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Background |
Causes |
Risk factors |
Signs and symptoms |
Complications |
Diagnosis |
Treatment |
Integrative therapies |
Prevention |
Bibliography
Peripheral vascular disease
Peripheral vascular disease (PVD), also known as peripheral artery disease (PAD), is a slow and progressive circulation disorder. It may involve disease in any of the blood vessels outside of the heart and diseases of the lymph vessels - the arteries, veins, or lymphatic vessels. Organs supplied by these vessels such as the brain, heart, and legs, may not receive adequate blood flow for ordinary function. However, the legs and feet are most commonly affected, thus the name peripheral vascular disease.Conditions associated with PVD that affect the veins include deep vein thrombosis (DVT), varicose veins, and chronic venous insufficiency. Lymphedema is an example of PVD that affects the lymphatic vessels.
An individual with PVD also has an increased risk of heart attack, stroke, and transient ischemic attack (TIA).
PVD affects eight to 12 million people in the United States. An estimated 5% of adults in the United States over age 50 have PVD. Among adults age 65 and older, 12-20% may have PVD.
Background
Peripheral vascular disease (PVD), also known as peripheral artery disease (PAD), is a slow and progressive circulation disorder. It may involve disease in any of the blood vessels outside of the heart and diseases of the lymph vessels - the arteries, veins, or lymphatic vessels. Organs supplied by these vessels such as the brain, heart, and legs, may not receive adequate blood flow for ordinary function. However, the legs and feet are most commonly affected, thus the name peripheral vascular disease.Conditions associated with PVD that affect the veins include deep vein thrombosis (DVT), varicose veins, and chronic venous insufficiency. Lymphedema is an example of PVD that affects the lymphatic vessels.
An individual with PVD also has an increased risk of heart attack, stroke, and transient ischemic attack (TIA).
PVD affects eight to 12 million people in the United States. An estimated 5% of adults in the United States over age 50 have PVD. Among adults age 65 and older, 12-20% may have PVD.
Causes
Atherosclerosis: The most common cause of peripheral vascular disease is atherosclerosis. Atherosclerosis is a gradual process in which a fatty material (called plaque) builds up inside the arteries. The fat may then mix with calcium, scar tissue, and other substances and harden slightly, forming plaques. These plaques block, narrow, or weaken the vessel walls. Blood flow through the arteries can be restricted or blocked totally.Other causes of peripheral vascular disease include blood clots, diabetes, inflammation of the arteries, infection, structural defects, and injury.
Blood clots: A blood clot can form and block a blood vessel, which is then called a thrombus or emboli. This process can lead to a stroke or heart attack. The cause of blood clots is often related to medications, trauma, and lifestyle (such as smoking or sedentary). Genetic factors can contribute to blood clot formation.
Diabetes: Chronic (long-term) high blood sugar levels in diabetics may damage blood vessels. This makes the blood vessels more likely to become narrowed or weakened. Additionally, those with diabetes frequently have high blood pressure and high cholesterol levels in the blood, which accelerates the development of atherosclerosis. In individuals with diabetes, sugar (glucose) accumulates in the blood to very high levels. The excess glucose can attach to proteins in the blood vessels and alter their normal structure and function. One effect of this is that the vessels become thicker and less elastic, making it hard for blood to squeeze through.
Inflammation of the arteries: Inflammation of the arteries, or arteritis, can cause narrowing or weakening of the arteries. Arteritis usually occurs due to autoimmune conditions (such as rheumatoid arthritis) or infection.
Infection: The inflammation and scarring caused by an infection may block, narrow, or weaken blood vessels. Both infection with Salmonella bacteria and syphilis may result in damage to the blood vessels.
Structural defects: Defects in the structure of a blood vessel can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown.
Injury: Blood vessels can be injured in an accident, such as a car wreck or a bad fall.
Risk factors
Smoking: Smoking is more closely related to developing peripheral vascular disease (PVD) than any other risk factor. Smoking increases the risk of developing PVD three to five times. On average, smokers who develop PVD experience symptoms 10 years earlier than nonsmokers who develop PVD. Nicotine constricts blood vessels and forces the heart to pump harder. A buildup of carbon monoxide (CO) reduces oxygen in the blood and damages the lining of the blood vessels. Stopping smoking will slow the progress of PVD. Smoking even one or two cigarettes daily can interfere with the treatment for PVD. Smokers who have diabetes have the greatest risk of complications from PVD, including gangrene in the leg from decreased blood flow.Chronic or serious illnesses: Chronic illnesses, such as diabetes, can increase the risk of developing PVD. One in three people over age 50 with diabetes is likely to have PVD. Anyone over age 50 with diabetes should be screened for PVD. Other conditions may also increase the risks of developing PVD, including kidney disease, high blood pressure, a high cholesterol level, heart disease, a family history of stroke, heart disease and high blood pressure, and age. Men who are older than age 50 and women who are older than age 55 are at higher risk for PVD.
