Peripheral Artery Disease

What is peripheral artery disease?

Peripheral artery disease (PAD) is plaque buildup in your leg arteries. Your leg arteries carry oxygen and nutrient-rich blood from your heart to your arms and legs. Other names for this are peripheral vascular disease or peripheral arterial disease.

Shaped like hollow tubes, arteries have a smooth lining that prevents blood from clotting and promotes steady blood flow. When you have peripheral artery disease, plaque (made of fat, cholesterol and other substances) forms gradually inside your artery walls. Slowly, this narrows your arteries. This is also known as atherosclerosis.

Many plaque deposits are hard on the outside and soft on the inside. The hard surface can crack or tear, allowing platelets (disc-shaped particles in your blood that help it clot) to come to the area. Blood clots can form around the plaque, making your artery even narrower.

If plaque or a blood clot narrows or blocks your arteries, blood can’t get through to nourish organs and other tissues. This causes damage ― and eventually death (gangrene) ― to the tissues below the blockage. This happens most often in your toes and feet.

PAD can get worse faster in some people more than others. Many other factors matter, including where in your body the plaque forms and your overall health.

How common is peripheral artery disease?

PAD is common, affecting between 8 and 12 million Americans. However, healthcare providers sometimes don’t diagnose or treat PAD enough. Actual numbers are probably higher.

How does peripheral artery disease affect my body?

The typical symptom of PAD is called claudication, a medical term for pain in your leg that starts with walking or exercise and goes away with rest. The pain occurs because your leg muscles aren’t getting enough oxygen.

The dangers of PAD extend well beyond difficulties in walking. Peripheral artery disease increases the risk of getting a nonhealing sore of your legs or feet. In cases of severe PAD, these sores can turn into areas of dead tissue (gangrene) that make it necessary to remove your foot or leg.

What are the stages of peripheral artery disease?

Healthcare providers can use two different systems — Fontaine and Rutherford — to assign a stage to your PAD. The Fontaine stages, which are simpler, are:

• I: Asymptomatic (without symptoms).
• IIa: Mild claudication (leg pain during exercise).
• IIb: Moderate to severe claudication.
• III: Ischemic rest pain (pain in your legs when you’re at rest).
• IV: Ulcers or gangrene.

What is considered the first symptom of peripheral artery disease?

The first symptom of PAD is usually pain, cramping or discomfort in your legs or buttocks (intermittent claudication). This happens when you’re active and goes away when you’re resting.

What are the typical symptoms of peripheral artery disease?

Symptoms of peripheral artery disease include:

• A burning or aching pain in your feet and toes while resting, especially at night while lying flat.
• Cool skin on your feet.
• Redness or other color changes of your skin.
• More frequent skin and soft tissue infections (usually in your feet or legs).
• Toe and foot sores that don’t heal.

Half of the people who have peripheral vascular disease don’t have any symptoms. PAD can build up over a lifetime. Symptoms may not become obvious until later in life. For many people, symptoms won’t appear until their artery narrows by 60% or more.

Talk to a healthcare provider if you’re having symptoms of PAD so they can start treatment as soon as possible. Early detection of PAD is important so you can begin the right treatments before the disease becomes severe enough to lead to complications like a heart attack or stroke.

What are the complications of peripheral artery disease?

Without treatment, people with PAD may need an amputation — the removal of part or all of your foot or leg (rarely your arm), especially in people who also have diabetes.

Because your body’s circulatory system is interconnected, the effects of PAD can extend beyond the affected limb. People with atherosclerosis of their legs often have it in other parts of their bodies.

What is the most common cause of peripheral artery disease?

Atherosclerosis that develops in the arteries of your legs — or, less commonly, your arms — causes peripheral arterial disease. Like atherosclerosis in your heart (coronary) arteries, a collection of fatty plaque in your blood vessel walls causes peripheral vascular disease. As plaque builds up, your blood vessels get narrower and narrower, until they’re blocked.

What are the risk factors for peripheral artery disease?

