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Peripheral Artery Disease Screening

Why Early Detection is Critical in the Battle Against Amputation

A brief overview of signs, symptoms, risk factors, and how peripheral arterial disease screening can be used to detect PAD early and triage high-need patients to the appropriate specialist.

Peripheral artery disease screening by checking foot pulse

Left to its natural progression, peripheral artery disease can lead to seriously impaired ambulation, worsening leg pain, ulceration, gangrene, and even amputation in the most dire cases. The rise in obesity, diabetes, and high blood pressure in America, and the continued prevalence of smoking have set the stage for a quiet pandemic that sees more than 50,000 avoidable amputations every year.

We need your help. In the hands of the right Vascular Specialist, minimally invasive endovascular treatments are able to reverse the course of peripheral artery disease, restore function, and salvage limbs that would otherwise require amputation. Even with the cure at our disposal, screening tests, referral, and patient engagement continue to be barriers to effective prophylaxis.

To aid in the battle against lower extremity arterial disease and its complications, our Vascular Specialists review the signs, symptoms, risk factors, and screening test methods that can be used to help detect peripheral artery disease early and triage patients to the appropriate specialist.

Peripheral artery disease doctor Michael Lalezarian in Los Angeles, California

Your Vascular Partner

Dr. Michael Lalezarian

Timely, accessible care is paramount in the effort against peripheral arterial disease and its complications.

Dr. Michael Lalezarian is a double-board certified Vascular Interventional Radiologist specializing in minimally invasive endovascular arterial revascularization. He is a committed partner in the battle against the devastating consequences of advanced peripheral arterial disease (PAD) and critical limb ischemia (CLI).

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“He is truly dedicated, and an extraordinary physician who’s really concerned with his patients!”

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Peripheral Artery Disease Signs & Symptoms

Leg Discomfort

Generalized leg discomfort should be cause for alarm in diabetics, smokers, and the elderly. Leg pain is certainly not specific to peripheral artery disease, but it may be the first sign that vascular issues are present in a routine check up. Pain patterns can include:

• Heavy or weak legs
• Aching or burning in the lower extremities
• Numbness or tingling

Cold Feet

Lack of blood flow and poor vascularity can render the lower extremity exceptionally cold. While a cold foot can be difficult to discern in bilateral disease, it can be especially indicative when there’s an obvious temperature differential between one foot and the other. Whether for pulse or for temperature, the feet should be examined routinely if PAD is a possible diagnosis.

Weak Pulse

A simple pulse check can be very telling in the absence of ultrasound imaging or an ankle-brachial index protocol. A weak or absent pulse at the groin, behind the knee, on the inner ankle, or on the top of the foot can indicate peripheral artery disease and should prompt further investigation.
Man in Los Angeles experiencing claudication from peripheral artery disease

Claudication

The hallmark symptom of worsening peripheral artery disease is claudication, a cramping pain that is felt in the hips, thighs, buttocks, calves, or feet during exertion that then subsides after rest. Because claudication is often intermittent in the earlier stages of PAD (only occurring after several minutes of strenuous activity), patients may dismiss it as an uncommon occurrence and fail to mention it to their physician. It’s important to take the lead and ask at-risk patients if they’ve experience leg pain after walking long distances.

Intermittent claudication is the classic, textbook-defined symptom of PAD, but not all patients experience this. It’s also understood that claudication can cease for multiple years as major collateral vessels form, allowing for ‘silent’ progression.

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PAD Specialist in Los Angeles

Rest Pain

Ischemic rest pain is an end-stage symptom of peripheral artery disease. Pain persists when sitting or lying down, and is typically localized in the forefoot and toes. By the time patients experience rest pain, it is likely that PAD has progressed to an advanced stage, and critical limb ischemia is imminent.

Ischemic rest pain is brought on or worsened by elevation of the lower extremity, particularly when reclining. Affected patients frequently find pain relief by hanging their feet over the edge of the bed or by walking around the room, as gravity helps pull blood down to the extremities to perfuse the tissues.

