Brief overview
- Symptoms: No symptoms for a long time, then mainly pain, possibly pale and cool legs
- Treatment: Cause treatment, gait training, blood thinning medication, possibly surgery.
- Causes and risk factors: smoking, calcified arteries as well as high blood pressure, diabetes mellitus, chronically high blood lipid levels, overweight
- Diagnostics: Medical consultation, physical examination, walking test, ultrasound, magnetic resonance tomography
- Prognosis and course of disease: Depends on cause elimination, prognosis can be positively influenced by a healthy lifestyle
- Prevention: non-smoking and healthy lifestyle reduce the risk of pAVK
What is smoker’s leg (pAVK)?
Smoker’s leg accounts for about 90 percent of all pAVK cases. The narrowing is located in the pelvic arteries in about one-third of patients, in the femoral arteries in 50 percent, and in the arteries of the lower leg in about 15 percent. In the remaining ten percent or so of pAVD patients, the narrowing is located in the upper arms, forearms or hands.
About three to ten percent of the total population has pAVD. The incidence of the disease increases with age and is 15 to 20 percent at over 70 years of age. Regardless of age, however, the majority of those affected do not experience any symptoms. In addition, gender plays a role: men are more frequently affected by smoker’s leg than women in a ratio of 4:1. The cause of pAVD in men is primarily smoking.
How do you recognize a smoker’s leg and what are the stages?
There are several stages during the development of a smoker’s leg. In the initial stage, those affected usually do not even notice that they are suffering from smoker’s leg. In the course, the most important symptom of a pAVK is the load-dependent pain in the affected body region and later cool and pale feet as well as poorly healing wounds. Sensory disturbances such as numbness may also occur. Thus, the symptoms and related complications manifest themselves gradually depending on the severity of the smoker’s leg.
Physicians divide pAVK into four different pAVK stages according to Fontaine-Ratschow, depending on the occurrence and severity of symptoms:
- Stage 1: No symptoms, although a constriction is detectable.
- Stage 2a: Pain occurs at a walking distance of more than 200 meters, which disappears again when standing still or at rest.
- Stage 3: The leg already hurts at rest.
- Stage 4: Ulcers and inflammation develop on the smoker’s leg as a sign that the undersupplied tissue is slowly dying.
Whereas those affected in stage 1 sometimes do not notice any symptoms, from stage 2 onwards the typical pain on exertion occurs when walking. Physicians also refer to this pain on exertion as intermittent claudication or shop window disease. The term comes from the fact that sufferers with pAVK stop repeatedly due to the pain when walking, as if window shopping. As a result, the pain temporarily subsides and sufferers are able to walk a short distance again.
For example, ulcers develop. Finally, in the final stage of the disease, the tissue dies due to the lack of oxygen and begins to rot downright – at the same time, there is a possibility that it may also become infected. The dead tissue (necrosis and gangrene) takes on a blackish color.
Basically, smoker’s leg or pAVK is a chronic disease that develops over years. In some cases, however, an artery closes suddenly (acutely). If this is the case, it is a medical emergency that may become life-threatening. Immediate medical treatment is then imperative.
Smoker’s leg symptoms depend on location and degree of narrowing
In smoker’s leg, the pain occurs below the constriction, since the reduced supply of blood and oxygen exists only here. A vasoconstriction in the right thigh, for example, is manifested by pain in the right lower leg, while a constriction in the pelvic region triggers the typical smoker’s leg symptoms in the thigh.
Depending on the degree and location of the narrowing, numbness also develops in the buttocks or thighs. In almost all cases, smoker’s leg is manifested by cold limbs below the narrowing.
The extent of smoker’s leg symptoms also depends on exactly where the stenosis is located: The closer it is to the trunk of the body, the more pronounced the symptoms usually are, since the entire subsequent blood supply is compromised. Thus, a stenosis in the iliac arteries causes more severe symptoms than one in the lower leg.
