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C H A P T E R 1 7
PERIPHERAL
VASCULAR DISEASE
Although the heart is the command center of the cir- Arteries carry freshly oxygenated blood from the culatory system, many medical conditions that afflict heart to the rest of the body, starting in the central the heart may also or independently affect the net- trunk artery, the aorta, which leads from the heart's work of arteries and veins that carry blood to and main pumping chamber (the left ventricle). From the from the body’s tissues. Such damage is generally aorta, the arteries branch and divide into successively referred to as peripheral vascular disease (PVD).
smaller vessels, and finally into tiny arterioles and Arterial diseases may cause narrowing or block- capillaries that deliver oxygen to the body’s tissues.
age of vessels in the legs and other parts of the body Arteries are thick-walled and muscular; if an artery distant from the heart (known as the periphery). Nar- is cut, blood will spurt at high pressure and velocity rowing of the peripheral arteries happens in essen- with each beat of the heart. Arterial blood is scarlet, tially the same way as narrowing of the coronary because it carries richly oxygenated red cells. Arter- arteries. In coronary disease, the narrowing causes ies such as the radial artery, located in the wrist near chest pain and, sometimes, heart attack. In peripheral the thumb, are cIose to the surface of the body and arterial vascular disease, however, the most common symptoms are leg pains from decreased circulation.
Veins carry blood that has left much of its oxygen The veins, which send blood from the limbs and other in the tissues back to the right side of the heart. It is tissues back to the heart, are also vulnerable to a then pumped into the lungs to pick up more oxygen.
variety of disorders that can cause blood clots to form Compared to the flow of arterial blood, which is driven by the heart's powerful pumping, the flow of venous blood is relatively slow, returning from the lower body against the force of gravity. (A series ofone-way valves inside the veins helps keep the blood from pooling or moving backward.) The flow of bloodfrom a cut vein is slow and steady. Veins are thinnerthan arteries, and they appear bluish, because the The circulation of blood through the human body is divided into two interlocking systems: venous and The real work of the circulatory system—the ex- arterial. Together, they keep a dynamic interchange change of nutrients for waste products—takes place of blood moving to and from the heart and lungs.
in microscopic vessels called capillaries. These struc- tures are as wide as a single cell and allow the dif- MAJOR CARDIOVASCULAR DISORDERS
Table 17.1
Diseases of the Veins
Diseases
Symptoms
Treatment
pulmonary embolism;bedrest for 3 to 5 days with knee; moist soaks and anti-inflammatory drugs such asaspirin or indomethacin(Indocin) knee-length elastic stockingindefinitely to preventswelling as aspirin bedrest and legelevation; anti-itch ointmentsuch as zinc oxide; moistheat long or during pregnancyhormonal changes, duringpregnancy, that dilate andrelax veins fusion, or passage, of oxygen and nutrients into lodge in a pulmonary blood vessel. This is a serious organs and tissues. The two sides of the circulatory condition called a pulmonary ernbolus, and if the system come together in these tiny vessels. The cap- blockage is large enough can be fatal. Blood clots in illaries terminate in the smallest of veins, which in the superficial veins—those near the skin’s surface— turn channel blood into the larger veins and back present little risk of embolization; they may cause toward the heart through the largest veins, the in- localized pain and inflammation, but these symptoms ferior vena cava (from the lower body) and the su- can usually be treated with moist heat and medica- perior vena cava (from the upper body).
tions such as aspirin. Clots in the deep veins in the calf are probably less threatening than clots in thedeep veins above the knee, but, in either case, theymust be treated aggressively.
Several conditions predispose a person to for- DISORDERS OF THE VEINS mation of blood clots in the veins. One is sluggish movement (stasis) of the blood in the veins of the
limbs, especially the legs and feet. Damage to the
Blood clot formation in the veins (venous thrombosis)
lining of a vein, which may be caused by infection, is the most common—and most threatening—med- injury, or trauma from a needle or catheter, can also ical condition involving the veins. It afflicts an esti- be a factor. Inflammation of a vein (phlebitis), usually mated 5 to 6 million Americans every year. (See in the legs, is associated with clot formation as well.
