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Diagnosing Peripheral Artery Disease

Program: Peripheral Artery Disease and Diabetes
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Andrew Schorr:

What are the signs of this, and are some people in a situation where it's developing but they don't even know it?

Dr. Conte:

In general most patients with PAD do not have symptoms, at least initially. That is, one can develop blockages in the arteries of the leg but until they reach a very critical level you may not have any signs or symptoms whatsoever. The earliest symptom of PAD is often that of pain or fatigue when walking. The pain can be in the calf muscle or in the thigh muscle, and is called claudication, and that is one of the cardinal signs of early PAD. When the disease progresses to involve more arteries farther down the leg, then the symptoms can be more severe-- such as pain in the foot, the development of ulcerations, or advanced changes such as gangrene in the toes. These developments imply that the foot is in danger if something is not done to increase blood flow. This more serious stage is far less common, but indicates an urgent situation.

Andrew Schorr:

Are there simple ways where a doctor can check to see if someone's at risk for this or maybe that it's developing even if there are no symptoms?

Dr. Conte:

Yes, most definitely we can make the diagnosis of PAD in the office ninety percent of the time with very simple physical examination and testing. First of all, patients who are at increased risk for PAD, and that includes all patients with diabetes, as well as people who smoke, the elderly, and those with known heart disease should undergo a complete vascular examination. The basic examination includes feeling of pulses in the leg all the way down to the foot and examination of the feet. The simple and most reliable test beyond that is to use a hand-held ultrasound instrument called a Doppler, and measure the pressure in the ankle in comparison to the pressure in the arm. That test is called an ankle-brachial index or ABI. The ABI, although it does have some areas where it's in error, is considered the best and simplest test to make a rapid screen for PAD.

Andrew Schorr:

Dr. Conte, some people who develop PAD are maybe older patients, and they may say, 'Well it's more difficult to walk' or 'I get this fatigue' or 'I get this pain in my leg or thighs when I walk because I'm getting older.' And they just kind of discount it and don't go further, but they could be risking much more serious events couldn't they?

Dr. Conte:

That's an excellent point Andrew. The importance of making the diagnosis of PAD is two-fold. First and most importantly, it's because making the diagnosis of PAD may be the first sign that a patient has atherosclerosis in their bodies. Because PAD is strongly associated with heart disease and stroke, these patients need to be treated aggressively from a medical standpoint to avoid cardiovascular complications like heart attack and stroke. So the implications are much greater than just the leg itself. In fact the risk to the leg is really not that high overall for the population with PAD, but the diagnosis does imply a significant amount of cardiovascular disease.

The second reason to make the diagnosis of PAD is to monitor people and treat them in a timely and aggressive fashion to avoid progressive loss of function in the leg, or worst case to avoid amputation. Making the diagnosis of PAD does not necessarily mean that a procedure needs to be done in the leg at that time. What it does mean is that those patients and their limbs need to be watched much more closely over time.

Andrew Schorr:

There are a couple of points I wanted to underscore from that. One is someone may have a fear if they're seeing changes in their leg or problems and if they know maybe somebody previously with diabetes they say, 'Oh my god I am risking amputation' and they just don't want to go there and so they don't get the early care, but as you were saying that's usually not the case. If you can get early intervention you're not risking the loss of a limb and also there are many interventions that can be explored, right?

Dr. Conte:

Yes absolutely, and all of us who take care of diabetic patients and patients with PAD know that amputation is one of the greatest fears. Amputation is far more common in diabetic patients in general not only because of their vascular disease but also because they can get peripheral neuropathy which affects nerve function. Neuropathy by itself can lead to the development of sores in the feet that can ultimately lead to infection and amputation. So diabetic patients are at increased risk for amputation, and it's a justifiable fear. What we want to do with education is avoid having patients turn that fear into denial to seek out appropriate therapy. What most of these patients really require is just good foot care, very careful attention to their medical risk factors, avoidance of smoking, certain simple measures to avoid problems with their feet and close monitoring, and with these basic measures we can very likely make a strong impact on avoiding amputation.

The other key point is that there are multiple different types of treatments available when the disease gets more severe in the leg, and making the right judgment about picking the right treatment at the right time is really the best way to preserve function long-term. However avoiding treatment altogether often unfortunately results in patients showing up too late, with a situation that becomes harder to salvage.

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