“Perform ABI measurements as standard“

For many physicians, the presence of peripheral arterial disease (PAD) still automatically rules out the use of compression. However, as lamented by Dr. med. Helmut Uhlemann, Chief Physician at the Clinic of Angiology at Altenburger Land Hospital in Altenburg in the German state of Thuringia, this practice robs many people of the chance of receiving effective treatment.

Bauerfeind life: How many people are affected by a combination of chronic venous insufficiency (CVI) and PAD?
Dr. Uhlemann: In Germany, around 32 million people are currently estimated to suffer from varicose veins. Approximately eight million are affected by an advanced venous disorder of medical relevance in the form of congestion in the legs. The prevalence of PAD in the total population is believed to be somewhere between three and ten percent. Based on this, the number of venous congestion patients with a combination of both advanced venous disorders and clinically relevant PAD probably reaches into the millions. On top of this, I believe there is a very high number of unreported cases and I also expect a rise in the proportion of people concerned. For example, in the decade from 2000 to 2010, the diagnosis code “severe PAD” appeared 32 percent more frequently than in the previous decade. Given this high incidence rate, we physicians must start thinking about the best way of treating both CVI and PAD at the same time.

Who is at risk of developing PAD?
Dr. Uhlemann: The classic risk factors are smoking, being male, high blood pressure, and high blood lipid levels. Stress and depression also have a part to play because hormonal changes cause your blood vessels to constrict if your autonomic nervous system is under chronic stress. And then there’s diabetes, of course. Although diabe­tics do not necessarily have arteriosclerosis, diabetes accelerates the development of arteriosclerosis in all organs.
On average, PAD patients die ten years earlier, mostly as a result of a heart attack, stroke, or kidney failure. PAD is therefore an indicator of a generally very high cardiovascular risk. And this danger is present whether or not the patient experiences any warning signs, for example in their legs.

What symptoms do patients typically notice in their legs during the early stages of the disease? Both in cases of PAD and PAD combined with CVI?
Dr. Uhlemann: Patients often report that they have heavy, tired, painful legs. PAD sufferers notice this particularly when walking. In most cases, they first experience pain and tight calves when going uphill. Over time, they find that even on flat stretches the distance they can walk without feeling any pain gradually reduces. Other patients may make comments like, “My legs are so cold, my toes look really strange and I can’t feel them.” These are the typical symptoms of PAD.
In vein patients, on the other hand, symptoms tend to develop at night , with patients reporting swollen, tired, heavy legs in the evening and overnight. In most instances, they feel better when they put weight on their legs. This is because movement reduces venous complaints, while rest causes the vein-induced symptoms to develop more frequently. Patients with both PAD and CVI, however, feel discomfort when moving and at rest.

How are the conditions diagnosed?
Dr. Uhlemann: The basic method is to measure the ankle arterial pressure. The ankle-brachial index (ABI) test involves working out the ratio of the blood pressure in the ankle to the blood pressure in the upper arm. If the ABI value is equal to or greater than 1,
the patient is not suffering from PAD. A false high value may, however, be recorded in patients with diabetes, a heart valve weakness, or severe edema. If the ABI value is less than 0.9, the patient has PAD and needs a duplex ultrasonography to ascertain not only whether the blood is circulating properly, but whether the vessels are constricted, calcified, or even inflamed. Depending on the severity of the condition, we may also measure the arterial oxygen partial pressure. In healthy people, this is usually over 80 mmHg. A value under 50 indicates that disease is present , while a value under 30 is chronic and critical , and a value under 10 means that amputation is vital. This measurement is often extremely helpful in showing us how severe the problem is and whether we still have time to escalate conservative treatment.

When a patient is suffering from both PAD and a congestive edema caused by venous insufficiency, what do you treat first?
Dr. Uhlemann: That is a very difficult question. When the leg is at risk of being amputated, it is imperative to treat the PAD immediately. You could be forgiven for thinking that arterial circulation always has priority because tissues need oxygen. But generally, the biggest enemy to a leg affected by PAD is edema, in other words, the build-up of fluid in the tissue between the vessel and cells. Edema not only delays venous drainage, but extends the diffusion pathway. It virtually prevents arterial oxygen, which is already low in PAD patients, from reaching the cells. Conversely, the lack of oxygen caused by PAD increases the risk of edema in the tissues, in turn worsening the PAD. All of this means that we quickly find ourselves in a vicious circle.
On top of this comes another danger, as the inflammation or ulcers caused by prolonged congestion may lead to infections and even potentially fatal sepsis.
This is why it is essential to treat edema in every case – by that I mean not only in patients with venous and lymphatic disorders without PAD, but above all in patients with PAD. Doing so is extremely important in order to both relieve the symptoms and improve the patient’s prognosis. In an ideal scenario, this involves treating the edema first and ensuring that venous drainage is possible. Otherwise, the little blood that can flow in is unable to flow away again. This causes circulation to gradually slow down. After that , it is time to improve the influx of arterial blood. It is therefore a matter of always treating both conditions.

