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Peripheral artery disease and intermittent

claudication

Description

An in-depth report on the causes, diagnosis, and treatment of peripheral artery disease (PAD).

Alternative Names

Peripheral arterial disease; PAD; Peripheral vascular disease;

Highlights

Peripheral Artery Disease

Peripheral artery disease (PAD) is a type of atherosclerosis. It occurs when arteries in the

limbs (most often the legs) become narrowed by cholesterol-rich material called plaque.

Because PAD interferes with circulation, advanced cases increase the risk for gangrene and

amputation. Patients with PAD are also at increased risk for other types of atherosclerosis,

including heart attacks and strokes.

Risk Factors of PAD

The main risk factors of PAD include:

• Smoking

• Diabetes

• Unhealthy cholesterol and lipid levels

• High blood pressure

• Advancing age

Symptoms

Many people with PAD do not have symptoms. When symptoms do occur, crampy leg pain

(intermittent claudication) is the main symptom. This symptom occurs off and on, usually

with exercise, and disappears when at rest. When PAD becomes more severe, symptoms can

include:

• Pain or tingling in the feet or toes, even at rest

• Weakened calf muscles

• Painful non-bleeding ulcers on the feet or toes that do not heal

Treatment

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Treatment for PAD includes both lifestyle measures and medications that help reduce

symptoms and prevent disease progression. These include:

• Smoking cessation

• Regular exercise, which is essential for patients with mild-to-moderate PAD

• Heart-healthy diet, low in saturated fat, to reduce unhealthy cholesterol levels

• Medications to help control high blood pressure and cholesterol. Other drugs that may

help include antiplatelet medications to prevent blood clots.

• In severe cases, procedures may be needed to open blocked blood vessels.

Introduction

Peripheral artery disease (PAD) occurs when the arteries in the extremities (usually legs and

feet, sometimes arms and hands) become clogged with a fatty substance called plaque. Itmost often occurs in the legs. The build-up of plaque causes the arteries to become narrow

and hard, obstructing blood flow. This hardening of the arteries is called atherosclerosis.

(Atherosclerosis that affects arteries to the heart and brain is the major process leading to

heart disease and stroke.)

PAD is a type of peripheral vascular disease, which also includes carotid artery disease, renal

artery disease, aortic disease, venous problems, and some other conditions, such as vasculitis.

Symptoms

People with peripheral artery disease (PAD) may or may not have symptoms. Because of 

symptoms may be mild or even absent, many cases of PAD go undiagnosed.

Intermittent Claudication

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Claudication comes from the Latin word "to limp." Claudication is crampy leg pain that

occurs during exercise, especially walking. The pain is due to insufficient blood flow in the

legs (caused by blocked arteries). Intermittent means the pain comes and goes. Intermittent

claudication is the most prominent symptom of PAD. About a third to a half of patients with

PAD have this symptom.

Symptoms may be felt as pain, achiness, cramping, a sense of fatigue, or nonspecific

discomfort that occurs with exercise. There is no discomfort while standing. Symptoms go

away rapidly with rest, usually within a few minutes. At first, symptoms may only

initially develop when walking uphill, walking faster, or walking longer distances.

Because the most frequently affected artery in intermittent claudication is the popliteal 

artery, symptoms are most common in the calf muscles. This artery leads off from the

 femoral artery (the major artery in the thigh). It continues below the knee where it branches

off and carries blood to the muscles in the calf and foot. Talk to your doctor about any leg or 

thigh pain you have.

Leg pain occurs in one leg in 40% of patients and in both legs in 60% of patients. Patients

may also have fatigue or pain in the thighs and buttocks.

Advanced Peripheral Artery Disease (Ischemic Rest Pain)

In advanced cases, the arteries are so blocked that even rest does not help. Leg pain that

continues when lying down is called ischemic rest pain. Ischemia is the medical term for 

insufficient blood flow to tissues.

Typical symptoms may include:

• Pain or tingling in the foot or toes, which may be so severe that even the weight of 

clothes or bed sheets cause or worsen the discomfort

• Pain worsens when leg is elevated and improves by dangling legs over the side of the

 bed

People with ischemic rest pain are at risk for ulcers and gangrene. In severe cases, amputation

may be required.

Other signs of advanced PAD can include:

• Calf muscles that shrink (wither)

• Hair loss over the toes and feet

• Thick toenails

• Shiny, tight skin

• Painful non-bleeding ulcers on the feet or toes (usually black) that are slow to heal

Sometimes, blood clots form in the arteries in the legs, producing abrupt symptoms.

Risk Factors

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About 8 million American adults have peripheral artery disease (PAD). Men and women are

equally susceptible although women face a greater risk for limb loss. African-Americans

have twice the risk for PAD as Caucasians. Between 12 - 20% of people over age 65 suffer 

from the condition.

PAD Risk Factors

The most important risk factors for PAD are the same as those for heart disease and

stroke. Smoking and high cholesterol levels increase the risk for PAD progression in large

 blood vessels (such as the legs), while diabetes increases the risk for PAD in small blood

vessels (such as the feet). Quitting smoking and controlling cholesterol are the two best ways

to slow PAD progression.

