Peripheral Vascular Disease (PVD)
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Underdiagnosed, Undertreated and a Major Killer.
Peripheral vascular disease is a progressive condition that is caused by atherosclerosis and subsequent narrowing of the peripheral arteries that carry blood to the arms and legs, neck, stomach or kidneys. The clinical presentation depends on the location and degree of obstruction in the arteries affected, but the most common presentation is lower limb disease. Symptoms range from pain or cramp in the leg when walking to pain at rest.
Atherosclerosis is caused when fatty deposits (called plaques) build up inside the artery walls. As these deposits build up, they begin to restrict the flow of blood through the peripheral blood vessels. As the disease progresses the atherosclerotic plaques can rupture resulting in the formation of a thrombus and arterial occlusion. Atherosclerotic plaque, thrombosis, and vasoconstriction of the arteries all lead to decreased blood flow in the periphery. In the peripheral or non-heart vessels, this is most likely to occur in the femoral and popliteal arteries (legs), the subclavian arteries (arms), the iliac arteries (lower abdomen leading to the legs), the carotid arteries (in the neck leading to the brain) and renal arteries (kidneys).
When organs and muscles receive an insufficient supply of oxygen-rich blood, they become starved (ischaemic) and pain results. This ischaemia leads to painful symptoms that can be worsened as the demand for oxygen increases in response to activity such as walking.
If the blockage occurs in the arteries supplying the legs, the resulting symptom is cramping pain in the hips, thighs or calf muscles during activity. If this pain is relieved with rest, it is called "intermittent claudication." Other symptoms of PVD in the lower limbs include:
- Coldness of the leg and foot
- Paleness of the leg or foot if elevated; redness on lowering
- Numbness or tingling in the leg, foot or toes
- Dry, shiny skin with poor toenail or hair growth
- Rash, marks or ulcers
- Sores that do not heal
Unfortunately, many people with these symptoms of PVD, especially pain on walking, assume that these are just part of getting older and do not seek medical attention until they become severely debilitated.
In advanced stages of the disease, severe ischaemia can result in cell death and tissue destruction. Progression of limb pain and destruction of tissue eventually leads to critical limb ischaemia (CLI) frequently requiring amputation and increasing physical impairment and mortality rates. People with PVD often have atherosclerosis in the heart and brain. Because of this association, they have a higher risk of death from heart disease, aortic aneurysms and stroke. PVD is also a marker for diabetes, hypertension and other conditions.
Techniques used to diagnose PVD include a medical history, physical examination, doppler ultrasound, computerized tomographic angiography (CTA) and magnetic resonance arteriography (MRA).
Probably the most useful, although underutilized, diagnostic tool for detecting peripheral arterial disease in the outpatient setting is the Ankle Brachial Index or ABI test. This simple, painless test compares the blood pressure in the legs to the blood pressure in the arms to help accurately measure the degree of blood flow in the lower extremities.
Underdiagnosed and undertreated
In contrast to coronary and cerebral artery disease, PVD is vastly underdiagnosed despite its abysmal mortality rates. Research suggests that PVD, previously estimated to affect 27 million people in Europe and North America, may be more common than previously thought.1 However, it is estimated that less than 30% of PVD patients are diagnosed, mainly due to the fact that over 50% are asymptomatic - leg pain may be present in only 10% of patients.1 Lack of awareness and appreciation of PVD is a major contributing factor to the underdiagnosis of this serious disease.
A major killer
With 5 and 10-year rates of 30% and 50% respectively, mortality due to PVD is greater than that caused by myocardial infarction and stroke.2 PVD is more common in people over 50 years and in the over 60s, the frequency of PVD is as high as 25%.3
Studies have shown a nearly 6-fold increase in relative risk of death from cardiovascular disease in patients with large-vessel PVD (average age 66 years) compared with those without.4
The elevated risk of death from all causes in patients with established PVD versus normal subjects was due mostly to increased rates of death from cardiovascular disease and coronary heart disease. Rates of death from other causes were not significantly elevated in PVD patients. There is a similar correlation between cerebrovascular disease and PVD. The incidence of ischemic stroke has been reported to be as high as 42% in patients with PVD.5 PVD patients appear to have a poorer prognosis following a stroke than do those without PVD following a stroke.
A number of treatment options are available today:
In some cases, lifestyle changes such as stopping smoking and exercising regularly will alleviate symptoms and prevent further progression of the disease. Like many patients with coronary artery disease caused by atherosclerosis, PVD patients often have elevated cholesterol levels that contribute to the disease. A low fat diet and other cholesterol-lowering strategies are often part of a treatment plan.
For many patients, lifestyle changes combined with drug treatment can control the symptoms of PVD. Drugs include: antiplatelet agents; medicines to improve walking distance (cilostazol and pentoxifylline); cholesterol-lowering agents.
Bypass surgery has been the gold standard interventional therapy for PVD, especially for occluded femoropopliteal arteries. Invasive surgery carries a relatively high risk of mortality and morbidity as well as being stressful for the patient and contra-indicated in the very elderly.
Angioplasty and stenting
Less invasive treatment options, such as angioplasty and stent implantation, are increasingly used in place of invasive surgery. These procedures are less stressful for the patient than vascular surgery and are associated with a considerably reduced mortality. Most procedures are performed on an outpatient basis or require no more than an overnight hospital stay, allowing patients to return to their normal activities. However, in some patients surgery may still be the best option.
Angioplasty is a non-surgical procedure that can be used to widen narrowed or blocked arteries. A catheter with a deflated balloon on its tip is passed into the narrowed artery segment. Then the balloon is inflated to open the blood vessel. The blood vessel can then be held open with a stent, a tiny cylindrical, wire mesh tube, that expands to keep the diseased artery open and restore blood flow. The stent remains in the artery as a permanent implant. This procedure is performed in a hospital suite equipped with x-ray instruments that enable the doctor to see the patient's arteries during the procedure. Following a stent procedure, many patients can go home on the same day.
Taking ACTION - The PVD awareness initiative
ACTION is a programme aimed at increasing the awareness and detection of peripheral vascular disease in clinical practice, as well as increasing the awareness of this condition amongst the general public. PVD is a progressive disease which, without intervention, carries a high risk of morbidity and mortality. However, general physicians' and patients' awareness of the disease and its serious consequences is low compared with other life-threatening conditions such as myocardial infarction, stroke and cancer. Moreover, as the older cohort expands with an ageing population, primary care providers will see an increasing number of patients at risk from the consequences of PVD.
PVD issues on awareness
General practitioners may overlook artery disease in the limbs because it is often asymptomatic and patients do not self-refer with "aching legs". It is, therefore, underdiagnosed and subsequently undertreated, even though it should be regarded as a severe disease leading to significant death and disability from stroke and myocardial infarction. Screening of at-risk patients is rare and could be improved; often patients are referred to the specialist too late or inappropriately. Accurate diagnosis of PVD could provide an early indication of the need for intervention and help prevent future morbidity and mortality. 6,7
Notes for editors
References for editors
1. Hirsch AT et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317-1324
2. Sharafuddin M, Anguelov Z, Currents: Fall, 2001, Volume 2, Number 4.
3. Norman et al. MJA 2004.
4. Criqui MH et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381-386.
5. Dawson DL, et al: Peripheral Arterial Disease: Medical care and prevention of complications. Prev Cardiol 2002;5:119-130.
6. Stoyioglou A and Jaff MR. Medical treatment of peripheral arterial disease: A comprehensive review. JVIR. 2004; 15:1197-1207.
7. Criqui MH. Peripheral arterial disease - epidemiological aspects. Vasc Med. 2001;6(3 Suppl):3-7.