Raucherbein

Smoking leg: description

A smoker’s leg is the pathological narrowing of arteries in the leg. The medically correct term is “peripheral artery disease (PAD). Narrowing sites (stenoses) are formed in the arteries, obstructing the flow of blood into the tissue and, in the worst case, completely preventing it. The term smoking smoker has evolved because the effects are most common in the leg first and smoking is the main risk factor for the development of PAOD. Smokers are therefore particularly often affected.

The smoker’s leg accounts for about 90 percent of all PAD cases. The constriction is then in about one third of the patients in the pelvic arteries, 50 percent in the femoral arteries and about 15 percent in the lower leg arteries. In about ten percent of PAOD patients, the upper body (upper arm, forearm, hand) is affected.

Experts estimate that around 4.5 million people in Germany suffer from a PAD. Men are more likely to be smoker-affected than women. In addition, the incidence increases significantly with age. In many cases, patients with a smoker’s leg additionally suffer from other chronic conditions such as diabetes, hypertension, or elevated cholesterol and blood lipid levels.

Smoker’s leg: symptoms

The most important symptom of PAD is pain in the affected body region. Physicians classify PAD depending on the onset and severity of symptoms in four different PAD stages:

• Stage 1: There is a bottleneck detectable, but the patient has no complaints
• Stage 2a: With a walking distance of over 200 meters pain occurs
• Stage 2b: The stress pain in the leg begins with a walking distance of less than 200 meters
• Stage 3: The leg already hurts in peace
• Stage 4: It causes the smoker’s leg ulcers and inflammation as an indication that the underserved tissue dies

While in Stage 1, so sometimes no symptoms are perceived, occur from the stage 2, the typical stress pain while walking on. These stress pain are also referred to by doctors as intermittent claudication or intermittent claudication. The term comes from the fact that sufferers with a PAOD because of the pain while walking like a window shopping again and again. As a result, the pain lasts temporarily and the affected person can go on for a short while.

From Stage 3 onwards, sufferers will also experience pain during physical rest due to one or more narrowing of the arteries. Everyday stress such as short walking distances are then often no longer possible or only under severe pain. Stage 4 shows typical changes in the skin due to the chronic lack of oxygen in the tissue. For example, ulcers (ulcers) develop. Finally, the tissue dies from the lack of oxygen and literally starts to rot – it can also become infected (necrosis and gangrene). The dead tissue assumes a blackish color.

Smoker’s leg symptoms depend on the location and degree of bottleneck

The pain occurs in the smoker’s leg below the bottleneck, because only here is the low supply of blood and oxygen. A vasoconstriction in the right thigh is thus shown, for example, by pain in the right lower leg, while a narrowing in the pelvic area triggers the typical smoker’s leg symptoms already in the thigh. Depending on the degree and location of the constriction, numbness may also develop on the buttocks or thighs. In almost all cases, a smoker’s leg shows through cold limbs below the bottleneck.

The extent of smoker’s leg symptoms also depends on where the stenosis is: the closer it is to the trunk of the body, the more pronounced the symptoms are, as all subsequent blood supply is compromised. Thus, the complaints of a stenosis in the pelvic arteries are more serious than in a stenosis in the lower leg.

Often a smoker’s leg remains undetected for a long time. The reason for this is that vasoconstriction only causes discomfort at a very advanced stage. Because the constriction is slow and the body has time to form bypass circuits (Kollateralkreisläufe) to compensate for the bottleneck. The supply of tissue below the bottleneck then runs partly over other, not pathologically altered blood vessels. However, such collateral circuits are only able to take over a certain proportion of the blood flow. At least at a narrowing of more than 90 percent of the inner diameter of the vessel causes the smoker’s leg symptoms.

Other diseases can hide a smoker’s leg

When affected people notice the symptoms of peripheral arterial disease and consult a doctor, is different. For example, people with diabetes mellitus and nerve damage (diabetic polyneuropathy) have a disturbed perception of pain and therefore often do not feel any symptoms even in advanced smoker’s legs. Smoker’s leg or PAD are therefore often diagnosed at a particularly late stage.

