By Dr Tariq Jagnarine
Fam Med, Endocrinology/Diabetes
Peripheral vascular disease (PVD) is a progressive disorder that restricts blood flow to the arms, legs, or other parts of the body. It occurs when blood vessels narrow, become blocked, or spasm. It can lead to pain and cramping. PVD describes the reduced blood circulation to a body part (excluding the brain and heart). If PVD occurs only in the arteries, it is called peripheral artery disease (PAD). Most cases of PVD affect the arteries, so research often uses the terms interchangeably.
• PVD affects more than 20% of individuals who are 80 years old or older.
• Common risk factors include being over the age of 50 years, having diabetes, smoking cigarettes, and having high blood pressure or high cholesterol.
• Common symptoms include pain and cramps in the legs, hips, and buttocks.
• According to the Centers for Disease Control and Prevention (CDC), PVD affects men and women equally.
• Arteriosclerosis and atherosclerosis are among the most common causes of PVD.
Risk factors
In general, the risk factors for PVD are like those for arteriosclerosis. They include:
• Age: People aged 50 years and over are more likely to get PVD and PAD.
• Obesity: Living with obesity increases the risk of arteriosclerosis, PVD, and other cardiovascular conditions.
• Lifestyle choices: Smoking, substance use, a sedentary lifestyle, and following a diet lacking nutrients may increase a person’s risk of PVD.
• Medical and family history: PVD risk increases for people who have a history of cerebrovascular disease or stroke. Those with a family history of high cholesterol or hypertension are also at higher risk.
• Other medical conditions: People with high cholesterol, hypertension, heart disease, or diabetes are at an increased risk of developing PVD.
• Race and ethnicity: African Americans tend to develop PVD more frequently.
Causes
Causes of PVD vary and depend on the type a person has. Arteriosclerosis, which is due to changes in the structure of the blood vessels, is the most common cause of PVD.
Atherosclerosis occurs when plaque (fats and other substances) builds up in the blood vessels. Atherosclerosis can restrict blood flow and, if left untreated, cause clots. Clots block the arteries and can cause loss of limbs or organ damage.
• Common risk factors for atherosclerosis include:
o High blood pressure (hypertension)
o High cholesterol or triglycerides
o Inflammation from arthritis, lupus, or other conditions
o Insulin resistance
o Smoking
The following conditions may also cause structural changes in the blood vessels:
• Buerger’s disease
• Chronic venous insufficiency
• Deep Vein Thrombosis (DVT)
• Raynaud’s disease
• Thrombophlebitis
• Varicose veins
Injury, inflammation, or infection in the blood vessels may also cause structural changes in the blood vessels.
Symptoms
Signs and symptoms of PVD often appear gradually. They occur more commonly in the legs than in the arms because the blood vessels in the legs are further from the heart. Typical symptoms of PVD include feeling pain, aches, or cramps while walking. However, up to 40 per cent of people with PVD or PAD do not experience leg pain. These pains, aches, and cramps related to physical activity are referred to as claudication, and they can occur in the following areas: buttocks, calf, hip, and thigh.
Symptoms of claudication often develop when someone is walking for longer distances or exercising. The symptoms typically go away with rest. However, as PVD progresses, symptoms may get worse and become more frequent. Leg pain and fatigue may persist even while resting. Other symptoms of PVD can include:
• Leg cramps when lying down
• Hair loss on the legs
• Skin that is cool to the touch
• Thin, pale, or shiny skin on the legs and feet
• Slow-healing wounds and ulcers
• Cold, burning, or numb toes
• Weak or absent pulse in the feet
• Sensations of heaviness or numbness in the muscles
• Atrophy, which is the wasting away of muscle (in severe cases)
Diagnosis
If a person suspects they have PVD, they must see a doctor. Early diagnosis and treatment can improve the outlook for the disease and prevent severe complications.
A doctor will diagnose PVD by:
• Taking a full medical and family history, which includes looking at lifestyle, diet, and medication use
• Performing a physical examination, which includes checking the skin’s temperature and appearance and looking for a pulse in the legs and feet
• They may also order tests to confirm a diagnosis or rule out other conditions. Several other disorders can mimic the symptoms of PVD and PAD.
Tests used to diagnose PVD include:
• Angiography
• Ankle-brachial index (ABI)
• Blood tests
• Photoplethysmography (PPG)
• Treadmill exercise test
• Computed tomography angiography (CTA)
• Magnetic resonance angiography (MRA): Like a CTA, magnetic resonance angiography highlights blood vessel blockages.
• Pure volume recording (PVR)
• Ultrasound
Treatment
Effective PVD treatment aims to slow or stop disease progression, manage pain and other symptoms, and reduce the risk of serious complications.
PVD treatment plans usually involve lifestyle changes. Some people may also require medication, and severe cases may require surgical treatment.
Lifestyle changes
Lifestyle changes include:
• Engaging in regular exercise, including walking
• Eating a balanced, nutritious diet
• Losing weight if a doctor has recommended it
• Quitting smoking
Medication
Medications to treat PVD include:
• cilostazol: reduces claudication symptoms, such as muscle pain or fatigue
• clopidogrel or aspirin: prevents platelets from clumping together on top of plaque buildup
• pentoxifylline: also treats claudication, but is an older drug occasionally prescribed for individuals who cannot take cilostazol
Co-occurring conditions may also require medications to keep symptoms under control. For example, some people may need:
• statins (such as atorvastatin and simvastatin) to reduce high cholesterol
• angiotensin-converting enzyme (ACE) inhibitors for hypertension
• metformin or other diabetes medications to manage blood sugar
Surgery
Complications
If PVD is left undiagnosed and untreated, it can cause severe or life-threatening complications, such as:
• Gangrene (tissue death), which can require amputation of the affected limb
• Severe pain that restricts mobility
• Slow-healing wounds
• Potentially fatal infections of the bones and blood
Prevention
A person can reduce their risk of developing PVD by engaging in behaviours that help lower their chance of developing many other chronic diseases. Some of these behaviours include:
• Quitting smoking, or not starting
• Getting daily physical activity, such as walking, biking, doing yoga, or going to a gym
• Eating a balanced, nutritious diet that focuses on whole foods
• Maintaining moderate body weight
• Managing blood sugar, cholesterol, and blood pressure levels