Smoker’s leg often remains undetected for a long time. The reason for this is that vasoconstriction only triggers symptoms at a very advanced stage. This is because the narrowing develops slowly and the body has time to form bypass circuits (collateral circuits) to compensate for the bottleneck in the blood vessels. The supply of the tissue below the constriction then runs partially through other, not pathologically altered blood vessels.
However, such collateral circuits are only capable of taking over a certain proportion of the blood flow. The smoker’s leg causes symptoms at the latest when there is a constriction of more than 90 percent of the inner diameter of the vessel.
How is smoker’s leg treated?
The therapy of pAVK depends primarily on the personal conditions of the patient and the stage of the smoker’s leg. In addition, the treatment of other diseases such as diabetes or cardiovascular diseases is important.
pAVK therapy in stage 1
If the smoker’s leg is detected at the first stage, the most important thing is to fight the causes. The most important measures are to stop smoking, to exercise regularly and to pay attention to a healthy diet. It is also important to normalize cholesterol levels, blood lipids and blood pressure. If a change in lifestyle with more exercise and a healthier diet is not enough to achieve this, medication may be necessary.
As a general rule, good foot care should already be observed from stage one. Affected persons are advised to apply cream to their feet regularly and to avoid injuries during pedicures, as well as to wear comfortable shoes. If pressure sores or injuries occur on the affected feet, it is important to have the wound treated carefully and to monitor healing.
pAVK therapy in stage 2
In addition to the measures already mentioned and regular walking training for pAVK therapy, the doctor also prescribes medication from stage two. The so-called platelet aggregation inhibitors improve the flowability of the blood and prevent the accumulation of blood platelets (thrombocytes), thus preventing blood clots. The drug of first choice is acetylsalicylic acid (ASA). In case of intolerance, the physician may prescribe other platelet inhibitors, such as clopidogrel.
pAVK therapy in stages 3 and 4
Surgical interventions are usually used from the third pAVK stage. However, this decision depends on several factors, such as the location of the narrowing, the wishes of the affected person and the possibilities of the surgeon. It is therefore entirely possible that pAVK from stage two onwards will also be treated, for example, by a catheter-based intervention.
The type of surgery depends on the length and exact location of the narrowing. In the case of vascular constrictions in the thigh or pelvic region that are only a few millimeters long, the constriction can in many cases simply be widened by minimally invasive surgery.
If dilatation is not possible because the narrowing is too rigid or extends to a longer section of the vessel, a larger incision is usually necessary. During thromb endarterectomy, the physician peels the deposits from the artery.
If necessary, bypass surgery is also an option. In this procedure, the doctor inserts either a vein or a Teflon tube as a bypass for the narrowed vessel. If the circulatory disorder in a smoker’s leg is so severe that the limb dies, the only last resort is amputation of the affected limb.
As a general rule, physicians who specialize in vascular disease will re-evaluate the smoker’s leg prior to a possible amputation and weigh whether there are other options for treatment.
How does a smoker’s leg develop?
In some places, however, the constrictions are particularly pronounced. The blood flow is so severely impaired there that too little blood flows through the subsequent tissue, resulting in a lack of oxygen. This ultimately leads to the pain and other smoker’s leg symptoms.
Several causes and risk factors have been confirmed by studies for the development of arteriosclerosis. Smoking is considered a particular risk factor for arteriosclerosis. Thus, it is a main reason for the development of pAVK. Certain ingredients in cigarettes promote calcification of the arteries, especially in the legs. Overall, smokers are about three times more likely to develop arterial circulatory disorders than nonsmokers, and about 85 percent of people with smoker’s leg disease are or were smokers.
In addition, other risk factors promote peripheral arterial disease. These include:
- High blood pressure (hypertension)
- Diabetes (diabetes mellitus)
- Elevated blood lipids (hypertriglyceridemia)
- Cardiovascular disease in blood relatives
- Overweight (obesity)
Very rare causes are particular forms of vasculitis, such as the diseases thrombangiitis obliterans or Takayasu syndrome.
How is smoker’s leg diagnosed?