A third abnormality involves the blood’s ability to The primary danger of a blood clot in the deep coagulate too easily and form clots. This is called a veins of the legs (see Figure 17.1) and abdomen is the hypercoagulable state. Injury to the inner lining of a possibility that a portion of the clot may break loose vein causes platelets to congregate at the site, setting (embolus), which can travel to the lungs, where it can the stage for clotting when blood is sluggish or Slow blood flow can be caused by any obstruction A blood clot that forms in a deep vein in the leg or abdomen may between the body’s periphery and the heart. The mas- travel through the bloodstream and lodge in the lung, a seriouscondition called pulmonary embolism. The arrows indicate the path saging action of muscle contractions helps venous blood make its return trip; thus, a prime cause of slowblood flow is prolonged inactivity, which might oc-cur, for example, as a result of a cast for a fracturedbone in the lower extremity, extended bedrest afterinjury or illness, or even along car or plane trip. Onlong trips, it is a good idea for someone who might be predisposed to getting a clot in a vein to get outof the car or stand up in the plane every hour andwalk around for one or two minutes. This advice is especially good for obese people or those with dia-betes, heart disease, heart failure, or other circulatoryproblems. Smokers are also very susceptible to clotformation and inflammation of the veins and arteries.
Other less common causes of sluggish blood flow include certain tumors and a buildup of fluid in theabdomen (ascites). A host of conditions, includingsome cancers, inherited abnormalities, and the after-math of a heart attack or surgery, can increase theblood’s tendency to clot.
A deep-vein clot may cause no symptoms; the first indication of its presence, in fact, may occur after ithas traveled to the lung (pulmonary embolism), caus-ing a person to cough up blood-tinged phlegm andexperience shortness of breath and chest pain. Theclot may also result in marked pain and swelling (edema) in one leg. Many other conditions, from joint during this time, the bloods coagulation time must diseases to heart failure, may cause pain or swelling periodically be monitored (about every four weeks in one or both legs. A carefully documented medical once it has stabilized) to guard against bleeding history and a few specific tests will usually lead to the diagnosis. Often a doctor can make the diagnosis In patients who cannot take anticoagulants-for merely by putting pressure on the calf or thigh muscle example, those with a bleeding ulcer or recent sur- or flexing the ankle. If these maneuvers elicit a painful gery patients—an umbrella-shaped filtering device response, a deep-vein clot may likely be the culprit.
may be inserted by catheter into the inferior vena In most cases, the diagnosis must be confirmed cava, where blood from the legs is funneled back to using the test described below. The test considered the lungs, to prevent any major clots from reaching the “gold standard” for diagnosing deep-vein clots the lungs. This procedure usually is reserved for pa- is contrast venography. In this test, also called a ven- tients who have already experienced a clot or em- ogram, a dye visible on an X-ray is injected into the veins of the feet; the patient is then tilted in various In addition to receiving medication, someone with positions to facilitate blood flow from the lower veins a deep-vein clot should remain in bed during the to the heart, providing an X-ray image of the vein acute attack (about three to five days), with legs el- network. Venography is cumbersome and uncom- evated to prevent further swelling and facilitate ven- fortable, and in a small percentage of tests, the results ous blood flow. Moist heat and anti-inflammatory are questionable. The test also carries a small risk of drugs such as aspirin or other, stronger nonsteroidal infection or allergy to the dye. In many cases, the medications such as indomethacin (Indocin) may also diagnosis can be made without this test.
be extremely helpful in controlling symptoms and Alternative tests include one in which blood flow aiding recovery. These should be used with care if in in the legs is measured using a blood pressure cuff combination with anticoagulants. Once swelling im- and two small electrodes. This quick technique, called proves, a firm elastic stocking should be worn below impedance plethysmography, is useful for diagnosing the knee whenever the person is out of bed. Most clots above the knee. Uhrasonography, a completely important, long periods of standing should be noninvasive but relatively expensive technique, uses sound waves to form a picture of the veins and, in a In some people, a condition called chronic venous variation called Doppler ultrasonography, measures insufficiency may occur as a long-term complication blood flow. Other tests using radioactive isotopes following a deep-vein clot. It is characterized by may also be used. In one such test, called platelet swelling and discoloration of one or both legs. In scintigraphy, an injection of radioactively labeled these cases, a knee-length elastic stocking should be platelets is used to locate clots and track their path worn indefinitely to prevent swelling.
through the veins over several days.
