10 PVD (peripheral vascular disease) facts
In this article we will describe 10 peripheral vascular disease (PVD) facts.
Key Points
- Peripheral Vascular Disease (PVD), also known as Peripheral Arterial Disease (PAD), is a common condition characterised by the narrowing of peripheral arteries, primarily affecting the legs. It is largely a disease of smokers.
- It is strongly associated with atherosclerosis and shares risk factors with other cardiovascular diseases, such as ischaemic heart disease (IHD) and stroke.
- Symptoms range from intermittent claudication (leg pain on exertion) to critical limb ischemia (rest pain, ulceration, gangrene).
- Diagnosis involves clinical assessment and is supported by non-invasive tests like the ankle-brachial index (ABI) and Doppler ultrasound.
- Management includes lifestyle modification, pharmacotherapy to control risk factors, and in severe cases, surgical interventions like angioplasty or bypass surgery.
1. Definition
- Peripheral Vascular Disease (PVD) refers to the obstruction or narrowing of blood vessels outside the heart and brain, primarily affecting the lower extremities.
- It most commonly results from atherosclerosis, leading to reduced blood flow to the limbs.
- The term is often used interchangeably with Peripheral Arterial Disease (PAD), which specifically involves arterial rather than venous disease.
2. Epidemiology
- Prevalence: PVD affects approximately 5-10% of adults in the UK, with higher rates in those over the age of 60. It is often underdiagnosed, as many patients are asymptomatic.
- Age and Gender: Prevalence increases with age, and men are more commonly affected than women, especially under the age of 70.
- Global Impact: PVD affects over 200 million people worldwide, with higher rates of morbidity and mortality in low- and middle-income countries.
3. Risk Factors
- Smoking: The most significant modifiable risk factor, greatly increasing the risk of atherosclerosis. PVD is very rare in non-smokers.
- Diabetes Mellitus: Accelerates atherosclerosis and is associated with more severe forms of PVD.
- Hypertension: Contributes to endothelial damage and plaque formation.
- Hyperlipidemia: High levels of LDL cholesterol promote atheroma development.
- Age: Risk increases markedly after age 50.
- Family History: Genetic predisposition to atherosclerosis.
- Chronic Kidney Disease (CKD): Accelerates vascular calcification and atherosclerosis.
- Obesity and Physical Inactivity: Contribute to metabolic syndrome and cardiovascular risk.
4. Causes
The primary cause of PVD is atherosclerosis, which involves the buildup of fatty plaques within the arterial walls. This leads to narrowing and hardening of the arteries, reducing blood flow to the limbs. Other, less common causes include:
- Vasculitis: Inflammation of the blood vessels.
- Arterial Entrapment Syndromes: Conditions like popliteal artery entrapment.
- Thromboembolic Events: Acute blockage of an artery by a blood clot.
5. Symptoms
Intermittent Claudication
- Pain or Cramping in the Legs: Typically occurs during walking or exercise and is relieved by rest. This is the cardinal symptom of PVD.
- Location: Pain usually affects the calf, but can also involve the thigh or buttocks, depending on the site of arterial narrowing.
Critical Limb Ischaemia (Advanced PVD)
- Rest Pain: Severe, persistent pain in the foot or toes, even at rest, particularly at night.
- Ulceration: Non-healing sores or ulcers on the feet or legs.
- Gangrene: Tissue necrosis due to inadequate blood supply, potentially leading to limb loss.
Other Symptoms
- Cool, Pale Skin: Due to reduced blood flow.
- Weak or Absent Pulses: Particularly in the feet.
- Hair Loss and Shiny Skin: In areas of reduced perfusion.
6. Diagnosis
Clinical Assessment
- History: Ask about leg pain during walking, rest pain, history of cardiovascular disease, smoking, and diabetes.
- Physical Examination: Assess pulses (femoral, popliteal, dorsalis pedis, posterior tibial), skin colour and temperature, and look for ulcers or gangrene.
Investigation
- Ankle-Brachial Index (ABI): A non-invasive test that compares blood pressure in the ankle with blood pressure in the arm. An ABI of <0.9 indicates PVD.