The first point of contact when a smoker’s leg is suspected is usually the family doctor. He or she will first take your medical history. Here you have the opportunity to describe your symptoms and the changes you have noticed in detail. The presence of certain risk factors and typical smoker’s leg symptoms often gives the doctor decisive indications of peripheral arterial occlusive disease. During the anamnesis interview, the doctor asks the following questions, for example:
- Do you experience increasing pain in the leg muscles after walking for long periods of time, which improves immediately when you take a break?
- Are you known to have diabetes, elevated cholesterol and/or blood lipid levels?
- Have you been diagnosed with elevated blood pressure?
- Do you have or have you had a family history of cardiovascular disease, such as smoker’s leg or heart attack?
Examination
During the examination, the doctor will first look at the skin on your legs. Pale or bluish discolored skin is the first indication of a possible smoker’s leg. Signs that sometimes indicate pAVD include curved nails (watch glass nails), small, poorly healing skin defects, and dead (necrotic) tissue.
Using a stethoscope, the physician often hears a typical flow noise above the constriction (stenosis), which is caused by turbulence at the constriction. In this way, the vessel or region where the narrowing is located can be roughly determined. A special ultrasound examination (duplex sonography) measures the blood flow in the vessels, giving doctors additional clues about any narrowing.
If the physician suspects a smoker’s leg, the calculation of the so-called ankle-brachial index (ABI) also provides important information. In this simple examination, the examiner applies a blood pressure cuff to the upper arm and lower leg and determines the pressure in the underlying arteries at which a pulse can no longer be felt.
Normally, the pressure in the lower leg is somewhat higher than in the upper arm, resulting in a quotient between 0.9 and 1.2. If the pressure in the lower leg is significantly lower than in the upper arm because the blood supply there is reduced, the quotient drops. The following evaluation standard applies to the ankle-arm index:
- 0.75-0.9: mild pAVK
- 0.5-0.75: moderate pAVD
- < 0.5: severe pAVD
In order to obtain even more precise information on the localization of the narrowing (stenosis), imaging procedures such as so-called contrast medium angiography are usually necessary. This examination is even absolutely necessary, especially before a planned operation of the constriction. Patients are injected with a contrast medium that makes the vessels visible on the image, and at the same time the examiner takes an X-ray image (digital subtraction angiography).
In order to determine the extent of the disease according to the pAVK stages (see above), the physician performs a stress test. For this purpose, the patient walks on a special treadmill for a certain time. The doctor measures from which walking distance covered which complaints occur.
What is the course of the smoker’s leg disease?
People suffering from smoker’s leg (peripheral arterial occlusive disease, pAVK) have a great deal of influence on the disease and its course. Affected people find support first of all from their family doctor, but also in self-help groups. First and foremost, the prognosis depends on whether the cause can be eliminated or significantly minimized.
Complete and permanent cessation of smoking is the most important measure in the treatment of PAOD. If those affected are unable to stop smoking on their own, it is advisable to seek professional support. The first point of contact for this is the family doctor.
An active lifestyle with a varied diet and regular physical activity also has a favorable prognostic effect. A daily walk of about half an hour is sufficient. Endurance sports such as swimming, jogging or cycling are also particularly recommended.
Make sure that your diet is as low in fat as possible and varied, with a high vegetable content. It is advisable to avoid saturated fats in particular, such as those found in chips, potato chips or even cookies. If overweight exists in a patient with smoker’s leg, weight reduction is also recommended.
People with stage two pAVD are often also affected by atherosclerosis in other areas of the body, such as the coronary arteries or the carotid arteries. They therefore usually also have a significantly increased risk of heart attack or stroke. Life expectancy is reduced by about 10 years as a result of PAOD.
Peripheral arterial occlusive disease is one of the diseases associated with chronic pain. For this reason, it is possible that the pension office determines a degree of disability and the affected person receives a corresponding severe disability certificate.
How high the degree of disability (GdB) or the degree of damage consequences (GdS) is and whether it is a severe disability depends on the present stage and the complaints that the disease causes. A severe disability exists from a GdS of 50.
Affected persons can find the table in the Versorgungsmedizin-Verordnung (Ordinance on Medical Care) of the Federal Ministry of Labor and Social Affairs.