The most important risk factors for PAD include:

• Smoking . Smoking is the number one risk factor for PAD, and smoking even a few

cigarettes a day can interfere with PAD treatment. Smoking increases the risk for 

PAD by 2 - 25 times, with the danger being higher when other risk factors are present.

Between 80 - 90% of patients with PAD are current or former smokers. Progression to

a more critical state of illness is likely for patients who continue to smoke. [For more

information, see In-Depth Report #41: Smoking.]

•  Diabetes. People with type 2 diabetes have 3 - 4 times the normal risk for PAD and

intermittent claudication. In fact, their risk for PAD is higher than their risk for heart

disease. People with type 2 diabetes also tend to develop PAD at an earlier age and

have more severe cases. Patients with both diabetes and PAD are at high risk for 

complications in the feet and ankles. Poor blood sugar (glucose) control increases the

risk of developing PAD. [For more information, see In-Depth Report #60: Diabetes -type 2.]

• Unhealthy cholesterol and lipid levels. The risk for PAD increases by 5 - 10% with

every 10 mg/dL increase in total cholesterol levels. Levels of HDL ("good

cholesterol") below 40 mg/dL and high triglyceride levels also increase the risk for 

PAD. LDL ("bad cholesterol") levels should be kept below 100 mg/dL in all patients

with PAD, and probably as low as 70 mg/dL when other risk factors are present (such

as diabetes, coronary artery disease, smoking, and HDL below 40 mg/dL). [For more

information, see In-Depth Report #23: Cholesterol.]

•  Hypertension. High blood pressure, especially when combined with other 

cardiovascular risk factors, increases the chances for PAD. [For more information, see

 In-Depth Report #14: High blood pressure.]

Blood pressure is the force applied against the walls of the arteries as the heart pumps blood

through the body. The pressure is determined by the force and amount of blood pumped and

the size and flexibility of the arteries.

•  Family history of heart and artery disease. Genetic factors that cause specific lipid

and cholesterol abnormalities may increase the risk for PAD.

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•  Artery inflammation and damage. High levels of C-reactive protein can indicate

 persistent inflammation in the arteries. Such inflammation can cause significant

damage in blood vessels, and is highly associated with PAD.

•  Age. PAD occurs more frequently in people over age 50 and affects 12 - 20% of 

Americans age 65 years and older.

•  Ethnicity. African-Americans are at highest risk for PAD. They are twice as likely to

develop PAD as Caucasians.

Diagnosis

PAD is greatly underdiagnosed. Many patients do not report symptoms, or may not even have

symptoms. People should be checked for peripheral artery disease if they have leg pain

during walking, or ulcers on their legs.

Physical Examination

The doctor should check for high blood pressure, heart abnormalities, blockage(s) in the

artery in the neck, and abdominal aneurysms. The doctor should also examine the skin of the

legs and feet for color changes, ulcers, infection, or injuries, and check the pulse of the

arteries in the leg.

Ankle-Brachial Index

Intermittent claudication caused by peripheral artery disease is typically diagnosed using a

calculation called the ankle-brachial index. This method also helps to diagnose PAD in patients without symptoms of intermittent claudication.

The procedure is done as follows:

• The doctor or technician measures the systolic blood pressure of both arms while the

 patient is lying down. (The systolic pressure is the "top" number in a blood pressure

measurement. It is the force that blood exerts on the artery walls as the heart contracts

to pump out the blood. For example, in a blood pressure reading of 120/80, 120 is the

systolic number.)

• The doctor or technician then puts blood pressure cuffs on four different locations on

each leg and passes a Doppler probe over arteries in the foot. The signal emitted fromthe strongest artery is recorded as the cuffs are inflated and deflated. This is the

ankle's systolic pressure.

The doctor divides the systolic pressure in the ankle by the systolic pressure in the arm. The

result is called the ankle-brachial index (ABI), also called ankle-arm pressure index (API).

What the results mean:

•  ABI over 0.90. A normal ABI can range from 0.90 to 1.30. In general, an ABI result

over 1.0 is considered normal and results from 0.91 to 0.99 are considered borderline.

If results fall in the borderline range, and the patient has specific risk factors for artery

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disease, the patient takes a treadmill test and another ABI measurement. If the API

index drops, the doctor makes a diagnosis of peripheral artery disease.

•  ABI 0.40 – 0.80. These measurements indicate moderate impairment and symptoms

such as leg pain.

•

 ABI less than 0.40. These measurements indicate very severe blockage in the legarteries and a risk for gangrene. Patients should take precautions to avoid foot

injuries, which can increase the risk for non-healing wounds and gangrene.

Doppler Ultrasound Imaging

Doppler ultrasound imaging is commonly the first imaging test of the arteries performed and

also may be used in follow-up of patients. It is able to provide an anatomic view of the

arteries and report on velocity and flow characteristics. It is non-invasive and is usually

 performed in an outpatient setting.