A smoking leg becomes particularly dangerous in the case of an acute occlusion of an arterial vessel. This can occur when a blood clot (thrombus) or the torn-off fragment of an arteriosclerotic plaque gets stuck in the constriction. Noticeable is an acute occlusion caused by severe pain in the leg, which does not diminish even in peace. In addition, there is a weakness or complete paralysis of the affected limb, feeling cold, the skin is pale and even the doctor can no longer feel the pulse on the arteries in the popliteal fossa or on the inner ankle joint. An acute arterial occlusion is an emergency and must be treated promptly.

Smoker’s leg: causes and risk factors

About 85 percent of all cases of PAD (smoker’s leg) are due to calcification of the arteries. Doctors speak of atherosclerosis. This is a plaque of fat, lime and connective tissue in the inner layer of the blood vessels. Arterial calcification usually affects all arteries of the body, including the coronary arteries and cervical arteries (blood supply to the brain). In some places, however, the bottlenecks are particularly common. There, the blood flow is so severely impaired that too little blood flows through the following tissue and thus there is a lack of oxygen. This ultimately leads to the pain and other smoker’s leg symptoms.

For the development of arteriosclerosis, several causes and risk factors have been confirmed by studies. Smoking is considered a particular risk factor for arteriosclerosis. It is thus a major reason for the development of a PAD. Betsimmte ingredients of cigarettes promote the calcification of the arteries, especially in the legs (smoker’s leg). Overall, smokers get about three times more often arterial circulatory disorders than non-smokers.

Peripheral arterial disease is favored by other risk factors. This includes:

• High blood pressure (hypertension)
• Diabetes (diabetes mellitus)
• elevated blood cholesterol level (hyperlipoproteinemia: elevated LDL cholesterol, decreased HDL cholesterol)
• increased blood lipids (hypertriglyceridemia)
• Cardiovascular diseases in blood relatives
• Overweight (obesity)

Smoker’s leg: examinations and diagnosis

The first point of contact when suspecting a smoker’s leg is usually the family doctor. This first records the medical history (anamnesis). This will give you the opportunity to accurately describe your symptoms and changes that you have noticed. However, the presence of certain risk factors and typical smoker’s leg symptoms often already provide the doctor with decisive indications of a peripheral arterial occlusive disease. In an anamnesis interview, for example, the doctor will ask the following questions:

• Do you experience increasing leg muscle pain after prolonged walking, which improves immediately when you take a break?
• Do you smoke or have you smoked in the past? If so, how long and how much?
• Are you diagnosed with diabetes, high cholesterol and / or blood lipid levels?
• Have you been diagnosed with high blood pressure?
• Does your family have cardiovascular diseases such as a smoker’s leg or a heart attack?

examination

During the examination, the doctor first looks at the skin on the legs. Pale or bluish discolored skin is a first indication of a possible smoker’s leg. Signs that may also indicate PAD are curved nails (watch glass nails), small, poorly healing skin defects, and dead (necrotic) tissue.

Now the doctor feels the pulse in the groin or on the thigh, in the popliteal fossa, the inner ankle area and on the back of the foot. With a pronounced PAD, the pulse in the affected limb is barely or not palpable. A temperature comparison of both legs also provides an indication of PAOD: the affected leg is noticeably cooler than the healthy one. In the case of a one-sided smoker’s leg, the crawling lack of oxygen often makes the muscles visibly slimmer than the healthy leg.

With a stethoscope, the doctor over the constriction (stenosis) often hear a typical flow noise that is caused by turbulence at the bottleneck. In this way, the vessel or region in which the constriction is located can be roughly determined. With a special ultrasound examination (duplex ultrasonography), the blood flow in the vessels can be measured and thus additional information on possible bottlenecks can be obtained.

