When cholesterol plaque builds up in the arteries that supply your legs (and in some cases, your arms) with blood, the arteries can become narrowed and even blocked. This condition is known as peripheral vascular disease. If you have peripheral vascular disease, the flow of blood to your legs is restricted, leading to poor circulation. Without the proper circulation, you can develop foot ulcers, gangrene, and other forms of tissue loss in your feet. If you have even minor foot surgery, or suffer any kind of injury or abrasion to the feet, your feet may be unable to heal properly. Frequently, people with peripheral vascular disease must face limp amputation. Fortunately, with the proper treatment, this can be avoided.
The major symptom of peripheral vascular disease is pain in the legs. You may experience pain in the calves while walking or exercising (claudication) or pain while resting or sleeping. The severity of the symptoms depends on how far peripheral vascular disease has progressed. When the arteries to the leg narrow gradually, you may begin to feel pain, aching, cramping or tiredness in the leg muscles—especially the calf muscles—while exercising. You may feel the pain while walking, for example.
The pain may come on faster and feel more severe when you are walking faster or walking uphill. Many people with peripheral vascular disease feel pain in the calf, but the foot, thigh, hip or buttocks can be affected. Usually claudication pain is relieved by resting. If you have neuropathy, or a degeneration of nerves, you may feel no pain, but rather a sensation of numbness or a ‘dead’ feeling in your limb.
As peripheral vascular disease progresses, you may find that the pain kicks in at shorter and shorter distances of walking or amounts of time spent exercising. Eventually you may feel pain while you are resting. You may feel severe, unrelenting pain in the lower leg or foot that gets worse when you try to elevate your leg. You may even feel pain while you are sleeping.
As the blockage in your legs gets worse, your leg may feel cold and numb, with no visible sign of a pulse or a very weak pulse. Your skin may feel dry and scaly and your hair and nails may grow poorly. You may even develop sores, or ulcers, on your toes or heels, or even on your lower leg. At its worst, your leg may shrink, and gangrene, or tissue death, can set in.
When the arteries in the leg become suddenly and completely obstructed, you may feel a severe pain, coldness and numbness. Your leg may take on a pale or blush tint and you may feel no pulse below the point at which your artery is blocked.
If you have diabetes, you are 20 times more likely to develop peripheral vascular disease than someone without diabetes. Your risk is increased further if you smoke, don’t eat properly, don’t exercise, have high blood levels of cholesterol and other lipids, and have poor blood glucose control. Peripheral vascular disease is prevalent in women as well as men, and is found in both the elderly and younger population.
If you have peripheral vascular disease, you face the risk of developing foot ulcers, gangrene and amputation. However, if you develop peripheral vascular disease, especially if you catch it in the early stages, it doesn’t mean you will eventually face amputation. Only 10% to 15% of all patients with peripheral vascular disease go on to face the prospect of losing a limb. Your best bet is to take preventive measures to keep peripheral vascular disease from developing in the first place and to treat it aggressively once it is diagnosed.
What You Should Do
In your experience any of the symptoms of peripheral vascular disease, contact your doctor right away. Although it is not an emergency situation, you should be diagnosed and treated promptly to avoid permanent damage to your legs and feet and to avoid amputation. The sooner you intervene and treat peripheral vascular disease, the more likely you are to restore circulation to your legs, and the less likely the prospect that you will lose your limbs.
Your doctor will assess the flow of blood to your legs. This can be done by feeling the pulse in the lower leg. If you have a significant obstruction, the pulse will be diminished or even absent below the knee. However, people with diabetes often have calcium deposits in the arterial walls, making the arteries rigid and the pulse difficult to detect.
Your doctor may measure the blood pressure in your leg and compare it to that in your arm. Usually the blood pressure in your leg is 90% of that in the arm, but with narrowing of the arteries to the leg, the blood pressure can be lower than 50% of that in the arm. However, because of the calcification of arteries, it may be more difficult to get an accurate blood pressure reading if you have diabetes. Your doctor may elect to check the blood pressure in your toe instead, because the blood vessels in your toes are not usually calcified even if you have diabetes.
Alternatively, your doctor may measure the amount of oxygen in the skin of your feet. This will tell your doctor whether sufficient blood supply is reaching your feet to keep the tissue supplied with oxygen. Your doctor may also use Doppler ultrasound to detect the amount of blood flowing through your legs. This measures the sound of blood flowing through your arteries. Or you may be given a Doppler color ultrasound, which provides a picture of the artery, with different colors used to illustrate the different flow rates.
