Peripheral Vascular Disease (PVD), Peripheral Artery Disease (PAD)

Peripheral vascular disease (PVD) is a problem with poor blood flow. It affects blood vessels outside of the heart and brain and gets worse over time. Parts of the body, like the brain, heart, arms, or legs, may not get enough blood. The legs and feet are most commonly affected.

Other blood vessel problems like deep vein thrombosis (DVT), varicose veins, and chronic venous insufficiency are linked to PVD.

PVD is often found in people with problems with the arteries that supply blood to the heart (coronary artery disease). That is because atherosclerosis, which causes coronary artery disease, affects arteries throughout the body. Atherosclerosis is the buildup of plaque on the walls of the arteries. Plaque is made up of cholesterol, fat, and waste from the cells, and other materials. It causes the arteries to become stiff and narrow.

What causes PVD?

PVD may result from a narrowing of the blood vessels that carry blood to the legs and arms. The most common cause is atherosclerosis.

Other causes of PVD may include injury to the arms or legs, abnormal muscles or ligaments, or infection. 

What conditions are linked to PVD?

The term peripheral vascular disease encompasses several different conditions including:

• Atherosclerosis. Atherosclerosis is the buildup of plaque inside the artery wall. Plaque is made up of deposits of fatty substances, cholesterol, cellular waste products, calcium, and fibrin. The artery wall then becomes thickened and loses its elasticity. Symptoms may develop gradually, and may be few, as the plaque builds up in the artery. However, when a major artery to the heart or brain is blocked, a heart attack or stroke may occur.
• Buerger disease (thromboangiitis obliterans). This is a chronic inflammatory disease in the arteries. It leads to blood clots in the small- and medium-sized arteries of the arms or legs, eventually blocking them. This disease most commonly occurs in men between ages 20 and 40 who smoke cigarettes. Symptoms include pain in the legs or feet, clammy cool skin, and a diminished sense of heat and cold. 
• Chronic venous insufficiency. This is a prolonged condition in which 1 or more veins don't adequately return blood from the legs back to the heart. It's due to valve damage in the veins. Symptoms include discoloration of the skin and ankles, swelling of the legs, and feelings of dull, aching pain, heaviness, or cramping in the legs.
• Venous thromboembolism (VTE). This term is used to describe 2 conditions, DVT and PE. They use the term VTE because the 2 conditions are very closely related. And, because their prevention and treatment are also closely related.
  • Deep vein thrombosis (DVT). DVT is a blood clot in a large vein deep inside a leg, arm, or other part of the body. These blood clots are common in those who have had long periods of inactivity like sitting while traveling or bed rest after surgery. Symptoms may include pain, swelling, and redness in the affected arm or leg. If you have these symptoms, call your health care provider.
  • Pulmonary embolism (PE). PE is a blood clot in the lungs. The most common cause is a part of a clot that breaks off and travels to the lungs. In the lungs, the clot can cut off the flow of blood. This is a medical emergency and may cause death. Common symptoms are chest pain, trouble breathing, fast heartbeat, sweating, coughing (may cough up blood), and fainting. If you have these symptoms, call 911 or get emergency help.
• Raynaud phenomenon. This is a condition in which the smallest arteries that bring blood to the fingers or toes tighten when exposed to cold or during emotional upset. It most commonly occurs in women between ages 18 and 30. Symptoms include cold, pain, and paleness in the fingertips or toes.
• Thrombophlebitis. Thrombophlebitis is a blood clot in an inflamed vein, most often in the legs, but it can also occur in the arms. It may result from pooling of blood, injury to the vein wall, and changes in how the blood clots. Symptoms in the affected extremity include swelling, pain, tenderness, redness, and warmth.
• Varicose veins. Dilated, twisted veins are caused by valves that allow backward flow of blood. This allows blood to pool. It's most commonly found in the legs or lower trunk. Symptoms include bruising and sensations of burning or aching. Pregnancy, obesity, and extended periods of standing make symptoms worse.

What are the risk factors for PVD?

Risk factors include:

• Age over 50 years
• Heart disease
• High blood cholesterol
• High blood pressure (hypertension)
• Diabetes
• No longer having menstrual periods (postmenopausal)
• Family history of high cholesterol, high blood pressure, or PVD
• Overweight or obesity
• Physical inactivity
• Smoking or use of tobacco products

Those who smoke or have diabetes have the highest risk of complications from PVD because these risk factors also cause poor blood flow.

What are the symptoms of PVD?

