If you feel cramping, pain or tiredness in the leg or hip muscles while walking or climbing stairs, and such discomfort goes away with rest and returns when you walk again, you might have claudication. Claudication, which literally means "to limp," is a set of symptoms most commonly caused by peripheral artery disease (PAD). Claudication can also be caused by other medical problems such as aneurysm, but we shall focus on PAD in this article.
English: peripheral artery disease (PAD)
Bahasa Melayu: penyakit arteri periferal
Tamil: புற தமனி நோய்
People with PAD may or may not experience symptoms. The common symptoms of PAD include:
Leg pain occurs during moving and is relieved by resting
Trouble walking up stairs
Trouble getting an erection (in men) or trouble with sexual arousal (in women)
Feeling numb or cold in the lower legs
Pale or blue tinged legs
Infections or sores on the feet or legs
Hair loss on the legs or feet
Extended healing process
A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years. Image credit: Jonathan Moore, CC BY 3.0, via Wikimedia Commons
Symptoms of PAD can be mild or severe, depending on:
Which arteries are affected
How narrow the arteries are
How much activity a person does
PAD is caused by deposits of fatty plaques within the vessel walls, a condition known as atherosclerosis. These plaques grow with time and result in narrowing or completely block blood flow in the leg arteries and blood flow to the muscles and skin. You are familiar with a similar drill: when these plaques block blood flow in the heart, it can lead to chest pain or heart attack– a condition known as coronary artery disease (CAD); if it travels to the brain and blocks the arteries there, you would have a stroke. PAD is similar to both CAD and stroke, but instead of blocking blood flow to the heart and brain, it blocks blood flow in your leg, stomach and arms.
The illustration shows how PAD can affect arteries in the legs. Figure on the left shows a normal artery with normal blood flow. The inset image shows a cross-section of the normal artery. Figure on the right shows an artery with plaque buildup that is partially blocking blood flow. The inset image shows a cross-section of the narrowed artery. Image credit: Jmarchn, CC BY-SA 3.0, via Wikimedia Commons
The following increases your risk of developing PAD:
Diabetes mellitus – Study has shown that approximately one third of people with PAD have diabetes. It’s not PAD that causes diabetes but the other way around: consistently high blood sugar level damages your blood vessels and promotes the buildup of fatty plaques in the vessel walls. In a large, multinational meta-analysis, the presence of diabetes among participants in developed countries was associated with nearly twofold risks for PAD. Diabetes is also a strong risk factor for all types of cardiovascular diseases, and PAD is just one of them.
Smoking – Cigarette smoking significantly links to all sorts of cardiovascular diseases, including PAD. Smoking damages your blood vessels, promotes contractions and blockages of blood vessels. On average, smokers are diagnosed with PAD 10 years earlier than non-smokers. That’s 10 years worth of peaceful and pain-free life!
High blood lipid levels – We have many types of lipids in the blood. Study found that patients with PAD are more likely to have higher levels of “bad” blood lipids: triglycerides and/or cholesterol, lipoprotein (a), apolipoprotein B, and very-low density lipoprotein, compared with patients without PAD. Conversely, the levels of high density lipoprotein (HDL) cholesterol and apolipoprotein A-I and A-II levels– the "good" blood lipids – are lower in patients with PAD.
High blood pressure – People with high blood pressure are twice more likely to develop PAD than people without high blood pressure.
Older age – Starting from age 40 and onwards, your risk of developing PAD increases every decade.
Metabolic syndrome (a constellation of obesity, high blood cholesterol, high blood pressure, and insulin resistance)
The prevalence of PAD in the high-risk Malaysian population is 30-40%. This does not come as a surprise, considering Malaysia is a nation with high prevalences of diabetes, obesity and smoking. Unfortunately, PAD is often mistaken for something else, undiagnosed and left untreated.
If left untreated, PAD can lead to gangrene (tissue death) and amputation.
Image credit: Karl-Christian Münter, CC BY 4.0, via Wikimedia Commons
Healthcare professionals use the ankle brachial pressure index (ABPI) to diagnose PAD. This test compares blood pressure in the ankle with blood pressure in the arm. If the former is lower then you may have PAD.
The illustration shows the ankle-brachial index test. The test compares blood pressure in the ankle to blood pressure in the arm. As the blood pressure cuff deflates, the blood pressure in the arteries is recorded. This image is a work of the National Institutes of Health, part of the United States Department of Health and Human Services. As a work of the U.S. federal government, the image is in the public domain.
Other tests to diagnose PAD may include angiograms, ultrasound, and MRI. PAD is easily diagnosed using these simple and painless approaches. If you suspect that you have PAD, it is best to get a medical check-up with a doctor. The earlier you detect PAD, the better the outcome will be.
As mentioned above, the main risk factors for PAD are cigarette smoking, diabetes, high blood pressure, high cholesterol or lipids, and morbid obesity. To reduce your PAD symptoms, it is important that you:
Lower your blood cholesterol/lipid to the optimal levels determined by your doctor. Treatment may include diet, exercise and/or cholesterol-lowering medications such as statins. Even if you do not have high blood cholesterol, your doctor may still prescribe you with cholesterol-lowering medications if you experience leg pain when moving.
Quit smoking, seriously. You can do this cold-turkey, or get professional advice from quitting smoking clinics at government hospitals and clinics; or mQUIT services from any community pharmacist.
If you have diabetes, control your blood sugar level by strictly sticking to your diet, exercise and medications plan recommended by your healthcare professionals. Your target should be keeping your HbA1c level under 6.5% or any target specified by your doctor. Remember to attend your annual foot examination with your doctor to prevent or treat diabetic foot.
Likewise, if you have high blood pressure, make sure you control your blood pressure. Watch out your daily sodium/salt intake, stay physically active and always remember to take your blood pressure medication as instructed by the healthcare professionals.
In some cases, your doctor may also prescribe you with antiplatelet therapy, in which you need to take aspirin, clopidogrel or ticagrelor. Follow your doctor’s and pharmacist’s instructions on how to take the medications.
Have a healthy diet and exercise regularly
Several different medications can help improve walking distance (ie, how far and how long you can walk without having pain) in people with claudication. Your doctor may suggest medication if lifestyle changes and exercise haven't been sufficient in relieving your symptoms. An example of medication that is used to improve claudication is known as cilostazol.
When medications are not sufficient to relieve symptoms, your doctor may recommend a procedure to increase the amount of blood flow to your legs, called revascularization. Revascularization procedures can be generally divided into two general categories: "catheter-based" endovascular procedures, which are done without incisions (eg, balloon angioplasty with or without stenting, atherectomy, recanalization), and "surgery" (eg, bypass, endarterectomy). Revascularization can also involve a combination of multiple techniques and devices, called "hybrid" procedures, all with the objective of improving blood flow. Discuss with a specialist or surgeon you trust if you wish to receive these procedures.
A 3D medical animation still shot depicting the vascular bypass grafting in legs. Image credit: Manu5, CC BY 4.0, via Wikimedia Commons
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UpToDate - Patient education: Peripheral artery disease and claudication (Beyond the Basics)
UpToDate - Overview of peripheral artery disease in patients with diabetes mellitus
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UpToDate - Epidemiology, risk factors, and natural history of lower extremity peripheral artery disease
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