So can patients with PAD receive compression therapy?
Dr. Uhlemann: It is, of course, crucial to always exercise extreme caution in patients with arterial circulatory disorders. Having said that , compression should not be ruled out per se. Doing so would deny many people the chance of receiving an effective treatment simply because they have been diagnosed with PAD. I of course don’t want to do anything to further restrict the blood supply to a leg with impaired circulation, but there is nothing worse than edema in a leg affected by PAD. What’s more, it has been scientifically proven that no damage can be inflicted up to a compression of 41 mmHg. This equates to a compression class of 2 to 3. During intermittent pneuma­tic compression (IPC) therapy, we can even apply much higher levels of pressure in the short term, before reducing them back to zero again. IPC increases the arterial-venous pressure difference, stimulating the arteries to carry blood and to even form new collateral arteries which bypass the blocked arteries.

Up to what degree of PAD severity would you use compression?
Dr. Uhlemann: It is often said that an ABI of 0.5 or below is an absolute contraindication to compression. My medical association, the German Society of Angiology, says do it – but only under medical supervision. This is the approach I would like to take as well. Each patient requires a course of therapy tailored precisely to their needs. And the suitability of the treatment must be checked on a daily basis. How is the patient responding to the treatment? How do they appear to be reacting to it on the outside? How are the pressure values changing? What is the transcutaneous oxygen partial pressure? If possible, this should be greater than 30. Nevertheless, we have already achieved some fantastic results after using compression therapy on patients with an oxygen partial pressure of less than ten. Doing so has enabled us to heal ulcers and even save legs in the process.

How do you treat edema patients with PAD in your hospital?
Dr. Uhlemann: We treat edema patients by initially performing manual lymphatic drainage followed by compression bandaging. When looking after PAD patients, it goes without saying that we examine their toes closely. We have already used this approach to treat 450 patients who were no longer able to be cared for on an outpatient basis. All of them received complex decongestive therapy, initially using bandaging and generally followed, after five to six days, with compression stockings – a flat-knit style for treating lymphedema and a round-knit style for venous edema. I continue to use this method today.

What , in your opinion, would be the perfect compression stocking for treating PAD patients?
Dr. Uhlemann: A stocking that replicates intermittent pneumatic compression as far as possible would be ideal. By that I mean one that has a low resting pressure and a high working pressure so that it massages the leg with every step. This doesn’t harm anyone and the compression helps to reduce the edema. When at rest and putting the stocking on, the compression needs to equate to class 1 and during movement this needs to rise to class 3. It is also important that it has a high level of stiffness.

Could compression stockings also have a positive impact on cardiovascular diseases?
Dr. Uhlemann: Reducing venous congestion in varicose veins also lowers the risk of thrombosis. In turn, this reduces the risk of a pulmonary embolism, which is still the third most fatal cardiovascular disease.
Another positive effect of compression stockings is that they increase the arterial-venous pressure difference. By activating the calf muscle pump, patients also constantly exercise their smallest collateral blood vessels. Cardiologists have gathered strong data demonstrating that physical exercise may stimulate the growth of collateral blood vessels. A lot more research still needs to be done into the effect of compression stockings, however.

What can patients do to minimize the risk of PAD?
Dr. Uhlemann: A great deal! They should stop smoking, consult with their physician to find ways to lower their blood pressure and blood lipid levels, learn to cope better with stress, and exercise. We recommend that our patients buy a pedometer and walk 10,000 steps a day. These guidelines also help patients who already have arteriosclerosis to slow down its development.

Do you have any requests for family physicians?
Dr. Uhlemann: Perform ABI measurements as standard! Not only in patients who are experiencing pain, but in everyone and especially those belonging to the risk groups I’ve mentioned. ABI measurements should be performed as routinely as colonoscopies for bowel cancer screening. If the ABI value is abnormal , the patient must be referred to a vascular specialist. Family physicians play an extremely important role in ensuring patients receive help from the right place.

Images: Paul-Philipp Braun