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Disease Information : PAD : FAQ’s

PAD : FAQ’s

Questions by category

General Information
Leg Pain / Cramps
Diagnostic Tests
Drug Treatments
Surgical Procedures
Other

General Information

Q. I hear the terms PVD and PAD used a lot when describing my disease. Is there a difference in these two terms?

A. PVD stands for peripheral vascular disease and PAD stands for peripheral arterial disease. They are often used interchangeably. PVD was the standard description for many years, but following an international consensus agreement on definitions (Trans-Atlantic Inter-Society Consensus) healthcare professionals have switched to using PAD, because it more accurately describes the atherosclerosis that affects the arteries. PVD is considered a broader term that encompasses more than atherosclerosis in the arteries.

Q. I am uncertain if I have peripheral arterial disease. I walk at least 5 days per week. I can walk for over an hour without any leg pain. Per my physician, I have a good pulse at the knees but almost none at the ankles and I have night cramps in the calf areas. I am 79 years old, have never smoked, do not have Diabetes or high blood pressure.

A. The fact that you can walk long distances daily is a better indication of adequate arterial circulation (and no significant Peripheral Arterial Disease) than the fact your doctor feels "almost" no pulses at the ankles.

The important point is that poor circulation is NEVER responsible for nocturnal or resting calf cramps. They are common in older patients and result from an overactive stretch reflex. If they are frequent and bothersome, they can usually be controlled by taking an inexpensive, over the counter drug at bedtime such as Benadryl.

As an aside, when pulses are easily felt behind the knee but not at the ankle, patients are sometimes found to have (popliteal) aneurysms (dilated arteries) behind the knee. They are important to detect in their own right (they may suddenly block off with a blood clot) so it is worth having your doctor check this out the next time you see him or her.

Q. I am 57 years old with a family history of PAD. I am interested in knowing the things I can do to prevent PAD.

A. First of all, not smoking is one of the most important things you can do. Even limited amounts of tobacco can be a major detriment in a patient's battle against PAD. Nicotine causes the blood vessels to narrow, leaving less room for blood flow and increases the risk of blood clot formation. Also, the smoke inhaled decreases the amount of oxygen in the blood. Consequently, tobacco is very damaging to the blood vessels.

Second, managing cholesterol and triglycerides using diet and medication is very important. By lowering cholesterol levels you can delay or even reverse the plaque build up in the arteries. The National Heart Lung and Blood Institute offers excellent information on their web site on cholesterol issues. This link http://www.nhlbi.nih.gov/health/public/heart/index.htm should list them. Be sure to look at their "Step-by-Step: Eating to Lower Your High Blood Cholesterol" section for advice on what to eat and portion management. They also have helpful material on high blood pressure, another factor you will want to watch in preventing PAD.

If you are diabetic, consult with your doctor about how you can best keep your blood sugar under control using diet and medication.  Proper foot care in the diabetic patient is important as well.  Besides your primary care physician you can consult a Podiatrist for advice on proper foot care.

Exercise is another important component in fighting PAD. An appropriate exercise program will help keep your heart and arteries healthy.  Walking is the most consistently effective treatment for those with intermittent claudication (pain in legs due to PAD).

Q. What is the difference between atherosclerosis and arteriosclerosis?

A. Arteriosclerosis is a general term meaning the arterial walls are thickened and stiff. Arteriosclerosis can occur as a part of the aging process and can refer to many various vascular diseases. Atherosclerosis is a more specific term describing plaque deposits within the artery wall that leads to blockages of arteries. The word "atherosclerosis" comes from the Greek words "athero" (gruel or paste) and "sclerosis" (hardness).

Q. When young persons in their 20s or 30s get PAD, is it because of an unusual hereditary problem with the structure of their arteries at birth, or a speeding up of the aging process?