High blood pressure: High blood pressure is a common and important risk factor for vascular disorders, including PVD. About 2-5% of individuals with hypertension have symptoms of PVD, with the prevalence increasing with age. Similarly, 35-55% of patients with PVD at presentation also have hypertension. Individuals who suffer from hypertension with PVD have a greatly increased risk of myocardial infarction and stroke.
High cholesterol: High cholesterol levels are present in 40% of individuals with PVD. The relative risk of PVD is 1.2-1.4 for each 40-50 milligrams per deciliter (mg/dl) increase in total cholesterol. High levels of triglycerides and an elevated plasma concentration of lipoprotein(a) each increase the risk of developing PVD.
Obesity: Being overweight contributes to other risk factors for stroke, such as high blood pressure, PVD, cardiovascular disease, and diabetes. Weight loss of as little as 10 pounds may lower blood pressure and improve cholesterol levels.
Sedentary lifestyle: People who do not exercise regularly have an increased risk of developing PVD. Exercise is important because it can lower blood pressure, increase the level of HDL cholesterol (good cholesterol), and improve the overall health of blood vessels and the heart. It also helps control weight, control diabetes, and reduce stress. Thirty minutes daily of moderate exercise is normally recommended. Patients should talk to their doctors before starting a new exercise program.
Uncontrolled diabetes: Managing diabetes with diet, exercise, weight control, and medication is essential. Strict control of blood sugar may reduce damage to the heart and blood vessels.
Inflammation: Elevations in markers of inflammation, including levels of C-reactive protein, may also be risk factors for the development of PVD.
Signs and symptoms
General: Only about half of people with peripheral vascular disease (PVD) have symptoms. Almost always, symptoms are caused by the leg muscles not getting enough blood. Whether the individual has symptoms depends partly on which artery is affected and to what extent blood flow is restricted.Pain: The most common symptom of peripheral vascular disease in the legs is pain in one or both calves, thighs, or hips. The pain usually occurs while walking or climbing stairs and stops when at rest. The muscles' demand for blood and oxygen increases during walking and other exercise. In PVD, the narrowed or blocked arteries cannot supply more blood, so the muscles are deprived of oxygen and other nutrients. This pain is called intermittent (comes and goes) claudication. Intermittent claudication is usually a dull, cramping pain. It may also feel like a heaviness, tightness, or tiredness in the muscles of the legs.
Muscle cramps: Cramps in the legs have several causes, but cramps that start with exercise and stop with rest most likely are due to intermittent claudication. When the blood vessels in the legs are completely blocked, leg pain at night is very typical, and the individual almost always hangs his or her feet down to ease the pain. Hanging the legs down allows for blood to passively flow into the distal part of the legs. Other symptoms of peripheral vascular disease include buttock pain, numbness, tingling, or weakness in the legs, burning or aching pain in the feet or toes while resting, a sore on a leg or a foot that will not heal, one or both legs or feet feel cold or change color (pale, bluish, dark reddish), loss of hair on the legs, and impotence. Having symptoms while at rest is a sign of more severe disease.
Complications
Open sores: Peripheral vascular disease (PVD) can lead to open sores that do not heal properly, injury, or infection of the feet and legs, especially if the individual also has diabetes. Diabetes damages small capillaries, so oxygen and nutrients cannot be carried to the cells, causing tissue death. Also, diabetes may damage nerve endings and decrease sensitivity in areas such as the feet. Trauma to the feet or other areas of the body may not be felt and may result in open sores that are difficult to heal (diabetic sores). Critical limb ischemia (CLI) is the extreme of this condition and can cause tissue death (gangrene), sometimes requiring amputation of the affected limb.Stroke and heart attack: Stroke (neurological damage caused by a lack of blood flow to the brain) and heart attack are among the more serious and most common complications that accompany peripheral arterial disease. Fat deposits also build up in arteries supplying the heart and brain. As a result, individuals have a greater risk of heart disease and stroke.
