Arterial and venous insufficiency are diseases that involve the vessels but both are different from each other with varied signs and symptoms and course of the disease.
Millions of people worldwide are affected by these two disease entity but only a handful of people know how each one differs from the other. If you think you have arterial or venous insufficiency then it is important that you get a consult with your health care provider to avoid further complications from these diseases.
Peripheral Arterial Disease
What is PAD?
Peripheral arterial disease (PAD) is a disease where poor circulation occurs in the lower extremity. In PAD, cholesterol plaques narrow the arterial blood flow which causes a restriction in the legs. This reduces blood flow often causes pain in the calf or thigh which makes it difficult to walk for a period of time when the ischemia happens.
Peripheral arterial disease affects more than 200 million adults in the world and by the age of 70, the incidences of peripheral arterial disease increase up to 20%. (1)
Peripheral arterial disease is most commonly caused by atherosclerosis or the deposition of plaques or fatty material in the arteries. PAD may also be caused by injuries, radiation, or inflammation of the blood vessel. (2)
Risk factors of PAD include ethnicity, diabetes mellitus, obesity, smoking, hypertension, increased age, a family history of PAD, heart disease or stroke, high blood levels of homocysteine, and high cholesterol levels. (3)
How does PAD occur?
Peripheral arterial disease usually involves cholesterol plaques deposited in the abdominal aorta, iliac, and femoral arteries. Cholesterol plaques slowly build up inside the arteries and stick to the walls. (4) Imagine it like a drain pipe which slowly builds up grime over the years, making the draining slow or even causing a blockage. The same mechanism happens in PAD.
In the early stages, even with the build-up, the arteries are still able to continue their usual function because the arteries can stretch to preserve the flow in the artery but eventually, as the cholesterol plaque gets bigger, the arteries are not able to stretch further and the plaque slowly narrows the arterial flow compromising the blood that’s supposed to pass by it.
Because of this blockage, ischemia happens more commonly in the lower extremity. In other cases, the ischemia may be caused by an embolus. An embolus is something that travels in the bloodstream and causes a block in the vessel. It could be in the form of a blood clot that has detached from its original area, air, or any bodily substance.
An embolus can most commonly be found in the femoral artery, the iliac arteries, aorta, and the popliteal arteries.
When 50% of the diameter of the artery has been compromised it means that there is already a 75% cross-sectional area and this is considered flow limiting. When the artery is fully obstructed, it will usually shift the flow of blood to smaller arteries.
The collateral flow will help in preserving the perfusion of the lower legs but because they are small compared to the main arteries, the blood will not be enough. This limitation of blood flow causes the hallmark signs and symptoms of peripheral arterial disease.
What are the Signs and Symptoms of PAD?
The symptom that is characteristic of PAD is claudication or pain in the lower extremities aggravated by walking and relieved by resting. The pain is often described as cramping, aching, or may be experienced as something that feels heavy or fatigued over the lower extremities.
Patients with mild to moderate PAD may have little symptoms or none at all. This will still depend on where the occlusion has occurred (if in a major artery or a minor one) and if the patient has enough activity that may cause the claudication.
Patients who have a severe peripheral arterial disease can develop pain even at rest. These patients are often bed-bound because even short walks can cause severe pain yet even at rest, they may feel it too. They may complain of burning pain especially on the soles of the feet, most often at night. This often results in fatigue from the lack of sleep and pain.
Patients with intractable pain usually relieve their symptoms by dangling the legs which in turn may cause edema. Other signs that are often seen by the doctor during the physical exam of a patient with PAD are pallor or paleness, atrophy or decrease in size of a muscle, loss of hair over the area with claudication, cool skin on palpation, the presence of bruit, pain on palpation and decreased pulses.
How is PAD Diagnosed?
The physical exam of your doctor may reveal decreased or absent lower extremity pulses and this may be confirmed by getting an ankle-brachial index (ABI). To do this, your doctor will take your blood pressure above the ankle and on both arms and use a handheld doppler to listen to the signal.
