What is peripheral arterial disease?

This is the technical term that is used by doctors to describe circulatory problems to the legs. It describes a complex process in the arteries called arteriosclerosis. Arteries are the blood vessels that take the blood from the heart to the rest of the body supplying oxygen. Arteriosclerosis means fatty and calcium deposits building up in the vessel wall over time. These deposits we also call plaque. You may have heard of the process of arteriosclerosis by the term of "hardening" or "narrowing" of the arteries. Some people also talk about "claudication" when they refer to arteriosclerosis in the legs, but this is rather a symptom and we will explain this in the next section.

What are the symptoms of PAD?

The main symptom of PAD is called claudication.
Claudication is the pain you feel in your legs when taking exercise, such as walking. It is often experienced as a cramp in the calf that starts after a certain distance. Once the patient stops walking the pain eases off and the patient is able to walk the same distance again. Then the same scenario starts all over again. The explanation to this phenomenon is fairly easy. As you may remember from above the arteries supply oxygen to the body. When walking our muscles need a lot of oxygen to function. If you have PAD not enough blood can squeeze through the narrowed bit of artery leaving the muscle starving for blood and oxygen: It starts hurting. Stopping walking decreases the need of oxygen as the muscle relaxes. Enough blood gets down there despite the narrowing: the pain goes away.

 In some cases the narrowing is very severe or an artery is even blocked. This may mean that the leg is not getting enough blood even when resting. Then symptoms can occur like rest pain. Here especially the toes hurt all the time particularly at night. You may also see some bluish discolouration. If left untreated a toe can turn black or an ulcer can form on the leg. But don't worry claudication always comes first, so generally there is plenty of time to treat things. But the above symptoms may be something to look out for if you have elderly relatives that are not very mobile anymore.

Why do the arteries narrow?

Atherosclerosis happens to a certain degree in the arteries of every one as we get older. In healthy individuals the degree remains minimal though and will never cause any symptoms. However there are certain risk factors, which will increase the severity of the arteriosclerosis and therefore its symptoms dramatically. These are:

• smoking! This is the number one risk factor. If you do smoke it is almost certain that you will suffer from PAD at some stage of your life. All the toxins in the smoke attack and damage the vessel walls severely and irreversible. It does not matter whether you smoke cigarettes, cigars, pipe or something else. Also it does not matter how much you smoke. This will only effect the timespan until the first symptoms show.

• high cholesterol: some of this is genetic, but your diet does play a vital role here. Cholesterol is blood fat and this sticks to the vessel wall.

• high blood pressure: this leads to permanent mechanical stress onto vessel wall and makes it loose its elasticity thus helping deposits to form

• diabetis: good blood sugar control is essential. Poor control disturbs the nutrition in the blood vessel cells and damages especially the small arteries.

Arteriosclerosis is a condition, which occurs elsewhere in the body, such as the coronary arteries of the heart. There is therefore a similarity between PAD and angina pains in the chest caused by narrowing of the coronary arteries. Indeed, patients with one condition often suffer from the other.

Does the blockage ever clear itself?

Unfortunately not. Arteriosclerosis is a progressive disease. Unfortunately we can not heal it, but only slow it down or stop it. Even if we do surgery we can only treat the symptoms, but the disease will still remain there. That is why risk factor management is so important! However the situation can improve with ideal treatment, because smaller arteries (the collateral circulation) may enlarge to carry blood around the blockage in the main artery.

Is PAD very common?

• Yes! Much depends on age, it is very low for people under the age of 60, but increases with age. There are various reports about what percentage of the population is actually affected. It is more common in men than women with a ratio of about 2:1. Although this ratio seems to shift towards 1:1 in the modern western world, as more and more women share the same risk factors as men. A recent study from Sweden (Sigvant et al.) estimated the prevalence (occurance rate) to be 7.2% in men and 6.5% in women.

What can I do about claudication or even prevent it?

Control your risk factors!

• If you smoke, stop! This is the most important step! It will help to reduce your symptoms. In case you need some sort of surgery it will ensure that the achieved improvement lasts as long as possible.
• Keep walking! Exercise increases the amount of blood that the arteries can carry to the muscles in your legs. This is because increases the amount of collateral circulation in your legs. So join a gym, go swimming, cycle or take regular walks/ hikes. Do not be afraid: We do not expect anyone to compete at olympic level, but every little helps.
• If you are overweight, try to lose weight. It is important not to be overweight. This is because the more weight the legs have to carry around the more blood they will need. Also it will decrease your risk of complications in case you will need surgery later on.
• Make sure your diabetis and blood pressure are well controlled. See your GP or specialist nurse regularly.
• Take care of your feet. Make sure you do not develop pressure sores from ill fitting shoes or suffer from any open wound. These may heal very poorly due to the limited blood supply and may cause to make your situation to become much worse.