Invasive Angiography, Magnetic Resonance Angiography (MRA), andComputed Tomography Angiography (CTA)

Before considering invasive procedures to treat peripheral artery disease, the surgeon needs a

 better understanding of which arteries are involved, how severe the blockage is, and the state

of the blood vessels surrounding the blockage. In the past, invasive or conventional

angiography was typically performed. This type of angiogram uses dye, which is injected

through a catheter that is inserted in the groin.

Magnetic resonance angiography (MRA) is a type of magnetic resonance imaging (MRI). It

 provides a non-invasive alternative to a traditional angiogram. The MRA uses a magneticfield and radiofrequency waves instead of radiation to provide pictures of arteries and blood

vessels. Patients are given gadolinium (a contrast material) through an IV to improve the

image quality. In many medical centers, MRA is considered almost or as accurate as invasive

angiography and will frequently be the only test required.

A newer technology called computed tomography angiography (CTA) uses x-rays to

visualize blood flow in arteries throughout the body. This technique is also highly effective in

diagnosing PAD. While it involves radiation exposure, it can be used in patients who have

contraindications to magnetic resonance imaging.

Treadmill Test

A patient is often given a treadmill test if the ankle-brachial index is questionable. Patients

with claudication have a 50 - 60% reduction in peak performance, which is comparable to

that in patients with heart failure. The treadmill test is also useful for determining the severity

of the pain while walking and assessing the effectiveness of treatments.

Waveform Analysis

A test called a wave form analysis may be used to confirm an abnormal API or pressure

reading. The patient lies on their back for at least 10 minutes in a warm room (so that the

 blood vessels will not narrow). The leg is turned outward, and the knee is slightly bent. The

doctor passes a handheld scanner over the leg, which picks up sound waves coming from the

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arteries. These signals are recorded, and the wave forms are traced to detect abnormal blood

flow.

Tests for Detecting Heart Disease

Patients with suspected PAD should have an electrocardiogram (ECG, EKG) and other teststhat can detect heart problems.

The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease,from congenital heart disease in infants to myocardial infarction and myocarditis in adults.

There are several different types of electrocardiograms.

Ruling out Other Disorders with Similar Symptoms

A number of other tests may be ordered to rule out disorders with similar symptoms. Such

disorders include:

• Arthritis

• Anemia

• Spinal stenosis -- narrowing of the spinal canal causing leg or lower back pain

Click the icon to see an image of spinal stenosis.

• Thrombophlebitis -- blood clots in the deep veins of the legs

•

Click the icon to see an image of deep venous thrombosis. 

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• Peripheral neuropathy -- nerve damage in the legs and feet, usually in people with

diabetes

•  Night cramps in older people that are not due to problems in blood vessels

• Muscle entrapment of the arteries or kinks in the arteries in the leg -- typically occurs

in young athletes

Complications

Coronary Artery Disease and Stroke

Patients with peripheral artery disease (PAD) have the same risk of death from heart events

or stroke as people already diagnosed with heart disease. The risk increases as PAD gets

worse. The worse the leg condition, the poorer the overall health of the patient.

If patients have blood clots and blockages in other arteries (brain, heart) as well as the legs,the risk for any vascular complication involving the heart, the brain, or the leg arteries

increases much more.

Acute Occlusion

In rare cases, blood clots can develop suddenly in a major artery in the leg -- a condition

called acute occlusion. Symptoms include numbness, pain, coolness, pale color, lack of pulse

in the artery, and weakness. This is a very serious event, which can lead to amputation or 

even loss of life. Treatment options include clot-busting drugs delivered to the blockage

or procedures to remove the clot.

Poor Physical and Mental Functioning

Peripheral artery disease can significantly impair daily physical functioning. Claudication

 pain severely limits physical activity. Even worse, intermittent claudication increases the risk 

for falling, usually because of unsteadiness, regardless of the severity of PAD. Intermittent

claudication and PAD are also associated with mental decline.

Treatment

There are two treatment goals for PAD and claudication:

• Manage the pain of intermittent claudication, improve functioning, and prevent PAD

from getting worse, so that gangrene does not occur.

• Reduce the risk for cardiovascular disease (heart attack and stroke).

Lifestyle changes, especially smoking cessation and exercise, are critical for every patient

with PAD. Medication is often required to improve function and protect the heart. In very

severe cases, surgery may be needed to improve blood flow.

Treatment for PAD also involves managing the medical conditions (diabetes, high

cholesterol, and high blood pressure) that often accompany it.

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Managing Diabetes

Patients with diabetes need to strictly control their blood sugar (glucose) levels. Poor 

glycemic control is associated with vascular and circulation complications such as PAD.

Patients should aim for an A1C level around 7%. The AIC test measures a patient’s average

 blood sugar over the past 2 - 3 months. Patients with diabetes need to follow certain dietaryrestrictions. Many different types of medications are used to control blood sugar levels. [For 

more information, see In-Depth Reports #60: Diabetes type 2, #09: Diabetes type 1, and #42:

Diabetes diet.]