If the doctor suspects a smoker’s leg, the calculation of the so-called ankle brachial index (ABI) can also provide important information. In this simple examination, a blood pressure cuff is placed on each of the upper arm and lower leg to determine from which pressure in the underlying arteries just no pulse is noticeable (corresponds to the systolic blood pressure). The index is now calculated from the quotient of the two systolic blood pressure values ​​(blood pressure systolic lower leg: blood pressure systolic upper arm = ABI). Normally the pressure in the lower leg is slightly higher than in the upper arm, so that normally a quotient of between 0.9 and 1.2 results. If the pressure in the lower leg is significantly lower than in the upper arm, the quotient drops. For the ankle-arm index, the following rating scale applies:

• 0.75-0.9: slight PAOD
• 0.5-0.75: moderate PAD
• <0.5: severe PAD

To get even more detailed information on the localization of the bottleneck (stenosis), usually imaging techniques such as the so-called contrast angiography are needed. This investigation is even necessary, especially before a planned operation of the bottleneck. The patient is injected with a contrast agent and an X-ray image is taken at the same time (digital subtraction angiography).. The computer-assisted image shows the X-ray contrast agent and any bottlenecks in the vessels. The vascular presentation can also be performed as computed tomography (CT) or as magnetic resonance imaging (MRI).

To determine the extent of disease according to the PAD stages (see above), a stress test is performed. To do this, the patient has to walk a certain amount of time on a special treadmill. The doctor measures, from which distance walked which discomfort occur.

Smoking leg: treatment

The therapy of PAD is primarily based on the personal requirements of the patient and the stage at which the smoker’s leg was detected.

PAD therapy in stage 1

If the smoker’s leg is recognized in the first stage, it is especially important to fight the causes. The most important measures are to quit smoking, to exercise regularly and to respect a healthy diet. It is also important to normalize cholesterol, blood lipid levels and blood pressure. If a lifestyle with more exercise and a healthier diet is not enough, medications may be necessary.

PAD therapy in stage 2

As of stage 3, in addition to the measures already mentioned, a regular walking training for PAD therapy is also required. The doctor determines the distance, which the patient can master painlessly despite smoker’s leg. In daily walking training at least half of this walking distance should be completed. This stimulates the body to form bypasses (collaterals). In addition, the doctor prescribes for the treatment of peripheral arterial disease medications that improve the fluidity of the blood. So-called platelet aggregation inhibitors prevent the attachment of platelets and prevent blood clots. The drug of first choice is acetylsalicylic acid (ASA). If incompatible, other platelet inhibitors (such as prasugrel or clopidogrel) may be prescribed. In addition, certain drugs (prostanoids) can be administered, which influence the flow properties of the blood. Put simply, the prostanoids make the blood thinner so it can better pass through bottlenecks in a smoker’s leg.

PAD therapy in stages 3 and 4

From the third of the PAD stages, surgical interventions are used. The type of operation depends on the length and exact localization of the bottleneck. With only a few millimeters of vessel narrowing in the thigh or pelvic area, the bottleneck can in many cases simply expand. This is done using a catheter (percutaneous transluminal angioplasty, PTA). A balloon catheter is inserted from the groin into the constriction and inflated with pressure. To avoid re-constriction, implantation of a stent may be required.

If an expansion is not possible because the narrowing is too rigid or extends to a longer vessel section, the doctor can shed the deposits (thrombendarteriectomy). If necessary, a bypass operation is also possible. The doctor uses either a vein or a Teflon tube as a diversion for the constricted vessel. If the circulatory disorder in a smoker’s leg is so severe that the extremity dies, the only option left is amputation of the affected limb.

Smoker’s leg: Disease course and prognosis

The prognosis of peripheral arterial occlusive disease (PAD, smoker’s leg) depends primarily on whether it is possible to eliminate the triggering factors. This is the only way to prevent the disease from progressing further. Even a surgical intervention is no guarantee for a permanent complaint-free, since an operated bottleneck can close again.

People who have had peripheral artery disease (smoker’s leg) are also often affected by atherosclerosis in other areas of the body, such as the coronary arteries or carotid arteries. Therefore, they usually have a significantly higher risk of heart attack or stroke. More than 75 percent of those with smoker’s death die from a stroke or heart attack.

Those affected have a major impact on the prognosis

The complete and permanent abstention from smoking is the most important measure in the treatment of PAOD (smoker’s leg). If you can not stop smoking alone, you should seek professional support. An active lifestyle with a varied diet and regular physical activity also have a prognostically favorable effect. Even a daily walk of about half an hour is enough. Especially recommended are endurance sports such as swimming, jogging or cycling. Make sure to eat as low as possible and varied with high vegetable content. Especially saturated fats, such as chips, chips or biscuits, should be avoided. If overweight at one Raucherbein weight loss should also be sought.