Laboratories may also be added like creatinine to check your renal function and electrolytes. Doppler studies of the arteries are important to see the site of blood flow occlusion and to see the velocities. CT angiography and MRA will determine if the occlusion should be further assessed and if angioplasty or bypass surgery is needed.
An electrocardiogram (ECG/EKG) may be taken to see if there are any other problems in your cardiovascular system.
How is PAD Treated?
The management of PAD is aimed to decrease your cardiovascular risk and improve your ability to walk. Lifestyle changes like decreasing cholesterol, quitting smoking, improvement of blood pressure (in patients with hypertension), and controlling diabetes are very important in the treatment of PAD. (5)
Medications such as cilostazol are given to improve claudication. This medication promotes vasodilation and suppresses the proliferation of smooth muscle cells of the vessels. Patients on this medication usually experience improvement in regards to claudication. Pentoxifylline, a medication used to improve oxygen delivery is also used by other doctors.
It is important that before taking these medications, you consult your doctor if it is right for you as there are co-morbidities that may contraindicate the intake of these medications.
What are the Complications of PAD?
Patients who do not modify their lifestyles are at risk to severe PAD. Peripheral arterial disease is generally a progressive disease and further complication may be any of the following:
- Infections of the lower extremity
- Ischemia or gangrene
- Blood clots
- Heart attack
- Erectile dysfunction
Chronic Venous Insufficiency
What is Chronic Venous Insufficiency (CVI)?
Chronic venous insufficiency is a common disease that approximately affects 150,000 new patients each year and about 7 million people in the United States. (6) It is progressive and causes lower extremity edema, changes in the skin, and discomfort of the legs. Venous ulcers are common in patients with moderate to severe CVI and have been a problem not only because of the appearance but because of the pain and risk for infection that comes with it.
CVI can either be primary or secondary to a deep vein thrombosis.
Primary chronic venous insufficiency means that the symptoms occur without a prior disease and may be due to congenital defects in the walls of the veins.
Secondary chronic venous insufficiency occurs due to a deep vein thrombosis that triggers the inflammatory response of the body.
Modifiable risk factors of CVI include smoking, obesity, pregnancy, hypertension, use of oral contraceptives, prolonged standing, venous injury, and deep vein thrombosis. Non-modifiable risk factors of CVI are female gender and a non-thrombotic iliac vein obstruction or the May Thurner syndrome.
How does CVI occur?
Chronic venous insufficiency is because of a reflux or an obstruction on the venous blood flow. It can develop in superficial, perforating, and deep veins and in almost all cases, results in venous hypertension.
The reflux or obstruction on the lower extremity is usually because of a weakened or unusually shaped valve or large venous diameter. This leaky valve may be congenital in origin or develops because of thrombosis, trauma, prolonged standing, or hormonal changes in the body.
Because of venous hypertension in the lower extremity, there is increased venous hydrostatic pressure which causes the pain, swelling, and even hyperpigmentation of the skin. May patients will also experience lipodermatosclerosis which is the thickening of the skin because of the fibrosis of fat. As CVI worsens, the disturbance in the circulation and weakening of the skin eventually causes the ulcer formation.
What are the Signs and Symptoms of CVI?
Patients with CVI typically presents with swelling of the lower extremity, leg discomfort and pain, fatigue, and even itching of the lower extremities. Some patients may complain of cramping or throbbing sensation in the lower extremities that improves with rest and elevation of the legs. Unlike in peripheral arterial disease, the pain is not associated with any activity.
With the worsening of the disease, varicose veins and tenderness may be seen in the legs and eventually, lesions, ulcers, hyperpigmentation (darkening of the leg), and dermal atrophy are commonly seen.
How is CVI Diagnosed?
A full history and physical exam will be taken once you’re in for a consult. It is important to divulge information that is important for the diagnosis of chronic venous insufficiency. Take note of other diseases that you have especially diabetes and hypertension.