Diagnosis
A medical and family history is important in diagnosing peripheral vascular disease (PVD). A doctor may ask about family history of heart disease and review medical history, including medications and the presence of health conditions, such as high blood pressure or diabetes. The doctor may also ask if the individual smokes or has any symptoms in the legs when sitting, standing, walking, or exercising. The physical exam may involve: checking blood flow in the leg or foot to see if the pulse is either weak or absent; checking pulses in the leg arteries for an abnormal whooshing sound called a bruit (a bruit can be heard with a stethoscope and may be a warning of a narrow or blocked section of an artery); checking for poor wound healing; comparing blood pressure between the limbs to see if blood pressure is lower in the affected limb; and checking hair, skin, and nails for any changes that may indicate PVD.Ankle-brachial index (ABI): The ankle-brachial index (ABI) test compares the blood pressure in the ankle with the blood pressure in the arm to determine how well the blood is flowing and if further tests are needed. To get a blood pressure reading, a doctor uses a regular blood pressure cuff and a special ultrasound device to evaluate blood pressure and flow. The individual may walk on a treadmill and have readings taken before and immediately after exercising to capture the severity of the narrowed arteries during walking. ABI blood pressure readings will appear higher than a blood pressure reading in the arm.
Angiography: An angiography is a form of imaging that allows a doctor to view blood flow through the arteries. A contrast material (dye) is injected into the blood vessels. This allows the doctor to see the flow of the contrast material with the use of imaging machines. Blood flow in individuals with PVD may be slow or blocked completely. Angiography can be done using X-ray imaging or procedures called magnetic resonance angiography (MRA) or computed tomography angiography (CTA).
Electrocardiogram (ECG): An electrocardiogram (ECG) is a diagnostic test in which electrode patches are attached to the skin to measure electrical impulses in the heart. A doctor may monitor an ECG during and after the treadmill test. If PVD is causing blocked arteries in the individual, changes in the ECG may be seen.
Blood tests: Doctors can check the individual's blood to measure cholesterol and check the level of C-reactive protein, which is a marker for heart disease.
Treatment
General:The goals of treatment for peripheral vascular disease (PVD) are to manage symptoms, such as leg pain, and to stop the progression throughout the body, in order to reduce the risk of heart attack and stroke.
Some individuals may be able to treat PVD appropriately with lifestyles changes. Lifestyle changes include quitting smoking, losing weight, exercising, and changing the diet (see "Prevention"). Smoking cessation is the single most important thing an individual can do to reduce the progression of the blockage and to reduce the risk of complications of PVD.
If lifestyle changes are not enough, additional medical treatment may be needed. A doctor may prescribe medicine to prevent blood clots, lower blood pressure and cholesterol, and control pain and other symptoms.
Lifestyle changes:
Experts recommend eating healthy foods. A brain-healthy diet should include five or more daily servings of fruits and vegetables, foods rich in soluble fiber (such as oatmeal and beans), foods rich in calcium (dairy products, spinach), soy products (such as tempeh, miso, tofu, and soy milk), and foods rich in omega-3 fatty acids, including cold-water fish, such as salmon, mackerel, and tuna. Pregnant women and women who plan to become pregnant in the next several years should limit their weekly intake of cold-water fish because of the potential for mercury contamination.
Eating less cholesterol and fat, especially saturated fat, may reduce the amount of plaque in the arteries. Weight loss of as little as 10 pounds may lower blood pressure and improve cholesterol levels.
People with PVD are encouraged to quit smoking because it may worsen symptoms. Quitting smoking will slow the progress of PVD.
People with diabetes should stay in close contact with their doctors to ensure that their condition is well controlled. Managing diabetes with diet, exercise, weight control, and medication is essential because strict control of blood sugar may reduce damage to the heart and blood vessels.
Exercise can lower blood pressure, increase the level of HDL cholesterol (good cholesterol), and improve the overall health of blood vessels and the heart. It also helps control weight, control diabetes, and reduce stress. Thirty minutes daily of exercise is normally recommended. Patients should talk to their doctors before starting a new exercise program.
Managing stress can be vital to keeping the heart and blood vessels healthy. This is because stress can cause an increase in blood pressure along with increasing the blood's tendency to clot.
Medications:
Medications for claudication: Medications used to treat PVD and intermittent claudication include those that aim to lower the risk and progression of atherosclerosis throughout the body, such as those that help quit smoking, lower blood pressure, lower cholesterol, and optimize the blood sugar in people with diabetes.