The most common form of phlebitis is an inflam- After a venous blood clot has been discovered, a phy- mation of the superficial veins in the leg, usually sician will first attempt to determine the underlying caused by an infection or injury. The affected vein causes of abnormal clotting. Much of the time, the may appear reddened and feel like a firm cord in the event causing the clot cannot be identified. However, calf or thigh. The condition is painful and is treated clots that occur after long plane or car rides, surgery, with moist heat and analgesics such as aspirin or or prolonged bedrest are relatively easy to explain.
some other nonsteroidal anti-inflammatory drug As a rule, immediate therapy consists of anticoagu- such as indomethacin (Indocin). Itching may be re- lant and blood-thinning medications such as warfarin lieved by a nonprescription ointment containing zinc (Coumadin) or heparin. The use of clot-dissolving (thrombolytic) drugs such as those now used to treat The chief danger of phlebitis is an increased risk heart attacks is still considered controversial for clots of clot formation and embolization, especially when in the veins, but may offer future promise. Lower it occurs in the deeper veins. Deep-vein phlebitis may doses of blood-thinning medications such as war- cause the same symptoms as deep-vein thrombosis.
farin are usually continued for several months; There may be severe pain, tenderness, and fever.
may be injected with an irritating (sclerosing) sub- Normally, blood returns to the heart at a steady pace, stance, which causes them to shrink. Again, nearby helped along by exercise and by the veins’ internal veins assume the blood flow. Individuals with vari- valve system. The valves act as one-way gates to pre- cose veins should remain as thin as possible to reduce vent blood from pooling; they aid in moving blood “back pressure” on the veins and should avoid stand- against the force of gravity. If blood flow is too slow ing for long periods of time. Elastic or support hose or the valves are damaged or ineffective, however, may provide some assistance to return blood flow, veins in the legs—especially superficial vessels in the but tight garters, which impede circulation, should lower legs—can swell, bulge, and twist into varicose be avoided. Many people who have varicose veins do veins, or varicosities. (See Figure 17.2.) Heredity of well and experience no limitations other than some poorly functioning or absent valves seems to be a major factor. People who spend a lot of time standingare especially prone to varicose veins. Women may get them for the first time during pregnancy, because The closer to the heart that a clot is formed, the more of pressure from the fetus on the veins in the abdo- likely it is to migrate to the lungs and form a pul- men (into which the leg veins drain) and hormonal monary embolism. Such a clot maybe fatal. It is also changes that dilate and relax the veins.
one of the most difficult causes of sudden death to Although varicose veins can cause pain or a sen- diagnose. In some instances, there are no symptoms sation of tingling or crawling, they often produce no at all. In others, however, it may produce a variety of symptoms. However, they are considered unsightly.
symptoms and signs, such as chest pain that worsens The condition can be corrected surgically in a pro- when a person inhales, a sandpaper-like sound heard cedure called “stripping,” during which the varicose through the stethoscope, shortness of breath, and veins are simply tied off at intervals through skin in- coughing up blood. The embolism may resolve, leav- cisions and pulled out from under the skin. (Nearby ing no permanent damage, but it can damage lung veins adapt by creating alternative pathways for the tissue or cause fluid buildup in the lung cavity. For return of blood.) Alternatively, the varicosed veins instance, increased pressure on the right side of theheart over long periods of time may cause increased Varicose veins develop when the one-way valves in the superficial blood pressure in the vessels in the lungs, a condition veins in the legs do not dose properly, allowing Mood to backflow To diagnose a pulmonary embolus, a physician measures the levels of oxygen in the arteries and per-forms other tests to determine how well the lung is ventilated with air and supplied with blood. An ob- struction to the lungs’ blood supply, indicated by alower percentage of oxygen in the blood, suggeststhe possibility of a clot. The diagnosis is confirmedby pulmonary angiography, in which the pulmonaryartery is injected via a catheter with a dye so it willappear on an X-ray. The treatment for pulmonaryembolus may involve clot-dissolving (thrombolytic)medication such as urokinase (Abbokinase) or strep-tokinase (Streptase), anticoagulants such as warfarin(Coumadin) or heparin, or other blood thinners; inrare cases, surgery is necessary to remove the clot.