- Doppler Ultrasound: Used to assess blood flow and locate areas of stenosis or occlusion.
- Treadmill Exercise Test: Helps evaluate exercise tolerance and the severity of claudication.
- Imaging:
- Magnetic Resonance Angiography (MRA) and Computed Tomography Angiography (CTA): Provide detailed images of the arterial system.
- Digital Subtraction Angiography (DSA): Considered the gold standard for diagnosis and is used when planning revascularization procedures.
Differential Diagnosis
- Spinal Stenosis: Can cause leg pain similar to claudication, known as neurogenic claudication, but typically improves with forward bending.
- Venous Insufficiency: Causes leg swelling and ulcers but usually without the cramping pain associated with PVD.
- Peripheral Neuropathy: Often associated with diabetes, causing burning or tingling sensations rather than the cramping of claudication.
- Deep Vein Thrombosis (DVT): Can present with leg pain and swelling but is acute and unrelated to exertion.
7. Treatment
Lifestyle Modifications
- Smoking Cessation: Critical for reducing disease progression.
- Exercise: Regular, supervised exercise programs (e.g. walking) improve symptoms of claudication and overall cardiovascular health.
- Diet: Heart-healthy diet low in saturated fats, cholesterol, and refined sugars.
- Weight Management: Achieving a healthy weight to reduce overall cardiovascular risk.
Pharmacological
- Antiplatelet Agents: Aspirin or clopidogrel to reduce the risk of cardiovascular events.
- Statins: Lower LDL cholesterol and have additional benefits in plaque stabilization.
- Antihypertensives: ACE inhibitors, beta-blockers, or calcium channel blockers to manage blood pressure.
- Glycaemic Control: Tight glucose control for diabetic patients to prevent complications.
- Cilostazol: A phosphodiesterase inhibitor that can improve walking distance in patients with intermittent claudication.
Surgical and Interventional Options
- Angioplasty and Stenting: Minimally invasive procedures to widen narrowed arteries and improve blood flow.
- Atherectomy: Removal of plaque from the artery.
- Bypass Surgery: Creating a graft to bypass the blocked section of the artery, typically used in severe cases or when endovascular procedures are not feasible.
- Amputation: Considered a last resort for patients with extensive tissue loss or severe infection.
8. Complications
- Critical Limb Ischaemia: Advanced stage of PVD leading to rest pain, ulcers, and gangrene, with a high risk of amputation.
- Acute Limb Ischaemia: Sudden, severe reduction in limb perfusion, typically caused by a thrombus or embolus, requiring urgent intervention.
- Cardiovascular Events: Patients with PVD are at increased risk of myocardial infarction, stroke, and cardiovascular death.
- Infection: Non-healing ulcers can become infected, potentially leading to sepsis.
9. Prognosis
- Variable Outcomes: Prognosis depends on the severity of the disease, comorbid conditions, and adherence to lifestyle modifications and treatment.
- Risk of Amputation: 1-2% of patients with intermittent claudication progress to critical limb ischemia annually, with up to 25% of these requiring amputation within one year.
- Mortality: PVD is a marker of systemic atherosclerosis; thus, patients have a higher risk of cardiovascular events, with a 5-year mortality rate of 20-30%.
10. Prevention
- Smoking Cessation: The single most effective measure to prevent PVD and reduce disease progression.
- Management of Risk Factors: Regular monitoring and management of hypertension, hyperlipidemia, and diabetes.
- Regular Physical Activity: Exercise promotes cardiovascular health and can prevent or delay the onset of symptoms.
- Healthy Diet: Adopting a balanced diet rich in fruits, vegetables, whole grains, and lean proteins.
- Regular Screening: Especially for individuals with risk factors like diabetes, hypertension, and a history of smoking. Early identification can lead to better outcomes.
Summary
We have described 10 peripheral vascular disease (PVD) facts. We hope it has been useful.
Other resource
MyHSN PVD podcast (2024) – 6 min, 41 sec
