Atherosclerotic cardiovascular disease (hardening of the arteries) very often involves significant plaque formation in the arterial circulation to parts of the body other than the heart. This condition is known as peripheral vascular disease. Involvement of the circulation to the lower half of the body is the subject of this article. The dominant symptom of this condition is known as intermittent claudication and is generally described as a pain, aching, or cramping of the muscles of one or both legs or buttocks when walking. The symptoms are typically precipitated by a certain amount of exertion and relieved after a certain amount of rest, but may gradually get worse with time as the disease progresses. Eventually, one or more of the large arteries in the lower part of the body may become completely occluded and the opening in the artery becomes replaced by scar tissue. Interconnecting blood vessels, known as collateral circulation, develop with time so that the good vessels can supply some blood to the obstructed vessels, but this process often does not supply enough blood to prevent symptoms. Intermittent claudication symptoms of muscular pain in the legs or buttocks can range from a minor nuisance, experienced only when walking rapidly uphill, to markedly debilitating symptoms that prevent even normal walking for short distances on a flat surface. In some cases, the circulation is so impaired that one or both legs are starved for blood even at rest, with corresponding symptoms of muscular pain at rest that is much worse when walking. When the arteries to one of the legs become narrowed or occluded the blood pressure beyond the point of narrowing becomes reduced and the pulses in the lower leg are reduced or absent. These findings allow your doctor to strongly suspect the presence of peripheral vascular disease based on a combination of typical or suggestive symptoms and findings on examination. The diagnosis is confirmed by actually measuring the blood pressure in the various arteries of the legs with special blood pressure cuffs and if peripheral vascular disease is confirmed angiograms (X ray dye tests) of the arteries to the legs are used to localize the blockages and see which vessels are still open.

The basic cause or causes of this condition are the same as coronary atherosclerosis in the blood vessels to the heart. This includes being a man, getting older, high blood pressure, elevated cholesterol levels, diabetes, cigarette smoking, family (genetic) predisposition to get atherosclerosis, physical inactivity, and others. The usual treatment almost always involves attempts to control these “risk factors” and to try to improve the blood supply to the legs if possible in patients who have claudication symptoms. Regular walking to the point that discomfort is very significant can gradually improve the circulation by enhancing the development of the collateral circulation with some improvement in symptoms. There are several medications that are sometimes successful in improving the circulation to a limited degree. Nothing works nearly as well as interventions that actually restore direct connection between the normal or more normal blood vessels and the obstructed ones. These interventions involve either surgery to bypass the points of obstruction or balloon / stent procedures to open the blocked blood vessels.

Surgery for peripheral vascular disease of the lower extremities offers a broad range of options but involves bypass grafts of some kind, requires general anesthesia, several days in the hospital, and the grafts used to connect the good vessels to the obstructed vessels may become occluded afterwards. Most physicians do not recommend surgery for intermittent claudication until the symptoms are so severe as to be truly debilitating or even present at rest. This strategy emphasizes exercise programs, medication, and risk factor reduction with surgery as a last resort. By the time surgery is seriously considered the major arteries to one or both legs may have become totally occluded.

Intervention with balloons or stents can be done under local anesthesia with hospitalization overnight. These procedures can be done on totally occluded vessels, but this situation makes the procedure more difficult and the segments that must be opened tend to be much longer and harder to keep open once the vessels are totally occluded. The best strategy is to open the narrowed vessels early when symptoms of intermittent claudication are first detected. This approach seeks to provide prompt and effective relief of symptoms, avoid the development of completely occluded vessels, prevent debilitating symptoms, and avoid the need for surgery unless there are no other options. Patients with peripheral vascular disease involving the arteries to the legs who do not have any symptoms from this condition are usually managed without any kind of attempt at surgery or stents since the tissues are probably getting enough blood already if there are no symptoms and the legs look OK on examination in the doctor’s office.

If you have or if you develop symptoms of discomfort in the muscles of the buttocks or legs brought on by walking and relieved by rest, you should definitely undergo evaluation of the blood pressure in the arteries to the legs (using special blood pressure cuffs). If you are found to have obstructed or significantly narrowed arteries that can be opened with balloons or stents, that will probably be our recommendation to prevent much worse problems from developing in the future. This strategy represents a change from the older practice of waiting until surgery becomes mandatory before trying to restore the blood supply to the legs and is a result of major medical progress in technology and skill in performing the balloon and stent procedures that are available today. Capital Cardiovascular Specialists wishes to make our patients and the medical community in general aware of these recommendations and the reasons for them. Please ask us any questions you may have concerning peripheral vascular disease.