Dr Paulino Souza Neto Vascular Surgery, Endovascular Surgery

English » Arterial Diseases » PAD - Peripheral Artery Disease

The Peripheral Artery Occlusive Disease (PAD) is more frequently a consequence of the formation of atheroma, a plaque mainly constituted of lipids that occludes the vessel lumen. This condition is known as Atherosclerosis the major exponent of the Arteriosclerosis (Arterial sclerosis). It is more prevalent in the coronary arteries causing angina and acute myocardial infarction (blockage), in the Carotid arteries causing the stroke (blockage) or in the legs causing PAD.

Other less frequent cause of PAD are a consequence of the inflammation of the arteries in a condition called Arteritis.

Anyway when the internal lumen of the artery slowly occludes, alternative pathways are developed.  Known as Collateral Circulation they allow the blood to reach the distal tissues of the limb. Those collaterals may be efficient enough to maintain the patient free of symptoms. On the other hand, when they do not provide enough flow to grant nurturing of the tissues, the onset of pain while walking occurs with recovery after resting. This condition is known as intermittent claudication.

If the occlusion occurs very fast without the opportunity to develop the collateral circulation, an acute isquemia occurs with its classical 6 "P" onset.

Pain, Paralysis, Paresthesia, Paresis, Pale member and  absence of Pulse

This is a medical emergency due to the risk of limb loss as well as it is a life threatening condition.

The patient shall be submitted to an Inferior Limb revascularization  either by open or Endovascular approach. If not treated on time the absence of limb perfusion leads to anaerobic metabolism causing a sever acidosis complicated with the release of intracellular acids and free radicals of oxygen due to cell death. Those toxins cause a systemic inflammation response (SIRS) leading to the paralysis of the kidney and lungs among others. This is a critical condition with high risk of death mainly among the diseased population.

To avoid this condition a fast revascularization is indicated. If the time os ischemia is too long or the frailty of the patient is high, an amputation might be the only life saving procedure to do.

Despite the dramatic condition of an amputation, it occurs between 0.012% and 0.05% per year in  patients with PAD.

 The resources of Endovascular revascularization are improving in the last years, making it possible to perform a revascularization even with local anesthesia.

Both techniques shall be used wisely and in selected cases among patients with Arteritis because of the technical difficulty and the limited outcome.

Risk factors for PAD are race, sex, age, smoking, sedentary lifestyle, Diabetes, Hypertension, Dyslipidemia, Blood Hyper-viscosity, Thrombophylia,  Hyper-Homocisteinemia, Chronic Renal Failure and family history.

Medical treatment

The medical treatment is fundamental even for the ones submitted to an intervention. Hence the control of the risk factors is of capital importance. Control of the Chronic Diseases (Hypertension, Diabetes, Dyslipidemia) avoid unhealthy habits (Sedentary lifestyle, smoking) and medical treatment with anti-platelet drugs, statins) are of major importance in the adjuvant therapy of this condition.

The best medical choice for each patient depends on a critical evaluation by the physician.

PAD in numbers:
-Occurs in 3 to 10% of the general population and in 15 to 20% of people over 70 years old.

-The incidence of amputation is estimated between 120 to 500 per mi patients with PAD. 
-Among patients with Atherosclerosis only 12,2% present PAD with more than 50% with Coronary Artery Disease (CAD) and almost ¼ with Cerebrovascular disease.

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