Managing Unhealthy Cholesterol and Lipid Levels

It is very important for people with PAD to keep their LDL ("bad" cholesterol) levels to

 below 100 mg/dL. If patients have serious heart disease risk factors (high blood pressure,

diabetes, other unhealthy lipids) in addition to PAD, they may need to aim for LDL levels

 below 70 mg/dL. Unhealthy cholesterol levels are major contributors to atherosclerosis, the

common factor in PAD and heart disease. Patients should avoid saturated fats and foods that

are high in cholesterol. A statin drug may is the most common type of medication used to

help lower LDL cholesterol and improve lipid profiles.

Statins include:

• Lovastatin (Mevacor, generic)

• Pravastatin (Pravachol, generic)

• Simvastatin (Zocor, generic)

• Fluvastatin (Lescol)

• Atorvastatin (Lipitor, generic)

• Rosuvastatin (Crestor)

• Pitavastatin (Livalo)

[For more information, see In-Depth Report #23: Cholesterol.]

Managing High Blood Pressure

In addition to dietary measures to reduce sodium (salt) and increase potassium intake, various

medications are used to control high blood pressure (hypertension). Patients with PAD should

aim for blood pressure less than 130/80 mm Hg.

Evidence suggests that the best drugs for patients with high blood pressure and PAD are

angiotensin-converting-enzyme (ACE) inhibitors. These drugs block the effects of the

angiotensin-renin-aldosterone system, which is associated with many harmful effects on the

heart and blood vessels. They are important drugs for patients with PAD and diabetes who

also have high blood pressure. In addition to heart protection, ACE inhibitors may help

reduce pain that patients experience when walking.

ACE inhibitors include:

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• Captopril (Capoten, generic)

• Enalapril (Vasotec, generic)

• Quinapril (Accupril, generic)

• Benazepril (Lotensin, generic)

• Ramipril (Altace, generic)

• Perindopril (Aceon, generic)

• Lisinopril (Prinivil, Zestril, generic)

[For more information, see In-Depth Report #14: High blood pressure.]

Lifestyle Changes

Quit Smoking

Patients who smoke should quit, and everyone should avoid second-hand smoke. Smoking is

one of the primary risk factors for PAD and a major cause of complications. Quitting

smoking may not make leg pain go away, at least not in the short term, but it certainly may

keep blockages from getting worse. Continued smoking is associated with the majority of 

 patients who progress from milder forms of PAD to critical limb ischemia involving severe

 pain, skin ulcers, and possible amputation. Smoking cessation also reduces the risk to the

heart.

Exercise

Exercise is second only to avoiding tobacco as the most important lifestyle measure for 

treating, and preventing, PAD.

 Exercise to Help the Heart . The benefits of regular moderate exercise for the heart are

undisputed. People who maintain an active lifestyle have a much lower risk of developing

heart disease than do sedentary people. And, according to the American Heart Association,

 patients with PAD who are physically active have death rates that are a third of those who are

less physically active.

 Exercise Training to Improve Blood Flow in the Legs. Exercise training improves blood flow

in the legs and, in some cases, can work as well as medications and surgical procedures in

increasing pain-free walking distance. To maintain benefits, exercise must be regular and

consistent. A regular walking program, either outside or on a treadmill, is the best type of 

exercise for patients with PAD and can significantly slow the rate of functional decline.

For patients with intermittent claudication who find that their leg cramps make it difficult to

walk or participate in lower-extremity exercise, upper-body aerobic exercise can still provide

 benefits.

Eat Healthy

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The goals of a heart-healthy diet are to:

• Reduce overall cholesterol levels and low-density lipoproteins (LDL), which are

harmful to the heart

• Increase high-density lipoproteins (HDL), which are beneficial for the heart

• Reduce other harmful lipids (fatty molecules) such as triglycerides and lipoprotein(a)

Any diet should also help keep blood pressure and weight under control. General guidelines

for a heart-healthy diet include:

• Choose fiber-rich food (such as whole grains, legumes, and nuts) as the main source

of carbohydrates, along with a high intake of fresh fruits and vegetables.

Dietary fiber is the part of food that is not affected by the body's digestive process. Only a

small amount of fiber is metabolized in the stomach and intestine. The rest is passed through

the gastrointestinal tract and makes up a part of the stool. There are two types of dietary fiber,

soluble and insoluble. Soluble fiber retains water and turns to gel during digestion. It also

slows digestion and nutrient absorption from the stomach and intestine. Soluble fiber is found

in foods such as oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits andvegetables. Insoluble fiber appears to speed the passage of foods through the stomach and

intestines and adds bulk to the stool. It is found in foods such as wheat bran, vegetables, and

whole grains. Fiber is very important to a healthy diet and can be a helpful aid in weight

management. One of the best sources of fiber comes from legumes, the group of food

containing dried peas and beans.

• Avoid saturated fats (found mostly in animal products) and trans fatty acids (found in

hydrogenated fats and many commercial baked products and fast-foods). Choose

unsaturated fats (particularly omega-3 fatty acids found in vegetable and fish oils).

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•

Click the icon to see an image of saturated fats. 

•

Click the icon to see an image of trans fatty acids. 

• When selecting proteins, choose soy protein, poultry, and fish over meat.

• Weight control, quitting smoking, and exercise are essential companions of any diet

 program.

