Rob Kawa, OMS III
Predoctoral OPP Fellow
DidacticsOnline.com
 Peripheral vascular disease (PVD) can really be a
vascular pathology of either the veins or arteries.
 PVD is also known as peripheral artery disease (PAD)
because it is generally thought of as a disease of the
blood vessels in which narrowing and hardening of the
arteries occur.
 The most common areas affected are the legs and feet.
 Arteriosclerosis is “the hardening of the arteries” and
is the process of fat build up on the walls of the arteries
in the form of plaques.
 The artery becomes narrow, the walls become stiff, and
together this blocks the dilation of arteries when there
is increased demand for blood and oxygen in working
tissues.
 As a result, your legs can not receive blood when
walking or running and pain develops. Eventually ,
due to disease progression, there may not be enough
blood available during rest.
 Why are there so many terms that all sound the same?
(arteriosclerosis, atherosclerosis, arteriolosclerosis)
 Where did the plaque come from?
 Arteriosclerosis A broad term describing thickening and loss of elasticity
of arterial walls.
 Three main types:
 Medial calcification which is dystrophic calcification and of
no clinical concern unless associated with atherosclerosis
(Ex: calcification in uterine arteries)
 Atherosclerosis
 Arteriolosclerosis
 Atherosclerosis Endothelial cell damage of muscular and elastic arteries
 Causes of endothelial damage include smoking, hypertension, homocysteine, and LDL.
 Cell response to endothelial injury
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Macrophage and platelets adhere to damaged endothelium
Released cytokines cause hyperplasia of medial smooth muscle cells.
Smooth muscle cells migrate to the tunica intima
Cholesterol enters muscle cells and macrophages (foam cells)
Smooth muscle cells release cytokines that produce extracellular matrix
Development of fibrous cap (plaque)
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Components include smooth muscle, foam cells, inflammatory cells, and ECM
Cap overlies a necrotic center
Disrupted plaque may extrude underlying necrotic material leading to vessel thrombosis
Fibrous plaque becomes dystrophically calcified and ulcerated
 Serum C-reactive peptide (CRP) is increased in patients with disrupted
inflammatory plaques. Plaques rupture, produce vessel thrombosis, and
cause acute MI. CRP may be a stronger predictor of cardiovascular events
than LDL
 Atherosclerosis
 Popular sites for atherosclerosis in descending order
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Abdominal aorta
Coronary artery
Popliteal artery
Internal carotid artery
 Complications of atherosclerosis
 Vessel weakness (aneurysm)
 Vessel thrombosis
 Acute MI
 Stroke
 Small bowel infarction
 Hypertension (renal artery may activate RAAS)
 Cerebral atrophy (block circle of willis or internal carotids)
 Peripheral vascular disease
 Increased risk of gangrene
 Pain when walking (claudication)
 Arteriolosclerosis
 Hardening of arterioles
 Hyaline arteriolosclerosis: Increased protein deposited in the
vessel walls occludes the lumen. Associated conditions
include diabetes mellitus and hypertension.
 Hyperplastic arteriolosclerosis:
 Renal arteriole effect from an acute increase in blood pressure
(Ex: malignant hypertension)
 Smooth muslce cell hyperplasia and basement membrane
duplication
 Arterioles have an “onion skin” appearance
 A common disorder that usually affects men over 50
 Higher risk with history of:
 Abnormal cholesterol
 Diabetes
 High blood pressure
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(hypertension)
Heart disease
(coronary artery disease)
Smoking
Kidney disease involving hemodialysis
Stroke (cerebrovascular disease)
 Pain, achiness, burning, fatigue, discomfort of the
calves, feet, or thighs. These symptoms usually appear
with exercise and go away with rest (Claudication).
 Numbness, pale skin, cool to the touch
 Severe disease:
 Impotence
 Ulcers that do not heal
 Worsening pain with leg elevation
 Leg pain at night
 Arterial bruits – a
whooshing sound heard
with the stethoscope
over an affected artery
 Decreased blood
pressure in the affected
limb
 Loss of hair on the legs
or feet
 Decreased or absent
pulses in the limb
 Calf muscles that shrink
 Hair loss over the toes and feet
 Painful non-bleeding ulcers (usually black) that are
slow to heal
 Pale skin or a blue appearance
(cyanosis)
 Shiny tight skin
 Thick toenails
 Blood test – A blood test may show high cholesterol or
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diabetes
Angiography of the arteries in the legs (arteriography)
Blood pressure measurements in the arms and legs for
comparison
Doppler ultrasonography
Magnetic resonance angiography or CT angiography
Plethysmography – Tests a change in volume in the
body, organs, or vessels.
 Self-care:
 Balance exercise and rest: If you exercise to the point of
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pain and follow with rest over time you can improve
circulation as new, small (collateral) blood vessels form.
Stop smoking
Reduce your weight
Keep your blood pressure under control
Take particular care with foot health, especially if
diabetic
Monitor blood sugar
If your cholesterol is high eat a low cholesterol, low fat
diet.
 Medications:
 Aspirin or a medication called clopidogrel (plavix) keep
your blood from clotting in the arteries by affecting
platelets.
 Cilostazol is also an anti-platelet medication but works
to dilate arteries in moderate to severe cases where
surgery is not an option. The dilated arteries can
improve blood flow to areas of claudication.
 Cholesterol medications
 Pain relievers
 Prostanoids for treating people with severe peripheral
arterial disease of the legs
First published: January 20, 2010; This version
published: 2010. Review content assessed as up-todate: October 28, 2009.
 The question is whether specific drugs such as prostanoids
reduce mortality and progression of the disease, including
amputations, more than placebo or other treatments. This
review of 20 trials did not find any evidence that
prostanoids provided long‐term benefit.
 Prostanoids seem to have efficacy regarding rest‐pain relief
and ulcer healing.
 Surgery/Procedures
 Angioplasty and stent
placement – This
procedure is similar to
the technique used to
open coronary arteries
but is done in the
affected leg.
 Surgery/Procedures:
 Arterial bypass
surgery for vessels
with significant
blockage. Lower
extremity vessels and
the abdominal aorta
are common sites.
 Surgery/Procedures:
 Endarterectomy – The surgical
removal of plaque in a blocked
vessel
 Limb Amputation – In severe
cases where tissue becomes
necrotic and gangrene is a
concern.
 An Osteopathic
Consideration:
 MFR and Fascial
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Ligamentous Release
LAS
Diaphragms
Lymphatics
Fluid Dynamics
Muscle Energy?
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Websites:
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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001224/
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001223/
http://www.fashion-writings.com/peripheral-vascular-disease-test/
http://www.endovascularsurgery.com/patient-vascular.html
http://www.acu-heal.com/vascular-progress.html
http://www.vascularweb.org/vascularhealth/pages/peripheral-artery-disease-(-pad-)-.aspx
http://jama.ama-assn.org/content/291/7/809.extract
http://www.alexkolesar.com/diabetic-foot/peripheral-vascular-disease.html
http://www.podiatricresidency.com/insight/insight9.html
http://www.tobaccolabels.ca/gallery/hongkong/hongko~9
http://www.osteoworks.com.au/1-services/osteopathy-brisbane
Books:
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Goljan E. (2010) Rapid Review Pathology Third Edition
Philadelphia: Mosby Elsevier
Wolfsthal S. (2008) NMS Medicine Sixth Edition
Baltimore: Lippincott Williams and Wilkins