Arteriosclerosis of the extremities

Peripheral vascular disease; PVD; Peripheral arterial disease; PAD; Arteriosclerosis obliterans; Atherosclerosis

Arteriosclerosis, or "hardening of the arteries," commonly first affects the legs and feet. The narrowing of the arteries may lead to a total closing (occlusion) of the vessel.

The vessel walls become less elastic and cannot open (dilate) to allow greater blood flow when needed (such as during exercise). Calcium deposits in the walls of the arteries contribute to the narrowing and stiffness.

This is a common disorder, usually affecting men over age 50. People are at higher risk if they have a personal or family history of:

• Diabetes
• Heart disease (coronary artery disease)
• High blood pressure (hypertension)
• Kidney disease involving hemodialysis
• Smoking
• Stroke (cerebrovascular disease)

Often, symptoms affect one limb. If arteriosclerosis is in both limbs, the intensity is usually different in each.

• Change of color of the legs
• Cold legs or feet
• Leg pain (intermittent claudication)
  • Occurs with exercise (such as walking)
  • Relieved with rest
• Loss of hair on the legs and/or feet
• Muscle pain in the thighs, calves, or feet
• Numbness of the legs or feet at rest
• Paleness or blueness (cyanosis)
• Walking/gait abnormalities
• Weak or absent pulse in the limb

During an examination, the health care provider may find:

• A whooshing sound with the stethoscope over the artery (arterial bruits)
• Decreased blood pressure in the affected limb
• Decreased or no pulse in the legs or feet

Blood tests may show high cholesterol.

Tests for peripheral artery disease:

• An abnormal ratio between the blood pressure of the ankle and arm (ankle/brachial index, or ABI)
• Angiography of the arteries in the legs (arteriography)
• Doppler ultrasound exam of an extremity
• Intravascular ultrasound (IVUS) of the legs or feet
• MRI scan

Treatment focuses on relieving symptoms and improving circulation.

Medications may be required to control the disorder, including:

• Blood thinners
• Medications to enlarge (dilate) the affected artery or arteries
• Pain relievers

Surgery is usually performed only in severe cases if the condition is affecting your ability to work or pursue essential activities. Surgery may involve:

• Bypass surgery using a vein or artificial graft
• Removing the lining of the artery (endarterectomy)
• Repairing or replacing the vessel (grafting)

Some people with peripheral artery disease may need to have the limb removed (amputated). Rates of amputation are particularly high among African Americans and Hispanics with diabetes.

Alternatives to surgery may include balloon angioplasty (a similar technique to that used to open the coronary arteries, but performed on the blood vessels of the affected extremity). This may be followed by stent implantation, laser treatment, or other treatments.

Self-care:

• Balance exercise with rest. Walk or do another activity to the point of pain and alternate it with rest periods. Over time, circulation improves as new, small (collateral) blood vessels form.
• Stop smoking. Smoking tightens arteries, decreases the blood's ability to carry oxygen, and increases the risk of forming clots (thrombi and emboli).
• Foot care is particularly important if you also have diabetes. Wear shoes that fit properly. Pay attention to any cuts, scrapes, or injuries. The tissues heal slowly when there is decreased circulation and are prone to infection.
• If your cholesterol is high, eat a low-cholesterol and low-fat diet.

You can usually control arteriosclerosis of the extremities with treatment. Surgery provides good symptom relief. Complications may require amputation of the affected leg or foot.

• Arterial emboli
• Impotence
• Injury or infection of the feet and legs
• Open sores (ischemic ulcers) on the lower extremities
• Tissue death (gangrene) -- see gas gangrene
• Ulcers on the feet and toes

Call your health care provider if you have symptoms of arteriosclerosis of the extremities.

Call your health care provider if you develop new symptoms, especially:

• New sores/ulcers
• Signs of infection (fever, redness, general ill feeling, or joint pain)

Control risk factors such as:

• High cholesterol
• High blood pressure
• Obesity
• Smoking

Creager MA, Libby P. Peripheral Arterial Disease. In: Libby P, Bonow RO, Mann DL, Zipes DP. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders; 2007:chap 57.

Aung PP, Maxwell HG, Jepson RG, Price JF, Leng GC. Lipid-lowering for peripheral arterial disease of the lower limb. Cochrane Database Syst Rev. 2007;Oct 17(4):CD000123.