[For more information, see In-Depth Report #43: Heart-healthy diet.]

Vitamins

Vitamins have not been proven to reduce the risk for PAD or heart disease. Low levels of 

vitamin D have been linked to an increased risk of PAD and many older Americans are

deficient in this vitamin. More research is needed to determine if vitamin D supplements

 protect against PAD. Deficiencies in the B vitamins folate and B12 have been linked with

elevated levels of homocysteine, an amino acid that has been associated with a higher risk for 

heart disease and PAD. However, while vitamin supplementation lowers homocysteinelevels, it has no effect on heart disease outcomes. Vitamin E has also not been shown to help

with symptoms.

Herbs and Supplements

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA

approval to sell their products. Just like a drug, herbs and supplements can affect the body's

chemistry, and therefore have the potential to produce side effects that may be harmful. There

have been a number of reported cases of serious and even lethal side effects from herbal

 products. Always check with your health care provider before using any herbal remedies or 

dietary supplements.

Gingko biloba is an herbal remedy reported to have blood-thinning properties. However,

studies have shown it does not provide any benefit for patients with PAD or intermittent

claudication. Although the risks for gingko appear to be low, there is an increased risk for 

 bleeding at high doses and harmful interaction with high doses of anti-clotting medications.

This is particularly important because patients with PAD often use these types of 

medications. Commercial gingko preparations have also been reported to contain colchicine,

a chemical that can be harmful in pregnant women and people with kidney or liver problems.

Medications

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Treatments for PAD help manage leg pain and improve function, as well as reduce the risk 

for heart attack and stroke. Drugs used for improving leg pain and function are generally

those that either prevent blood clots (typically antiplatelet drugs) or improve blood flow.

Aspirin and Other Antiplatelet Drugs

Antiplatelet drugs such as aspirin reduce the risk for blood clots. Most patients with

 peripheral artery disease receive antiplatelet medication. For the most part, this

recommendation is made to prevent future death from heart attack or stroke. (However,

recent studies have indicated that aspirin may not have much benefit in preventing heart

attack or stroke in patients who have PAD without also having heart disease.) Antiplatelet

drugs may or may not provide benefit for PAD symptoms and progression.

Aspirin is usually the recommended first-line choice. Clopidogrel (Plavix, generic) is

recommended as an alternative.

Dipyridamole (Persantine, generic) may help prevent complications of PAD when taken

along with aspirin. Studies are mixed on the benefits of the combination. Without aspirin, the

drug does not appear to have any advantages for patients with PAD.

Research indicates that adding an anticoagulant drug, such as warfarin (Coumadin, generic),

to antiplatelet therapy does not help prevent heart complications of PAD, and can increase the

risks for life-threatening bleeding.

[For more information on these drugs, see In-Depth Report #03: Coronary artery disease.]

Phosphodiesterase Inhibitors

Phosphodiesterase inhibitors are drugs that help improve blood flow.

Cilostazol. Cilostazol (Pletal, generic) is used to treat disabling intermittent claudication. A

number of studies have reported that the drug helps improve walking distance and quality of 

life. It also helps improve HDL and triglyceride levels. Cilostazol works better than

 pentoxifylline, the first drug approved for claudication. It is expensive, however, and

currently recommended only for patients with moderate-to-severe intermittent claudication

who do not respond to aspirin or less costly treatments. Common side effects include

headache, swelling in the limbs, and stomach problems such as diarrhea and flatulence (gas).

It does not appear to have bad effects on the liver or kidney. Similar drugs have had seriousside effects in patients with heart failure, so these patients should avoid cilostazol.

 Pentoxifylline. Pentoxifylline (Trental, generic) reduces the sticky properties of blood,

improving its flow. It is approved in the U.S. for managing claudication, although doctors do

not recommend its routine use. Studies regarding the drug's effectiveness have been mixed.

Some studies have reported a small effect on walking ability; another found the drug

significantly improved walking distance. Other research has found that the drug does not

work any better than a dummy pill (placebo). The most common side effects include

headache, nausea, heartburn, flatulence (gas), dizziness, blurred vision, and flushing.

Thrombolytics (Clot-Busters)

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Alteplase (Activase), also called t-PA, and reteplase (Retavase) are thrombolytic drugs. Such

drugs are commonly called "clot-busters." They break up existing clots, and may be used in

cases of acute vascular occlusion (the sudden development of a blood clot). They may also be

used if a clot is present. Researchers are investigating whether thrombolytics are an effective

alternative to surgery in severe cases of PAD. In severe cases, the drugs can be delivered

directly into the artery.

Other Drugs Used to Treat Intermittent Claudication

 ACE Inhibitors. ACE inhibitors are a type of drug used to treat high blood pressure. The ACE

inhibitor ramipril (Altace, generic) is often recommended for patients with symptomatic

 peripheral artery disease, primarily to reduce the risk of cardiovascular events.

Surgery

In severe cases, surgery may be needed to open blocked blood vessels. Many surgical procedures can be performed. These include open bypass procedures, which connect an artery

 before the location of the obstruction to an artery below the obstruction, or minimally

invasive endovascular techniques such as angioplasty and stenting. The location of the

lesions and how many other risk factors and illnesses patients have often determine which

 procedure is chosen.

