Peripheral Vascular Disease (PVD)
Peripheral vascular disease (PVD) is a slow problem with blood circulation. It affects blood vessels outside of the heart and brain and gets worse over time. Organs supplied by these vessels such as the brain, arms, and legs, may not get enough blood flow to work well. The legs and feet are most commonly affected.
Deep vein thrombosis (DVT), varicose veins, and chronic venous insufficiency are conditions that are linked to PVD.
The terms "peripheral vascular disease" and "peripheral arterial disease" are often used interchangeably. PVD is often found in people with coronary artery disease. That is because atherosclerosis, which causes coronary artery disease, affects arteries throughout the body.
What causes PVD?
PVD may result from a narrowing of the vessels that carry blood to the leg and arm muscles. The most common cause is atherosclerosis. This is the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs and decreases the oxygen and nutrients available to the tissue. Clots may form on the artery walls, further decreasing the inner size of the vessel and can block off major arteries.
Other causes of PVD may include injury to the arms or legs, irregular anatomy of muscles or ligaments, or infection. People with coronary artery disease often also have PVD.
What conditions are linked to PVD?
The term "peripheral vascular disease" encompasses several different conditions including:
Atherosclerosis. Atherosclerosis is the build up of plaque inside the artery wall. Plaque is made up of deposits of fatty substances, cholesterol, cellular waste products, calcium, and fibrin. The artery wall then becomes thickened and loses its elasticity. Symptoms may develop gradually, and may be few, as the plaque builds up in the artery. However, when a major artery to the heart or brain is blocked, a heart attack or stroke may occur.
Buerger's disease (thromboangiitis obliterans). This is a chronic inflammatory disease in the arteries. It leads to blood clots in the small- and medium-sized arteries of the arms or legs, eventually blocking them. This disease most commonly occurs in men between ages 20 and 40 who smoke cigarettes. Symptoms include pain in the legs or feet, clammy cool skin, and a diminished sense of heat and cold.
Chronic venous insufficiency. This is a prolonged condition in which one or more veins don't adequately return blood from the legs back to the heart. It's due to valve damage in the veins. Symptoms include discoloration of the skin and ankles, swelling of the legs, and feelings of dull, aching pain, heaviness, or cramping in the legs.
Deep vein thrombosis (DVT) and pulmonary embolism (PE). A deep vein thrombosis (DVT) is a blood clot in a large vein deep inside a leg, arm, or other parts of the body. DVTs are common in those who have had long periods of inactivity. These include sitting while traveling or with bed rest after surgery. Symptoms may be absent or mild, but can include pain, swelling and tenderness in the affected arm or leg. The clot can break off from the vein and travel to the lungs, forming a pulmonary embolism (PE). In the lungs, the clot can cut off the flow of blood. This is a medical emergency and may cause death. Health care providers use the term venous thromboembolism (VTE) to describe both DVT and PE. They use the term VTE because the two conditions are very closely related. And, because their prevention and treatment are also closely related.
Raynaud's phenomenon. This is a condition in which the smallest arteries that bring blood to the fingers or toes tighten when exposed to cold or during emotional upset. It most commonly occurs in women between ages 18 and 30. Symptoms include cold, pain, and paleness in the fingertips or toes.
Thrombophlebitis. Thrombophlebitis is a blood clot in an inflamed vein, most often in the legs, but it can also occur in the arms. It may result from pooling of blood, injury to the vein wall, and changes in how the blood clots. Symptoms in the affected extremity include swelling, pain, tenderness, redness, and warmth.
Varicose veins. Dilated, twisted veins are caused by valves that allow backward flow of blood. This allows blood to pool. It's most commonly found in the legs or lower trunk. Symptoms include bruising and sensations of burning or aching. Pregnancy, obesity, and extended periods of standing make symptoms worse.
What are the risk factors for PVD?
Risk factors include:
Age (especially older than age 50)
History of heart disease
Family history of high cholesterol, high blood pressure, or PVD
Those who smoke or have diabetes have the highest risk of complications from PVD because these risk factors also cause impaired blood flow.
What are the symptoms of PVD?
Up to half the people diagnosed with PVD are symptom free. For those who do have symptoms, the most common is intermittent claudication in the calf. This means you have leg discomfort described as painful cramping that occurs with exercise and is relieved by rest. During rest, the muscles need less blood flow, so the pain disappears. It may occur in one or both legs depending on the location of the clogged or narrowed artery.
Other symptoms may include:
Changes in the skin, including decreased skin temperature, or thin, brittle shiny skin on the legs and feet
Diminished pulses in the legs and the feet
Gangrene (dead tissue due to lack of blood flow)
Hair loss on the legs
Nonhealing wounds over pressure points, such as heels or ankles
Numbness, weakness, or heaviness in muscles
Pain (described as burning or aching) at rest, commonly in the toes and at night while lying flat
Pallor (paleness) when the legs are elevated
Reddish-blue color of the extremities
Thickened, opaque toenails
The symptoms of PVD may look like other conditions. Always see your doctor for a diagnosis.
