Overview: Peripheral Vascular Disease

• Peripheral vascular disease (PVD) is a term applicable to several vessel occlusive diseases, whether they stem from the venous system or the arterial system.

• For the purpose of this write-up discussion is limited to peripheral atherosclerotic vascular disease, also known as peripheral vascular occlusive disease or peripheral artery disease (PAD), because this entity correlates with coronary artery disease, hypertension, and diabetes.

• However, PVD can arise from numerous vasculitides and from other venous problems such as chronic venous insufficiency.

• These conditions would require different assessments and treatment strategies, depending on the underlying cause.

• The American Heart Association divides PVD into two categories: functional and organic. Functional PVD is not related to structural problems in blood vessel walls; instead, this type of PVD can stem from vessel spasm or compression.

• Organic PVD is associated with vessel blockage resulting from fatty infiltrates, inflammation, or tissue damage. PAD is a subset of organic PVD.

• Other diseases and risk factors that place patients at risk for PAD include diabetes, hypertension, tobacco use, and hyperlipidemia.

• Symptoms of PAD may be variable depending on the vessel involved and range from no symptoms, intermittent claudication, impotence, a feeling of weakness in the hip or thigh, or variable pain in the buttocks, thighs, or feet.

• Signs on physician examination may also be variable and include the following: ulcerations or non-healing wounds; loss of hair; skin redness; skin coolness to touch; decreased, or absent pulses; impaired capillary refill; and dry, scaly, or shiny skin.

• The best way to diagnose PAD is noninvasive and can be done in the office setting by using the ankle-brachial index (ABI), a comparison of the systolic blood pressure (SBP) in the dorsalis pedis and posterior tibial arteries in the ankle with the brachial artery of the arm.

• In comparison with confirmed PAD by angiogram, this simple technique is 95% sensitive and almost 100% specific.

Important Points to Consider:

• A graduated walking program over 6 months for at least 30 minutes, three or more times per week, can significantly improve claudication pain and exercise endurance.

• All the antiplatelet agents have potentially serious interactions with most of, if not all, the botanical supplements indicated for peripheral artery disease. Using antiplatelet agents in combination with these supplements is not advised.

• Economic data showed that a 120-mg daily dose of ginkgo extract in the United States ranged from $0.41 to $0.84 retail. In contrast, costs of the conventional drug pentoxifylline (1200mg) ranged from $1.83 to $1.93 and for cilostazol (200mg) from $2.90 to $4.23.

• The data for antioxidant use in peripheral vascular disease are currently insufficient to recommend the use of these agents, especially in light of potential safety issues.

Prevention Prescription

• Promote risk factor reduction in the following areas: diabetes, hypertension, and hyperlipidemia.

• Strongly support tobacco cessation.

• Provide an exercise prescription

• Providea comprehensive nutritional plan, incorporating the previously mentioned medical issues as needed.

• Add dietary fiber and omega-3 fatty acids (The Antiinflammatory [Omega-3] Diet).

• Recommend a total of 25 to 30 g/day of fiber.

• Specific instructions to help patients achieve this goal may include the following:

  • Eat at least 41⁄2 cups of fruits and vegetables daily; replace white bread with whole grain breads and cereals; add 1⁄4 cup of wheat bran to foods (e.g., cooked cereal, applesauce, or meat loaf); eat cooked beans each week.

  • Caution patients to add fiber to the diet gradually, to avoid excessive abdominal bloating and discomfort.

  • Recommend foods abundant in omega-3 fatty acids (e.g., cold-water fish such as salmon, mackerel, and sardines), but limit fish intake to two 6-oz portions per week.

  • Include omega-3–enriched eggs, flaxseed products, or fish oil supplements (500-mg capsules, 2 to 4 g/day total dose).

• Evaluate for depression and anger proneness.

• Consider autogenic or biofeedback training.

Therapeutic Review

Risk Factor Reduction

• Address diabetes control, hypertension, hyperlipidemia, and tobacco cessation.

Nutrition Recommendations and Weight Loss, If Needed

• Include recommendations for dietary fiber, dietary antioxidants (not supplements), and omega-3 fatty acid intake.

Exercise

Prescribe a supervised claudication exercise program of 30 to 45 minutes at least three times a week for a minimum of 12 weeks.

Autogenic/Biofeedback Training

Antiplatelet Agent (Standard of Care)

• Aspirin: 160 to 325 mg daily

• Alternatives include the following:

  • Clopidogrel (Plavix): 75 mg daily (preferred)

  • Cilostazol (Pletal): 100 mg twice daily

Precautions: All antiplatelet agents have potentially serious interactions with most of, if not all, the botanical supplements indicated for peripheral artery disease (PAD). Using antiplatelet agents in combination with these supplements is not advised. Statin therapy is indicated to lower low-density lipoprotein cholesterol to less than 100 mg/dL (or less than 70 mg/dL in patients with PAD with a very high risk of ischemic events). Angiotensin-converting enzyme therapy should be highly considered.

Botanicals

• Ginkgo (Ginkgo biloba): 120 to 240 mg of standardized leaf extract taken daily in two to three divided doses

• Policosanol (sugar cane derived): 10 to 20 mg daily

• Padma 28 (Padma Basic in United States): 403 mg, two capsules, twice daily

• Acetyl-L-carnitine: 500 to 2000 mg daily in divided doses

• Inositol hexaniacinate: 2 g twice daily (Avoid inositol in patients with known liver disease; monitor liver function tests during the initial 3 to 6 months of treatment in other patients.)

• Mesoglycan: 100 mg by mouth daily (Mesoglycan has an anticoagulant function; do not use in conjunction with any drugs or supplements that affect blood clotting.)

Percutaneous Interventional Procedures

• These procedures are indicated for claudication symptoms that are functionally limiting, pain at rest, or tissue loss, for attempted salvage before a more invasive approach, and for patients who are not surgical candidates.

Surgical Intervention

• May include revascularization, angioplasty, or stenting.

Key Web Sources

• Natural Medicines Comprehensive Database: www.naturaldatabase.therapeuticresearch.com

• American Heart Association: www.americanheart.org

• National Heart, Lung and Blood Institute: www.nhlbi.nih.gov