Surgery is generally performed for claudication that has become disabling despite full

medical and exercise therapy. Surgery may also be necessary for patients with rest pain, and

to save a limb when a patient develops critical limb ischemia and is in danger of amputation.

Leg Bypass Surgery

For many years, leg bypass surgery was the main type of surgery used for extensive PAD.

This procedure involves the creation of a tube (graft) that acts as a new blood vessel. Grafts

can be made from synthetic material (artificial vein) or from a vein taken from a different

location in the patient's leg (natural vein). The graft reroutes blood flow in the leg, around the

 blocked artery. Possible bypass connections between arteries include aorta to iliac arteries,

aorta to femoral arteries, and bypass between the femoral artery and popliteal, tibial, and

 peroneal arteries.

Artificial veins tend to pose a much higher risk for blood clots, and the consequences of re- blockage are must more severe than when the natural vein recloses. To keep the artificial vein

open, oral anti-clotting drugs such as aspirin or warfarin may be used. (Such drugs do not

work with natural vein bypass.)

In general, less invasive procedures, such as balloon angioplasty and stenting, are now more

frequently performed.

Percutaneous Transluminal Angioplasty

Percutaneous transluminal angioplasty (PTA) is an approach that has several variations. The

object of the procedure is to open the blocked blood vessels that are causing intermittent

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claudication. Angioplasty is being increasingly used in place of leg bypass surgery, especially

in patients who have other medical conditions.

The PTA procedure requires only a local anesthetic. Patients can return to normal activity in

24 - 48 hours. Complication rates are low. The effects are not permanent, but the procedure

can be repeated without any greater risk than with the original one.

Anticoagulants (such as warfarin or heparin) and antiplatelets (such as aspirin) may be used

to prevent blood clots occurring during surgery. All of these drugs increase the risk for 

 bleeding. Thrombolytic drugs may be used before, during, or after angioplasty if a blood clot

is present.

 Balloon Angioplasty. The standard procedure is balloon angioplasty. A thin tube is inserted

through an artery in the groin and passed through the blocked artery. A wire is threaded

through the tube. A deflated balloon is passed over the wire to the blockage. When inflated, it

opens the artery.

Because of the risk for reclosure from blood clots after balloon angioplasty, various other 

 procedures are used or are being investigated.

Stenting . Reblockage of the blood vessels from blood clotting, even long after surgery, is an

important complication. To help prevent this complication, and repeat surgery, a tiny

expandable metal mesh tube (stent) is often used along with angioplasty. However, even with

stents, some patients experience new blockages within a year of surgery. Some angioplasties

are performed with a drug-eluting stent, which is coated with the drug paclitaxel to help

 prevent artery blockages.

Drug-eluting stents may not be recommended for patients who had recent heart surgery, or 

women who are nursing or pregnant. Patients who receive a drug-eluting stent may need

 blood thinning drugs for at least several months.

Resources

• www.padcoalition.org -- Peripheral Arterial Disease Coalition

• www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute

• www.heart.org-- American Heart Association

• www.acc.org -- American College of Cardiology

• www.diabetes.org -- American Diabetes Association

• www.vdf.org -- Vascular Disease Foundation

• www.sirweb.org -- Society of Interventional Radiology

References

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Aboyans V, Criqui MH, Denenberg JO, Knoke JD, Ridker PM, Fronek A. Risk factors for 

 progression of peripheral arterial disease in large and small vessels. Circulation. 2006 Jun

6;113(22):2623-9.

Alonso-Coello P, Bellmunt S, McGorrian C, Anand SS, Guzman R, Criqui MH, et al.

Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Preventionof Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical

Practice Guidelines. Chest . 2012 Feb;141(2 Suppl):e669S-90S.

Arain FA, Cooper LT Jr. Peripheral arterial disease: diagnosis and management.  Mayo Clin

 Proc. 2008 Aug;83(8):944-49; quiz 949-50.

Aung PP, Maxwell HG, Jepson RG, Price JF, Leng GC. Lipid-lowering for peripheral arterial

disease of the lower limb. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000123.

Berger JS, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular 

events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA.2009 May 13;301(18):1909-19.

Collins R, Burch J, Cranny G, Aguiar-Ibáñez R, Craig D, Wright K, et al. Duplex

ultrasonography, magnetic resonance angiography, and computed tomography angiography

for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease:

systematic review. BMJ. 2007 Jun 16;334(7606):1257. Epub 2007 Jun 4

Creager MA and Libby P. Peripheral arterial disease. In: Bonow RO, Mann DL, Zipes DP,

Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed.

Saunders; 2012:chap 61..

Fowkes FG, Price JF, Stewart MC, Butcher I, Leng GC, Pell AC, et al. Aspirin for prevention

of cardiovascular events in a general population screened for a low ankle brachial index: a

randomized controlled trial. JAMA. 2010 Mar 3;303(9):841-8.