A. First, one has to be sure that the young person has an accurate diagnosis of PAD. If so, PAD can occur even at an early age in the presence of the same risk factors that cause PAD in older individuals: smoking, diabetes, high cholesterol, high blood homocysteine, and a family history of PAD or coronary heart disease. While it is quite unusual to develop the symptoms of PAD before age 40, we know that artery damage starts at young ages (we find evidence of artery damage even in young healthy soldiers who are killed in war). However, not all artery blockages in young individuals are due to PAD. These may be due to other conditions that can block the arteries to the legs such as inflammatory diseases (arteritis) or congenital abnormalities. Other medical conditions can also lead to artery blockages at younger ages, including severe kidney disease or trauma.

Q. My husband was diagnosed with hardening of the arteries. He is 52 and has numerous health problems (atrial fibrillation at age 40, a stroke at 45, and since then, many TIAs). He is a heavy smoker, and we do know that he definitely needs to quit in order to slow this progression. Since he has been on Coumadin and medications for these conditions for many years, why would this happen?

A. It is never possible to know for certain why some individuals, like your husband, would have so many health problems in their 40s or 50s. As you are likely aware, stroke can occur from either atrial fibrillation alone or from damaged carotid arteries that lead to the brain, or both. In order to best decrease his risk of stroke, the Coumadin prevents blood clots from forming and traveling to the brain. The other medications prevent artery damage, and help to decrease the risk of heart attack and stroke. But, while these medications are effective at diminishing the effects of the diseases, they are a cure. The impact of continued smoking is profound, and can diminish the benefit of Coumadin (tobacco makes blood clot more easily), blood pressure pills (tobacco raises blood pressure), and cholesterol lowering drugs (tobacco directly damages the artery wall). He needs to stop smoking. Until then, taking medications regularly and as prescribed likely has helped your husband more than not being on them by providing him at least some protection.

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Leg Pain / Cramps

Q. I have leg cramps at night. Are these signs of peripheral arterial disease?

A. Nocturnal leg cramps are not a typical symptom of PAD but leg cramps when walking are. Cramps you experience while walking can be a sign that the muscles are not receiving enough oxygen rich blood due to PAD. There are many reasons for leg cramps at night such as exercising without stretching, “restless legs”, or a muscle strain. You should bring any concern about long-term pain to your physician's attention.

Q. What is the difference between a "Charlie horse" and pain from intermittent claudication?

A. Pain from intermittent claudication is caused by your leg muscles not receiving the oxygen rich blood they require during exercise. The pain can be severe enough to hinder a person from walking. A "Charlie horse" is a leg cramp in the muscle and can normally be relieved by rubbing or massaging, and this may occur at rest or merely with stretching. The pain from intermittent claudication will always subside upon resting. If you are not sure if you have PAD, see your doctor!

Q. Recently my husband has been having hot flushes in his feet, sometimes in one foot, sometimes the other. Could this be a sign of vascular disease? It seems to occur after he has been sitting around then starts to walk around.

A. The symptoms you describe are not those of PAD or any other serious vascular disease. They could be related to autonomic nerve dysfunction, which control dilation or constriction of blood vessels, but it is not possible to tell from your brief description.

Q. My feet and legs have been tingling and they hurt when I walk, but when I rest they feel better. I am a little scared. How do I know if it's bad enough to be amputated?

A. Only a doctor can determine if you will require an amputation. However, please do not delay. Visit your doctor as quickly as possible to make a proper diagnosis, and begin treatment. Be assured that amputation is never taken lightly by any health care provider. Earlier determination, however, will help you achieve a better result.

Q. Is bicycle riding good for eliminating pain from claudication?

A. While riding a bike is good exercise and good for your heart, it does not work the muscles that are impacted by claudication as well as walking. Walking has been proven to be the best form of exercise in treatment for PAD. It can increase the time before the onset of leg pain by one-half to three times.

Q. I have started having pain in my buttock, hip and thigh down the back and outside on the right leg only. The pain is much worse when I sit (have tried many different positions thinking I was cutting off circulation) and at night unable to sleep. I am 64 years old and while I am active, I do not have an exercise program. Any suggestions for me?