Lower extremity affected by peripheral artery disease ulcer

Skin Lesions and Visible Tissue Loss

Tissue loss and ulceration are often viewed as complications of diabetes first and foremost, especially when present on the foot, leaving the vascular component ignored. When managing diabetes, it can be easy to forget that healing is compromised when tissue does not have an adequate blood supply. Tissue loss manifests as visible skin color changes, open wounds, and sores on the leg or foot. Advanced stages of PAD are characterized by open wounds that are slow to heal and can become complicated by infection. Other symptoms may include:

• Redness of the skin or other discolored lesions
• Open sores, ulcers, or wounds on the leg or foot with a foul-smelling discharge. Often, the wound or ulcer starts as a minor traumatic injury and then fails to heal due to insufficient blood supply.
• Gangrene, which occurs when tissue dies and the skin turns black

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PAD Specialist in Los Angeles

Peripheral Artery Disease Risk Factors

Major risk factors for PAD are similar to those for cardiovascular diseases. If a patient is suspected of ischemic heart disease, they should also be considered for a screening test for PAD. Risk factors include:

Smoking — smokers are 2 to 4 times as likely to develop PAD than non-smokers. Smoking is the most significant risk factor for developing PAD. Nicotine is a vasoconstrictor that exacerbates the narrowing of blood vessels and arteries. Smoking also accelerates stiffening of plaques, which further restricts blood flow.

Diabetes — the risk of diabetics developing PAD is 2 to 3 times the risk for non-diabetics. Diabetics are also 2 to 3 times more likely to develop symptomatic PAD. Patients with diabetes have more advanced and aggressive arterial disease at initial diagnosis and poorer outcomes than nondiabetic patients. In fact, diabetics with lower extremity PAD have amputation rates that are 5 to 10 times higher compared to nondiabetic patients with PAD. The increased amputation rate in diabetics is at least partly attributable to sensory neuropathy and increased likelihood of infection.

High LDL cholesterol and low HDL cholesterol — patients with PAD are more likely to have increased levels of ‘bad’ cholesterol (LDL) and total triglycerides in conjunction with low levels of ‘good,’ protective cholesterol (HDL) compared to patients without PAD.
The atherosclerotic plaques that obstruct arteries and increase the risk of developing PAD are composed of cholesterol, fat, calcium, and other blood substances.

High blood pressure — high blood pressure is extremely common in the United States, with a 30% prevalence rate among adults. Hypertension can double your risk of developing PAD when compared to individuals with healthy blood pressure. High blood pressure also increases the risk of developing symptoms of PAD, such as intermittent claudication. Hypertensive patients also have a higher prevalence of asymptomatic PAD. In one study of 4.2 million adults done by Emdin et al in 2015, a 20 mmHg higher than usual systolic blood pressure was associated with a 63 percent higher risk of PAD.

Known atherosclerosis at other sites or in the family — patients with existing coronary artery disease or atherosclerosis in the carotid or renal arteries are at increased risk of developing PAD. Family history of PAD or cardiovascular disease may also increase the risk of developing PAD. Patients with asymptomatic PAD may still have underlying atherosclerotic occlusive disease present.

Age — according to the American College of Cardiology/American Heart Association, you are at increased risk of developing PAD if you are 65 years or older and should be screened regardless of other risk factors. Beginning after age 40, the prevalence of PAD increases progressively. Individuals over 70 are at a significantly increased risk for PAD due to age alone.

Patient with peripheral artery disease getting screened with ankle-brachial index measurement device

Vascular specialist taking an ankle-brachial index reading.

Peripheral Arterial Disease Screening

Early detection is absolutely critical in the battle against peripheral artery disease and its sequelae. Early identification can lead to lifestyle changes and, if necessary, early intervention that can dramatically lower the likelihood of amputation and other serious complications.

PAD Screening Test Criteria

Even if immediate symptoms are absent, PAD screening tests are now recommended if a patient:

• Is age 65 or older
• Is age 50 to 69 years with a history of diabetes or smoking
• Has a history of diabetes and are less than 50 years old with one additional risk factor such as smoking, dyslipidemia, hypertension, or homocysteinemia
• Has abnormal lower extremity pulses
• Has leg symptoms with exertion
• Has ischemic rest pain
• Has known coronary, carotid, or renal atherosclerosis

PAD Screening tests and classifying its severity involves the evaluation of patient symptoms and non-invasive objective tests.