Garg PK, Tian L, Criqui MH, Liu K, Ferrucci L, Guralnik JM, et al. Physical activity during

daily life and mortality in patients with peripheral arterial disease. Circulation. 2006 Jul

18;114(3):242-8.

Hamburg NM, Balady GJ. Exercise rehabilitation in peripheral artery disease: functional

impact and mechanisms of benefits. Circulation. 2011 Jan 4;123(1):87-97.

Hirsch AT, Allison MA, Gomes AS, Corriere MA, Duval S, Ershow AG, et al. A Call to

Action: Women and Peripheral Artery Disease: A Scientific Statement From the American

Heart Association. Circulation. 2012 Mar 20;125(11):1449-1472. Epub 2012 Feb 15..

McDermott MM, Ades P, Guralnik JM, Dyer A, Ferrucci L, Liu K, et al. Treadmill exercise

and resistance training in patients with peripheral arterial disease with and without

intermittent claudication: a randomized controlled trial. JAMA. 2009 Jan 14;301(2):165-74.

Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of 

computed tomography angiography in peripheral arterial disease: a systematic review andmeta-analysis. JAMA. 2009 Jan 28;301(4):415-24.

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Olin JW, Allie DE, Belkin M, Bonow RO, Casey DE Jr, Creager MA, et al.

ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with

 peripheral artery disease: a report of the American College of Cardiology

Foundation/American Heart Association Task Force on Performance Measures, the American

College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for 

Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular  Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical

Performance Measures for Peripheral Artery Disease). J Am Coll Cardiol . 2010 Dec

14;56(25):2147-81.

Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart

disease and stroke statistics--2012 update: a report from the American Heart Association.

Circulation. 2012 Jan 3;125(1):e2-e220. Epub 2011 Dec 15.

Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, et al. 2011

ACCF/AHA Focused Update of the Guideline for the Management of Patients With

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Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT,Creager MA, Franklin BA, et al.

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Version Info

• Last Reviewed on 05/24/2012

• Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard

Medical School; Physician, Massachusetts General Hospital. Also reviewed by David

Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation

HealthCare Commission (www.urac.org). URAC's accreditation program is an independent

audit to verify th

Single Herbs

• Bayberry - Astringent, internal and external bleeding, sinus drainage, diarrhea.

• Bee Pollen - Contains all known vitamins and essential amino acids, many minerals,

enzymes, coenzymes; used to increase energy, reduce allergic response in hay fever,

improve athletic performance. Good source of Potassium.

• Bilberry - aids eye problems such as failing vision, night vision, glaucoma, cataracts,

irritated and tired eyes.

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• Black Walnut - high in iodine for thyroid. Used for hemorrhoids, intestinal worms,

fungus, cold sores, fever blisters. Antifungal and antiparasitic. Useful also for pets.

• Blessed Thistle - strengthens liver, purifies blood, helps hormonal imbalances.

Increases flow of breast milk for nursing mothers. Use for teenage acne, menstrual

 problems, loss of memory.

• Burdock - helps skin and liver problems. Stimulates the flow of bile and purifies the

 blood. Used for acne, arthritis, blood poisoning.

• Butcher's Broom - prevents blood clots, cleans and tones veins, is useful for varicose

veins, spider veins, hemorrhoids, stroke preventive because it strengthens arteries and

veins, increases circulation in the legs, useful for "heavy legs" or the feeling legs get

when circulation is bad. The ancient healers have said that butcher's broom can make

the lame get up and walk .

• Capsicum (Cayenne pepper) - promotes circulation, improves high or low blood

 pressure, stimulates digestion, clears congestion, helps stop bleeding; useful for  bleeding ulcers, fibroids, highest form of vitamin C.

• Chickweed - contains saponins which break down fats and suppress the appetite.

Helps with weight loss, fatty congestion in the liver and fatty tumors. Mildly diuretic.

Used topically for itching.

• Cordyceps - strengthens the immune system. Builds strength and endurance. Eases

chronic cough and coughing of blood; builds up weak lungs. Used for impotence and

menopausal problems.

•

Cornsilk - soothing diuretic used for kidney and bladder inflammation, painfulurination, water retention, high blood pressure.

• Damiana - a natural aphrodisiac for enhancing sexual drive in men and women. Helps

 prostate inflammation. Blood purifier. Eases nervous anxiety and depression.

• Dandelion - a blood purifier or alterative and diuretic. High in potassium. Used for 

anemia, arthritis, jaundice, water retention, stomach troubles and liver problems.

• Devil's Claw - anti-inflammatory used for joint pain, backache and some types of 

headaches. Stimulates digestion. Can be used topically for boils, sores and wounds.

• Dulse - a seaweed rich in iodine used to promote thyroid health. Helps the skin.Iodine is needed for healthy heart and it is known that an iodine deficiency is

responsible for vitamins not being properly assimilated in the body. *See Dulse

liquid.

• Eyebright - used topically as an eyewash for cataracts, inflamed eyes and lids, pink 

eye. Used internally for upper respiratory congestion, hay fever and headaches.

Reduces swelling in the Eustachian tubes to ease or prevent earaches. Has been used

successfully for optical neuritis (inflammation of the optic nerve). *See Perfect Eyes

combination.