A. The symptoms for peripheral arterial disease (PAD) do include pain in the buttock, thigh and calf but it usually occurs when walking, and then stops when you stop. This is not your situation, so you probably do not have PAD. This can easily be determined by having an ankle brachial index (ABI) that compares blood pressure measurements at the ankles with those at the arms. Because your pain occurs mostly when you sit, it sounds as if it might be more likely related to nerve compression in your back. We strongly suggest you see a health care professional, particularly a spine specialist (orthopedist or neurosurgeon) for a complete checkup. Once your pain has been cleared up, you should ask your physician what exercise would be best for you, as the benefits from exercise would be helpful for your general health.

Q. My wife has an infection in her toe which has persisted for over a month. She had a Doppler exam of the right leg but it was negative. Still her doctor believes the problem is vascular. Do you have information on the Internet where I could read a simple description of this problem?

A. Your wife's doctor is probably correct in suspecting that she has vascular disease. A foot ulcer or sore that does not heal can be a strong indication of peripheral arterial disease (PAD). It is possible that her arteries are narrowed or blocked and are not delivering a sufficient amount of blood to her feet. Not all cases of arterial disease will show up on Doppler tests or ankle brachial index tests, especially if the arteries are significantly hardened or calcified due to diabetes or normal aging. You can read about further diagnostic tests in the Risk Factors for Peripheral Arterial Disease section. We encourage you and your wife to continue working closely with her doctors and continue to ask good questions.

Q. I have been having chronic leg pain that occurs mostly at night. However, it can also occur while I’m sitting. This disrupts my sleep. I cannot get comfortable in bed, and I don’t like for my legs to touch each other because of the pain. Could this be PAD?

A. We can be reasonably sure this is not PAD. If it were rest pain, it would be primarily at night or when lying down, and be relieved when legs were down/dependent, as in sitting or standing. Nor does it sound like it is venous or lymphatic. Lymphedema is painless, and venous pain is relieved by lying down and made worse by standing or walking, and both are associated with swelling, which you did not mention. If you have diabetes, the pain can be from damage to the nerves in the feet, and you should discuss this with the doctor who manages your diabetes. You may consider consulting a dermatologist (a skin specialist) or a neurologist (a nerve specialist). Perhaps your primary care doctor can suggest the best step for you.

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Surgical Procedures

Q. My 46-year-old family member has had bypass surgery on each leg. The surgeons declared his surgery a success, yet intermittent claudication has returned. How common is recurrent leg pain after a successful bypass? What do you recommend for rehab and management of this type of condition?

A. It is quite common for claudication to persist after surgery but ideally this symptom should be less severe. This is because it is usually not possible for the surgeon to bypass all of the many blockages that may exist in patients with PAD. The ABI (ankle-brachial index) does not predict functional ability to walk since individuals with the same ABI may have very different walking limitations. Recommended care and management is to embark on an exercise rehabilitation program in a supervised setting. Such a program usually involves treadmill walking at least three times a week. Often these programs are administered by vascular specialists, or at the Vascular or Cardiac Rehab settings usually located in nearby hospitals. A vascular internist or cardiologist should supervise the care.

Q. How effective is aorto-bifemoral bypass surgery and how safe is the procedure?

A. This operation is the gold standard for all surgical interventions for bilateral aortoiliac occlusive disease (Atherosclerosis that affects both legs in the pelvic area where the main artery from the heart splits into the two main leg arteries.) The long-term effectiveness of this surgical procedure has been established with many studies showing that over 90% of these bypass grafts remain open at five years, which compares to 80-85% rates for balloon angioplasty and stents in this location. The procedure is usually safe, with mortality from studies performed in the 1990’s being less than two percent (1.9 %). Patients usually can go home from the hospital in about 5 days.

Despite this success, an aorto-bifemoral bypass procedure is not always the best choice. For some patients, the area of narrowing in the aorta or iliac arteries is short and would be favorable for balloon angioplasty or stenting which are less invasive procedures.