Tobacco use is the most important risk factor for PAD and its complications. In fact, 80% of people with PAD are people who currently smoke or used to smoke. Tobacco use increases the risk for PAD by 400%. It also brings on PAD symptoms almost 10 years earlier.

Compared with nonsmokers of the same age, people who smoke and have PAD are more likely to:

• Die of heart attack or stroke.
• Have poorer results with bypass surgery procedures on their legs.
• Have a limb amputation.

Regardless of your sex, you’re at risk of developing peripheral arterial disease when you have one or more of these risk factors:

• Using tobacco products (the most potent risk factor).
• Having diabetes.
• Being age 50 and older.
• Being African American.
• Having a personal or family history of heart or blood vessel disease.
• Having high blood pressure (hypertension).
• Having high cholesterol (hyperlipidemia).
• Having abdominal obesity.
• Having a blood clotting disorder.
• Having kidney disease (both a risk factor and a consequence of PAD).

Although PAD is a different condition from coronary artery disease, the two are related. People who have one are likely to have the other. A person with PAD has a higher risk of coronary artery disease, heart attack, stroke or a transient ischemic attack (mini-stroke) than someone without peripheral artery disease. A person with heart disease has a 1 in 3 chance of having peripheral artery disease in their legs.

Not surprisingly, the two diseases also share some common risk factors. This is because these risk factors cause the same changes in arteries in your arms and legs as they do in your heart’s arteries.

How is peripheral artery disease diagnosed?

A provider will perform a physical exam and review your medical history and risk factors. They may order noninvasive tests to help diagnose PAD and determine its severity. If you have a blockage in a blood vessel, these tests can help find it:

• Ankle-brachial index (ABI).
• Pulse volume recording (PVR).
• Vascular ultrasound.

You may also need an invasive test called an angiogram to find artery blockages.

Can peripheral artery disease be reversed?

Yes. Some studies have shown that you can reverse peripheral vascular disease symptoms with exercise and control of cholesterol and blood pressure.

With early diagnosis, lifestyle changes and treatment, you can stop PAD from getting worse. If you think you’re at risk for PAD or may already have the disease, talk to your primary care doctor, vascular medicine specialist or cardiologist so you can get started on a prevention or treatment program right away.

How is peripheral artery disease treated?

Lifestyle changes, medications and procedures can treat PAD.

The two main goals of peripheral artery disease treatments are:

• Reducing your risk of cardiovascular events.
• Improving your quality of life by easing the pain that occurs with walking.

Lifestyle changes

Treatment of PAD starts with making lifestyle changes to reduce your risk factors. Changes you can make to manage your condition include:

• Quit using tobacco products. Ask your healthcare provider about smoking cessation programs.
• Eat a balanced diet that’s high in fiber and low in cholesterol, fat and sodium. Limit fat to 30% of your total daily calories. Saturated fat should account for no more than 7% of your total calories. Avoid trans fats, including products made with partially hydrogenated and hydrogenated vegetable oils.
• Exercise. Start a regular exercise program, such as walking. Walking can help treat PAD. People who walk regularly can increase the distance they’re able to walk before their legs hurt.
• Manage other health conditions, such as high blood pressure, diabetes or high cholesterol.
• Keep your stress level low. Exercise, yoga and meditation may help with this.
• Practice good foot and skin care to prevent infection and reduce the risk of complications.

Medications

Medicines can help you with conditions such as high blood pressure (antihypertensive medications), high cholesterol (statin medications) and diabetes. These medicines treat the risk factors of PAD and decrease your risk of stroke and heart attack.

Your healthcare provider may prescribe an antiplatelet medication such as aspirin or clopidogrel. They also may prescribe cilostazol to improve your walking distance. This medication helps people with intermittent claudication exercise longer before they get leg pain.

Supervised exercise programs

A supervised exercise program will improve the symptoms of pain in your legs with walking, allowing you to walk farther. A structured program typically includes walking on a treadmill in a supervised setting at least three times per week.