When will my GP refer me?

If your symptoms are severe enough, your GP may refer you to a vascular surgeon who can discuss the treatment options with you.

What happens at the consultation with the vascular surgeon?

You will be seen by one of our vascular consultants or a senior member of their team in outpatients clinic. We will want to hear about your complaints and take your history. Questions we may ask involve for example: the type of pain, where in your legs you get it, when you get the pain and how far you can walk before the pain starts. Questions about your medical history include smoking, diet and exercise.

We will also wish to examine you, which includes checking the pulses in your groin and legs. This will involve you having to take off the trousers and socks. Of course your decency will be respected at all times.

Often we use a small machine called Doppler to listen to the blood flow in your arteries. At that time we would also measure the blood pressure in your legs. This works pretty much in the same way as you know it from your GP practice, just that we do it on the legs and not the arm.

If your symptoms are quite severe the surgeon will usually ask you to attend the vascular studies laboratory, where you will have a duplex ultrasound scan.  This enables us to actually see the arteries and the blood flow in them. The duplex scan is completely harmless and painless and gives an indication of the site of disease in an artery and its severity.  The duplex scan may happen at your same clinic appointment or it may be scheduled for your next one.

At the end of your appointment we will explain our findings and give you treatment advice.

How will I get treated?

Treatment for claudication compromises three types, conservative, minimally invasive procedures ("key hole surgery"/ angioplasty)  or open surgical reconstruction:

Conservative treatment

Luckily only the vast minority of people we see will require surgery. Most patients will be sufficiently treated with conservative management for the time being. This will involve advice to help improve your symptoms, such as that outlined earlier. So once again: the most important thing is to control your risk factors! Exercise is also important, as explained before, to help your blood find alternative routes. You may also be prescribed medications to help the arterial disease, which will thin your blood and help to stabilise the plaque. These you will usually have to take life long. You then will be given a follow up appointment, so we can check on your progress.

What if you require surgery?

If we think that you do require surgical treatment we will organise some more tests. This will be an angiogram or an MR-scan. For the angiogram we will puncture your groin and inject some dye. Then we can see your blood vessels exactly. For an MR-scan you will have to go to one of the big x-ray machines. If you had a similar investigation before you will remember as they look like a big doughnut. Then we can decide what sort of surgery you need. Any procedure will be done as an inpatient. That means you will have to attend a special clinic usually one week prior to admission. Here a nurse and a doctor will examine you again and take your history to ensure that you have not gotten ill (i.e. flu or chest infection) in the intervening period.

Then you will get admitted for your procedure. The length of stay depends on the kind of procedure you require.

Angioplasty/stenting

Sometimes we can do the angioplasty in the same session as the angiogram. These procedures are performed in the vascular suite, which is located in the X-ray department. During an angioplasty the radiologist inflates a small balloon inside the narrowed blood vessel. This widens the blood vessel and helps to improve blood flow. After widening the vessel with the balloon a stent may or may not be inserted, depending on the circumstances. A stent is a tiny metal tube made of mesh which helps to keep the blood vessel open.

Angioplasty and stenting is performed via a small puncture in the skin through which a small tube called a catheter is inserted. An x-ray machine guides the catheter to the site of the narrowing, and the balloon or stent is deployed from the tip of the catheter. A local anaesthetic will be used at the puncture site. So you will be awake during the procedure as it it generally painless. However, if you wish we can give you some medication that will help you to relax and maybe even have a little nap.

After your angioplasty you will usually be required to stay in hospital overnight. Often you can go home the next day. The vascular surgeon will follow you up in six weeks time.

Bypass surgery

The more complex disease often requires open surgery. Most of the time this will be bypass surgery. In this type of surgery we create a new road for the blood to take down your leg by connecting a "new" vessel to the original one in front and beyond the blockage. So a bypass is a diversion for the blood. Ideally we use one of your leg veins that you do not need, but sometimes we will have to use an artificial tube made from a special textile. Bypass grafting usually requires that you will go under general anaesthetic. Before the procedure you will be seen by a senior member of the team. The procedure will be explained in detail again. All the questions you may still have will be answered and afterward you will have to sign the consent form.

After the operation you can expect to stay in hospital for 5 to 10 days, depending on the procedure, until your wounds have healed and you can walk comfortably. We will then see you again in our clinic six weeks after discharge.