Rutherford & Fontaine Classification Systems

Under the Rutherford and Fontaine classification systems, patients complete a treadmill test or walk a specified distance. Walking impairment is described as mild, moderate, or severe, and advanced stages of PAD include observed tissue loss.

The Rutherford and Fontaine classifications are decades old and were designed to categorize chronic limb ischemia among patients with peripheral artery disease. However, due to dramatic shifts in patient demographics, particularly in the increasing number of individuals with diabetes, other classification schemes have been created and are widely adopted.

Wound, Ischemia, Foot Infection (WIfI)

A newer grading methodology, called the Lower Extremity Threatened Limb Classification System, was developed by the Society for Vascular Surgery. It is also known as the Wound, Ischemia, foot Infection (WIfI) classification system. WIfI grades three factors: the extent of wound, the severity of ischemia (evaluated with an ankle-brachial index measurement), and the presence of foot infection. Each factor is assigned a numeric rating from 0 to 3, with 3 indicating the greatest level of severity.
Your Partner in Vascular Care
PAD Specialist in Los Angeles

PAD Confirmatory Diagnostic Tests

Ankle-Brachial Index & Segmental Limb Pressures

An ankle-brachial index (ABI) measurement alone can be used as a screening test for PAD if there is strong clinical suspicion based on symptoms and physical exam findings. ABI is used to assess how well blood is flowing in the legs by measuring blood pressure in the ankles and comparing it to blood pressure in the arms. More than 50% of patients who meet ABI criteria for PAD fail to receive a proper diagnosis, indicating that screening is underutilized.

A diagnosis of PAD is confirmed in patients who have an ankle-brachial index (ABI) of ≤0.9 and who have an appropriate history and physical examination. An ABI is a measurement of the blood pressure in your ankles compared to the blood pressure in your arms. Patients with PAD symptoms such as claudication may have a normal ABI at rest. In these cases, an ABI is obtained following exercise testing. Blood pressures can also be measured at other levels in the legs such as at the calf or the upper thigh to determine the extent of PAD.

Imaging

Imaging methods may be required to obtain a definitive diagnosis of lower extremity arterial disease, and may also be used to evaluate the extent of disease and/or plan for endovascular treatment. In the hands of a trained technician, ultrasound can help pinpoint the location and severity of artery obstruction, while advanced vascular imaging techniques such as computed tomographic magnetic resonance angiography and contrast arteriography can provide rich detail on the exact location and extent of blockages.
More Resources
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Lower Extremity Arterial Disease
A brief 101 on the treatment options available for arterial disease.
Los Angeles Vascular Specialist Dr. Michael Lalezarian
Vascular Specialist in Los Angeles
Learn more about Los Angeles Vascular Specialist Dr. Michael Lalezarian.
References

[1] Berger, JS., Davies, MG. Overview of lower extremity peripheral artery disease (Beyond the Basics). UptoDate. Accessed November 2020.
[2] Berger, JS., Newman, JD. Overview of peripheral artery disease in patients with diabetes mellitus. UptoDate. Accessed November 2020.
[3] Emdin CA, Anderson SG, Callender T, et al. Usual blood pressure, peripheral arterial disease, and vascular risk: cohort study of 4.2 million adults. BMJ. 2015;351:h4865. Published 2015 Sep 29.
[4] Harris, L. Epidemiology, risk factors, and natural history of lower extremity peripheral artery disease. UptoDate. Accessed November 2020.
[5] Hayward, RA.Screening for lower extremity peripheral artery disease. UptoDate. Accessed November 2020.
[6] Mills, JL. Classification of acute and chronic lower extremity ischemia. UptoDate. Accessed November 2020.
[7] Neschis, DG., Golden, MA. Clinical features and diagnosis of lower extremity peripheral artery disease. UptoDate. Accessed November 2020.

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