Q. I have just been told I have Atherosclerosis and that a femoral bypass would allow me to walk again. But I have been told that a femoral bypass is only good for about 4 to 5 years and then I would die. Is this true?

A. This is certainly not true. Some bypasses function better than others, but properly performed bypasses using vein grafts approach 80% patency (open and working) by the 5-year mark. More importantly, bypasses are only occasionally performed to help people walk. There are better more conservative approaches to this problem called intermittent claudication. Bypasses are more commonly used when there is true threat of limb loss from rest pain, ulceration or gangrene. The comment "and then I would die" is inappropriate. It is true that patients with Atherosclerosis in their leg arteries often have it elsewhere, such as in their coronary arteries or arteries to the brain. This is the reason we advise control of the risk factors contributing to Atherosclerosis. However, while up to 20% of such patients will die in 5 years, it does not relate to bypass function but how well the patients care for themselves and control the factors leading to Atherosclerosis that include smoking, diabetes, hypertension and lipid ( cholesterol/triglyceride) abnormalities. The 80% who survive include those who use this opportunity to change their life style and control existing risk factors. See our risk factors section for more information.

Q. My 76 year-old mother had femoral bypass surgery this week. Can you tell me what the average recuperation time is after this surgery? I'm hoping to fly her home with me two weeks after she's back home. If all goes as expected, would that be possible?

A. Naturally each patient's recovery time will vary, but on average the hospital stay is about 5 -7 days. Some individuals may also require rehabilitation services at home or in the hospital. After resting at home, they are usually feeling back to normal in about 4 - 5 weeks unless any wound problems or leg swelling has occurred. The time period you are wondering about seems reasonable for her to fly provided all goes well. The most common complication is infection at the groin incision. Keep a close watch on her wounds and gradually return her activity to normal depending on how she is feeling.

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Diagnostic Tests

Q. I was told that my ABI test was inconclusive because I have diabetes. What does that mean?

A. ABI stands for ankle brachial index and compares the blood pressure measured at the ankle to the pressure measured at the brachial artery, which is located in the arm. Diabetes can cause the artery wall to become calcified or hard and the blood pressure cuff cannot compress the artery to get an accurate pressure. As an illustration, think of water flowing through a garden hose and a pipe in your home - you can bend the hose but not the pipe. Calcified arteries are stiff, more like a pipe, and blood pressure measurements cannot be performed. Without an ankle pressure, there is no comparison for an ABI. When this occurs, often a toe pressure is compared to the arm, or the doctor may look at the waveforms from the Doppler ultrasound signal or from blood pulse volume.

Q. My wife has an infection in her toe which has persisted for over a month. She had a Doppler exam of the right leg the other evening but it was negative. Still her doctor believes the problem is vascular. Is this true?

A. Your wife's doctor is probably correct in suspecting that she has vascular disease. A foot ulcer or sore that does not heal can be a strong indication of PAD. It is possible that her arteries are narrowed or blocked and are not delivering a sufficient amount of blood to her feet. Not all cases of arterial disease will show up on Doppler tests or ankle brachial index tests, especially if the arteries are hardened due to diabetes or normal aging. You can read about further tests under our Diagnoses section. We encourage you and your wife to continue working closely with her doctors and continue to ask good questions.

Drug Treatments

Q. Your Web site talks about the drug treatment for intermittent claudication but does not mention what the treatment is. What is it and where can I find more information?

A. The FDA has approved two drugs for the treatment of intermittent claudication. Pentoxifylline (Trental) has been available for several years. A new drug was approved in 1999 called cilostazol (Pletal). Cilostazol is prescribed by many doctors to help with the pain of walking caused by intermittent claudication. Your physician can tell you if either medication is right for you or in combination with exercise therapy or other treatments. You can find out more about cilostazol online or by calling 800.562.3974.

