What is Peripheral Artery Disease? Symptoms, Diagnosis, and Treatment

What is Peripheral Artery Disease?

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Peripheral artery disease is a condition where arteries outside the heart and brain narrow or become blocked. It most commonly affects leg arteries but can also affect arteries going to the arms, stomach, kidneys, and other organs. The disease usually develops as a result of atherosclerosis, a process where fatty plaques accumulate on artery walls.

In normal healthy arteries, blood flows freely and carries sufficient oxygen and nutrients to tissues. In arteries narrowed by atherosclerosis, blood flow decreases, causing insufficient blood supply to muscles, especially during exercise, and resulting in pain.

Why Peripheral Artery Disease Matters

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Peripheral artery disease is not just a leg problem but an indicator of vascular health throughout the body:

• Heart attack risk: Heart attack risk increases 4-6 fold in PAD patients
• Stroke risk: Brain vessels may also be affected
• Amputation risk: Risk of limb loss in advanced cases
• Quality of life: Walking difficulty seriously affects daily life
• Prevalence: Affects 15-20% of individuals over 65 years old

Stages of Peripheral Artery Disease

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PAD is divided into four stages based on severity (Fontaine classification):

Stage I: Asymptomatic

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• Patient feels no symptoms
• Detected during examination or testing
• Vessel narrowing exists but blood flow is adequate

Stage II: Intermittent Claudication

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• Leg pain or cramping during walking
• Pain resolves with rest
• IIa: Able to walk more than 200 meters
• IIb: Able to walk less than 200 meters

Stage III: Rest Pain

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• Pain even without movement
• Increases especially at night and when leg is elevated
• Relieved when leg is lowered
• Beginning of critical limb ischemia

Stage IV: Tissue Loss

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• Impaired wound healing
• Development of ulcers and gangrene
• High risk of amputation
• Requires urgent intervention

Symptoms of Peripheral Artery Disease

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PAD symptoms vary depending on the stage of disease and affected arteries:

Classic Symptoms

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• Intermittent claudication: Pain, cramping, or fatigue in legs, hips, or calves while walking. Resolves within 5-10 minutes with rest
• Cold legs and feet: Due to decreased blood flow
• Skin color changes: Pale or bluish appearance
• Hair loss: On legs and feet
• Nail changes: Thickening and slow growth
• Weak pulse: Weak or absent pulses in feet and legs
• Erectile dysfunction: In men with pelvic artery involvement

Advanced Stage Symptoms

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• Leg pain even at rest
• Non-healing wounds (especially on feet and toes)
• Gangrene (tissue death)
• Numbness in leg or foot

Silent PAD

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A significant portion of patients may have PAD without any symptoms. In diabetic patients, pain sensation may be reduced due to peripheral neuropathy. Therefore, regular screening is important for individuals with risk factors.

Risk Factors

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Non-Modifiable Risk Factors

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• Age: Risk increases after 50, more pronounced after 65
• Gender: More common in men, but prognosis is worse in women
• Genetics: Family history of vascular disease
• Ethnicity: More common in certain populations

Modifiable Risk Factors

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• Smoking: Most important risk factor! Increases PAD risk 4-fold
• Diabetes: Increases PAD risk 2-4 fold
• Hypertension: Accelerates vascular damage
• High cholesterol: Triggers atherosclerosis development
• Obesity: Increases metabolic disorders
• Sedentary lifestyle: Negatively affects vascular health

Associated Conditions

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• Coronary artery disease
• Carotid artery disease
• Chronic kidney disease
• Metabolic syndrome

Diagnostic Methods

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Peripheral artery disease diagnosis is made through clinical evaluation and various tests:

Physical Examination

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• Pulse check: Evaluation of foot and leg pulses
• Skin assessment: Color, temperature, and tissue changes
• Wound inspection: Presence of ulcers or gangrene
• Auscultation: Listening for bruits over vessels

Ankle-Brachial Index (ABI)

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• Gold standard screening test for PAD diagnosis
• Ratio of ankle to arm blood pressures
• Normal: 1.0-1.4
• Mild PAD: 0.9-0.99
• Moderate PAD: 0.7-0.89
• Severe PAD: 0.5-0.69
• Critical ischemia: <0.5
• Simple, painless, and inexpensive test

Doppler Ultrasonography

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• Evaluates blood flow in vessels
• Shows location of narrowing and blockage
• Non-invasive and repeatable
• Helps with treatment planning

CT Angiography

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• 3D imaging of vessel structure
• For surgical and interventional planning
• Requires contrast agent use
• Kidney function should be evaluated

MR Angiography

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• Radiation-free imaging
• Detailed evaluation of vessel structure
• Contrast agent may be needed in some patients
• Caution needed in patients with pacemakers

Conventional Angiography

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• Gold standard diagnostic method
• Imaging from inside vessel via catheter
• Treatment can be done in same session (balloon-stent)
• Is an invasive procedure

Exercise Testing

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• Measuring pain distance on treadmill
• Evaluates functional capacity
• Monitoring treatment effectiveness

Treatment Approaches

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PAD treatment is planned according to disease stage and patient’s general condition. The main goals of treatment are to reduce symptoms, stop disease progression, and prevent complications.

