Over the last 15 years the interventional treatment of peripheral artery disease (PAD) has changed significantly with endovascular revascularization replacing surgically invasive procedures as the dominant therapy. Early detection and treatment are important to control the disease and allow patients a full selection of treatment options.
Many types of health care providers can diagnose and treat PAD. Family physicians, internists, physician assistants, nurse practitioners and vascular specialists can all diagnose PAD by examining a patient’s medical and family history, performing a physical exam, and conducting diagnostic tests.
PAD can be diagnosed through a variety of diagnostic procedures including:
- Ankle-brachial index (ABI): A common test used to measures the difference between blood pressure at the arm and at the ankle. A difference in the two areas indicates restricted blood flow.
- CT and MR angiograms
- Blood tests
There are multiple options for treatment of PAD, ranging from medical interventions, surgical revascularization, and endovascular therapy. Specialists including vascular medicine specialists, vascular surgeons, cardiologists, podiatrists, and interventional radiologists can all treat patients diagnosed with PAD.
Approaches to treatment include:
- Minimally invasive endovascular procedures
- Medical management
- Exercise and lifestyle modifications
- Surgical bypass
Minimally invasive procedures are now backed by years of clinical data and offers effective alternative to surgery or amputation.
Minimally Invasive EndoVascular Procedures
For people suffering from PAD, the build-up of plaque in the arteries of the legs often leads to severe and even debilitating leg pain. Minimally invasive endovascular procedures include atherectomy, balloon angioplasty, and stents. Patients who receive these procedures can often avoid amputation as well as prolonged hospitalizations and recovery times associated with surgery.
Atherectomy is a procedure where plaque buildup is removed from an artery. Like various tools for a job, several different atherectomy devices are available to remove plaque from the artery. When the plaque becomes calcified or “bone-like,” minimally invasive endovascular devices can be used to break down or sand the calcium deposits narrowing or blocking the artery, making the deposits small enough to wash away in the bloodstream and restoring blood flow. During another procedure, a catheter is used to insert a small cutting device into the blocked artery. The device is used to shave or cut off the plaque. The bits of plaque are removed from the body through the catheter and discarded. Doctors also can do atherectomy using a special laser that dissolves the blockage. Approximately 80% of patients who undergo atherectomy treatments are able to save their limbs from amputation.
Balloon angioplasty is a procedure where a balloon is inflated and plaque is pushed against the arterial walls, causing the artery to widen and restoring blood flow. Angioplasty can be performed alone or in combination with atherectomy and stents. When a balloon angioplasty is performed after atherectomy to calcified or longer lesions, it is associated with fewer complications.
A stent (tiny metal cylinder) can be placed in the artery after the angioplasty procedure with the intent to keep the diseased artery open. These are particularly successful when used for larger arteries.
There are a number of ways that doctors and patients may medically manage PAD.
Antiplatelet (Aspirin) Therapy
While the function of aspirin for PAD patients is consistently reevaluated, a number of studies suggest beneficial effects for those suffering from the disease. In fact, a 2009 study revealed a 34% risk reduction for nonfatal stroke among PAD patients taking the medication.
Doctors will often prescribe patients with medications that lower cholesterol and blood pressure, prevent blood clots, and help manage pain. Proper medical therapy is important to reduce the risk of cardiovascular events such as death, heart attack and stroke.
Experimental Cell and Gene Therapies
A number of new therapies are currently under development, being studied by medical researchers across the country. However, cell and gene therapies are currently only available in clinical trials.
When PAD goes undiagnosed and untreated, many patients reach Critical Limb Ischemia (CLI) and must undergo amputation. However, amputation is life-altering and often leads to additional health complications, and even subsequent amputation.
Despite the success of minimally invasive endovascular procedures, major amputation continues to be a primary therapy for extreme cases of PAD and is frequently the only treatment offered to patients. Approximately 65,000 to 75,000 major amputations take place each year in the United States. This means about a third of CLI patients undergo amputation, two thirds of which are seniors over the age of 65.
Experts now recommend amputation is an appropriate procedure in only 15% of cases whereas revascularization is considered appropriate in 70%, with the other 15% recommended to undergo palliative care/wound care.
The effects of PAD can be diminished by certain every-day lifestyle adjustments:
Smoking is the main risk factor for PAD and can exacerbate negative affects on those diagnosed with the disease. Recent studies have revealed that that those able to quit smoking following a PAD diagnosis have substantially lower risk of death, myocardial infraction, and amputation.
A healthy diet is essential for PAD patients. Those diagnosed with the disease must maintain low levels of blood pressure and blood cholesterol. A diet that is low in fat, saturated fat, cholesterol, and salt may help stabilize arterial plaque or delay plaque accumulation. Patients with diabetes must also work to achieve controlled blood glucose (sugar) levels.
Finally, supervised and consistent exercise programs have been shown to reduce PAD symptoms over time.