Peripheral Artery Disease
& Raynaud's Disease

What is peripheral artery disease?

Peripheral artery disease (PAD) is narrowing of the arteries that transport blood to the legs and arms.

How does PAD occur and what are the symptoms?

Similar to what happens with coronary artery disease, atherosclerosis causes gradual build-up of fatty deposits/plaques in the arterial walls of the limbs (arms and legs).

This often occurs in the legs, where the blood flow to the large leg muscles becomes restricted and the muscles receive too little oxygen and nutrients as a result, leading to pain, cramping and weakness, especially during exercise.

Claudication (sometimes also referred to as intermittent claudication) is the term given to leg pain due to PAD that usually occurs in the calf muscles when walking, sometimes causing limping, but which typically resolves after a few minutes.

PAD may also cause limbs to feel cold or numb. People with PAD may also have poor pulses in their feet and experience sores in the feet or legs that do not heal easily, and which can cause gangrene, occasionally requiring amputation.

PAD may also cause erectile dysfunction in men.

You are at increased risk of PAD if you have the following:

• Diabetes
• Overweight or obesity
• High blood pressure
• High cholesterol
• A family history of peripheral artery disease, heart disease or stroke
• Older age (typically 65 years and older).

Can you prevent PAD and how can you manage it?

Similar to coronary artery disease, PAD can be prevented and improved by healthy living, including a balanced, low fat-diet, regular exercise, and not smoking or drinking.

Additionally, it is important to manage your blood glucose levels, blood pressure and cholesterol levels.

If you have intermittent claudication, it might be better if you talk to your doctor about a supervised exercise programme.

What treatments are available for PAD?

Treatment for peripheral artery disease is to manage symptoms, such as leg pain, so that you can resume physical activities, and to slow the progression of atherosclerosis to reduce your risk of heart attack and stroke.

If you have signs or symptoms of peripheral artery disease, you must follow healthy lifestyle practices, and will likely need additional medical treatment, such as the following:

• Cholesterol-lowering medications
• High blood pressure medications
• Medication to control blood sugar levels if you have diabetes
• Medications to prevent blood clots: Because peripheral artery disease is related to reduced blood flow to your limbs, it is important to improve that flow to prevent clots from developing.
• Vasodilators to reduce symptoms
• Haemorheological agents: This mainly refers to the prescription medication pentoxifylline which is used to improve the symptoms of certain blood flow problems in the legs and arms caused by peripheral artery disease. Pentoxifylline has been found to help decrease the muscle aching/pain/cramps during exercise, including walking, that occur with intermittent claudication. Pentoxifylline works by helping blood flow more easily through narrowed arteries, increasing the amount of oxygen that can be delivered by the blood; for example, when the muscles need more such as during exercise.

In some cases, angioplasty or surgery may be necessary to treat severe PAD.

• Angioplasty is a procedure where a catheter is inserted through a blood vessel to the affected artery. A small balloon on the tip of the catheter is inflated to flatten the plaque and re-open the artery, stretching to increase blood flow. Your doctor may also insert a mesh tube (stent) in the artery to help keep it open. This is the same procedure doctors use to open the arteries of the heart (the coronary arteries).
• Bypass surgery is a surgical procedure where your doctor creates a path around the blocked artery using either a blood vessel from another part of your body or a synthetic vessel.
• Thrombolytic therapy is done if you have a blood clot blocking an artery. Your doctor will inject a clot-dissolving medication directly into your artery at the point of the clot to break it up.

What is Raynaud’s disease?

If you have Raynaud’s disease it means that your hands, and sometimes your feet, change colour because the blood vessels in these areas narrow too much when exposed to cold conditions, limiting blood flow.

It appears that women and people who live in colder climates are more likely to have Raynaud’s disease.

While most people are not troubled by mild symptoms of Raynaud’s disease, it can affect your quality of life. Treatment depends on the severity of your symptoms and whether you have other underlying health conditions.

How do you know that you have Raynaud’s disease?

If you have Raynaud’s disease, affected areas of your skin usually first turn white (blanching) on exposure to cold and stress. They then may turn blue and feel cold and numb. As you warm and your circulation improves, the affected areas may turn red, become numb or feel tingly. After you warm up, the return of normal blood flow to the area can take 15 minutes or longer.

Although Raynaud’s most commonly affects your fingers and toes, it can also affect your other extremities, such as your nose, lips, ears and even nipples.

When to see your doctor:

See your doctor immediately if you experience severe Raynaud’s symptoms, or if you develop a sore or infection in one of your affected fingers, toes, hands or feet.

What causes Raynaud’s Disease?

While doctors do not completely understand the cause of Raynaud’s disease, blood vessels in the hands and feet appear to overreact to cold temperatures or stress. When this happens, the smaller arteries that supply blood to your skin become narrow (vasospasm), limiting blood flow to affected areas. While this phenomenon is usually brief, over time, these small arteries can thicken slightly, further limiting blood flow.