•

Guggul Lipid - shown to lower cholesterol by over 20% without dietary changes. prevents blood clots, strengthens the heart and helps with weight loss.

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• Hawthorn Berries - used to strengthen the heart and prevent heart disease. Improves

the tone, oxygen uptake and circulation of the heart muscle. Dilates blood vessels and

normalizes high or low blood pressure. *See HSII combination.

• Ho Shou Wu - Means Black Haired Man. A Chinese herb used as an anti-aging tonic.

Reported to help restore color to gray hair. Helps lower cholesterol.

• Horsetail - high in natural silica, a mineral important to the health and formation of 

 bone, hair, skin, nails. Also used for urinary disorders and blood in urine.

• Hydrangea - calcium solvent. Helps dissolve kidney and bladder stones, bone spurs,

calcifications. Takes pain out of kidney stones passing in ureters.

• Juniper berries - stimulating diuretic. Used for water retention, difficulty passing

urine, bladder and urinary problems. Avoid if kidney inflammation.

• Kava Kava - Calms the nerves relieving nervousness, anxiety, tension, insomnia.

Produces a sense of well-being. Relaxes muscle spasms, can be helpful for backache,cramps. Also used for urinary and bladder infections.

• Maca - used to increase sexual desire and stamina in both men and women. As a tonic

and adaptagen it reduces stress, enhances energy, improves mental concentration and

general health and well-being.

• Marshmallow - mucilaginous herb that soothes and reduces irritation in the digestive

system, urinary passages and lungs. Used for dry cough, irritated bladder, inflamed

kidneys and intestinal inflammation.

• Milk Thistle - protects the liver against poisons and environment toxins. Stimulates

 bile and production. Helpful for hepatitis and other liver disorders enriches and

increases breast milk in nursing mothers.

• Mullein - strengthens and dehydrates the lungs in chronic, degenerative respiratory

disease. Use for lung congestion, chest colds, bronchitis, croup.

•  Noni - the juice is alkalizing and antioxidant, reduces inflammation, and strengthens

the immune system by increasing white blood-cell count. May be helpful with type II

diabetes and arthritis. A tonic for the kidneys.

• Oregon Grape - anti-microbial properties similar to goldenseal. Used for bacterial and

viral infections (especially in children). Alterative and blood purifier for skineruptions. Can also be applied topically for skin eruptions and itching.

• Pau d'Arco - anti-fungal for yeast infections such as athlete's foot and Candida. Has

antibiotic properties which treat viruses, fever, infections, cold, flu, respiratory and

circulatory problems. Used in arthritis and AIDS.

• Red Yeast Rice - helps to lower cholesterol production in the liver, naturally, which

lowers blood cholesterol levels.

• Safflowers - relieves digestive problems even in children - very mild. Strengthens the

liver and gallbladder. Helps to break fevers by inducing perspiration. Neutralizes

lactic acid.

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• Sage - astringent and antiseptic. Reduces night sweats and excessive perspiration.

Used for dyspepsia, sore throat, night sweats.

• Saw Palmetto - tones the male reproductive system, relieving symptoms of benign

 prostatic hypertrophy and enhancing male sex hormones. Also helps with weight loss,

respiratory and digestive weakness.

• Slippery Elm - absorbs toxins from the GI tract and calms and soothes the entire

digestive system. A mild bulk laxative, also useful for diarrhea, especially in children.

 Nutritive food for sick children and the elderly. Balances diarrhea and constipation.

• Spiralina - source of easily digested proteins, vitamins, minerals. Brings a full feeling

to those trying to lose weight and provides all the essential amino acids. Useful for 

toxicity and fatigue, said to balance negative and positive polarity.

• Stevia - a naturally sweet herb used as a substitute for sugar in diabetes and

hypoglycemia. Helps balance blood sugar.

• Uva Ursi - strong diuretic and astringent which disinfects the urinary tract. Used for 

kidney and bladder infections, incontinence. See Urinary Maintenance Formula

• White Oak Bark - astringent used for diarrhea, hemorrhoids, varicose veins. Has

antiviral and antimicrobial activity. Helps sore throat, bleeding gums, canker sores in

mouth.

• Wild Yam - antispasmodic and anti-inflammatory, helps intestinal cramps and pain,

menstrual cramps, rheumatism and diarrhea. Has been used for natural birth control,

 but does not contain progesterone.

• Wood Betony - a sedative that helps calm tension headaches and hyperactive children.

Also used for tics, spasms and Bell's palsy.

• Yarrow - Astringent, styptic and wound healer with antiseptic action. Stops bleeding

and reduces pain in bleeding wounds. Powerful herb for reducing fevers. Also helpful

for colds, flu and lymphatic congestion.

• Yellow Dock - blood purifier which strengthens the liver and increases the flow of 

 bile. Used for skin rashes and jaundice. Improves assimilation of iron in anemia.

Helpful for skin eruptive diseases like measles and chicken pox.

• Yucca - blood-purifier and anti-inflammatory. Has been used to help problems suchas arthritis and infection of the bowel. Natural alternative to cortisone drugs.