Peripheral vascular diseases (PVDs) are circulation disorders that affect blood vessels outside of the heart and brain writes Fergus Bescoby.
PVD typically affects the veins and arteries that supply the arms, legs, and organs located below the stomach. These are the blood vessels that are distant from the heart and are known as peripheral vessels.
In PVD, blood vessels are narrowed. The narrowing is usually caused by arteriosclerosis which is a condition where atheromatous plaque builds up inside a vessel. It is also called "hardening of the arteries." Plaque decreases the amount of blood and oxygen that is supplied to the arms and legs. As plaque growth progresses, clots may develop. This further restricts the affected vessel and eventually, arteries can become obstructed.
PVD that develops only in the arteries is called peripheral arterial disease (PAD). This is the most common form of PVD and approximately 12 to 20 per cent of people over age 65 have PAD.
PVD that develops in the deep veins in the body is usually caused from claudication and is called deep vein thrombosis (DVT).
PVD and PAD are often used to mean the same condition that affects the arteries. PVD may also be referred to as:
arteriosclerosis obliterans
arterial insufficiency of the legs
claudication
intermittent claudication
Types of PVD
There are two main types of PVD:
1. Functional PVD, which does not involve physical problems in the blood vessels but causes incidental or short-term symptoms such as spasms which occur erratically. The most common causes of functional PVDs are:
emotional stress
smoking
cold temperatures
operating vibrating machinery or tools
2. Organic PVD, which involves changes in blood vessel structure. This type of PVD causes inflammation, tissue damage and blockages. The primary causes of such organic PVDs are:
smoking
high blood pressure
diabetes
high cholesterol
Additional causes of organic PVDs include:
injury to extremities
muscles or ligaments with abnormal structures
infection
coronary artery disease
Risk Factors
There are numerous risk factors for PVD. Some are due to underlying medical conditions, age, and gender while others are due to lifestyle choices.
Males over the age of 50 have a greater risk of developing PVD, as do postmenopausal woman. The likelihood of developing PVD also increases if you have:
raised cholesterol
cerebrovascular disease (stroke)
heart disease
diabetes mellitus
family history of high cholesterol, high blood pressure, or PVD
high blood pressure
kidney disease on haemodialysis
The lifestyle choices that can increase the risk of developing PVD are:
being overweight
being sedentary and not engaging in physical exercise
smoking
Symptoms
For many people, there are no symptoms of PVD. For others, the first signs of PVD begin slowly and irregularly and can include discomfort in the legs and feet (cramping, fatigue and burning).
Typically, these sensations will be felt when walking, often first noticed when walking quicker, with more exertion, or for long distances.
The pain will intensify with activity and subside with rest. This is called intermittent claudication.
Intermittent claudication occurs because the muscles need more blood flow during activity.
In PVD, the vessels are narrowed with plaque and can only supply a limited amount of blood. This causes more problems during activity than at rest. Lack of blood causes pain and discomfort.
As the PVD progresses, symptoms will occur more frequently and will require less exertion to bring them on. Eventually leg pain and fatigue will be present even at rest.
Additional symptoms may occur as a result of reduced blood supply. These could include:
skin changes on legs and feet (thinning, shiny, or paleness may occur)
weak pulses in legs and feet
gangrene-tissue death caused by lack of blood flow
wounds or ulcers on the legs and feet that won't heal
toes that turn blue
severe burning pain in the toes
leg cramps and pain when lying in bed
muscles that feel numb or heavy
arms and legs that are a reddish blue colour
toenails that are thick and opaque
Complications of PVD
Complications from undiagnosed and untreated PVD can be serious and even fatal.
The restricted blood flow of PVD can be a warning sign of other forms of vascular disease. When arteries leading to the heart and brain become clogged with plaque, it can cause:
heart attack/coronary artery disease
stroke
blood clots that obstruct small arteries
limb amputation due to tissue death in the limb
impotence
severe pain that restricts mobility
wounds that don't heal
Diagnosis
Early diagnosis is crucial to successful treatment. It can prevent life-threatening complications, such as heart attack and stroke. To diagnose PVD, the physician will begin with a complete medical history and physical examination. Several tests may be used to diagnose PVD. They include:
Measuring the pulses in the legs and feet - a physician can check the pulses in the legs and feet with a stethoscope. A whooshing sound called a bruit indicates a narrowed area in the vessel.
Doppler ultrasound - this test shows the blood flow in the vessels. Ultrasound is not invasive and uses sound waves to take images.
Ankle-brachial index (ABI) - this is the most common test used to diagnose PVD. A blood pressure cuff and ultrasound measure blood pressure and flow. The blood pressure in the ankle is compared to the blood pressure in the arm.
In some cases, readings will be taken before and after exercising on a treadmill. This helps demonstrate how the arteries react to exercise.
Pulse volume recording (PVR)-this test measures the blood flow in the legs. Blood pressure cuffs are wrapped around one arm and leg whilst lying down. The cuffs are inflated slightly.
As blood flows through the arteries, a device records the ability of the vessels to expand.
Angiography - a catheter is guided through an artery in the groin and passed to the targeted area. Contrast dye is injected.
An X-ray can then diagnose the clogged artery. By inflating a balloon at the end of the catheter, the artery can be opened in the same procedure (angioplasty).
Magnetic resonance angiography (MRA) and computerized tomography angiography (CTA) - these are non-invasive imaging techniques that allow doctors to view blood flow and diagnose blockages.
Treatment
There are two main goals of PVD treatment. The first is to control pain and symptoms, allowing the person to remain active. The second is to stop the disease from progressing, which in turn lowers the risk of serious and life-threatening complications.
Treatment typically includes lifestyle modifications, for example smoking cessation, regular exercise programme, eating a balanced diet with proper nutrition and treating and controlling conditions such as diabetes, high blood pressure, or high cholesterol.
If lifestyle changes don't control PVD, medication may be required, and these could include:
cilostazol or pentoxifylline to increase blood flow to the legs, and relieve symptoms of claudication
clopidrogel or daily aspirin to reduce the risk of blood clots forming
statins to lower high cholesterol
angiotensin-converting enzyme (ACE) inhibitors to lower high blood pressure
Diabetes medication to control blood sugar if you have diabetes
Significant artery blockages may require surgery. There are several surgical treatments for PVD.
Angioplasty is performed by inserting a catheter or long tube into the blocked artery. A balloon on the tip of the catheter is inflated. This opens the blockage. In some cases a stent (small wire tube) is placed in the artery to keep it open.
Vascular surgery is done to bypass the blocked vein. A vein from another part of the body, or a synthetic graft, is attached to the affected vein. This allows blood to bypass the narrow area.
Prognosis
Studies that have followed up people with PVD have shown that:
In 75% of cases the symptoms remain stable or improve
In 20% of cases the symptoms gradually become worse
In 5% of cases the symptoms become severe
So, in most cases, the outlook is quite good, and if diagnosed early, most cases of PVD will respond to lifestyle treatments and modifications.
There does however remain an increased risk of developing fatty patches (atheroma) in other blood vessels (arteries) and the main concern for most people with PAD is the increased risk of having a heart attack or stroke.
Underwriting considerations
The underwriter will need to be in possession of all relevant medical reports, confirming frequency and severity of symptoms, results of all investigations, tests etc, details of treatment and details of the arteries affected.
Final terms will depend on the client's age, co-existing conditions (coronary artery disease, diabetes etc), tobacco use and the severity of the symptoms.
Reference
Hannover Life Re
NHS Choices
British Heart Foundation
Healthline.com
Fergus Bescoby is underwriting development manager at VitalityLife