Duplex ultrasonography is done to help identify the regions affected. Invasive venography may be done in patients who have stenosis. (7) An ankle-brachial index may also be taken to exclude other causes like peripheral arterial disease.
A blood test may be done to see if the cause of your peripheral arterial disease is unknown.
How is CVI Treated?
Patients with chronic venous insufficiency are treated base on the severity of the disease.
The goals of treatment in patients with CVI are the following:
- Reduce leg discomfort or pain
- Reduce swelling of the leg
- Stabilize or improve leg appearance
- Removing painful varicose veins
- Healing ulcers and avoiding infection
Patients are initially treated conservatively in the early course of the disease with leg elevation, exercises aimed to improve the calf muscle pump, improvement of weight, and compression stockings.
Ulcers are treated with antibiotics if infected and compression bandages. The use of compression bandage is done with the help of a health care provided because it is used in caution especially when a coexisting peripheral arterial disease is noted. If ulcers do not heal, then surgery may be beneficial.
For patients with superficial vein reflux, radiofrequency ablation, vein stripping, and foam sclerotherapy may be done. Perforator reflux can also be managed with radiofrequency ablation, sclerotherapy, and subfascial endoscopic perforator surgery. Deep vein reflux is managed with valve transplant or reconstruction.
Compression therapy regimen is highly effective in the management of chronic venous insufficiency; however, the patient’s adherence is always difficult to follow up.
What are the Complications of CVI?
Complications of CVI include venous ulcers, thrombophlebitis, deep vein thrombosis, pulmonary embolism, bleeding, chronic pain, and secondary lymphedema. Deep vein thrombosis and pulmonary embolism are emergency cases and should be treated ASAP.
This is why if you have early or mild symptoms of CVI, it is important to get yourself checked to avoid further complications of the disease.
Since we have discussed both peripheral arterial disease and chronic venous insufficiency in details, here are the important signs and symptoms that differ both from one another:
|Peripheral Arterial Disease||Chronic Venous Insufficiency|
|Color||Cool to touch, hairless, dry and shiny, legs become pale when elevated and returns back to normal color or may be reddish in color||Warm to touch, thickened, hyperpigmented, mottled in appearance|
|Pain||Sharp, stabbing and worsens with activity and relief noted when feet are lowered||Aching, cramping pain regardless of activity|
|Pulse||Absent or diminished||Present|
|Edema||Not common||Commonly seen especially near areas with ulceration|
|Ulcers||Severely painful, pale with grey base often in the toes, heel or dorsum of the foot||Moderately painful with a pink base found on the medial aspect of the ankle|
We have also discussed these in details:
- Peripheral Arterial Disease
- Chronic Venous Insufficiency
If you think you have a peripheral arterial disease or a chronic venous insufficiency, you must have a doctor check on you to avoid further complications. You may contact us here for a free consult and have an expert give you advice on what to do.
- Zemaitis MR, Boll JM, Dreyer MA. Peripheral Arterial Disease. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430745/
- Simon F, Oberhuber A, Floros N, Düppers P, Schelzig H, Duran M. Pathophysiology of chronic limb ischemia. Gefasschirurgie. 2018;23(Suppl 1):13-18.
- Jelani QU, Petrov M, Martinez SC, Holmvang L, Al-Shaibi K, Alasnag M. Peripheral Arterial Disease in Women: an Overview of Risk Factor Profile, Clinical Features, and Outcomes. Curr Atheroscler Rep. 2018 Jun 02;20(8):40
- Kim HO, Kim W. Elucidation of the Diagnosis and Treatment of Peripheral Arterial Disease. Korean Circ J. 2018 Sep;48(9):826-827.
- US Preventive Services Task Force. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-Brachial Index: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Jul 10;320(2):177-183.
- Patel SK, Surowiec SM. Venous Insufficiency. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430975/
- Knupfer J, Reich-Schupke S, Stücker M. [Conservative management of varicosis and postthrombotic syndrome]. Hautarzt. 2018 May;69(5):413-424
Dr. Nima Azarbehi
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