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.
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.
Your Vascular Partner
Dr. Michael Lalezarian
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).
“I have seen several vascular doctors in the High Desert, and I usually only end up seeing nurses and not the doctor. I had full evaluation on my first visit with the doctor. Very pleased and very grateful. Highly recommend.”
Carol S, February 2022
Peripheral Artery Disease Signs & Symptoms
• Heavy or weak legs
• Aching or burning in the lower extremities
• Numbness or tingling
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.
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.
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
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.
Vascular specialist taking an ankle-brachial index reading.
Peripheral Arterial Disease Screening
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
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)
PAD Confirmatory Diagnostic Tests
Ankle-Brachial Index & Segmental Limb Pressures
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.
Arterial vs. Venous Ulcers
Endovascular Treatment of Lower Extremity Arterial Disease
Vascular Specialist in Los Angeles
Learn more about Los Angeles Vascular Specialist Dr. Michael Lalezarian.
 Berger, JS., Davies, MG. Overview of lower extremity peripheral artery disease (Beyond the Basics). UptoDate. Accessed November 2020.
 Berger, JS., Newman, JD. Overview of peripheral artery disease in patients with diabetes mellitus. UptoDate. Accessed November 2020.
 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.
 Harris, L. Epidemiology, risk factors, and natural history of lower extremity peripheral artery disease. UptoDate. Accessed November 2020.
 Hayward, RA.Screening for lower extremity peripheral artery disease. UptoDate. Accessed November 2020.
 Mills, JL. Classification of acute and chronic lower extremity ischemia. UptoDate. Accessed November 2020.
 Neschis, DG., Golden, MA. Clinical features and diagnosis of lower extremity peripheral artery disease. UptoDate. Accessed November 2020.
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