All about Peripheral Vascular

lntroduction

Peripheral Vascular Disease (PVD) can be defined as a blood circulation disorder that is caused by abnormal narrowing, spasm or blocking of the blood vessels outside of the heart and brain (including both arteries and veins). PVD is a slow and progressive disease. The vascular disease of the heart and brain is known as coronary artery disease and cerebrovascular disease respectively and both are different from

PVD. PVD most commonly affects the lower limb blood vessels. Other affected blood vessels include those of the upper limb, kidneys and abdomen.

PVD is also known as claudication (pain or cramping in the lower leg due to affected blood supply), intermittent claudication, arteriosclerosis obliterans, arterial Insufficiency of the legs and peripheral arterial disease. Peripheral Artery Disease (PAD) develops in the artery which leads to an imbalance between the supply and demand of oxygenated blood; resulting in symptoms such as pain in the affected area. Pain in PVD is very specific which is intermittent or claudication pain. This pain increases with physical activity and relieves with rest.

PVD, if not treated and managed in time, may lead to several complications such as severe pain in the affected extremities, limited and painful mobility, non-healing wounds, gangrene, amputation, heart attack and stroke.

Causes

Some of the main causes of peripheral vascular disease are:

• Atherosclerosis or a build-up of fats and cholesterol that are present in the blood on the walls of the arteries (most common)

• Extreme injuries to the limb

• Abnormal anatomy or structure of muscles or ligaments

• Infection

Also, emotional stress, cold temperature and long term operating of vibrating machinery or tools may trigger PVD.

Risk factors for PVD

Some of the risk factors of PVD can be modifiable through medical intervention while some cannot be changed. The risk factors which can't be changed are:

• Age (>50 years)

• Gender (male)

• Post-menopausal state in women

• History of heart disease

• Family history of peripheral vascular disease, high blood pressure and high cholesterol

The risk factors that can be treated, controlled or managed are:

• Overweight

• Smoking or tobacco consumption in any form

• Physical inactivity

• Diabetes

• Stroke or cerebrovascular disease

• High blood pressure

• High cholesterol levels

• Heart disease or blockage in the arteries of the heart

Symptoms

Nearly 50 per cent of people who have PVD may not experience any symptoms at all.

One of the most common symptoms is pain in the calf muscles. Such kind of pain starts while walking or during exercise and intensifies with further exercise. This pain is

relieved by rest and is known as intermittent claudication. It may affect one or both legs.

Other symptoms include:

• Numbness, heaviness or weakness in the muscles

• Hair loss on legs

• Changes in the skin like colour, decrease in the temperature, thin brittle shiny skin on legs and feet

• Thickened, opaque toenails

• Reddish-blue discolouration of extremities

• Burning or aching pain in the toes at rest, mostly at night while lying down

• paleness when legs are elevated

• Restricted mobility

• Non-healing wounds on pressure points of the feet, like wounds on heels and ankles

• Unbearable severe pain when an artery gets narrowed or blocked

• Gangrene (dead tissue due to complete loss of blood supply)

• Impotence

Diagnosis

Visit your doctor if any of the

above-mentioned symptoms occur. Also, people with a history of Diabetes should go for an annual assessment to diagnose any underlying issues. The doctor will record your medical history and will do a physical examination like checking your pulses on the hands and feet.

The doctor may suggest a few tests to confirm the diagnosis of PVD. Specific tests for PVD include an ankle-brachia) index, transcutaneous oxygen measurement, Doppler ultrasound, exercise doppler stress testing, peripheral angiography, magnetic resonance angiography, computerized tomography angiography.

Ankle Brachia) Index (ABI) is a simple, non-invasive, inexpensive and most practical method of PVD detection. It is a

comparison of your blood pressure in the ankle to the arm with the help of a regular blood pressure cuff and Doppler ultrasound device. ABI is an effective method to not

only identify PVD but also to detect its severity. There are few limitations to ABI such as a person with Diabetes and calcified artery of the lower limb may have falsely high ABI reading or people with rich collateral arterial network. In such cases, they may need further investigations.

Angiography is one of the important tests to diagnose PVD. A contrast dye is injected into the blood vessels and the location and size of blockage are detected with the help of the X-Ray technique or magnetic resonance (MRI) or computerized

tomography (CT). This test is also helpful in planning a further line of management.

Treatment

The goals of PVD treatment are to restore blood supply and prevent disease progression, reduce the risk of heart disease, cerebrovascular diseases such as stroke and other complications.

Medical management - This consists of treating and controlling underlying conditions such as high blood sugar levels, high blood pressure and high cholesterol levels. Some people may require blood thinner medication (to improve blood flow) and medicine to relax the blood vessels.

Surgical management - If medical management is not helpful or a person has serious complications of PVD then the doctor may suggest surgical management like angioplasty or bypass surgery. In angioplasty, a large opening is made at the site of the blocked artery to improve the blood flow. The different types of angioplasty are - balloon angioplasty, atherectomy and laser angioplasty. In bypass surgery, a bypass graft (a blood vessel from another part of the body or a tube made up of synthetic material) is used at the site of blockage to widen the artery and restore blood flow.

Prevention

PVD is a serious complication among people with Diabetes affecting their quality of life, yet it is preventable. Early detection of the signs and timely medical intervention can help prevent the progression of PVD. Lifestyle modification is the key to reduce the risk of complications. Quitting smoking and discarding the use of tobacco in any form is highly recommended. Also quitting alcohol or limiting alcohol intake is important. Dietary changes such as increasing consumption of fruits and vegetables, reducing the consumption of simple carbohydrates, fat and avoiding red meat can be helpful. Along with these, regular exercise aids in weight loss, increases insulin sensitivity, balances lipid

levels and blood circulation and reduces the risk of developing PVD.

Dr Manish Bothale is a Consultant

Diabetologist.