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cardiovascular diseases

A.Griguolo Peripheral Arteriopathy

Generality

Peripheral arteriopathy is a vascular pathology, characterized by a more or less severe occlusion of the arteries destined to supply the limbs, trunk or head.

Also known as peripheral arterial disease, peripheral arterial disease determines, due to the aforementioned phenomenon of arterial occlusion, a reduction in the supply of oxygenated blood to the anatomical districts involved and a suffering of these districts due to the lack of oxygen and nutrients.

More frequent in the lower limbs than in all other parts of the human body, peripheral arteriopathy recognizes atherosclerosis as the main cause.

For the diagnosis of peripheral arterial disease, the history, the patient's symptoms, the physical examination, a blood test, the calculation of the ankle / arm index and a test such as the ecodoppler or the l 'angiography.

Peripheral arterial disease involves symptomatic therapy and causal therapy.

What is Peripheral Arteriopathy?

Peripheral arterial disease is a vascular disease characterized by a narrowing of the arteries responsible for blood circulation in the upper or lower limbs, the organs of the head (eg: brain) or the organs of the trunk (eg stomach, kidneys and heart).

What are the consequences?

By causing narrowing of the aforementioned arteries, peripheral arterial disease leads to a reduction in the supply of oxygenated blood to the anatomical districts involved and a suffering of these districts due to the lack of oxygen and nutrients .

The supply of oxygen and nutrients provided by the blood is essential to keep the organs and tissues of the human body alive and to function better.

What is the most common site of peripheral arteriopathy?

As stated above, peripheral arterial disease can affect the arteries of different districts of the human body; however, it has preferred targets: the arteries of the lower limbs .

With what other names is peripheral arteriopathy known?

Peripheral arteriopathy is also known as: peripheral arterial disease, peripheral arterial arterial disease and AOP (from Peripheral Arteriopathy Obliterans).

Epidemiology

Extensive statistical studies say that:

  • In 2015, there were about 155 million peripheral arterial disease patients worldwide;
  • In developed countries, peripheral arterial disease affects 5.3% of individuals aged between 45 and 50, and 18.6% of individuals aged between 85 and 90; in developing countries, on the other hand, it affects 4.6% of people between the ages of 45 and 50, and 15% of people between the ages of 85 and 90;
  • In developed countries, peripheral arteriopathy affects men and women equally; in developing countries, on the contrary, it is more common among males;
  • In 2015, deaths due to peripheral arteriopathy were 52, 500 compared to 16, 000 in 1990;
  • Peripheral arteriopathy is more common in the African-American race.

Causes

In most cases, peripheral arterial disease is due to atherosclerosis ; more rarely, it is the consequence of: a vasculitis of the arteries, a serious traumatic injury to the limbs, an arterial vascular spasm, an exposure to ionizing radiations or an unusual muscular anatomy in the limbs.

Note : since peripheral arteriopathy is almost always supported by atherosclerosis, this article will focus, from now on, its attentions on the aforementioned circumstance, as it is of greater interest to the reading public.

What is atherosclerosis and how does peripheral arteriopathy cause it?

Atherosclerosis is the phenomenon of hardening of the arteries of medium and large caliber, which induces the formation of atheromas on the inner wall of the arterial vessels just mentioned.

Also known as atherosclerotic plaques, atheromas are aggregates of lipid material (especially cholesterol ), protein and fibrous which, due to the position they occupy, prevent the normal blood flow inside the arteries; moreover, they can be the object of inflammatory processes, which cause their fragmentation and dispersion into other blood vessels - this time smaller - with consequent occlusive phenomena.

When it is related to atherosclerosis, peripheral arteriopathy appears following the formation of atheromas in the arteries, which constrict the so-called vasal lumen (ie the inside of the blood vessel) and reduce the flow of blood in that area, with negative repercussions on oxygen supply to neighboring organs and tissues.

WHAT ARE THE CAUSES OF ATEROSCLEROSIS?

The conditions of atherosclerosis are caused by various conditions, including: hypertension, hypercholesterolemia, high triglycerides, advanced age, cigarette smoking and smoking in general, diabetes mellitus, obesity and some inflammatory diseases such as systemic lupus erythematosus.

Did you know that ...

Peripheral arterial disease affecting the coronary arteries of the heart corresponds to the most famous coronary artery disease (or coronary artery disease ), while peripheral arterial disease affecting the arteries of the brain corresponds to the best known cerebrovascular disease .

Risk factors of peripheral arteriopathy

Among the risk factors of peripheral arteriopathy, obviously, are all the causes of atherosclerosis, episodes of vasculitis affecting the arteries, events of arterial spasm, serious injuries to the limbs and exposure to ionizing radiation.