The coronary arteries that encircle and nourish the heart are the most common targets for the damage caused by atherosclerosis, the blockage of arterieswith fatty deposits. However, atherosclerosis can af- Foot Care for People with
fect arteries virtually anywhere in the body. When it Peripheral Vascular Disease
occurs in the neck or the brain, it can cause a stroke.
(See Chapter 18.) In the arteries supplying the legs, Poor circulation caused by peripheral vascular it can cause pain and, in a small minority of cases, disease makes feet more vulnerable to injury tissue damage so severe it results in gangrene and and infection and slower to heal. For this reason, it is especially important to take proper Atherosclerosis in the peripheral arteries is similar care of the feet to avoid complications. Here aresome tips: to that in the heart: Blood-borne fats, or lipids, infil-trate a damaged area of the vessel wall and cause ● Inspect feet daily for calluses, ulcers, and further damage and thickening with the formation of a plaque. The inside passage of the artery becomes ● Wash feet gently each day in lukewarm water narrowed and may be blocked completely by a blood and mild soap (this can be part of a bath or clot. This leads to ischemia, a condition in which ar- terial blood flow is impeded, resulting in too little ● If skin is dry, thin, or scaly, use a gentle lubricant or moisturizing lotion after bathing.
oxygen being delivered to the tissue “downstream”from the narrowing or obstruction. The risk factors ● To avoid fungal infection such as athlete’s foot, use a plain, unmedicated foot powder.
for arterial blockage in the periphery are identical to ● Cut toenails straight across and avoid cutting those for blockage in the coronary arteries, including close to skin. If your eyesight or manual high blood cholesterol, cigarette smoking, diabetes, and high blood pressure. Smoking is a particularly reaching your feet, have a family member or a important risk factor for peripheral artery disease.
The classic symptom of peripheral arterial disease ● If you have calluses or corns, have them treated is crampy leg pain while walking, called intermittent by a podiatrist. Avoid adhesive plasters, tape, chemicals, abrasives, or cutting tools.
claudication. Pain may worsen when a person walks faster or uphill. The pain usually stops when he or ● Wear sensible, properly fitted shoes; avoid high heels, open-toed shoes, sandals, and walking she rests. The cause is ischemia in the working mus- around barefoot. If any foot problems are cles, a sort of “leg angina.” (Angina pectoris, or chest present, such as bunions or hammer toes, have pain, is usually caused by inadequate blood supply to shoes specially fitted to avoid rubbing or heart muscle.) The pain of claudication is most often triggered by exercise, but maybe brought on by other ● Keep feet warm in cold weather with loose- fitting wool socks or stockings, but avoid using factors, including exposure to cold or certain medi- hot-water bottles or heating pads directly on cations, such as some beta blockers, that constrict feet. (Poor circulation can reduce sensation in blood vessels and decrease peripheral blood flow.
The location of the blockage determines the symp- toms. If the obstruction is relatively low in the arterialbranches supplying the legs, calf pain may be theresult; higher blockage may cause thigh pain; andblockage higher than the groin (in the blood vessels However, such serious complications of peripheral in the abdomen) may also cause buttock pain and Patients with poor circulation to the feet and toes When arteries are badly narrowed—or blocked should discontinue smoking if applicable, and pay altogether-leg pain may be noticed even when rest- particular attention to avoiding injury to those areas.
