End-Stage Peripheral Vascular Disease : Understanding Symptoms, Diagnosis, and Management

1. Introduction

   1. What is End-Stage Peripheral Vascular Disease?

      End-stage peripheral vascular disease is an advanced and severe form of peripheral arterial disease affecting blood vessels outside the heart and brain.

      Peripheral vascular disease is characterized by narrowing, blockage, or damage to the arteries that supply blood to the extremities such as legs and arms. It is known to most commonly affect the legs.⁽¹⁾

      In end-stage peripheral vascular disease, the progression of the disease is significant that can cause severe and irreversible damage to the blood vessels. The narrowing of the arteries severely limits the blood flow to the affected limbs resulting in chronic ischemia and tissue damage. There is critical limb ischemia characterized by severe pain, non-healing wound, and tissue loss.

      End-stage peripheral vascular disease is associated with high-risk complications, including non-healing ulcers, infections, gangrene, and reduced overall quality of life.

   2. Progression from Earlier Stages to End-Stage Peripheral Vascular Disease

      Progression from earlier to end-stage peripheral vascular disease involves gradual deterioration of blood vessels and worsening of symptoms.

      Progression from earlier to end-stage peripheral vascular disease involves gradual deterioration of blood vessels and worsening of symptoms. 

      • Early Stage: In the early stages of peripheral vascular disease, an individual may experience mild symptoms or be asymptomatic. There is some narrowing or blockage of the peripheral arteries but the blood flow to the extremities is still preserved. There may be pain, cramping, or fatigue in the legs during physical activity.
      • Moderate Stage: Progression of peripheral vascular disease to moderate stage involves more significant blockage of the arteries. The blood flow to the limbs is affected and is further compromised leading to frequent and severe symptoms. There may be intermittent claudication with less exertion even at rest. Some people may develop non-healing wounds or ulcers on the legs and feet because of reduced blood supply.
      • Severe Stage: In the severe stage of peripheral vascular disease there is severe obstruction or complete blockage of the arteries. The blood flow to the affected limb is severely compromised, resulting in severe pain that is constant and even at rest. The affected limb may be cold and the skin may appear pale and discolored. If prompt and appropriate treatment is not given the disease may progress to end-stage peripheral vascular disease.
      • End-Stage: This is an advanced and irreversible form of disease. It is characterized by significant and widespread arterial damage, leading to ischemia and tissue loss. The symptoms get debilitating and the quality of life is severely affected.

      Progression to end-stage peripheral vascular disease is influenced by underlying causes, individual risk factors, and the effectiveness of early interventions.

   3. Causes of End-Stage Peripheral Vascular Disease

      Worsening atherosclerosis is the most common cause of end-stage peripheral vascular disease.⁽²⁾ It occurs when the plaque build-up blocks and narrows a person’s blood vessels, causing loss of some or all blood circulation.⁽³⁾

      Factors that may increase the risk of peripheral vascular disease include:⁽⁴⁾ 

      • Hypertension
      • Type 2 diabetes
      • Smoking
      • High cholesterol levels
      • Body mass index over 30
      • Being over 50 years
      • HIV
      • Family history of cardiovascular disease
      • High homocysteine level in the blood

2. Symptoms of End-Stage Peripheral Vascular Disease

   End-stage peripheral vascular disease indicates advanced arterial damage with significant blood flow restriction to the affected limbs.

   The symptoms may be similar to the symptoms of critical limb ischemia.⁽⁵⁾ The common symptoms include: 

   • Constant and severe, burning, aching, and throbbing pain in the affected limb. The pain is severe and is not relieved by rest or medication.
   • There are non-healing ulcers and wounds that fail to heal properly. Sometimes they may get infected, leading to further complications.
   • The lack of blood flow may cause tissue death and the development of gangrene. The affected skin may appear discolored, bluish, or black, and may have a foul odor.
   • In end-stage peripheral vascular disease, the affected limb may get weak, diminished, or completely absent. This may be due to a significant reduction in blood flow.
   • The lack of blood supply may lead to muscle atrophy causing the affected limb to shrink and weaken. This may lead to reduced strength, mobility, and overall function.
   • Severe pain, non-healing wound, and muscle weakness together may impair an individual’s ability to walk, perform daily activities and maintain a good quality of life.

