What to know about peripheral artery disease

Transcript

Caitlin Whyte (Host): September is peripheral artery disease or PAD Awareness Month. So, joining us to talk about just what that is, risk factors and more is Dr. Samantha Cox, a vascular surgeon at Prisma Health. This is Flourish, a podcast brought to you by Prisma Health. I’m Caitlin Whyte. So, what is PAD to start us off?

Samantha R. Cox, DO (Guest): PAD is a chronic disease in which plaque builds up in the arteries in the body. We often see it commonly affecting the legs or the lower extremities. The buildup generally occurs gradually. And if allowed to progress, blood flow in that artery can become more limited or blocked altogether. And it’s actually a relatively common problem. It affects more than 10 million people in the US. It’s most common in older folks, generally people who are 65 or older, but can occur at really any age.

We specifically see it affecting smokers most commonly and it often affect smokers at a younger age, but it also affects people with disease processes that I think of as, as more mainstream or common diseases that we may have experienced with ourselves or our family, or loved ones, such as high blood pressure, high cholesterol, or high triglycerides, diabetes, or kidney disease.

Host: What are the symptoms?

Dr. Cox: That’s a great question. So, the symptoms, most commonly are leg pain with walking, but there can be no symptoms at all, really. People may find that they have no symptoms, but then they get some testing maybe in their doctor’s office. And there’s a particular test that we might do called an ankle-brachial index.

And they may find that these numbers are lower on the ankle-brachial index than a normal value. What that would mean is they’re developing plaque in their lower extremities that may or may not be affecting them. But some people actually do experience quite a bit of fatigue or cramping of their muscles while walking.

And that actually has a special name. It’s called claudication. It can commonly occur in the calves and the thigh and the hip area or buttock region. And that also may be a sign that you have peripheral arterial disease. Typically the walking is what causes the symptoms to occur. And usually people recognize this happens at a certain distance.

For example, they may say every time I walk out to my mailbox, by the time I get there, my ankle, my calf and ankle region is cramping quite significantly. That may be a sign that they have peripheral artery disease. You may have pain in your feet or toes while resting. If the pain is so severe that it’s waking you up at night, that’s something that you would want to discuss with your physician and perhaps even be referred to a vascular surgeon to be evaluated.

And then the most significant form of peripheral artery disease, which we would consider, you know, the end stages of peripheral artery disease, would be open wounds on your toes or feet. There’s a lot of things that we can do to help someone to heal those wounds, but we would need to evaluate you and do some of these tests that I’ve described such as the ankle brachial index, or even maybe a test called an angiogram where we actually look at the blood vessel and understand the blood flow down the legs.

Host: And what are the risk factors? Does it impact any group more than others?

Dr. Cox: So the risk factors, I would say most commonly are related to smoking. It does tend to show up in people who have high levels of cholesterol. Usually patients that have diabetes should be having a foot check by their family physician commonly throughout their medical care throughout the year to identify if there’s any problems with healing of wounds on their feet.

People that have end stage renal disease that are on dialysis are also impacted more so with this disease process. But I think the largest risk factor people that it would most commonly affect would be smokers.

Host: How is PAD diagnosed and treated?

Dr. Cox: We can generally diagnose this in an office setting. We would perform some bedside testing when you’re in the office, such as an ankle brachial index, where they apply a blood pressure cuff to your arm and your lower leg, and we generate a number. And from that number, it provides us with an index to understand if the blood flow is normal or diminished to any certain degree. It would also involve a physical exam where we would do a pulse exam of the legs, starting at the groin region, behind the knee, and to the feet to make sure we can either palpate the pulse in your foot and legs.

And if we can’t feel it with our hand, with an examination, then we would use a, a bedside instrument called a Doppler to understand the sound of the blood flow, going down the leg to interpret if there would be any disease in the blood vessels, any of the arterial narrowing that may impact the bloodflow.

Host: Can you reverse PAD?

Dr. Cox: Although it’s not technically reversible, we can definitely control for risk factors, things such as stopping smoking and continuing to take your medications for high cholesterol or high triglycerides, taking your diabetic medications and so on would help to slow down the disease process. But it’s not reversible. We have a number of things we can do though, to improve upon the issues that someone may be experiencing such as pain. Or as we mentioned before, with tissue loss or wounds on the feet and legs. Those are things we definitely can help with, but the disease itself doesn’t actually go away. We just improve the symptoms by doing an intervention to help the blood flow, improve to the legs and the feet.

Host: How can I best manage symptoms such as leg pain?