Two prescription medications have been approved by the U.S. Food and Drug Administration (FDA) for the direct treatment of the symptom of intermittent claudication. Pentoxifylline (Trental®) is believed to improve blood flow by decreasing the viscosity (thickness) of blood and making red blood cells more flexible. With these alterations, the blood can move more easily past obstructions in the blood vessel. Cilostazol (Pletal®) keeps platelets from clumping together. This clumping promotes formation of clots and slows down blood flow. The drug also helps dilate, or expand, the blood vessels, encouraging the flow of blood.
Other prescription medications used to treat symptoms of PVD include antiplatelet agents, anticoagulants, and "clot-busters" (thrombolytics). Antiplatelet agents include aspirin, ticlopidine (Ticlid®), and clopidogrel (Plavix®). These drugs do not get rid of an existing clot, but they prevent further clots from forming by keeping blood cells and platelets from clumping together. Anticoagulant agents include heparin, warfarin (Coumadin®), enoxaparin (Lovenox®), and low-molecular-weight heparin. These drugs also do not remove an existing clot, but they interfere with the sequence of blood clotting factors that causes a clot to form. Thrombolytics are drugs that can actually dissolve an existing clot. Thrombolytics can be used only under certain circumstances and are given only in the hospital. Thrombolytics can be injected directly into the blocked artery under angiographic guidance. To be effective, they have to be administered intravenously within the first four to eight hours after an individual develops symptoms. All of these medications may increase the chances of bleeding. Individuals should inform their healthcare providers about over-the-counter (OTC) medicines and integrative therapies (such as herbs and vitamins) they may be taking.
Cholesterol-lowering medications: Cholesterol-lowering drugs called statins, such as lovastatin (Mevacor®) or atorvastatin (Lipitor®), may be prescribed by a doctor to reduce the risk for heart attack and stroke. The goal for individuals who have PVD is to reduce low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, to less than 100 milligrams per deciliter (mg/dL). The goal is even lower if there are additional major risk factors for heart attack and stroke, especially diabetes, or continued smoking. Statin drugs may deplete Coenzyme Q10 from the body, leading to muscle weakness and pain. Coenzyme Q10 is important in cellular energy production.
Blood pressure-lowering medications: If high blood pressure exists, a doctor may prescribe medications to lower it, such as beta-blockers or ACE inhibitors. The goal of these medications is to reduce the systolic blood pressure (the top number of the two numbers) to 140 millimeters of mercury (mmHg) and the diastolic blood pressure (the bottom number) to 90 mmHg or lower. If diabetes is present, the blood pressure goals are even lower.
Medications to control blood sugar: If the individual also has diabetes, blood sugar (glucose) control is even more important. Taking prescribed medications, such as metformin (Glucophage®), appropriately and following a proper diet is necessary.
Medications to prevent blood clots: Because peripheral arterial disease is related to reduced blood flow to the limbs, it is important to reduce the risk of blood clots. A blood clot can completely block an already narrowed blood vessel and cause tissue death. A doctor may prescribe daily aspirin therapy or another medication that helps prevent blood clots, such as clopidogrel (Plavix®) or warfarin (Coumadin®).
Surgery:
Balloon angioplasty: In a balloon angioplasty, a small hollow tube (called a catheter) is threaded through a blood vessel to the affected artery. Then, a small balloon on the tip of the catheter is inflated to reopen the artery and flatten the blockage into the artery wall, while at the same time stretching the artery open to increase blood flow. In some cases, a mesh framework called a stent is deployed and left in the artery to help keep it open. This is the same procedure doctors use to open heart arteries. Stents can also contain drugs that decrease blood clotting. Risks of angioplasty include: bleeding in area where the catheter was inserted, blockage of blood flow to an area of the heart (very rare), damage to a heart valve or blood vessel, kidney failure (higher risk in those with existing kidney problems), irregular heartbeats (arrhythmias), stroke (rare), and death.
Bypass surgery: Bypass surgery can be done on arteries to improve circulation. Bypass surgery involves using one of the individual's own veins or a synthetic graft to re-route blood around a segment of a narrow or blocked artery. Blood flow then goes from the artery, through the bypassed graft, and out to the rest of the body.
