Preventing Limb Loss in PAD: Know Your Treatment Options

This article is for people who have peripheral artery disease (PAD) and want to learn how to lower their risk for limb or heart problems or for anyone who wants to learn more about those topics. The goal of this patient education activity is to learn about the treatment options for PAD.

You will learn:

• How having PAD increases your risk for problems in your limbs and heart

• What the treatment options for PAD are, including blood thinners

• When you should get emergency help

• Tips to keep yourself healthy with PAD

• Questions to ask your healthcare provider

If your healthcare provider told you that you have peripheral artery disease (PAD), that means your limbs (arms and legs) are not getting enough blood and oxygen.

The main reasons for why your limbs are not getting enough blood are:

• Cholesterol builds up as plaque and decreases blood flow to your limbs by making your arteries narrow, or it can block your artery

• Plaque can break off and cause your body to form a blood clot (which is a clump of plaque, platelets, and red blood cells); a blood clot can block your artery and cut off blood flow to your limbs

Blockage or less blood flow to your limbs can cause cramping or very bad pain, making it harder for you to do your daily activities.

PAD is a serious condition. When PAD is not managed, your limbs can feel numb, sore, or painful even when you're sitting or lying down.

If PAD continues to get worse, you can develop what is called "critical limb ischemia." Critical limb ischemia is when an injury, infection, or open sore does not heal and it causes tissue death (called gangrene). You may need surgery to remove the damaged body part (known as amputation).

A blood clot can block blood flow to your artery and also lead to limb ischemia.

Having PAD increases your risk for experiencing a heart attack, stroke, or sudden death. How? Since you have plaque in your arms and legs, you can also have plaque in the arteries of your heart and brain, causing less blood flow to those important organs.

Another way to have a heart attack or stroke is that a blood clot in your arms and legs can travel to your heart or brain.

To treat PAD, you will have to take cholesterol- and blood pressure-lowering medicines. You may also need to take other medicines to manage symptoms like pain or to help you walk better.

To prevent blood clots from forming and blocking blood flow to your limbs, heart, and brain, your healthcare provider may ask you to take blood thinners. Blood thinners include antiplatelet agents like aspirin and a new treatment option for people with PAD called anticoagulant or "NOAC." It is important to talk to your healthcare provider about how these medicines work and their safety.

To keep track of blood flow in your limbs, your healthcare provider will perform a simple test called an ankle-brachial index (ABI) on your ankles.

There are also lifesaving surgical and nonsurgical procedures that improve blood flow to your limbs by rerouting blood flow, opening your artery, or removing the blockage:

• Limb bypass surgery: connects blood vessels taken from another part of your body to blood vessels around the blocked artery in your limb

• Peripheral angioplasty: a small balloon is inflated inside your blocked artery to open it up

• Stent implantation: during angioplasty, a thin mesh tube or "stent" is placed to permanently keep your artery open

• Thrombectomy: a procedure that removes clots and plaque blocking your artery

• Thrombolytic therapy: medicine given through your vein to dissolve a blood clot; this can be given during thrombectomy

• Limb amputation: when the damaged portion of a limb is removed

Antiplatelet agents are blood thinners that have been used to treat people with heart disease for a long time. Antiplatelet agents are used to treat PAD, too. They work by stopping platelets in your blood from sticking to plaque and forming a clot.

There are a few blood thinner options you can discuss with your healthcare provider for PAD. You can take an antiplatelet drug like aspirin or clopidogrel, or they can even be taken together.

Antiplatelet Treatment for PAD
Aspirin alone Clopidogrel (Plavix®) alone Aspirin + clopidogrel Cilostazol (Pletal®)

There are also blood thinners called anticoagulants (also known as "NOACs"). NOACs slow down your body's process of making blood clots and stop red blood cells from forming a clot in veins.

They have been used to prevent blood clots in the legs and lungs (called "VTE" -- venous thromboembolism). A NOAC called rivaroxaban can be used to prevent blood clots in people with PAD. Talk to your healthcare provider to see if rivaroxaban is right for you.

Even if you are being treated with other medicines to lower your cholesterol and blood pressure, for extra help in preventing blood clots, your healthcare provider may add on a NOAC to aspirin.

Antiplatelet + Anticoagulant (NOAC) Treatment for PAD
Aspirin + rivaroxaban (Xarelto®)

People on blood thinners are at risk for serious side effects. Call your healthcare provider if you have any of these problems:

• Unusual bruising

• Bleeding for a long time from cuts, the gums, shaving

• Nosebleeds that are uncommon or that don't stop

• Coughing up blood

• Blood in vomit or urine

• Unusual pain/swelling/discomfort

• Severe headache, dizziness/fainting, feeling tired

• Trouble swallowing

Call 9-1-1 if you have any of the following symptoms in your legs or arms.

If you have a blood clot in your leg you may suddenly feel:

• Pain in the calf, buttocks, thigh, or hip

• Skin looks pale or blue and feels cold

• Prickling like "pins and needles" or burning

• You can't move your leg (paralyzed)

• You faint or become unconscious

If you have a blood clot in your arm, you may have pain or cramping and your skin can feel warm, looking red and swollen.

Call 9-1-1 immediately if you think you are having a heart attack or stroke:

Symptoms of a Heart Attack
Chest pain or pressure that comes back after rest Chest pain or pressure that moves from your chest to your arms, neck, jaw, or back Shortness of breath Stomach pain or nausea Other symptoms: cold sweat, dizziness, feeling tired
Symptoms of a Stroke
Face droops or feels numb Arm feels weak or numb; trouble lifting arms Speech is slurred or jumbled Trouble walking; lose balance Other symptoms: confusion, headache, dizziness

For a heart attack, women may not have the same symptoms as men. Some women experience shortness of breath, pressure or pain in the lower chest or upper abdomen, dizziness, lightheaded, fainting, upper back pressure, or feeling very tired. If in doubt, call 9-1-1!

When you have PAD, it's important to take good care of your legs to protect them from developing injuries, sores, and infections.

• Wash and moisturize daily

• Cut your toenails carefully

• Wear comfortable shoes with socks

• Don't walk around barefoot

• Check your legs and toes for infections (fungal or bacterial) and open sores or cuts daily

• Stretch and exercise to get blood flowing

Remember to take good care of your arms, too!

Risk factors are things that increase your chances of having limb or heart problems in PAD. Along with taking your medicines, practice these healthy habits:

• Quit smoking

• Keep your blood sugar in control, if you have diabetes

• Lose weight if you are overweight

• Choose a healthy eating pattern with increased fruits, vegetables, and grains

• Be physically active for least 30 minutes, 3 to 4 times a week

• Limit alcohol

• Manage stress

• Get 7 to 9 hours of sleep nightly

Ask your healthcare provider these questions to find out how you can lower your risk for limb and heart problems and if a NOAC may be appropriate for you:

• What are my risk factors for having problems in my arms, legs, or heart?

• Should I be taking a NOAC?

• What do you recommend I do to stay healthy?

• When should I get emergency help?

Congratulations!

You have successfully completed the program: Preventing Limb Loss in PAD: Know Your Treatment Options