About half of the people diagnosed with PVD do not have symptoms. The most common symptom is lower leg cramps with activity that stop with rest (intermittent claudication). It may occur in 1 or both legs.

Other symptoms may include:

• Changes of the skin of the legs and feet, including red to blue color, coldness, or thin, shiny skin
• Weak pulses in the legs and the feet
• Dead tissue due to lack of blood flow (gangrene)
• Hair loss on the legs
• Wounds that will not heal, like on the heels or ankles
• Numbness, weakness, or heaviness in the leg muscles
• Pain in the legs that may be specific, like in the toes at night
• Thickened, discolored toenails
• Inability to have an erection (impotence)

The symptoms of PVD may look like other conditions. Always see your health care provider for a diagnosis.

How is PVD diagnosed?

To diagnose PVD, your health care provider will do a complete medical history and physical exam. Other tests may include:

• Angiography. A procedure that allows the health care provider to see blocked or narrowed blood vessels. This procedure involves inserting a thin, flexible tube into an artery in the leg and injecting a contrast dye. The contrast dye makes the arteries and veins visible on the X-ray.
• Ankle-brachial index (ABI). An ABI is a comparison of the blood pressure in the ankle with the blood pressure in the arm. It helps to diagnose PVD and checks for changes in blood flow over time.
• Doppler ultrasound flow studies. This uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Doppler technique is used to measure and assess the flow of blood. Faintness or absence of sound may mean an obstruction in the blood flow.
• Magnetic resonance angiography (MRA). This procedure uses large magnets, radio frequencies, and a computer to produce detailed images. An MRA is typically only done if plans are being made to restore normal blood flow through a procedure or surgery.
• Photoplethysmography (PPG). This exam is like the ankle brachial index except that it uses a very tiny blood pressure cuff around the toe and a PPG sensor (infrared light to evaluate blood flow near the surface of the skin) to record waveforms and blood pressure measurements. These measurements are then compared to the systolic blood pressure in the arm.
• Pulse volume recording (PVR) waveform analysis. This test checks for changes in the amount of blood in the legs.
• Segmental blood pressure measurements. Blood pressure measurements are taken at various points along the arms or legs. The level and severity of disease can be identified through segmental blood pressures.
• Exercise tests. Some of the above tests can be done before and after exercise. This is especially helpful for evaluating patients with symptoms during exercise.

What is the treatment for PVD?

The main goals for treatment of PVD are to control the symptoms and to prevent complications.

Specific treatment is based on:

• How old you are
• Your overall health and medical history
• How sick you are
• How well you can handle specific medicines, procedures, or therapies
• How long the condition is expected to last
• Your opinion or preference

Treatment may include:

• Lifestyle changes to control risk factors. The changes may include the following: regular exercise, a healthy diet, and, for smokers, stop smoking
• Treating other conditions that may worsen PVD. These include control of diabetes, high blood sugar, blood pressure, and cholesterol levels
• Medicine. This is for improving blood flow, like antiplatelet agents (blood thinners) and medicine that relax the blood vessel walls
• Angioplasty. A long hollow tube (catheter) is used to create a larger opening in an artery to increase blood flow. Angioplasty may be done in many of the arteries in the body. There are several types of angioplasty procedures, including:
  • Balloon angioplasty. In this procedure, a small balloon is inflated inside the blocked artery.
  • Atherectomy. In this procedure, plaque is removed from inside an artery with special tools on the end of a catheter.
  • Stent. A tiny, wire mesh coil is placed inside the blocked artery to keep the artery open.
• Vascular surgery. A bypass graft using a blood vessel from another part of the body or a tube made of synthetic material is placed in the area of the blocked or narrowed artery to reroute the blood flow

With both angioplasty and vascular surgery, angiography is often done before the procedure.

What are the complications of PVD?

Complications of PVD most often occur because of decreased or absent blood flow and include:

• Amputation
• Heart attack
• Stroke
• Poor wound healing, which may result in loss of a limb (amputation)
• Trouble walking due to pain

Can PVD be prevented?

Steps to prevent PVD, or prevent it from getting worse, may include:

• Stop smoking, including staying away from secondhand smoke
• Healthy eating including reduced fat, cholesterol, and sugar, and increased fruits, vegetables, whole grains, and healthy protein (lean meats, fish, and soy)
• Treatment of high cholesterol with diet, exercise, and medicine
• Losing weight if overweight
• Limiting the amount of alcohol you drink
• Taking medicine to reduce your risk for blood clots
• Regular exercise
• Control of blood sugar levels
• Control of blood pressure