Peripheral Vascular Disease and Arterial Ulcers
Peripheral Vascular Disease (PVD) is more commonly referred to as ‘poor circulation’, that happens due to the narrowing of the arteries that supply blood to various parts of the body.
Narrowing of the arteries (stenosis) is caused by atherosclerosis – the build-up of fatty deposits (plaque) on the inside walls of the arteries. When the arteries that carry blood to the legs become narrower, blood flow is reduced and the muscles don’t receive an adequate amount of oxygen to support physical activity, which causes the cramping pain called intermittent claudication (muscle ischaemia).
PVD often affects the arteries that supply blood to the legs, leading to a circulation disorder in the lower limbs that is commonly experienced as cramping pain in the leg, particularly the calf muscles.
If left untreated, PVD can seriously impair a person’s ability to walk.
Progression of untreated PVD can lead toward the advanced disease stage called Critical Limb Ischaemia (CLI). This initially presents itself as ongoing pain usually located in the toes and feet (Rest Pain) frequently worse during the night time (Nocturnal Pain). It can also cause arterial ulcers (commonly found in the feet and lower legs) and gangrene (tissue loss) due to the critically inadequate supply of blood making wounds more susceptible to further damage from minor trauma and pressure.
Major Risk Factors for development and progression of PVD:
- Smoking (5-7 fold risk increase)
- Diabetes (5 fold risk increase)
- High blood pressure
- High cholesterol
- Increasing age
- Family history
- Physical examination
- Blood pressure measurements in the legs (Ankle Brachial Pressure Index and Toe Pressure assessment)
- Doppler Ultrasound (Duplex) imaging
- Computer Tomography with contrast (dye) called CT Angiogram (CTA)
- Magnetic Resonance Imaging (MRI) with contrast called MRA
- Diagnostic Angiography
- Lifestyle changes – stopping smoking, taking regular exercise, improving your diet, looking after your feet.
- Medication – including medication to prevent blood clots, control high blood pressure or to lower cholesterol.
- Angioplasty – an access is gained to the groin artery (Femoral Artery) using ultrasound guidance and a thin wire and tube called a catheter are guided through the blood vessels to the location of the plaque, where a small balloon is inflated to flatten the plaque, removing the obstruction.
- Angioplasty and Stenting – After the plaque is then flattened by angioplasty balloon occasionally a stent is inserted to hold the artery open. This is required when angioplasty alone will not correct the problem.
- Atherectomy – this procedure enables surgeon to remove excessive plaque from the artery by using highly sophisticated mechanical device inserted into the artery in the same way as angioplasty balloon. Atherectomy reduces the need for use of arterial stents.
- Endarterectomy and Patch Angioplasty – this open vascular surgery procedure aims to remove atherosclerotic plaque from the artery. It usually treats only short arterial segments affected by severe narrowing (stenosis) or blockage (occlusion) in important location where arteries frequently divide into two major branches. The most common location is the main artery in the groin (Common Femoral Artery) where it divides into the Superficial Femoral Artery and Profunda Femoris Artery.
- Open Bypass Surgery – less frequent way of addressing this problem nowadays, requiring creation of communication between arteries above and beyond narrowing (stenosis) or blockage (occlusion) using either native material (vein bypass) or synthetic one (prosthetic bypass). The most common arterial bypass surgery involves bypassing blocked (occluded) artery in the thigh (Superficial Femoral Artery) and is called Femoro-Popliteal Bypass Graft
- Major Amputations – this option are only used in the end stage disease where no reconstructive options are available and the affected limb is affected by an intractable pain or gangrene. The rate of this operations has diminished significantly over the last 20 years due to significant advances in vascular and endovascular surgery.