ing. At this point, the legs may look normal, but the Otherwise healing will be slower and infection more toes may appear pale, discolored, or bluish (especially likely. (See box, “Foot Care for People with Peripheral when the legs are dangling). Feet will feel cold to the Vascular Disease.”) Feet should be kept warm, dry, touch. Pulses in the legs may be weak or absent. In and away from excessive heat (baths, heating pads), the most severe cases, blood-starved tissues may ac- and avoid cutting toenails too short. Since peripheral tually begin to die. Lower-leg, toe, or ankle ulcers may arterial disease is more common in individuals with occur, and in the most advanced cases, gangrene may diabetes than in those with normal blood sugar, con- result and necessitate the amputation of toes or feet.
ularly to people with other joint and muscle problems for whom strenuous weight-bearing exercise (such Other conditions, including various joint, muscle, and as jogging) could present a significant risk of injury. lower-back problems, can also cause a person to ex- People with symptoms of peripheral arterial disease perience leg pain while walking. With peripheral ar- should consult a physician before taking up any new terial disease, however, the presence of typical symptoms-pain in the calf or thigh while walking Anticlotting agents, such as an aspirin taken each that ceases upon stopping—and decreased pulses in day, and vasodilator drugs, such as hydralazine the arteries in the feet are sufficient to make the di- (Apresoline) or prazosin (Minipress), may be used to treat peripheral arterial disease. (Most of these reed- Decreased hair on the lower extremities indicates ications, however, have not been proved effective.) a chronic problem. Taking cuff measurements of An agent called pentoxifylline (Trental) is also avail- blood pressure in the ankles or in other segments of able for the pain of claudication. (Beta blockers, often the legs may help determine how much blood is get- used for other cardiovascular conditions, may make ting to the feet. Tests maybe performed before and peripheral arterial disease worse.) If these measures after exercise. The diagnosis of peripheral arterial fail to halt peripheral arterial disease, and disability disease may be made using Doppler ultrasonography is severe or limbs are threatened, invasive techniques to see blood flow in the arteries, magnetic resonance such as angioplasty or surgery may have to be used imaging (MRI) to identify obstructions, or—most to open blocked arteries, but this is uncommon.
important-angiography. These procedures are ex-pensive and are not necessary inmost cases. Because angiography is an invasive procedure involving theinjection of dye into the arteries, it is usually reserved for cases when surgery or angioplasty is a likely op- Balloon angioplasty is being used successfully to tion. For example, in cases of severe claudication with open blocked arteries in the legs of people with severe evidence of poor circulation, discoloration, absent cases of peripheral arterial disease. The procedure, pulses, and cold extremities, angiography can deter- usually performed by a radiologist or cardiologist, is similar to that used in the heart. A balloon-tipped It has been estimated that 80 to 90 percent of pa- catheter is inserted through the skin and threaded tients with claudication will stabilize or improve with through the arteries to the site of the blockage. When time. Perhaps 10 to 15 percent will require some type the balloon is inflated, it flattens the obstructing of interventional therapy; less than 3 to 5 percent will plaque against the artery walls and, ideally, widens require amputation. In treating peripheral arterial disease, conservative measures should be given a fair Balloon angioplasty is most successful on periph- trial before any invasive procedures are considered.
eral blockages that are relatively short and well-de- Several steps are essential: control of obesity and fined, rather than those that are long or scattered.
diabetes if present, the cessation of cigarette smoking For peripheral arterial disease, it has proved safe and (the majority of peripheral arterial disease sufferers effective for appropriately selected patients, offering are smokers), and adherence to a program of regular the advantage of faster recovery time than that of exercise, such as daily walking. Patients may typically bypass surgery. It usually requires only one to two be instructed to walk for a half hour to an hour a day, days of hospitalization. However, in about 30 percent walking until the pain comes on, resting until it of all cases, the leg arteries become reclogged (called abates, then continuing to walk. Often such a walking restenosis) within a year or two, and angioplasty or regimen can increase the distance of pain-free walk- surgery may eventually be necessary again. In ad- ing, thanks to increased fitness and perhaps the de- dition to balloon angioplasty, a variety of new cath- velopment of alternate circulation paths through eter techniques are under investigation for use in the surrounding smaller vessels, called collateral circu- heart and the peripheral arteries, including devices lation. Control of the risk factors for “hardening of that shave out plaques and laser tips that burn the arteries," including elevated blood pressure and cholesterol, if present, is also extremely important.