Exposure to cold temperatures is the most likely to trigger; for example, putting your hands or feet in cold water, taking something from a freezer or being in cold air. For some people, emotional stress can also trigger symptoms.

What are the two types of Raynaud’s disease?

• Primary Raynaud’s disease: This is the most common form. It is not the result of an associated medical condition. Primary Raynaud’s disease may be so mild that you do not even realise you are affected, and you do not need treatment and it can resolve on its own.
• Secondary Raynaud’s: This is also called Raynaud’s phenomenon, and is caused by an underlying medical condition. Although secondary Raynaud’s is less common than the primary form, it tends to be more serious and symptoms usually appear in adults over 30 years of age, later than they do for primary Raynaud’s.

Risk factors for primary Raynaud’s include:

• Sex: Women are more likely than men to be affected.
• Age: Although anyone can develop Raynaud’s disease, it typically begins before the age of 30 years.
• Climate: People who live in colder climates are more likely to develop Raynaud’s disease.
• Genetics/Having a family history: If you have a first-degree relative (a parent or sibling) who suffers from Raynaud’s disease, the risk of you having Raynaud’s disease is higher.
• Emotional stress: Some people experience Raynaud’s disease symptoms when they are acutely stressed or going through a difficult emotional experience.

Causes of secondary Raynaud’s include:

• Connective tissue diseases: Most people with scleroderma (a rare disease that leads to hardening and scarring of the skin) will have Raynaud’s disease too. Other diseases that increase the risk of Raynaud’s include lupus, rheumatoid arthritis and Sjogren’s syndrome.
• Diseases of the arteries: These include atherosclerosis (a build-up of fatty plaques in blood vessels) in the coronary arteries and peripheral artery disease which causes the blood vessels in the hands and feet to  become inflamed.
  Pulmonary arterial hypertension may also cause Raynaud’s phenomenon.
• Carpal tunnel syndrome: This occurs when there is pressure on a major nerve of your hands. Carpal tunnel syndrome can cause numbness and pain in the hand that can make the hand more susceptible to cold temperatures.
• Repetitive action or vibration: This includes typing, for example, and other activities that require doing similar hand movements over long periods. Operating vibrating tools, such as jackhammers, can lead to overuse injuries and Raynaud’s disease as well.
• Smoking: Smoking causes blood vessel disease and potentiates atherosclerosis.
• Injuries to the hands or feet: This could include a wrist fracture, surgery or frostbite, for example.
• Certain medications: Beta-blockers, some migraine medications, some attention-deficit/hyperactivity disorder (ADHD) medications, certain chemotherapeutics, and medications that cause blood vessels to narrow, such as some over-the-counter common cold medications, can cause Raynaud’s symptoms.

Living and managing

To help prevent Raynaud’s attacks, it is advised that you follow easy lifestyle behaviours:

• Dress warmly: This is especially important during winter when it is cold and when you are going outdoors. Try to wear clothing like gloves or mittens that prevent cold air from reaching your hands.
• Take precautions indoors and travelling: Avoid rapid changes in temperature.
  You may find it helpful to wear mittens and socks to bed during winter. Because air conditioning can trigger attacks, set your air conditioner to a warmer temperature, and consider running your car heater for a few minutes before driving in cold weather.
  You may also need to use insulated drinking glasses and wear oven-mitts or other protection when taking things out of the fridge or freezer.
• Avoid cigarette smoke and caffeine that can cause blood vessels to constrict.
• Exercise regularly: Exercise improves circulation.
• Manage stress.

What treatments are available for Raynaud’s disease?

Depending on the cause of your Raynaud’s disease, medications to widen blood vessels and increase blood flow might help. These medication may include:

• Haemorheological agents: This mainly refers to the prescription medication pentoxifylline which is used to improve the symptoms of certain blood flow problems in the legs and arms. It can help blood flow more easily through narrowed arteries.
• Calcium channel blockers: These types of medications relax small blood vessels in your hands and feet, reducing the severity and number of Raynaud’s attacks. These medications can also help heal skin ulcers on your fingers or toes. An example of a calcium channel blocker is amlodipine.
• Vasodilators: These medications also relax blood vessels and may include nitroglycerin, some high blood pressure medications, the erectile dysfunction medication sildenafil, some antidepressants and a class of medication called prostaglandins.

Your doctor may suggest the following in select cases of severe Raynaud’s disease:

• Nerve surgery: Sympathetic nerves in your hands and feet control the narrowing of blood vessels in your skin. Therefore, cutting these nerves interrupts their exaggerated responses.
• Chemical injection: Doctors can inject certain local anaesthetics or onabotulinumtoxinA (Botox) to help block the sympathetic nerves in affected hands or feet.

What complications are associated with Raynaud’s disease?

If you have severe secondary Raynaud’s disease, it can reduce the blood flow to your fingers or toes, to such an extent that it causes tissue damage. A completely blocked artery can cause ulcers and gangrene; rarely, this can lead to amputation of the affected areas.