October 11, 2019 by John Fernandez
Leg Pain May Signal Vascular Disease
Atherosclerosis, plaque, hardening of the arteries, bypass surgery – people recognize these terms because they are usually part of a story about someone who had a heart attack or stroke.
But, did you know that plaque buildup in the vessels outside of the heart can be extremely dangerous as well?
According to the National Institutes of Health (NIH), peripheral arterial disease, or PAD, occurs when plaque – a substance made up of cholesterol, fat, calcium and other particles – partially or completely blocks blood flow to legs, arms, the brain and other structures of the body outside of the heart. Without oxygen-rich blood to feed those tissues, they stop functioning properly and die.
“PAD can be very serious if left untreated,” said Barry Katzen, M.D., an interventional radiologist who treats patients with PAD and is the founder and chief medical executive of Miami Cardiac & Vascular Institute. “And while it can affect the arteries leading to the arms, brain, stomach and kidneys, we most commonly see it in the legs first because of all the large muscular structures in the legs.”
Dr. Katzen says the first sign of PAD in active people is pain in the legs when they walk.
“The large muscles in the leg need more blood when they are being used,” he said. “If they are being deprived of oxygen, they will ache, cramp or burn.”
He adds that in patients with inactive lifestyles, the disease may advance further to non-healing wounds or gangrene (tissue death) before a problem is detected. That’s because the pain, which signals a problem, is only present when the muscles are being used.
That pain, known as intermittent claudication, usually subsides with rest, so many people brush it off as a sign of aging or a pulled muscle and don’t seek help. Or they may go to an orthopedic doctor, who will focus on the muscles, joints and bones to pinpoint the source of pain.
“When those structures appear normal, we look for a potential vascular issue, especially if they have risk factors for PAD,” Dr. Katzen said.
Those risk factors include:
• Age – One in 20 people over the age of 60 have PAD, according to the NIH.
• Family history of PAD
• Personal history of atherosclerosis in the blood vessels of the heart
• High cholesterol
• History of smoking
To determine if someone has PAD, the first step is an examination of the pulses in the legs, Dr. Katzen says. Weak or absent pulses in the affected leg may indicate a blockage, according to the National Library of Medicine.
Dr. Katzen, and other vascular specialists, will then order non-invasive testing to confirm that a blockage in the artery is causing the weak pulse.
These tests may include:
• Ankle-brachial Index (ABI) – Measures blood pressure in the legs and compares it to blood pressure in the arms to determine the efficiency of the blood flow.
• CT or MR Angiogram – Uses X-ray or magnetic resonance to show the arteries and how blood is flowing through them, much like a traffic map.
• Doppler and Ultrasound Imaging – Uses sound waves to view blockages in the arteries within the legs and measure the amount of blood flowing through them.
Once PAD is confirmed through these tests, doctors can determine the best treatment to restore blood flow and leg function and get rid of the pain.
Dr. Katzen usually suggests lifestyle changes to his patients as the first treatment option. These include establishing a regular exercise program, quitting smoking and losing weight, if overweight.
Medications that prevent blood platelets from sticking together may also be prescribed.
“The goal of these treatments is to get rid of the symptoms of PAD,” Dr. Katzen said.
Depending on the severity of the PAD and whether initial treatments helped, Dr. Katzen says doctors may perform minimally invasive procedures that use a catheter to access the blockage. As in angioplasty within the heart’s blood vessels, a balloon may be deployed through the catheter to push the plaque against the wall of the artery, allowing blood to flow again. Additionally, a stent – or small metal tube with or without medicine on it – may be placed in the vessel to keep it propped open. Another option is to use an instrument to break up and remove the plaque in the vessel – a process known as an atherectomy.
If the disease is advanced enough, or if minimally invasive treatments prove unsuccessful, Dr. Katzen says bypass surgery to restore blood around the blockage may be necessary. This may be performed by a vascular surgeon.
“It’s important to look for a doctor who has a specialized interest in treating vascular disease,” Dr. Katzen recommended.
If left untreated, PAD may lead to critical limb ischemia, where the pain will still be present at rest and ulcers or gangrene will develop. In those cases, Dr. Katzen says, doctors must look at limb salvage surgery to prevent having to perform an amputation. For a small percentage of patients, amputation may be necessary.
“Most people know about the dangers of blocked arteries in the heart,” Dr. Katzen said. “Now we need to make people aware of the dangers of vascular diseases, like PAD, that can affect quality of life.”