One surgical option for people with severe block- Other forms of exercise, such as swimming or us- age involves opening the blocked vessel and stripping ing an exercise bicycle, may also be helpful, partic- the plaque out, a procedure called endarterectomy.
Another is bypass surgery, in which a patient’s ownvein or a synthetic equivalent is grafted onto theblocked artery so that blood can flow around the ob- structed area. The physician’s thoughtful evaluationof an individual’s profile as a surgical candidate iscrucial in deciding upon the optimal treatment.
What makes an individual an appropriate candi- date for angioplasty, surgery, or other procedures?As a rule, the potential benefits of intervention mustclearly outweigh the risks. Patients with mild inter-mittent claudication are not candidates for surgeryor catheterization. People with tissue damage orthose who experience severe pain while at rest, how-ever, may require opening of clogged arteries (re-vascularization) to avoid disability. Between thesetwo extremes, individuals with severe intermittentclaudication may benefit from angioplasty or even surgery if the blockages are of a type that can bereadily corrected. (See Chapters 24 and 25.) If major surgery is contemplated for peripheral vascular disease, a full cardiologic evaluation shouldbe ordered. This is recommended because people with peripheral vascular disease may also have An aneurysm is the result of a weakening of an artery that causes it coronary artery disease, which may pose an addi- to balloon out. The most common site is in tbe abdominal aortabelow the renal arteries. tional risk that should be evaluated and treated In the aorta, the main artery leading away from theheart, such a rupture can have devastating conse-quences, flooding nearby tissues with blood and markedly reducing the supply of blood to the rest ofthe body, leading to possible immediate death if nottreated promptly.
An aneurysm is a weakened area of a blood vessel Aortic aneurysms generally fall into three cate- wall that balloons outward and threatens to rupture.
gories. The walls of arteries consist of three tissuelayers, with the middle muscular layer providing Figure 17.3
structural support. If an aneurysm forms as a result In a dissecting aneurysm, the inner and outer layers of an artery of damage to the middle layer, it is a saccular aneu- separate, and blood pools between the layers, causing a swelling of
the wall.
rysm. A fusiform aneurysm may form when the entirecircumference of a section of the aortic wall is dam- aged. If the layers separate as a result of high bloodpressure and blood is forced between them, causing the outer wall to swell, it is called a dissecting aneu-rysm. (See Figure 17.3.) An aortic aneurysm may occur below the renal arteries that supply the kidneys, in the abdominalarea (see Figure 17.4), or in the chest (thoracic) areaat the arch of the aorta where it first branches offfrom the heart. The aneurysm is usually caused byatherosclerotic damage to the vessel wall, whichweakens its structure. Hypertension may acceleratethe process. It may also result from genetic or con-genital conditions, such as Marfan syndrome, an in-herited disease.
An aneurysm may cause no symptoms, or it may redness and tingling as the blood flows back into cause abdominal or chest pain. Large aneurysms can tissues. People with this disorder should not apply also produce more symptoms because they may ap- too much heat to the affected fingers and toes; the ply pressure to adjacent blood vessels, nerves, and use of moderate heat will be effective without the organs. In these cases, symptoms may include hoarseness, coughing, difficulty swallowing, or Raynaud's phenomenon may be associated with various connective tissue disorders, such as rheu- Perhaps most often, an aneurysm is detected as a matoid arthritis or lupus erythematosis, but in a ma- result of a routine chest X-ray or when a physician jority of cases the underlying cause is unknown; when palpitates the abdomen. Echocardiography, com- there is no other primary cause, the condition is puted tomography (CT) scan, and magnetic reso- nance imaging (MRI) are techniques that can define Treatment of Raynaud's can be difficult and frus- the size and location of an aneurysm quite precisely.
trating. Various approaches to drug therapy are un- der investigation, many of them directed at The larger the aneurysm, the more likely it is to influencing the biochemical factors that constrict or rupture. Surgical repair is usually imperative for relax the smooth muscles in the walls of the arteries.
large aneurysms or aneurysms that are expanding.
