Peripheral Arterial Diseases, Dialysis Access & Complicated Wound Care

Hoenig Vein & Vascular

Peripheral Arterial Disease (PAD)

Peripheral Arterial Disease (PAD), also known as peripheral vascular disease, atherosclerosis or hardening of the arteries, is a disorder that occurs in the arteries of the circulatory system. Arteries carry oxygen-rich blood from the heart to all areas of the body.

In PAD, arteries become narrowed or blocked when plaque forms inside the artery walls. This plaque or “atherosclerosis” is composed of cholesterol-rich material and calcium. When this develops, blood cannot get through to nourish organs. This can cause damage and eventually tissue death. The rate at which PAD progresses varies with each individual and depends on many factors including location of the blockage, smoking history and other medical conditions.

Symptoms of PAD may progress slowly over a life time, or develop rapidly within hours. For many people, symptoms will not develop until the artery has narrowed by 60 percent or more. The first noticeable symptoms may be intermittent claudication – leg discomfort, pain or cramping that develops with activity and is relieved with rest. The pain is typically in the calf, but may also be felt in the buttocks or thigh depending on the location of the obstructive process. The pain can be severe enough to interfere with normal walking. This may progress to rest pain – burning or aching pain in toes or heels without activity often relieved with dependent positioning, and ulceration or gangrene, when tissue begins to die from critically poor blood flow and compromised oxygen delivery.

Risk factors for the development of PAD include diabetes, cigarette use, age greater than 50, hypertension and high cholesterol. Individuals with heart disease often suffer from PAD in other areas of the body.

Aneurysmal Disease

Aneurysmal Disease –Arteries are elastic and allow blood to be carried under high pressure throughout the body. When the wall of the artery becomes weakened and distended like a balloon, this is called an aneurysm. Aneurysms can occur anywhere in the vascular tree but are most commonly found in the abdominal and thoracic aorta followed by the popliteal, renal and visceral arteries. Aneurysms usually are discovered before they produce symptoms, such as back pain, but may rupture if they become too large. Since a ruptured aneurysm is dangerous and can cause life-threatening bleeding, aneurysms are best corrected by an operation before this happens. Occasionally, clot that forms within the aneurysm “sac” can detach from the wall and shower into the tissue downstream. These are called “emboli” and they also can lead to problems that require intervention.

Risk factors for the development of aneurysmal disease include cigarette use, family history of aneurysmal disease, hypertension, concurrent peripheral arterial disease, congenital diseases such as inherited weakness of the blood vessel wall; i.e. Marfan’s syndrome and Ellers-Danlos Syndrome, trauma and infection.

Screening for aneurysmal disease with the use of duplex ultrasound can be important in making the diagnosis since the disease often goes undetected deep within the body. Currently, Medicare is offering a one-time, abdominal aortic aneurysm (AAA) screening test to qualified seniors as part of its “Welcome to Medicare” physical. This must be conducted within the first 12 months of enrollment in Medicare. Men who have smoked at least 100 cigarettes during their lifetime and men and women with family history of AAA, qualify for this screening. Coverage for AAA screening may differ depending on insurance policies.

Venous Testing

Duplex ultrasound is used to view the veins of the arms or legs as well as the flow of blood within them. The absence of flow might suggest a blood clot while reversal of flow with the veins might suggest a cause of painful varicose veins. Ultrasound is also used to measure the size of arm veins in preparation for hemodialysis access.

Carotid Artery Disease

The carotid arteries lie on the side of the neck and carry oxygen-rich blood to the front of the brain, where thinking, speech, personality and sensory and motor functions reside. When atherosclerosis develops within these vessels with narrowing and obstruction, individuals are at an increased risk of stroke. Strokes develop when particles of plaque break loose from this obstructive process and shower into the brain.

Many patients have carotid artery disease that has not yet become symptomatic. A transient ischemic attack (TIA or mini-stroke), on the other hand, is an important warning sign of a developing stroke. These are temporary and may last only a few minutes or hours . These include the following symptoms:

  • sudden loss of vision or blurred vision in one eye
  • weakness and/or numbness on one side of the face, or in one arm or leg, or one side of the body
  • slurred speech, difficulty talking or understanding what others are saying
  • loss of coordination
  • dizziness or confusion
  • difficulty swallowing

TIA’s are medical emergencies and immediate medical attention is important.

Screening for carotid artery disease can be performed with the use of duplex ultrasound. This is indicated when a “bruit” or whistling sound is heard with a stethoscope over the carotid arteries in the neck, or in a patients with a history of carotid artery disease. Additional testing with MRI or CT angiography may be helpful in some cases.

Risk factors for the development of carotid artery disease include age,, cigarette use, personal or family history of PAD or heart disease, hypertension, diabetes, obesity and sedentary lifestyle.