People with PAD should also walk at home for a total of at least 30 to 60 minutes every day. The usual prescription is called the “Start/Stop” exercise:

1. Walk until the discomfort reaches a moderate level and then stop.
2. Wait until the discomfort goes away completely.
3. Start walking again.

Minimally invasive or surgical treatments

For some people with more severe PAD, leg pain may still cause problems in daily life, even after a few months of exercise and medications. In more severe cases, people need to improve their blood flow to relieve pain at rest or to heal a wound.

More advanced PAD that’s causing severe pain and limited mobility may require endovascular (minimally invasive) or surgical treatment. Some heart disease treatments also treat peripheral artery disease, including:

• Angioplasty.
• Stents.
• Peripheral artery bypass surgery.
• Atherectomy.

Complications of PAD treatment

You should contact your healthcare provider if you have these issues after your procedure. They could be signs of an infection or other complications:

• Swelling, bleeding or pain where the catheter went into your skin.
• Chest pain.
• Shortness of breath.
• Fever or chills.
• Dizziness.
• Swelling in your legs.
• Belly pain.
• An incision that’s coming open.

How long does it take to recover from treatment for peripheral artery disease?

Depending on the treatment you received, you may spend one night or several in the hospital. You may only need a few days to recover from an atherectomy. But you’ll need a week after an angioplasty. It can take six to eight weeks to recover completely from peripheral artery bypass surgery.

What can I expect if I have peripheral artery disease?

Like most health conditions, PAD is more treatable when a healthcare provider finds it early. Peripheral vascular disease progresses at different rates. This depends on many factors, including where the plaque formed in your body and your overall health.

Outlook for peripheral artery disease

Peripheral artery disease is a condition you’ll have for the rest of your life. Although there’s no cure for PAD, you can manage it. You can help keep peripheral vascular disease from progressing in several ways:

• Not using tobacco products.
• Exercising regularly.
• Limiting fat and following a healthy diet.
• Managing your risk factors, such as diabetes, high cholesterol and high blood pressure.

How can I reduce my risk of peripheral artery disease?

Knowing that you have risk factors for PAD may motivate you to prevent it. The same advice for keeping your heart healthy applies to caring for your circulation, too:

• Manage your weight.
• Eat a low-fat, low-sugar diet that includes at least five servings of fresh fruits and vegetables every day.
• Don’t use tobacco products.
• With your doctor’s approval, exercise for at least 30 minutes a day on most days of the week.

If you have heart disease, you should discuss your risk factors for PAD with your healthcare provider. Report any symptoms you’re having, such as pain, weakness or numbness in your legs.

How do I take care of myself?

It’s important to take good care of your feet to prevent nonhealing sores. Foot care for people who have PAD includes:

• Wearing comfortable, appropriately fitting shoes.
• Inspecting your legs and feet daily for blisters, cuts, cracks, scratches or sores. Also check for redness, increased warmth, ingrown toenails, corns and calluses.
• Not waiting to treat a minor foot or skin problem.
• Keeping your feet clean and well moisturized. (Don’t moisturize an area with an open sore.)
• Cutting your toenails after bathing, when they’re soft. Cut them straight across and smooth them with a nail file.

In some cases, your healthcare provider may refer you to a podiatrist (foot expert) for specialized foot care ― especially if you have diabetes. A podiatrist can help you with corns, calluses or other foot problems.

When should I see my healthcare provider?

Contact your healthcare provider if you:

• Get a bad infection in a sore on your foot. The infection can expand into your muscles, tissues, blood and bones. If your infection is severe, you may need to go to the hospital.
• Can’t walk around enough to do normal activities.
• Have pain in your legs when you’re resting. This is a sign of poor blood flow.

When should I go to the ER?

Get immediate help if you can’t feel or move your foot or if it looks different from your other foot’s skin color. This means you’ve lost blood flow to your leg without warning.

What questions should I ask my doctor?

• Do I need medications to reduce my risk of PAD?
• How far should I walk when I start a walking program?
• Do I need surgical procedures for peripheral vascular disease?