Why do my legs hurts?
Peripheral Artery Disease – Diagnosis and Treatment
Randy Minton, M.D., F.A.C.C.
Pain in the legs is a common complaint for patients and can have a multitude of causes related to skin, muscle, nerve or bone. The symptom of muscle pain brought upon by walking and relieved with rest is known as claudication, and often this is the result of poor blood flow. Peripheral artery disease (PAD), also known as peripheral vascular disease (PVD), is generally the culprit and can be diagnosed in an outpatient clinic. Simply put, PAD is “clogged plumbing” and the symptoms arise downstream from the blockage. As this condition affects all arteries, upon diagnosing PAD, there is a 60% chance that patient will have coronary artery disease (CAD), and a 30% chance a patient will have CAD severe enough to need coronary bypass surgery. This article will review the tests to diagnose this condition and the treatment options available.
The first step is the history and physical exam with the primary physician. The sages of medicine say ‘If you never take the patient’s temperature they never have a fever.’ Or better put, ‘You can’t fix it until you find it.’ The simple question ‘Do your legs hurt with walking?’ will often lead to further evaluation in symptomatic patients and diagnostic testing can be ordered. The simplest is the ankle-brachial index (ABI). This is done with a blood pressure cuff and a hand held ultrasound device. The blood pressure is measured in the arm, then at each of the ankles. If no blockage is present, all pressures are equal. If either or both of the ankle pressures are below 90% of the arm pressure, significant blockage may be present in the legs and further testing is indicated. The arteries can then be imaged, as an outpatient, typically with a CT or MR scan requiring only an IV in the arm. Some cases may require imaging in a catheterization lab with a catheter inserted directly into the artery at the groin. Once the degree and location of blockage is seen, treatment can then be pursued.
The mainstay of PAD treatment is a good medical regimen to control blood pressure, glucose and cholesterol. Total cholesterol should be maintained below 150 and LDL (bad cholesterol) below 70. Daily aspirin will help reduce heart attack and stroke risk. Smoking cessation is an absolute requirement if real, lasting improvement is to be attained. One medication, Pletal, can be prescribed to relieve claudication by making the red blood cells more “slippery.” This allows the cells to pass more easily through small, restricted arteries, but may take up to 2 months to have full effect. A free treatment, exercise, can be very effective in relieving symptoms by inducing branch vessels to enlarge and, in effect, “grow bypasses” around blockages. The patient is instructed to walk daily to the point of cramping, typically in the thigh or calf muscles, then rest. Once the cramping has subsided, resume walking until pain reoccurs. Gradually, collateral circulation develops, and the distance walked until pain occurs lengthens. These collateral vessels will generally maintain their flow longer than options below, however, they may take several months and many miles to develop.
Procedural options for PAD should be pursued when symptoms limit daily activity or evidence of tissue damage is present. Surgical or catheter approaches for revascularization are available and each has its indications and limitations.
Traditionally, surgical bypass grafts have been used to route blood flow around the blockages of PAD just as they have been done for heart blockages. Surgical grafts are more common if the vessels are totally occluded or diffusely diseased. This may involve artificial grafts placed in the abdomen from the aorta to the iliac arteries in the pelvis. In the legs, vein is usually harvested and used from the groin to just above the knee. Less frequently, the graft may pass from the groin to below knee although the longer the graft and the smaller the artery, the more likely the graft will close with time. These operations typically involve general anesthesia and may require hospitalization of 2 to 5 days or more. Several weeks’ recovery is required before resuming all normal activities and all medical and exercise treatments above should be applied.
Technology advancements continue to improve catheter options for endovascular revascularization, and are generally preferred by patients, as they are typically outpatient procedures, without general anesthesia, and have a much shorter recovery time. The catheter is about the size of a coffee straw and the incision is covered with a Band-Aid after the procedure. Balloon angioplasty is used to dilate the site of blockage and restore normal flow, especially in larger arteries. For some blockages, wire mesh tubes, known as stents, may be place inside the artery to serve as scaffolding and keep the artery open. Laser atherectomy uses a “cold tipped” laser to vaporize plaque and can pass through areas of total occlusion which may then be further treated with angioplasty or stents. A recent advancement has been catheter atherectomy, which can remove the blockage with a small cutter and pack the plaque in the catheter to be removed from the artery. Usually, this procedure does not require use of angioplasty or stents. For most patients treated with catheters, they are discharged the day of the procedure and instructed to resume normal activity the following day. The blood thinner Plavix is prescribed for 3 to 6 months until healing within the artery is complete, and the same medical and exercise treatments are recommended. Although debate continues, catheter outcomes are generally equivalent to surgical outcomes.
Treatment for PAD is underused by patients and physicians often due to the fact that the right questions aren’t asked of, or by, the physicians. Maintaining the use of the legs leads to better cardiovascular fitness and improves overall health and decreases time spent in the hospital. Start with daily exercise and if symptomatic talk to your physician or seek out a specialist who treats peripheral artery disease. The sooner the ‘fever’ is found, the better and more complete will be the ‘fix.’