Integrative therapies
Strong scientific evidence:Ginkgo: Ginkgo (Ginkgo biloba) has been used medicinally for thousands of years. Today, it is one of the top-selling herbs in the United States. Numerous studies suggest that Ginkgo biloba taken by mouth causes small improvements in claudication symptoms (leg pain with exercise or at rest due to clogged arteries). However, ginkgo may not be as helpful for this condition as exercise therapy or prescription drugs. Additional evidence is needed. Ginkgo may increase bleeding in sensitive individuals, including those taking blood-thinning medications such warfarin (Coumadin®) and aspirin.
Good scientific evidence:
Aortic acid: Aortic acid comes from the hearts of animals, usually sheep, cows, or pigs. Aortic acid is a broad term encompassing several constituents. Mesoglycan, a preparation of glycosaminoglycans, is the most studied of these constituents. Intermittent claudication is part of late stage atherosclerosis, and mesoglycan has shown some therapeutic ability in preliminary atherosclerosis studies in humans. In addition, mesoglycan is a heparin-like substance that has shown anticoagulation ("blood thinning") properties in clinical studies. Additional study is needed.
There are currently no reported allergic reactions available. Due to the heparan sulfate content of mesoglycan, patients with an allergy to heparin or heparinoid derivatives should use caution.
L-carnitine: L-carnitine, or acetyl-L-carnitine, is an amino acid found in the body. There is strong evidence to support l-carnitine's use at least in those cases when there are severe limitations in peripheral circulation. It is not clear, however, whether angiopathies caused by atherosclerosis and diabetes are equally sensitive to the drugs. Additionally, it is important to know comparative efficiency of propionyl-L-carnitine and other recognized treatments.
Policosanol: Policosanol is a cholesterol-lowering natural mixture of primary alcohols, isolated and purified from sugar cane wax. Policosanol is safe and well tolerated. There is limited study on the effects of policosanol supplementation on walking distance in individuals with intermittent claudication. Additional human trials are necessary before a strong recommendation can be made. Avoid in individuals with a known allergy or hypersensitivity to policosanol.
Unclear or conflicting scientific evidence:
L-arginine: L-arginine, or arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Intermittent claudication is a condition characterized by leg pain and fatigue due to buildup of cholesterol plaques or clots in leg arteries. A small number of studies report that arginine therapy may improve walking distance in patients with claudication. Further research is needed.
Garlic: Garlic (Allium sativum) is traditionally used for heart health. Some human studies suggest that garlic may improve circulation in the legs by a small amount, but this issue remains unclear. Better-designed studies are needed. Garlic may increase bleeding in sensitive individuals, including those taking blood-thinning medications such as warfarin (Coumadin®) and aspirin.
People with a known allergy to garlic, any of its ingredients, or to other members of the Liliaceae (lily) family, including hyacinth, tulip, onion, leek, and chives, should avoid garlic. Allergic reactions have been reported with garlic taken by mouth, inhaled, or applied to the skin.
Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Hydrotherapy may help increase blood flow, temporarily relieving symptoms of PVD.
Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Multiple studies have evaluated the use of vitamin E in patients with peripheral vascular disease to improve exercise tolerance and intermittent claudication (pain in the legs with walking due to cholesterol buildup in blood vessels). Although some results have been promising, most studies have been small and poorly designed. It remains unclear if vitamin E is beneficial in this condition. Vitamin E may increase bleeding in sensitive individuals, including those taking blood-thinning medications such warfarin (Coumadin®) and aspirin.
Fair negative scientific evidence:
Chelation therapy: Individuals with clogged arteries in the legs (peripheral vascular disease) may experience a sensation of pain or fatigue in the legs with exercise ("claudication"). Chelation is sometimes suggested as a treatment in this situation, but studies suggest that chelation may not be helpful. Chelation therapy is the administration of chelating agents, such as EDTA, to remove heavy metals from the body.
Traditional or theoretical uses lacking sufficient evidence:
Integrative therapies with historical or theoretical uses in peripheral vascular disease but lack sufficient clinical evidence include: aconite (Aconitum napellus), bromelain, hawthorn (Crataegus oxyacantha), meditation, niacin (Vitamin B3, Nicotinic acid), niacinamide, octacosanol, omega-3 fatty acids, qi gong, rosemary (Rosmarinus officinalis), and tai chi.
