Peripheral Artery Disease

Peripheral arterial (PAD) is a form of hardening of the arteries (arteriosclerosis) which causes partial or complete obstruction of the arteries of the legs. The three main risk factors for PAD are advanced age (older than 60 years), cigarette smoking, and diabetes mellitus (DM), similar to the risk factors for atherosclerosis elsewhere. PAD is more frequent in older adults, with a 1.5- to twofold increase in risk for every 10-year increase in age. Smoking or DM increases the risk of PAD independently by approximately threefold. In addition, smoking has a synergistic effect on other risk factors, and the number of pack/years is associated with disease severity. Smokers have at least double the risks of mortality, disease progression, and limb amputation rates compared with nonsmokers.

The primary symptom of PAD is exercise induced thigh muscle or calf muscle pain which is relieved with rest. The pain is usually reproducible in terms of length of walking required before onset of pain. Physical examination will include diminished or absent foot pulses, hair loss on the lower part of the leg and muscle atrophy in longstanding case. A careful history will often distinguish between venous insufficiency (VI) and PAD. Leg symptoms due to VI are usually worsened with sitting or standing, and improved with walking and contraction of calf muscles, the opposite is true for PAD, with ambulation induced pain relieved with sitting or standing. Older patients can have both entities, VI and PAD, and the challenge in these patients is the proper identification and stratification of the disease and determination of which is more symptomatic.

In summary, PAD is the result of deposition of cholesterol and scar tissue on the inside of arteries, eventually leading to partial or complete obstruction with symptoms of exercise induced calf or thigh muscle pain. VI is a disorder of the valves of the veins leading to high venous pressure, further dilating veins, causing leg edema and skin changes due to components of the blood leaking out through the thin walled veins. The treatment of PAD is to modify medical risk factors, open up the vessels with balloon/stents or perform a surgical bypass when appropriate. The treatment of symptomatic VI is to seal the veins closed with heated catheters.

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