Symptoms and Complications

Premise: since peripheral arteriopathy mainly affects the arteries of the lower limbs, in this section the attentions will be turned above all to the symptomatology of peripheral arteriopathy on the lower extremities of the human body.

Peripheral arteriopathy in the lower limbs tends to be an asymptomatic condition; according to some statistical studies, in fact, it would be free of symptoms in more than 50% of patients.

Having specified this important aspect, when peripheral arterial disease of the lower limbs is symptomatic, it is responsible for the so-called intermittent claudication .

Also known as intermittent lameness, intermittent claudication is a particular pain in the lower limbs, characterized by painful cramps especially in the legs, difficulty in walking and a sense of weakness, which appears (or worsens) in coincidence with a physical effort, while it disappears (or tends to become less intense with rest.

In people with peripheral arterial disease of the lower limbs, intermittent claudication is the direct consequence of narrowing of the arterial lumen and reduced supply of oxygenated blood to muscles and tissues of the thighs and legs.

The severity of intermittent claudication (thus the severity of cramps, difficulty in walking, etc.) varies from patient to patient, depending on the degree of shrinkage: in those who have a considerable narrowing, the suffering is strongly debilitating; in those who have a slight narrowing, suffering is more than bearable.

Did you know that ...

In people with peripheral arterial disease of the lower limbs symptomatic, intermittent claudication may appear even on the occasion of a simple walk.

Is peripheral arteriopathy in the lower limbs mono- or bilateral?

Peripheral arteriopathy in the lower limbs can be mono- or bilateral, depending on whether the arterial narrowing affects one or both the lower extremities of the human body.

What other symptoms can intermittent claudication cause?

In addition to painful cramps, difficulty in walking and weakness, intermittent claudication resulting from peripheral arteriopathy of the lower limbs can cause:

  • Cyanosis;
  • Hair loss (especially on the legs and feet);
  • Thinning of the skin and shiny leather;
  • Cold sensation, especially in the ankles and feet;
  • Brittle and slow-growing nails;
  • Tingling;
  • Muscular atrophy (especially in the legs).

Complications

When arterial narrowing is severe, peripheral arteriopathy in the lower limbs tends to lead to a complication, known as critical ischemia in the lower limbs .

Ischemia critical to the lower limbs is the serious medical condition that results from an important interruption of the supply of oxygenated blood to the lower limbs and which causes symptoms and signs such as:

  • Painful cramps even at rest ;
  • Tissue lesions ( ulcers ) especially on legs and feet, whose healing is very slow;
  • Pain in the soles of the feet (especially when the feet are raised);
  • Cancer (or gangrene ). It is the pathological condition characterized by the massive putrefaction of one or more body tissues.

It is important to point out that, in male patients, the picture of the possible complications of peripheral arteriopathy in the lower limbs is not limited to critical ischemia in the lower limbs, but may also include the so-called erectile dysfunction .

Curiosity: the complications of peripheral arteriopathy at the level of coronaries and arteries of the brain

When peripheral arteriopathy affects the coronaries or arteries of the brain, it can lead to two very serious medical conditions that are certainly known to most people. These conditions are, in the case of coronary peripheral arteriopathy, the heart attack (or myocardial infarction ) while, in the case of peripheral arterial disease to the arteries of the brain, the stroke .

When should I go to the doctor?

Especially in an individual at risk (therefore over seventy, smoker, diabetic etc.), it is a valid reason to immediately contact a doctor or go to the nearest hospital center the unjustified appearance of painful cramps in the lower limbs during trivial physical activities, combined with weakness and difficulty in walking.

WHAT TO DO IF YOU HAVE NO SYMPTOMS?

According to the doctors, an apparently healthy individual should undergo a check-up to detect vascular problems such as peripheral arteriopathy when:

  • He is over 70 years old;
  • He is over 50 years old and has a history of smoking and / or diabetes;
  • He is less than 50 years old, suffers from diabetes and has another factor favoring atherosclerosis, such as obesity or hypertension.

Diagnosis

To make the diagnosis of peripheral arterial disease, doctors need information from:

  • The anamnesis and the account of the symptoms performed by the patient during the anamnesis;
  • The physical examination The calculation of the so-called ankle / arm index . Specific for peripheral arteriopathy in the lower limbs, this exam consists in quantifying arterial pressure at the level of the lower limbs (ankle) and upper limbs (arm), both at rest and under stress, and in the subsequent comparison of the values ​​obtained.

    In normal conditions, the ankle / arm index measures between 1 and 1.4 (ie the arterial pressure at the ankle level is equal to or greater than the arm); in the presence of peripheral arterial disease, however, the ankle / arm index is less than or at most equal to 0.9 (ie the arterial pressure of the ankle is lower than the pressure of the arm).

