Peripheral arterial disease

Published by Bupa's health information team, healthinfo@bupa.com, April 2008.

This factsheet is for people who have peripheral arterial disease, or who would like information about it.

In peripheral arterial disease, your arteries (the blood vessels carrying blood from your heart to the rest of your body) become narrowed, restricting blood flow to the muscles in your limbs (usually just your legs). It is often associated with pain and weakness in the legs, which come on after walking.

About peripheral arterial disease

Peripheral arterial disease can happen in any artery of your body, but most commonly the disease affects the lower limbs. It's also called peripheral vascular disease.

Peripheral arterial disease usually happens when fatty deposits (plaques) build up in the walls of your arteries. This is called atherosclerosis. The fatty deposits cause your arteries to become narrower, restricting blood flow. You get pain when you start to exercise, because the muscle in your leg has to work harder and can't get enough blood.

The main concern with peripheral arterial disease is that it can mean the arteries supplying your heart (the coronary arteries) or brain are also becoming narrowed. This can cause serious problems. For more information, see Complications.

How peripheral arterial disease affects the arteries

Symptoms

Many people who have peripheral arterial disease don't even know they have it. Half of those with the disease don't have any symptoms. However, you may notice the following symptoms:

pain in the lower leg, which comes on after walking or other exercise and goes away after rest - this is the most common symptom and is called intermittent claudication
an ache, cramp, numbness or sense of fatigue in the muscles
pain in the thigh or buttock
walking more slowly than normal, finding walking difficult or not being able to walk very far

If your condition gets worse and there isn't enough blood getting to your legs, you may also develop the following symptoms:

cold and numb feet and toes, especially after you have been lying down for some time
pain in your legs coming on even when you are resting
losing hair from your feet, toes or legs

Complications

Coronary heart disease and stroke

If the arteries to your legs have become narrowed due to a build up of fatty deposits, then it is possible that the same thing could be happening in other arteries throughout your body. This can cause more serious problems.

When the arteries supplying the heart muscle become narrowed, it is called coronary heart disease. The blood supply to the heart can eventually become blocked, leading to heart failure or a heart attack. When arteries leading to, or within the brain become narrowed, it can result in a stroke.

People with peripheral arterial disease are at much greater risk of having a heart attack or a stroke.

Amputation

In most people with peripheral arterial disease, symptoms such as leg pain don't get any worse, but just stay about the same. However in a few people the condition can worsen, causing ulceration and even gangrene as the blood supply to the lower limbs is cut off altogether. When this happens, amputation may be necessary. However, this only happens in around five in 100 people with peripheral arterial disease.

There is a greater risk of your disease progressing if you have diabetes or smoke cigarettes. People who smoke are much more likely to develop peripheral arterial disease. And people who continue to smoke after being diagnosed are more likely to develop gangrene in a leg.

Causes

Peripheral arterial disease is usually caused by atherosclerosis. This is when fatty deposits build up in your arteries.

You are more likely to develop atherosclerosis if you:

are older than 50
are male
are a smoker
have diabetes
have high blood pressure
have high cholesterol
are obese
are physically inactive

Diagnosis

You should see your GP if you have trouble walking or get pain in your legs after walking. Your GP will ask about your symptoms and examine you. He or she will probably feel your feet to test for a pulse. Your GP may also ask you about your medical history.

You may have a test to compare the blood pressure in your arm and in your ankle. This is called an ankle brachial pressure index. By looking at the difference in these measurements, your GP usually tell whether you have peripheral arterial disease and how severe it is. You may be asked to do this test before and after exercise.

Sometimes, your GP may refer you to a hospital for further tests, to get an image of your blood vessels. These tests are usually only done if you are being considered for surgery, or if your GP isn't sure whether your symptoms are a cause of peripheral arterial disease or something else. You may have the following tests:

digital subtraction arteriography - this is when a dye is injected into your arteries, allowing them to show up on an X-ray image
duplex ultrasound - this uses two types of ultrasound to see how blood is moving through your arteries
magnetic resonance angiography - this uses magnets and radiowaves to produce images of your blood vessels
computed tomography angiography - this uses X-rays to make a three-dimensional picture of your blood vessels

Treatments

Treatment for peripheral arterial disease aims to at reduce your risk of heart attack and stroke, as well as helping to ease the symptoms of leg pain you may have.

Your GP will probably advise you about making lifestyle changes, as well as about any medical or surgical treatment he or she feels is necessary.

Self-help

Your GP will discuss any lifestyle changes he or she thinks will be of benefit to you. If you smoke, your GP will help you to stop, as smoking greatly increases the chances of your peripheral arterial disease getting worse.

You will probably be advised to take up regular exercise. This may include walking every day as far as you can before you feel any pain, and gradually increasing the amount you walk. This can be a very effective way of reducing pain and helping you to walk further.

If you are overweight, your GP can suggest ways to help you to lose weight.

Medicines

Your GP will want to ensure that any conditions you have that may be causing your peripheral arterial disease are being properly treated.

If you have a high cholesterol level, you may be given a type of drug called a statin. If you have diabetes, your GP will want to make sure that your diabetes is under control and being properly managed. If you have high blood pressure, you will be given medication to treat this.

You may also be given an anti-platelet drug. These drugs prevent blood clots from forming, which can lead to heart attack and stroke. Anti-platelet drugs include clopidogrel and aspirin.

There are some other drugs that can help improve blood flow to the legs. However, these aren't usually used, as there is limited evidence on how well they work.

Surgery

Surgery isn't necessary for most people with peripheral arterial disease. It is usually only done if your condition is very severe, is getting much worse, or if other treatment hasn't worked. Your GP will refer you to a vascular surgeon (a doctor specialising in conditions affecting the blood vessels) if he or she thinks you need surgery. You may have one of the following procedures.

Angioplasty - this involves inserting a tiny balloon into the affected artery with a catheter (fine tube). The balloon is inflated and then removed. This stretches the artery allowing more blood to flow through. Angioplasty is normally done under local anaesthesia. This means feeling from the area will be blocked, but you will stay awake during the procedure.
Bypass surgery - this involves creating a detour around your affected artery, with a piece of healthy blood vessel taken from somewhere else in your body. Bypass surgery is usually done under general anaesthesia. This means you will be asleep during the procedure.

Before the operation you will talk to your surgeon about the procedure and you will be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

Further information

The Circulation Foundation
020 7304 4779
www.circulationfoundation.org.uk
British Heart Foundation
08450 70 80 70 (Heart Helpline)
www.bhf.org.uk

Sources

Simon C, Everitt H, Kendrick T. Chronic peripheral ischaemia. In: Oxford Handbook of General Practice. 2nd ed. Oxford: Oxford University Press, 2005: 360
Diagnosis and management of peripheral arterial disease. Scottish Intercollegiate Guidelines Network (SIGN), October 2006. www.sign.ac.uk
Creager MA, Dzau VJ. Vascular disease of the extremities. In: Harrison's Principles of Internal Medicine, D.L. Kasper, et al. 16th ed. New York: McGraw-Hill, 2005: 1486-1494
Intermittent claudication. The Circulation Foundation. www.circulationfoundation.org.uk, accessed 17 January 2008
Burns P, Gough S, Bradbury AW., Management of peripheral arterial disease in primary care. BMJ 2003; 326:584-588
Cassar K. Peripheral arterial disease. BMJ Clinical Evidence. www.clinicalevidence.com, accessed 17 January 2008
Essential information on smoking, the heart and circulation. ASH - Action on smoking and health. www.newash.org.uk, accessed 18 February 2008