Although totally effective drug treatment remains For this reason, patients with small aneurysms are elusive for many sufferers, many others are helped monitored regularly with full exams and imaging significantly with a calcium channel blocker such as techniques. (Patients who spontaneously rupture the nifedipine. The use of phenoxybenzamine (Dibenzy- line), a medication that blocks the effects of adrena- Corrective surgery requires clamping the aorta line on blood vessels, may occasionally produce relief and repairing the affected segment with a woven of symptoms. (Some beta blockers may aggravate Dacron patch or graft. The strain on the heart that results when the aorta is clamped presents serious Usually, therapy consists of measures such as risks of its own in people with cardiovascular disease.
avoiding exposure to cold and wearing thermal For this reason, a person with significant associated gloves and thick socks. Because smoking causes coronary artery blockage should be carefully evalu- blood vessel constriction, tobacco use should be dis- ated and may be advised to undergo coronary bypass continued. Biofeedback has had mixed results in re- surgery or angiography before the procedure to re- lieving symptoms. Most individuals with the disease learn to live with it and, when possible, to avoid sit-uations that cause it, but this cannot always be done.
Raynaud's disease doesn’t usually cause tissue death, but over a long time, it may cause the skin of the fingers to become shiny and tight-looking, pos-sibly with small ulcers caused by repeated ischemia.
In advanced cases, the lining of the small arteries maythicken, and clotting may result, but this is rather rare. When Raynaud’s phenomenon is caused by an- This vascular disorder is characterized by intermit- other disorder (such as lupus), effective treatment of tent coldness, blueness, numbness, tingling, or even the underlying condition may provide relief.
pain in the fingers and toes. (Usually it affects bothhands simultaneously and the same fingers of eachhand.) It is more common in women, who accountfor 60 to 90 percent of all cases, and those who are thin and high-strung seem to be most vulnerable.
This relatively rare condition, also called thromboan- Caused by excessive constriction of the tiny arteries giitis obliterans, occurs overwhelmingly in men aged that nourish the fingers and toes (vasospasm), it may 20 to 40 who smoke cigarettes. (Only about 5 percent be triggered by a number of factors, particularly ex- of all cases occur in women.) The disease causes in- posure to cold temperatures, emotional stress, smok- flammation in the small and medium-sized arteries ing cigarettes, and activities such as swimming.
and veins and eventually produces irreversible When the hands are gradually warmed, normal color changes in the muscle walls of the blood vessels. It's and sensation return, often accompanied by some a type of smoking-induced peripheral arterial dis- ease, and the resulting ischemia can be so severe as ducing the toll from heart disease. Unfortunately, the to warrant amputation of fingers and toes. All smok- effects of atherosclerosis on the rest of the cardio- ers experience some degree of clamping down of the vascular system have received less attention. Anyone peripheral blood vessels (vasoconstriction). It is un- with peripheral arterial blockage, however, is suffer- known why people with Buerger’s disease experience ing from essentially the same disease, and it is just this to such a severe degree. Genetic or autoimmune as important for him or her to control high blood defects have been suggested as possible explanations cholesterol, high blood pressure, diabetes, and obes- ity, and to stop smoking, as it is for the patient with Treatment consists of giving up smoking com- heart disease. (Often, heart disease and peripheral pletely as soon as possible. Other measures maybe arterial disease occur together—and one should be taken to improve blood flow and treat tissue damage, a warning that risk factors are present for the other.) but without the cessation of cigarette use, progres- Too often, treatment of peripheral vascular disease has neglected to include alteration of life-style riskfactors such as cessation of smoking, a low-fat andlow-cholesterol diet, regular moderate exercise, weight control, maintenance of appropriate bloodpressure, and control of diabetes. To prevent therecurrence or progression of symptoms, implement- The well-publicized campaign to control cardiovas- ing these measures must be an integral part of any cular risk factors has already made progress in re-

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