In addition to these tests, your doctor may also recommend angiography, an X-ray test that measures blood flow. For this test, you will be injected with a substance that appears opaque in an X-ray. An X-ray is then taken that will provide you and your doctor with a picture of your arteries, showing the extent of obstruction. Your doctor may also recommend magnetic resonance angiography, an imaging technique that can be performed without the use of a dye. This is especially useful in people who have kidney problems.
If your doctor determines that you have blockages in your leg arteries, he may recommend one of several treatments to restore blood flow to your legs. If you are a smoker, you should stop smoking immediately. Ask your doctor for help in finding ways to stop smoking if you find this task daunting. You may also try elevating the head of your bed while sleeping to increase the flow of blood to your legs.
If your peripheral vascular disease is in the early stages and you are experiencing intermittent claudication, your doctor may suggest that you walk 30 minute each day, if possible, or consider the use of an exercise bicycle. If you feel pain while exercising, stop and rest until the pain subsides, then resume activity. If you do this on a regular basis, you will probably find that you can go longer and longer each time before you feel pain. Exercise increases the circulation to your legs and improves muscle function.
Your doctor may prescribe medication to improve oxygen delivery. Pentoxifylline, for example, can improve oxygen delivery to muscles. Although calcium blockers and aspirin can help some patient, calcium blockers should be used with caution in patients with diabetes. Beta-blockers, which are often used to help people with blockages in the heart arteries, can worsen the condition of people with blockages in the leg arteries.
If you doctor finds a moderate obstruction in your leg arteries, she may perform an angioplasty. This can be done at the same time you are examined by angiography. In an angioplasty, your doctor will insert a catheter equipped with a deflated balloon into your narrowed artery. When the blood is inflated, it will open up the artery to allow blood to flow. Alternatively, your doctor may recommend another procedure to open the narrowed blood vessel. This could include mechanical cutters, lasers, stents and rotary sanders. All of these devices serve to bore through the blockage and open up the blood vessel. Following these procedures, you may be given a blood-thinning medication such as heparin or a platelet inhibitor such as aspirin to prevent further blockage or narrowing from occurring.
Angiography is not recommended for people with extensive narrowing, blockages that extend for long distances, or if the artery is severely hardened. If you have significant obstruction in your leg arteries, your doctor may suggest surgery to remove or bypass the obstruction. Surgery is also recommended if there is a blood clot blocking the narrowed blood vessel of if a clot has broken away and blocked a more distant blood vessel.
If the blockage is severe, your doctor may recommend a bypass operation. To do this, a vein from another part of the body or a synthetic tube is grafted to the artery below and above the blockage so that blood can flow around the blocked artery. In some cases, a piece of artery that contains the blockage is surgically removed and replaced with a graft of vein or synthetic tube. Bypasses are only performed when the survival of your limb is threatened. Studies have shown that it can save the limb in 90% of cases, even 5 years after surgery.
In severe case, amputation may be the only way to save a limb. Amputation may be performed to cut out an area of infected tissue, to relieve incessant pain, or to prevent the spread of gangrene. In these cases, the surgeon will do everything to save as much of the leg as possible, especially if you plan to wear an artificial limb.
Like other forms of cardiac and arterial disease, the key to controlling peripheral vascular disease is preventing it from occurring in the first place, or preventing it from progressing as much as possible. For people with diabetes, maintaining good blood glucose control is a key first step. Eating a healthy, low-fat diet will help prevent cholesterol plaque from accumulating in the arteries. And starting or maintaining a moderate exercise or activity program will improve blood circulation and keep blood flowing.
Try walking 30 minutes a day or talk to your doctor or exercise physiologist about other activities that will improve blood circulation in your legs or arms. Finally, if you are a smoker, quit smoking. Talk to your doctor about programs or medications that can help you stop. This is one of the most important steps you can take to prevent peripheral vascular disease and other types of circulatory problems.
Sources and References
The Diabetes Problem Solver—Quick Answers to Your Questions About Treatment and Self-Care by Nancy Touchette
Peripheral Vascular Disease by Constance Swenty and Mellisa Hall
Peripheral vascular disease assessment in the lower limb: a review of current and emerging non-invasive diagnostic methods by Paul Breen, Gaetano Gargiulo et al