Q. I was prescribed a drug with niacin. I thought that was what you took for heart pain, which I don’t have. How does it help my leg pain?

A. You may be confusing niacin with nitroglycerin. Nitroglycerin is often prescribed when someone has a discomfort or pain in the chest area that is presumed due to blockages in the arteries that supply the heart muscle. This discomfort is called angina. Niacin is one of the B vitamins. This vitamin, when taken in the right doses, can often improve your total cholesterol, HDL cholesterol, and lipoprotein(a). Improving these risk factors can help reduce your risk for vascular problems including heart disease, stroke and peripheral arterial disease. Niacin is not now known to improve leg pain or claudication, although this is under study.

Q. Is it true that taking Vitamin C supplements with smoking and vascular disease, replaces the Vitamin C that nicotine destroys and which is needed to build and maintain good veins and arteries? My husband has smoked since he was a very young boy and still smokes 1 to 1.5 packs a day. He also has diabetes and vascular disease. I am looking for anything that will improve his chances. I know the best thing is for him to quit, but so far, no go.

A. There seems to be a misconception about the benefits of Vitamin C, or at least the mechanisms of its action in relation to blood vessels and nicotine from smoking. Vitamin C has no proven benefit in vascular disease, but it does have other benefits that you did not mention. Similar claims can be made for Vitamin E which is closer to the truth but again, not through these mechanisms. Instead, vitamin E mildly dilates blood vessels. The benefits from vitamins pale in comparison to the proven benefits of exercise therapy, anti-platelet drug therapy, control of elevated cholesterol, and STOPPING SMOKING.

Q. I was diagnosed with PAD 20 months ago. Exploratory surgery determined that bypass or a stent could not be done. I have been taking Pletal, Zocor, and aspirin along with exercise and have been able to walk a little farther. Are any other medications being used to help this disease? Will anything be available soon?

A. It is good you are seeing some progress with your current treatment plan of medications and exercise, and that you are able to walk a little further. There are only three drugs approved by the FDA for treatment of PAD. These are Trental, Pletal, and Plavix. Pletal helps the pain of intermittent claudication and improves the blood flow so you can walk further. Trental was the first drug used to improve blood flow, and is less commonly used today. Plavix is used to prevent blood from sticking together causing little clots, and can thus help prevent a heart attack or stroke. Aspirin is also used to keep the blood from sticking together. There are several new medications undergoing clinical trials, but none are likely to be approved in the next year or two. We have a section on our Web site about clinical trials, and we will keep you posted.

Q. I recently had some blood work done called a CRP profile. Results show that my CRP was 3.1 and 3.2. What is it and should I be concerned about this CRP profile or not?

A. C-reactive protein (CRP) is a marker of inflammation. It is produced primarily in the liver in response to inflammatory conditions and infections. Recently it has been shown that CRP levels may be elevated in individuals with atherosclerosis, a vascular disease in which there are plaque deposits on the walls of the arteries (a type of blood vessel). Individuals with elevated CRP levels are at higher risk for heart attacks than those with low levels. It must be emphasized that CRP is not a problem, but rather a marker of a potential cardiovascular event caused by blood vessel inflammation. Therefore, patients and physicians should pay particular attention to treating conditions such as high cholesterol, diabetes and the effects of smoking that cause atherosclerotic vascular disease, particularly in people with elevated CRP. Drugs such as statins decrease CRP levels, whereas typical doses of anti-inflammatory medications such as aspirin or ibuprofen do not. Research trials are in progress to determine whether treatment with statins will be helpful in reducing the risk for heart attack or death in otherwise healthy persons in whom a routine blood test detects elevated CRP levels. Increased physical activity may also decrease inflammation.