   The symptoms may vary depending on the individual and the extent of arterial damage.

3. Diagnosis of End-Stage Peripheral Vascular Disease

   The end-stage peripheral vascular disease involves comprehensive evaluation to confirm the severity of arterial damage. The diagnostic methods include:

   • Physical Examination: the healthcare provider conducts a thorough physical examination to assess the symptoms, observe the affected limbs and the overall condition. He may look for skin changes, temperature differences, non-healing wounds, and the absence of pulses.
   • Imaging tests: The imaging test involved in diagnosing end-stage peripheral vascular disease include:
     • Angiography to visualize the flow of blood and identify any signs of blockage or narrowing of the arteries
     • Magnetic resonance imaging creates detailed images of the blood vessels and assesses the blood flow.
     • CT angiography for detailed cross-sectional images of the blood vessels to identify arterial obstruction.
     • Ankle-brachial index, a test that compares blood pressure in ankles and arms. The difference in pressure indicates arterial narrowing and blockage in the lower extremities.
     • Blood tests are done to assess cholesterol levels, blood sugar, and inflammation markers.

4. Management of End-Stage Peripheral Vascular Disease

   Managing end-stage peripheral vascular disease focuses on improving the symptoms and maximizing functional ability, preventing complications, and improving the quality of life.

   • Palliative Care: The focus of palliative care is to alleviate pain and discomfort and the patient’s overall health. Pain medications may be prescribed for pain management. Wound care, physical therapy, and assistive device also contribute to symptom management.
   • Revascularization Procedures: In some cases, revascularization procedures would be considered to improve blood flow to the affected limb. This includes bypass procedures in which a graft is used to bypass the blocked and narrowed arteries. Endovascular interventions such as angioplasty and stenting can be done to restore the blood flow to the arteries.
   • Amputation Considerations: If the revascularization fails, amputations may be considered as a last resort to remove the severely compromised limb. It aims to relieve pain, prevent infection, and improve the patient’s mobility and overall quality of life. The decision for amputation is taken on the patient’s overall health, functional status, and individual preference.
   • Supportive Therapies: Rehabilitation and physical therapy have a major role to play in managing end-stage peripheral vascular disease. These therapies focus on improving the mobility, strength, and functioning of the affected limb. Occupational therapy can assist in adapting to functional limitations and using assistive devices such as prosthetics and orthotics.
   • Psychological and Emotional Support: Coping with the challenges of end-stage peripheral vascular disease can be challenging for patients and their families. Psychological support, counseling, and education can be helpful for the individual to cope with the emotional impact of the disease.
   • End-of-Life Considerations: In the advanced stage of peripheral vascular disease, end-of-life care and discussions are necessary. This includes advance care planning including discussion about goals, palliative care options, and hospice service. This can help ensure that the patient’s wishes are respected and appropriate support is provided to them.

   A multidisciplinary approach is involved in the management of end-stage peripheral vascular disease. The focus of the treatment is to provide comprehensive care, improve quality of life and support the patient and their family throughout the treatment process.

5. Complications and Prognosis of End-Stage Peripheral Vascular Disease

   The end-stage peripheral vascular disease has life-threatening complications. The blockage in the blood vessels may affect the other areas of the body such as the brain and heart leading to stroke, heart attack, and angina.

   Other complications include: 

   • Gangrene
   • Limb amputation
   • Erectile dysfunction
   • Deep vein thrombosis
   • Non-healing ulcers

   It is observed that 50% of people with end-stage peripheral vascular disease have a life expectancy of 5 years from the time the disease is diagnosed.⁽⁶⁾

A build-up of plaque in the blood vessels can lead to end-stage peripheral vascular disease, which is known to worsen over time.

Without treatment, the disease can have serious life-threatening complications.

End-stage peripheral vascular disease can be treated with revascularization procedures. Lifestyle strategies such as quitting smoking, maintaining a moderate weight, and eating a healthy and well-balanced diet can be helpful in reducing the risk of peripheral vascular disease and its progression to end-stage.