Let's Understand Peripheral Arterial Occlusive Disease to Prevent Amputation

Peripheral arterial occlusive disease (PAOD) refers to blockages in the arteries, usually of the lower limbs. Arteries are part of the vascular system and tubular structures that carry oxygenated blood from the heart to various parts of the body. Any narrowing or obstruction of the artery supplying that part of the body will deprive the organ of oxygenated blood, resulting in symptoms related to its functioning. For example, if arteries to the heart are blocked, one can get chest pain, angina, or a heart attack. Similarly, if blood supply to the brain is compromised, one gets a minor or major stroke.

Blockages of the arteries to the lower limbs are what we call PAOD, and it has three stages:

1.Asymptomatic: A person has mild disease and no symptoms. This can be picked up by a doctor on clinical examination by checking the pulses on the feet. Feeble or absent pulses indicate the presence of PAOD, even in the absence of symptoms. It is important to recognize this stage since preventive measures can be used to not only arrest the progress of PAOD to the next stages but also to improve cardiovascular health and reduce the risk of stroke and heart attack. Certainly, "A stitch in time, saves nine".

2.Claudication: The name of this symptom is derived from the name of a Roman Emperor, Claudius, who used to limp. This symptom refers to pain in the lower limbs while walking. It could affect the calf muscles, thighs, or buttocks, depending on at what level the arterial blockages are. The pain appears on walking and is relieved by stopping. It is again very important to recognize this symptom since most patients can be managed with medication and exercise, not only to improve their pain-free walking but also to improve cardiovascular health and to minimize the risk of progression to the next stage of PAOD.

3.Critical or Chronic Limb Threatening Ischemia. As the name suggests, this is a critical leg at high risk of limb loss or amputation. Such patients have severe PAOD with blockages in arteries at multiple levels. They often visit the Vascular Surgeon because of pain in the foot that does not allow them to sleep or requires painkillers daily, the presence of an ulcer on the foot or leg, and the presence of toe gangrene. Such patients typically need urgent angiography and revascularization along with medication to improve their cardiovascular health.

Major Risk Factors for PAOD

1.Smoking and tobacco use: Increases the risk of PAOD by 3 - 4 times. Of course, it also increases the risk of many other diseases like heart attack, stroke, and cancer.

2.Diabetes mellitus: This is like a pandemic in India and is related to our genes, sedentary lifestyle, belly fat, and obesity. This increases the risk of PAOD by 3 - 4 times. Combined with smoking, the risk goes up by 16x. Of course, diabetes affects other organs too: the heart, brain, kidneys, eyes, and nerves.

3.Increasing Age: All of us want to live long. The risk of many diseases increases with age. Our aim should be to minimize the risk of diseases and live long and healthy.

4.Genes: We inherit these and can mitigate the genetic risk by a healthy lifestyle.

5.Cholesterol: Especially total cholesterol, LDL, and LP(a). These can be managed by diet, medicine, and exercise. We hear of good cholesterol called HDL: it can be improved by exercise.

6.Hypertension: This worsens the stiffness of arteries.

Diagnosis of PAOD

1.Clinical examination of pulses on feet, presence of symptoms like claudication, rest pain, non-healing ulcer, and toe gangrene.

2.Noninvasive tests: These include Color Doppler, Ankle Brachial index, and toe brachial index. They can be done on an outpatient basis.

3.Angiography: This is done to confirm the level of blockages in arteries and to plan revascularization procedures. Commonly used modalities are MR angiography, CT angiography, and Digital Subtraction Angiography.

4.The Vascular Surgeon will also assess the patient for risk factors.

Treatment of PAOD by Vascular Surgeons.

1.Asymptomatic: management of risk factors and primary prevention. One should stop tobacco use, manage diabetes, hypertension, and cholesterol, and adopt a healthy lifestyle (will outline later). Medicines are also prescribed to reduce the progression of PAOD and reduce the risk of all cardiovascular complications.

2.Claudication: All measures that are used for asymptomatic patients. In addition, medicines and exercise to improve walking distance.

3.Critical or Limb Threatening Ischemia: Such patients are at high risk of minor or major amputation, heart attack, and stroke. Blockages in the arteries can be treated by endovascular methods (balloon angioplasty, stenting, atherectomy) open surgery (endarterectomy, bypass in the legs), or Hybrid procedures (combination of endovascular and open techniques). Wounds may need cleaning, antibiotics, and minor amputation of toes. A regular follow-up is needed to improve the longevity of the procedure and limb salvage.

Prevention and Care

1.Diet: Plenty of fresh vegetables, and salads. Include fruits (avoid juices), whole grains, millet, and healthy fats. Avoid refined oils, sugar, refined flour, and hydrogenated vegetable fats. Minimize fried food. Avoid overeating. Follow the Japanese principle of "Hara Hachi Bu": eat till you are about 80% full.

2.Activity: Remaining physically active is important. The body is designed to be active and not remain lazy. The activity becomes even more important as we age. 30 - 45 minutes of exercise daily in the form of brisk walking/cycling/jogging / weight training is good. Breathing exercises improve lung capacity and calm the mind. Yoga helps to improve flexibility and mobility.

3.Sleeping: one must sleep enough to wake up refreshed and rested.

4.Friends and social circle: important to avoid stress and to be able to share happiness and problems. Sharing multiplies happiness and divides problems.

5.Health checks: Please ensure that your doctor checks your upper and lower limb pulses during any physical examination. Follow up regularly if you have a problem.

6.Risk factor management. It would be ideal if we could do away with risk factors for atherosclerosis and PAOD. We can of course stop tobacco use completely. Make sure that you avoid even passive smoking since that is equally or at times, even more harmful. The use of e-cigarettes or vaping is worse since we do not realize that it has all the effects of regular smoking. Good control of diabetes, cholesterol, hypertension, and body weight will go a long way in reducing the risk of PAOD.

7.Foot care: this applies to all diabetics, irrespective of whether or not they have PAOD, and also all patients of PAOD. Keep your feet clean, avoid cracks, moisturize them (except between toes), avoid walking barefoot, and use good socks and shoes or sandals. Buy footwear in the evenings since feet might be a bit swollen and shoes bought in the mornings may become very tight in the evenings resulting in shoe bites.

8.Use of blood thinners (Aspirin / Clopidogrel), statins, and other newer drugs for cholesterol management as prescribed by your Vascular Surgeon.

Finally, let all of us join hands to raise awareness of PAOD and march towards an "Amputation Free India" and take this campaign globally for an "Amputation Free World"

Join for Walkathon 2.0: Step Towards an Amputation-Free World 🌟

Let's strive towards better vascular health and a brighter, healthier future. Every step counts!

The Vascular Society of India invites you to Walkathon 2.0 on 4th August 2024, a vibrant event promoting vascular health and preventing amputations. Like last year, join to walk together for a cause that matters, in 34 cities across India, spreading awareness for an amputation-free future.

REGISTER NOW and be part of the change. See you there!

👉 Join Now: https://bit.ly/vsi-walkthon

Dr P C Gupta
Clinical Director and Chief of Vascular Surgery, Care Hospital, Hyderabad
President, Vascular Society of India
President, WFVS.