How is PVD diagnosed?
To diagnose PVD, your doctor will do a complete medical history and physical exam. Other tests may include:
Angiogram. This is an X-ray of the arteries and veins to detect blockage or narrowing of the vessels. This procedure involves inserting a thin, flexible tube into an artery in the leg and injecting a contrast dye. The contrast dye makes the arteries and veins visible on the X-ray.
Ankle-brachial index (ABI). An ABI is a comparison of the blood pressure in the ankle with the blood pressure in the arm using a regular blood pressure cuff and a Doppler ultrasound device. To determine the ABI, the systolic blood pressure (the top number of the blood pressure measurement) of the ankle is divided by the systolic blood pressure of the arm.
Doppler ultrasound flow studies. This uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Doppler technique is used to measure and assess the flow of blood. Faintness or absence of sound may mean an obstruction in the blood flow.
Magnetic resonance angiography (MRA). This noninvasive diagnostic procedure uses a combination of a large magnet, radio frequencies, and a computer to produce detailed images of organs and structures within the body. An MRA is typically only done if plans are being made to restore normal blood flow through a procedure or surgery.
Photoplethysmography (PPG). This exam is comparable to the ankle brachial index except that it uses a very tiny blood pressure cuff around the toe and a PPG sensor (infrared light to evaluate blood flow near the surface of the skin) to record waveforms and blood pressure measurements. These measurements are then compared to the systolic blood pressure in the arm.
Pulse volume recording (PVR) waveform analysis. This technique is used to calculate blood volume changes in the legs using a recording device that displays the results as a waveform.
Reactive hyperemia test. This test is similar to an ABI or a treadmill test but used for people who are unable to walk on a treadmill. While a person is lying on his or her back, comparative blood pressure measurements are taken on the thighs and ankles to determine any decrease between the two sites.
Segmental blood pressure measurements. This is a means of comparing blood pressure measurements using a Doppler device in the upper thigh, above and below the knee, at the ankle, and on the arm to determine any constriction in blood flow. The level and severity of disease can be identified through segmental blood pressures.
Exercise tests. Some studies can be done before and after exercise. This is especially helpful for evaluating patients with symptoms during exercise, but normal study results at rest. These studies may include an ABI, PVR waveforms, and segmental blood pressure testing.
What is the treatment for PVD?
There are two main goals for treatment of PVD: control the symptoms and halt the progression of the disease to lower the risk for heart attack, stroke, and other complications.
Specific treatment is based on:
How old you are
Your overall health and medical history
How sick you are
How well youcan handle specific medications, procedures, or therapies
How long the condition is expected to last
Your opinion or preference
Treatment may include:
Lifestyle changes to control risk factors, including regular exercise, proper nutrition, and smoking cessation
Aggressive treatment of existing conditions that may aggravate PVD, such as diabetes, high blood pressure, and high cholesterol
Medications for improving blood flow, such as antiplatelet agents (blood thinners) and medications that relax the blood vessel walls
Angioplasty—a catheter (long hollow tube) is used to create a larger opening in an artery to increase blood flow. Angioplasty may be done in many of the arteries in the body. There are several types of angioplasty procedures, including:
Balloon angioplasty. In this procedure, a small balloon is inflated inside the blocked artery to open the blocked area.
Atherectomy. In this procedure, the blocked area inside the artery is "shaved" away by a tiny device or laser on the end of a catheter.
Stent. In some cases, a tiny wire mesh coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open.
Vascular surgery—a bypass graft using a blood vessel from another part of the body or a tube made of synthetic material is placed in the area of the blocked or narrowed artery to reroute the blood flow
With both angioplasty and vascular surgery, an angiogram is often done prior to the procedure.
What are the complications of PVD?
Complications of PVD most often occur because of decreased or absent blood flow and include:
Amputation (loss of a limb)
Poor wound healing
Restricted mobility due to pain or discomfort with exertion
Severe pain in the affected extremity
By following an aggressive treatment plan for PVD, you can often prevent complications such as these.
Can PVD be prevented?
Steps to prevent PVD are aimed at managing the risk factors and may include:
Smoking cessation, including avoidance of second hand smoke and use of tobacco products
Dietary changes including reduced fat, cholesterol, and simple carbohydrates (such as sweets), and increased fruits and vegetables
Treatment of high cholesterol with medications and lifestyle changes
Moderation in alcohol intake
Medications to reduce your risk for blood clots
Control of diabetes
Control of high blood pressure
A prevention plan for PVD may also be used to prevent or lessen the progress of PVD once it has been diagnosed. Consult your doctor for diagnosis and treatment.