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Other

Q. I have heard that ginko biloba helps blood circulation to the legs. Is that true?

A. Ginko was recently reported in the American Journal of Medicine to have a modest effect on someone’s ability to increase the distance walked without pain. However, it did not help as much as a regular exercise program or conventional drug therapy. Because ginkgo seems to make blood less likely to clot, it increases the risk of bleeding if you are using aspirin, blood thinners such as Coumadin (warfarin) or clot-busting medications. As with all herbal products and vitamins, let your health care provider know what you are taking. These products are not controlled in terms of potency and may interfere with medications your doctor has prescribed.

Q. I was told I have peripheral neuropathy. Is this the same as PAD?

A. No, this is actually a group of nerve diseases affecting the nerves to the limbs. To learn more about neuropathy go here.

Q. I have been told my "homocysteine levels" are high. What does this mean?

A. Homocysteine is an amino acid. It is normally found in the body and is used to make protein. It is thought that too much homocysteine contributes to plaque build up and blood clot formation. High levels of homocysteine have been linked to increased risk for PAD and for damage to blood vessels in the heart and brain. Taking folic acid may reduce homocysteine levels, but it is not known whether folic acid prevents vascular diseases. Clinical trials are currently underway. It is important to discuss all options with your health care provider.


Q. My sister has restless leg syndrome (RLS). Is this related to peripheral arterial disease?

A. No, this is thought to be a neurological problem and not caused by atherosclerosis. The symptoms occur in the legs but are not the same as for PAD. RLS sensations are deep in the legs and produce an irresistible urge to move and cause an involuntary jerk of the leg. It usually isn’t painful but can be described as an itching, pulling or tugging. RLS symptoms are worse in the evening and at night, especially when the individual lies down. For more information contact the Restless Leg Syndrome Foundation at www.rls.org.

Q. I've had severe claudication for some time and my legs were diagnosed as 100% blocked in 1996. Also, my ability to have sex disappeared a few years back! Not even Viagra 50 mg allows it. If I follow your outline and stop smoking entirely plus start an exercise program, can the benefits you describe also include the ability to have sex again, or at age 66 is that now impossible to recover?

A. Thank you for your question that likely others have wanted to ask. Your problem with sexual performance could be a result of the same basic vascular problem that caused your claudication. Erections are produced by a buildup of blood in the shaft of the penis. Poor blood flow into the penis can result in difficulty having or maintaining erections. Blockage of blood vessels by atherosclerosis (also called hardening of the arteries) can lead to both impotence and symptoms of PAD - intermittent claudication if the disease is in the arteries that supply blood to both areas. Even though both may be a result of hardening of your arteries the treatments differ. Treating your leg pain with exercise therapy can not be expected to improve your other symptoms or result in a return of your sexual function. Your exercise therapy works on the leg muscles by improving circulation only. However, if the same blocked arteries are involved in producing both symptoms, it may be possible that they can be opened with a balloon-stent or bypass surgery. In this situation, one treatment could relieve both symptoms. The feasibility of these treatments can be determined by imaging tests showing where the blocked arteries are and if they can be opened up.

Viagra works in approximately 70% of men with vascular impotence who receive prescriptions. Other therapies using medications that widen the blood vessels may sometimes be better alternatives. We highly encourage you to discuss this problem openly with your doctor or request a referral to a physician that specializes in male sexual function. Problems with sexual function may arise from a number of causes other than atherosclerosis such as medications you are taking, nerve damage, diabetes, depression, hormonal imbalances, pituitary gland dysfunction, thyroid problems and other diseases. We also encourage you to stop smoking. Any treatment or exercise program you would undertake for your claudication would not be totally effective if you still smoked and also makes you more susceptible to heart attack and stroke. Please take some time to read our information on Smoking and PAD or in our Winter Newsletter 2002.

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Please note that our experts cannot perform diagnosis or recommend medical treatment.  We are able to provide only general information on vascular disease and its management. Please indicate your city and state on all e-mails to help us with future outreach efforts.


Peripheral Arterial Disease section was last modified: December 21, 2010 - 06:12 pm

All of the medical information contained on VDF's Web site has been written by medical professionals and then peer-reviewed by a multidisciplinary committee who edits the material appropriately.