Peripheral Vascular Disease

What is peripheral vascular disease?

Peripheral vascular disease (PVD) is a slow and progressive disorder of the blood vessels. Narrowing, blockage, or spasms in a blood vessel can cause PVD.

PVD may affect any blood vessel outside of the heart. This includes the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain or legs, may not get enough blood flow for healthy function. The legs and feet are most often affected.

Peripheral vascular disease is also called peripheral arterial disease (PAD). 

What causes peripheral vascular disease?

The most common cause of PVD is atherosclerosis. This is the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs. It decreases the oxygen and nutrients sent to the tissue. Blood clots may form on the artery walls. This makes the inner size of the blood vessels even smaller and blocks off major arteries.

Other causes of PVD may include:

• Injury to the arms or legs
• Irregular anatomy of muscles or ligaments
• Infection

People with coronary artery disease (CAD) often also have PVD. 

Who is at risk for peripheral vascular disease?

Risk factors that you can’t change include:

• Age (higher risk over age 50)
• History of heart disease
• Male gender
• Postmenopausal women
• Family history of high cholesterol, high blood pressure, or peripheral vascular disease

Risk factors that may be changed or treated include:

• Coronary artery disease
• Diabetes
• High cholesterol
• High blood pressure
• Overweight
• Physical inactivity
• Smoking or use of tobacco products

Those who smoke or have diabetes have the highest risk of complications from PVD. This is because these risk factors cause impaired blood flow. 

What are the symptoms of peripheral vascular disease?

About half the people diagnosed with PVD have no symptoms. For those with symptoms, the most common first symptom is painful leg cramping that occurs with exercise and is relieved by rest. This is known as intermittent claudication. During rest, the muscles need less blood flow, so the pain disappears. It may occur in one or both legs. This depends on the location of the clogged or narrowed artery.

Other symptoms of PVD may include:

• Changes in the skin, including decreased skin temperature, or thin, brittle, shiny skin on the legs and feet
• Weak pulses in the legs and the feet
• Gangrene (dead tissue due to lack of blood flow)
• Hair loss on the legs
• Impotence
• Wounds that won't heal 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
• Paleness when the legs are elevated
• Reddish-blue discoloration of the extremities
• Restricted mobility
• Severe pain when the artery is very narrow or blocked
• Thickened, opaque toenails

The symptoms of PVD may look like other conditions. See your healthcare provider for a diagnosis. 

How is peripheral vascular disease diagnosed?

Your healthcare provider will ask about your medical history. They will give you a physical exam. You may also have tests such as:

• Angiogram. This is an X-ray of the arteries and veins to find blockage or narrowing. This procedure is done by putting 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. It is done 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. Your healthcare provider may use the Doppler test to measure and assess the flow of blood. Faintness or absence of sound may mean blood flow is blocked. 
• Magnetic resonance angiography (MRA).  This noninvasive test uses a large magnet, radio waves, and a computer to make detailed images of organs and other tissues in the body. Your provider injects a special dye during the procedure. This is done so that blood vessels are more visible. 
• Treadmill exercise test. For this test, you will walk on a treadmill so your provider can monitor blood flow during exercise.
• 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. Your healthcare provider can then compare these measurements to the systolic blood pressure in the arm.
• Pulse volume recording waveform analysis. Your healthcare provider uses this test 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 can't walk on a treadmill. While you are lying on your back, your healthcare provider takes comparative blood pressure measurements on the thighs and ankles to determine any decrease between the sites. 

What is the treatment for peripheral vascular disease?

The main goals for treatment of PVD are to control the symptoms and halt the progression of the disease. This is important to lower the risk for heart attack, stroke, and other problems. 

Treatment may include:

• Lifestyle changes to control risk factors. These include regular exercise, good nutrition, and not smoking.
• Aggressive treatment of other problems that may worsen PVD. These include diabetes, high blood pressure, and high cholesterol.
• Medicines to improve blood flow. These include antiplatelet medicines (blood thinners) and medicines that relax the blood vessel walls.
• 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. This is done to reroute the blood flow.
• Angioplasty. Your healthcare provider puts a catheter (thin, flexible tube) to create a larger opening in an artery. This is done to increase blood flow. There are several types of angioplasty procedures. They are:
  • Balloon angioplasty. A small balloon is inflated inside the blocked artery to open the blocked area)
  • Atherectomy. The blocked area inside the artery is "shaved" away by a tiny device on the end of a catheter.
  • Laser angioplasty. A laser is used to "vaporize" the blockage in the artery.
  • Stent. A tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open.

An angiogram may be done before angioplasty and vascular surgery. 

What are possible complications of peripheral vascular disease?

Complications of PVD most often occur because of decreased or absent blood flow. Such complications may include:

• Amputation (loss of a limb)
• Poor wound healing
• Restricted mobility due to pain or discomfort
• Severe pain in the affected extremity
• Stroke (three times more likely in people with PVD)

Following an aggressive treatment plan for PVD can help prevent complications.

What can I do to prevent peripheral vascular disease?

To prevent PVD, take steps to manage the risk factors. A prevention program for PVD may include:

• Quit smoking, stay away from secondhand smoke, and don't use any tobacco products
• Dietary changes including reduced fat, cholesterol, and simple carbohydrates (such as sweets), and increased amounts of fruits and vegetables, low-fat dairy, and lean meats
• Treatment of high blood cholesterol with medicine as determined by your healthcare provider
• Weight loss
• Limiting or quitting alcohol intake
• Medicine to reduce your risk for blood clots, as determined by your healthcare provider
• Exercise 30 minutes or more daily
• Control of diabetes
• Control of high blood pressure

To prevent or reduce the progress of PVD, your healthcare provider may advise a prevention plan. 

When should I call my healthcare provider?

If your symptoms get worse or you get new symptoms, let your healthcare provider know right away.

Key points about peripheral vascular disease

• Peripheral vascular disease can affect all types of blood vessels.
• Blood flow is restricted to the tissue because of spasm or narrowing of the vessel.
• This disease more often affects the blood vessels in the legs.
• The most common symptom is pain, which becomes worse as the circulation more limited.
• Restoring blood flow and preventing disease progression is the goal of treatment.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are and when they should be reported.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your healthcare provider if you have questions, especially after office hours or on weekends.