Dr. Cox: When you talk about managing the symptoms, it’s going to sound somewhat ironic when I say this, because I mentioned that some of the pain begins with walking, but one of the things that we recommend for people who are experiencing claudication, as I said before, claudication is pain in the lower legs with ambulation. We have found that people who get involved in a walking program. Adding a walking program to their exercise regimen actually build up collateral blood supply to their lower legs, which over time will improve their symptoms. I know a number of patients I see in my office say to me, Dr. Cox, I told you my legs hurt when I walk yet, you’re telling me to walk and I say, that’s exactly correct, because usually you can improve upon the blood supply to your legs.

Your body wants to deliver the blood supply that you need to help to nourish the muscles that are doing the exercise. That cramping that you feel when you’re walking is actually the muscles starving for the oxygen and the nutrients that the blood supplies. So, by doing more walking, we build up that blood supply and improve upon those blood vessels. Those collateral blood vessels that are getting the blood flow right. So I do recommend walking as something to improve upon the symptoms. Also having an examination by a vascular surgeon would be helpful so that we can help to support you in these efforts and verify that what we’re looking at is in fact vascular disease, and we can help assist you with your goals and achieve your exercise program.

Host: So, does elevating the legs help at all?

Dr. Cox: Not usually. When we talk about elevating legs, we generally talk about elevating the legs for swelling. And that usually is a symptom of venous disease, which is somewhat different. The peripheral arterial disease or PAD is affecting the arteries. Whereas the venous disease actually affects the veins, which is the outflow, the return of the blood from your feet and legs back to your heart. So, it’s basically the other side of, of a highway system, if you will, of an advanced highway system that brings blood to, and from your legs. The outflow or the venous side would cause the swelling. And usually when we talk about elevating, that’s more of a venous problem.

Host: And what about heat? Is that beneficial?

Dr. Cox: Not necessarily. And actually, I, I do get concerned sometimes when my patients with diabetes are talking about using heat on their legs, because with diabetes over a prolonged period, patients have the tendency to develop neuropathy and neuropathy deprives, the lower legs of sensation, therefore applying heat or a heating pad may actually cause a skin burn that a diabetic patient may not be able to sense is too hot for their skin. So, I would actually avoid applying any type of heat. It would not help up peripheral arterial disease at any rate.

Host: How about exercise? What are the best exercises for PAD?

Dr. Cox: I think the best and most simplest exercise that we can do is a walking program, 20 minutes of cardiovascular exercise a day with walking. If you have a safe area or a safe area in the neighborhood that you can walk. Sometimes people even find that they’re allowed to go up and use the track at the local high school or walk the track around an elementary school, or even going up to the mall. Before COVID when everyone was in masks, it was a little easier to find indoor spaces when the weather was not as forgiving. But I think that finding somewhere in your neighborhood where you feel safe, where it’s lighted, where there’s a good road or path that you can walk on. Walking is something that we all can do. If we just give 20 minutes of our day to do that, to try to perform that kind of cardiovascular exercise, it seems the simplest thing for most people.

Host: And what is the best diet?

Dr. Cox: We generally recommend what we would call a heart healthy diet. This would be a low sodium, lower fat diet, especially if you’re a diabetic, you want to be certain that you’re managing your blood glucose and your blood sugar appropriately. Maintaining a heart healthy diet will help you to some degree to keep your cholesterol at a lower level, which we know impacts peripheral artery disease.

Host: In conclusion, are there any vitamins or supplements that can help?

Dr. Cox: There aren’t really any supplements that we would necessarily prescribe. I think apart from taking your medications and if blood pressure is an issue, diabetes is an issue, hypertension would be an issue. These are all the medications that you would want to continue. We also recommend statin therapy. These are medications that tend to lower your cholesterol, and these are helpful because again, the plaque and the narrowing of the blood vessels by the depositing of the plaque in the arteries. We know there are some very good studies that demonstrate that cholesterol lowering medications such as statins help with that problem.

But there is no supplement that’s been tested, that’s been proven to be beneficial. I think the biggest thing, the biggest message that we can give our patients that suffer from this problem is to avoid tobacco. Avoiding tobacco and smoking cessation is going to really help to set you in the right direction to achieve your goals with improving your lower extremity pain with walking.

Host: Well, thank you for taking the time to tell us all about PAD today Dr. Cox. That was Dr. Samantha Cox, a vascular surgeon at Prisma Health. For more information and other podcasts like this, head on over to PrismaHealth.org/Flourish. This has been Flourish, a podcast brought to you by Prisma Health. I’m Caitlin Whyte. Stay well.