam. The most diagnostic invasive exam is the Aortogram with Run-off which is a nuclear scan performed on the vessels that show the degree of flow blockage of the major vessels from the abdomen all the way down to the feet. The exam is performed in a Nuclear Medicine-capable facility. The patient presents for the exam. A radioactive dye is injected into the bloodstream and a series of special X-Rays are taken that show the blood coursing through the vessels. If there is a narrowing of the vessel, we see it as a narrowing of the stream of blood flowing through that area. Because of the risks and other complicating circumstances associated with the aortogram, Arterial Doppler has become the Gold Standard of Non-Invasive Vascular Studies.
Arterial Doppler gives us quite a bit of information. We are not only able to actually see the flow through the vessels, but we are able to see a graphical depiction of the vessel wall flexibility (from a monophasic flow to a triphasic flow) as well as an actual flow velocity in cm/sec. This test is easily performed by the well-trainer practitioner. Because it can be performed in the office by the physician, the patient is able to get a brief synopsis of the findings at the time of the study. At azcryo, we perform several studies per day. Dr. Rampertab performs the study and we are able to discuss the findings in great detail at the time of the testing. The test is simple and takes less than 20 minutes in most cases. After the test, the findings are reviewed and a treatment plan (if necessary) is discussed and instituted.
If it is determined that all the patient needs is education and to be started on a good walking program, Dr. Rampertab takes the time to discuss a proper start and continuation of a walking program. He instructs each patient on how to start the routine, how to continue it without getting bored and what results to expect. If it is determined that medications to increase the blood flow may be necessary, Dr. Rampertab may start the patient on appropriate medication and see the patient for follow-up to make sure that the instituted treatment is producing adequate improvement.
If it is determined that the symptoms are more serious and a consult with a Vascular Surgeon is necessary, Dr. Rampertab can recommend a physician on the patient’s health plan. Even with such a referral, it is understood with the Vascular Surgeon that Dr. Rampertab will continue to treat the patient’s feet and legs. If surgery becomes necessary, Dr. Rampertab will provide supportive care during the post-operative period for any complications that may arise or pre-existing wounds that may need periodic debridement as they heal.
At azcryo, we have a state of the art Diagnostic Ultrasound that is capable of Full Color Arterial Dopplers and Venous Ultrasounds. A report can be sent to the Family Practice or Primary Care Physician. This Doppler exam proves quite helpful to the Vascular Surgeon as such a test is required prior to referral.