Prevention
High blood pressure (hypertension) control: One of the most important things that can be done for the prevention of peripheral vascular disease (PVD) is to reduce high blood pressure. Blood pressure for a healthy individual should be a systolic reading of 120 and a diastolic reading of 80 (120/80 millimeters of mercury or mmg Hg). Exercising, managing stress, maintaining a healthy weight, and limiting sodium and alcohol intake are all ways to keep blood pressure in check. Medications to treat hypertension, such as diuretics, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers, may be used.Cholesterol and saturated fat intake reduction: Eating less cholesterol and fat, especially saturated fat, may reduce the amount of plaque arteries. Most people should aim for a low density lipoprotein (LDL) level below 130 milligrams per deciliter. If there are other risk factors for PVD, such as diabetes, the target LDL may be below 100 milligrams per deciliter. Statin drugs (HMG-CoA reductase inhibitors) can be prescribed to help maintain healthy cholesterol levels.
Smoking cessation: Smoking is a major risk factor for PVD. Nicotine constricts blood vessels and forces the heart to pump harder. A buildup of carbon monoxide (CO) reduces oxygen in the blood and damages the lining of the blood vessels.
Diabetes control: Managing diabetes with diet, exercise, weight control, and medication is essential. Strict control of blood sugar may reduce damage to the heart and blood vessels.
Weight control: Being overweight contributes to other risk factors for stroke, such as high blood pressure, PVD, cardiovascular disease, and diabetes. Weight loss of as little as 10 pounds may lower blood pressure and improve cholesterol levels.
Exercise: Exercise can lower blood pressure, increase the level of HDL cholesterol (good cholesterol), and improve the overall health of blood vessels and heart. It also helps control weight, control diabetes, and reduce stress. Thirty minutes of daily of exercise is normally recommended. Patients should talk to their doctors before starting a new exercise program.
Stress management: Stress can cause an increase in blood pressure along with increasing the blood's tendency to clot. Managing stress can be vital to keeping the heart and blood vessels healthy.
Diet modification: Experts recommend eating healthy foods. A healthy diet should include five or more daily servings of fruits and vegetables, foods rich in soluble fiber (such as oatmeal and beans), foods rich in calcium (dairy products, spinach), soy products (such as tempeh, miso, tofu, and soy milk), and foods rich in omega-3 fatty acids, including cold-water fish, such as salmon, mackerel, and tuna. Pregnant women and women who plan to become pregnant in the next several years should limit their weekly intake of cold-water fish because of the potential for mercury contamination.
Bibliography
American Academy of Family Physicians (AAFP). http://familydoctor.org. Accessed October 25, 2007.
American Heart Association (AHA). www.americanheart.org. Accessed October 25, 2007.
Brass EP, Hiatt WR. Review of mortality and cardiovascular event rates in patients enrolled in clinical trials for claudication therapies. Vasc Med. 2006 Nov;11(3):141-5. View Abstract
Brass EP, Jiao J, Hiatt W. Optimal assessment of baseline treadmill walking performance in claudication clinical trials. Vasc Med. 2007 May;12(2):97-103. View Abstract
Centers for Disease Control and Prevention (CDC). www.cdc.gov. Accessed October 25, 2007.
Hankey GJ, Norman PE, Eikelboom JW. Medical treatment of peripheral arterial disease. JAMA. 2006 Feb 1;295(5):547-53. View Abstract
National Heart, Lung, and Blood Institute (NHLBI) www.nhlbi.nih.gov. Accessed October 25, 2007.
Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com. Copyright © 2008. Accessed October 25, 2007.
Robless P, Mikhailidis DP, Stansby GP. Cilostazol for peripheral arterial disease. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD003748. View Abstract
Santilli SM. The Coronary Artery Revascularization Prophylaxis (CARP) Trial: results and remaining controversies. Perspect Vasc Surg Endovasc Ther. 2006 Dec;18(4):282-5. View Abstract
Related Terms
ABI, aneurysm, angiography, ankle-brachial index, arteritis, atherosclerosis, balloon angioplasty, bruit, Buerger's disease, bypass surgery, capillary fragility, cholesterol, chronic thromboangiitis, chronic venous insufficiency (CVI), chronic venous ulcers, circulatory disorders, claudication, CLI, critical limb ischemia, CVI, diabetes, ECG, edema, electrocardiogram, fluid retention, gangrene, heart attack, intermittent claudication, lower extremity edema, PAD, peripheral arterial disease, plaque, PVD, Salmonella, stent, stroke, syphilis, Takayasu disease, ultrasound, varicose leg ulcers, vascular damage, vascular fragility, vasculitis, venous disorders, venous leg ulcers, water retention, yellow nail syndrome.
Natural Standard Bottom Line Monograph, Copyright © 2009 (www.naturalstandard.com). Commercial distribution prohibited. This monograph is intendedfor informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.
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