1. Lifestyle Modifications

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Fundamental treatment for all PAD patients:

Smoking Cessation:

• Most critical step! Slows disease progression
• Reduces amputation risk
• Increases walking distance
• Support programs and medications can help

Exercise Program:

• Supervised walking programs
• At least 3 times per week, 30-45 minutes
• Rest when pain starts, continue when it passes
• Can increase walking distance by 100-200%

Nutrition:

• Heart-healthy diet
• Saturated fat and salt restriction
• Vegetables, fruits, and whole grains
• Ideal weight goal

2. Medication Therapy

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Antiplatelet Therapy:

• Aspirin or clopidogrel
• Prevents blood clotting
• Reduces heart attack and stroke risk

Cholesterol-Lowering Medications:

• Statins (atorvastatin, rosuvastatin)
• LDL cholesterol target <70 mg/dL
• Provides plaque stabilization
• Reduces cardiovascular events

Blood Pressure Medications:

• ACE inhibitors or ARBs
• Target <130/80 mmHg
• Vascular protective effect

Diabetes Control:

• HbA1c target <7%
• SGLT2 inhibitors provide cardiovascular protection

Symptom-Relieving Medications:

• Cilostazol: Increases walking distance
• Naftidrofuryl: Used in some countries
• Prostaglandin analogs: In critical ischemia

3. Endovascular (Interventional) Treatment

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Minimally invasive procedures performed from inside the vessel:

Balloon Angioplasty:

• Widening the narrowing with balloon
• Short hospital stay
• Recurrent narrowing may occur

Stent Placement:

• Metal cage to keep vessel open
• Drug-coated stents are more effective
• Preferred for long lesions

Atherectomy:

• Mechanical removal of plaque
• Used in calcified vessels
• Can be combined with balloon and stent

4. Surgical Treatment

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In advanced cases or when interventional treatment is not suitable:

Bypass Surgery:

• Bypassing the blocked area
• Use of vein or synthetic graft
• Effective in long segment blockages
• Longer recovery time

Endarterectomy:

• Surgical removal of plaque
• Can be applied in certain areas

Amputation:

• Last resort treatment option
• Can be life-saving
• Rehabilitation is important

Critical Limb Ischemia

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Critical limb ischemia (CLI) is the most severe form of peripheral artery disease and requires urgent intervention:

Definition and Findings

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• Rest pain (lasting more than 2 weeks)
• Wounds on feet or toes
• Gangrene (tissue death)
• ABI <0.4 or foot pressure <50 mmHg

Treatment Approach

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• Urgent revascularization (vessel opening) is required
• Endovascular or surgical treatment
• Wound care and infection control
• Rapid intervention is essential to prevent amputation

Lifestyle Recommendations

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Things to pay attention to when living with PAD:

Foot Care

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• Check your feet every day
• Look for cracks, wounds, or color changes
• Wear appropriate shoes (not tight, comfortable)
• Keep your feet warm but do not apply direct heat
• Regular nail care (podiatrist recommended for diabetic patients)

Exercise

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• Participate in a regular walking program
• Stop when pain starts, continue when it passes
• Gradually increase the distance
• Exercise at least 3-5 days per week

Nutrition

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• Follow a Mediterranean-type diet
• Consume foods rich in omega-3 fatty acids
• Reduce salt and saturated fat consumption
• Eat plenty of vegetables and fruits
• Avoid processed foods

Medication Compliance

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• Take your medications regularly
• Do not skip blood thinners
• Do not miss your check-ups

Frequently Asked Questions (FAQ)

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When Should You See a Doctor?

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Seek medical help without delay in the following situations:

• Pain or cramping in leg, hip, or calf while walking
• Leg pain that doesn’t resolve even with rest
• Coldness and color change in feet or legs
• Non-healing foot wounds
• Numbness in feet or legs
• Erectile dysfunction in men
• Hair loss on legs and nail changes

Regular vascular health check-ups are recommended especially if you smoke or have diabetes, hypertension, or high cholesterol. Early diagnosis is critically important to prevent serious complications.

If you have questions about peripheral artery disease or would like to schedule an evaluation, please feel free to contact me.