  • An examination for the evaluation of blood flow in the arteries for which the doctor suspects a narrowing. Such an evaluation is possible through an ecodoppler (non-invasive method) or an angiography (invasive method, but very effective);
  • A blood test . It is used to assess blood levels of cholesterol, triglycerides and glucose, all substances somehow related to peripheral arteriopathy supported by atherosclerosis.

Therapy

The presence of peripheral arteriopathy involves a therapy whose objectives are substantially two:

  • Check the symptoms (painful cramps, difficulty walking, etc.), so that the patient can return to lead an almost normal life (symptomatic therapy);
  • Stop the progression of atherosclerosis, so as to minimize the risk of complications (causal therapy).

To achieve these goals, treatments planned by doctors vary according to the severity of peripheral arteriopathy in place. In fact, if peripheral arteriopathy is mild, doctors only act on the patient 's lifestyle, correcting the diet and / or certain bad habits; if instead peripheral arteriopathy is severe, they are forced to add a pharmacological therapy to a healthy lifestyle, if not even in the most critical cases, a surgical therapy .

How should the lifestyle be in the presence of peripheral arterial disease?

Peripheral arteriopathy is a disease that mainly affects those who smoke, those who have diabetes, those who suffer from hypertension, those who are obese, those who follow an unhealthy diet and so on. From this it follows that the fundamental points relating to how life style should be for a person with peripheral arterial disease are:

  • Not smoking;
  • Control diabetes; if you are at risk of diabetes, adopt any strategy to prevent it;
  • Check hypertension;
  • Check cholesterol and triglyceride levels; if you are at risk of high cholesterol and / or high triglycerides, take any strategy to prevent these conditions;
  • Control body weight, having the attention to follow a weight loss program in case of obesity;
  • Practice physical activity constantly. This has beneficial effects in all the above conditions.

Pharmacological therapy

Useful drugs for peripheral arterial disease include:

  • Cholesterol lowering agents (eg, statins). They are used to control excess cholesterol in the blood, in patients with peripheral arterial disease related to hypercholesterolemia.
  • Hypotensives (eg, diuretics, beta-blockers and calcium channel blockers). They are used to control high blood pressure in patients with peripheral arterial disease dependent on hypertension;
  • Blood glucose control drugs (eg hypoglycemic agents and insulin). They are used to control diabetes, in patients with peripheral arterial disease related to this metabolic disease;
  • Antiplatelet agents (eg: clopidogrel and aspirin). They are medicines that prevent the formation of blood clots, which could further damage the blood circulation in the arteries affected by peripheral arterial disease;
  • Drugs for improving blood circulation (eg: cilostazol and pentoxifylline). They are medicines that induce dilation of blood vessels; they are especially useful in the presence of peripheral arterial disease in the limbs.

Surgical therapy

Surgical treatments suitable for treating peripheral arterial disease include: angioplasty, vascular bypass surgery, thrombectomy, atherectomy and amputation .

ANGIOPLASTY

Angioplasty is the vascular surgery intervention for dilating an artery affected by stenosis.

VASCULAR BYPASS

The vascular bypass operation consists of inserting a new blood vessel, where there is a restricted artery, in order to restore blood circulation in that anatomical sector.

The new jar can come from another part of the body or it can be a synthetic product.

thrombectomy

Thrombectomy is an emergency surgical procedure for removing a thrombus from an artery.

Did you know that ...

As an alternative to thrombectomy, doctors could resort to thrombolysis, ie the dissolution of a thrombus by injecting a special drug.

atherectomy

Atherectomy is the surgical procedure of removal of an atheroma from a blood vessel.

AMPUTATION

The amputation is reserved for cases of peripheral arterial disease of the lower limbs, which have resulted in gangrene.

Prognosis

For those suffering from peripheral arterial disease, the prognosis depends on several factors, including:

  • The severity of arterial narrowing. The more severe the narrowing, the greater the probability that the prognosis is poor;
  • Timeliness of diagnosis. An early diagnosis allows planning a therapy when peripheral arteriopathy is not at an advanced stage;
  • The attention that the patient places on the lifestyle and therapies provided for him. The patient who scrupulously follows the indications of the treating physician draws many more benefits from the therapy, compared to that which neglects the treatments.

Prevention

Do not smoke or stop smoking as soon as possible, keep your blood sugar under control (especially in the case of diabetes), exercise regularly, maintain normal blood pressure and blood cholesterol, eat healthily and finally control body weight. the main countermeasures, recommended by doctors, to prevent the onset of a vascular disease related to atherosclerosis, such as peripheral arterial disease.

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