Peripheral Artery Disease

Peripheral artery disease (PAD) is a vascular condition where arteries in your legs, pelvic area or arms become narrowed or blocked, usually due to plaque buildup. This limits how much blood can get through and may lead to symptoms like leg pain. This condition is treatable, especially when diagnosed early.

PAD is common. It affects more than 200 million people around the world and around 12 million adults age 40 or older in the U.S. Anyone can develop peripheral artery disease, but your risk goes up with age. Black people face a higher risk compared to non-Hispanic white people, especially after age 50 (in males) and age 60 (in females).

Peripheral arterial disease is another name for this condition. While it can rarely affect your arms, PAD usually affects your butt, legs or feet. This form, sometimes called lower-extremity PAD, is the focus of this article.

Symptoms of peripheral artery disease

Most often, the first symptom of PAD is leg discomfort when you’re active. This happens when your arteries can’t keep up with your muscles’ increased demand for blood. As PAD progresses, you may have leg or foot pain when you’re resting. But many people have no symptoms and are only diagnosed through screenings.

Possible symptoms include:

• Leg discomfort when active: You might feel pain, cramping, numbness or fatigue in your calves, thighs or butt. It starts during physical activity, like walking or climbing stairs. And it stops when you stop moving — typically within 10 minutes. 
• Leg discomfort when resting: This can occur as PAD gets more severe. You’ll feel a burning or aching pain in your legs, feet or toes. This often happens when you’re lying flat. Dangling your leg or feet over the edge of your bed may relieve the pain.
• Foot and toe ulcers: These are wounds on your skin that may get infected. They can take a long time to heal.
• Changes in skin color or temperature: A sudden blockage in your artery can make your skin turn purple, green, black or very pale. Your skin may also feel cool to the touch or like “pins and needles.” These are signs of severe PAD. Seek medical care immediately.

Exactly where you feel leg discomfort depends on which artery is too narrow. Symptoms occur below the affected artery:

• Discomfort in your butt, hip or thigh: There’s narrowing of your lower aorta or iliac arteries (in your pelvic area).
• Discomfort in your calf: There’s narrowing of your femoral or popliteal arteries (in your thigh and knee area).

Males might also experience erectile dysfunction related to peripheral artery disease when there’s narrowing of the lower aorta or iliac arteries.

PAD causes

The gradual buildup of plaque in your arteries (atherosclerosis) is the most common cause of peripheral artery disease. Your arteries are shaped like hollow tubes. They have a smooth lining that prevents blood from clotting and promotes steady blood flow. When you have PAD, plaque slowly forms inside your artery walls. This narrows the space where blood can flow.

Many plaque deposits are hard on the outside and soft on the inside. The hard surface can crack or tear. This allows 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 tissues beyond that point. Those tissues may even start to die. This happens most often in your toes and feet.

Most people use “PAD” to refer to arteries that are narrowed from plaque buildup. But other things, besides plaque, can limit blood flow in your peripheral arteries. Less common causes of PAD include swelling in an artery (vasculitis) and repeated squeezing of an artery behind your knee (PAES).

Risk factors

You have a higher risk of getting peripheral artery disease if you have:

• A history of smoking (in the past or now)
• Chronic kidney disease
• Diabetes
• High blood pressure
• High cholesterol or triglycerides

Research shows that smoking and diabetes are two of the strongest risk factors for PAD. People in these groups are two to four times more likely to develop PAD than people who don’t smoke or have diabetes.

If you have coronary artery disease or many risk factors for atherosclerosis, your provider may suspect you have PAD. This will lead them to order a screening test for PAD.

Complications of this condition

Without treatment, PAD can lead to limb loss. Most people with PAD don’t lose a limb. Providers do everything possible to avoid it. But if there’s enough tissue damage or your life is at risk, you may need surgery to remove your toe, foot or part of your leg.

Conditions like coronary artery disease and cerebrovascular disease often affect people with PAD. These aren’t direct complications. But they often occur together with PAD because plaque tends to build up in multiple spots, not just your leg arteries. That’s why treatment for PAD may also involve medicines to lower your risk of issues like a heart attack or stroke.

How doctors diagnose peripheral artery disease

Your provider will perform a physical exam and review your medical history. They’ll ask about your symptoms, including what makes them start or end. Your provider will closely examine your bare feet. They’ll also feel your pulse in different areas of your leg.

Tests help your provider diagnose PAD and determine its severity. These include:

• Ankle-brachial index (ABI): Providers use this test to screen for PAD in people with risk factors. It’s also usually the first test they do to check for PAD if you have symptoms. It compares blood pressure in your arm versus your ankle.
• Vascular ultrasound: This test measures the speed of blood flow through your arteries. Providers may use it if ABI results are normal, but they still think you might have PAD.
• Pulse volume recording (PVR): This test measures blood flow in your legs. It can show how much blood is reaching your tissues.
• CT angiogram: This test makes detailed pictures of your blood vessels. It lets your provider see narrow spots or blockages.
• Magnetic resonance angiogram (MRA): This imaging test can help show how narrow your arteries have become.

What are the stages of peripheral artery disease?

There are four main stages:

• Asymptomatic PAD: You don’t have symptoms in your daily life. But this might be because you limit your activity to avoid feeling any discomfort.
• Chronic symptomatic PAD: You have leg discomfort that starts when you’re active and stops when you rest.
• Chronic limb-threatening ischemia: Severe blockages in your artery lead to leg pain when resting, sores that won’t heal and possibly gangrene. About 12 to 20 out of every 100 people diagnosed with PAD reach this stage.
• Acute arterial occlusion: A blood clot suddenly blocks blood flow in your leg. This causes pain, pale skin, cool skin, “pins and needles” and/or numbness. You need a procedure or surgery right away. Fewer than 2 in 100 people with symptomatic PAD reach this stage.

You may move among these stages over time. For example, your symptoms may suddenly get worse. Or treatment may improve your symptoms.

How is peripheral artery disease treated?

PAD treatment depends on how far the condition has progressed. If you don’t yet have symptoms or your symptoms are mild, medicines and changes to your daily habits may be enough. But your provider will keep a close eye on your condition and recommend further treatment as needed. If you have severe symptoms or are at risk of losing a limb, you’ll need a procedure or surgery.

Medication

Medicines for peripheral artery disease include:

• Blood thinners: These lower your risk of blood clots. Your provider may prescribe an antiplatelet drug like clopidogrel or aspirin. They may prescribe a low dose of rivaroxaban, too.
• Vasodilators: These help your arteries open up better so blood can flow through. This can let you walk farther without leg pain. Cilostazol is an example of a medicine your provider might prescribe.
• Statins: These reduce your LDL cholesterol level. A lower LDL helps protect you from limb loss and death from cardiovascular disease.
• Blood pressure medicines: These lower your risk of heart attack, stroke, heart failure and death.
• Medications to quit smoking: If you currently smoke and have PAD, quitting is one of the best ways to reduce the risk of it progressing to limb loss. Your provider may prescribe medicines to help you do this.

Changes to your daily habits

Your healthcare provider may recommend you:

• Exercise: Structured exercise therapy (SET) is a key part of treating PAD. A healthcare provider plans and supervises routine sessions. You walk on a treadmill and take breaks when your legs hurt. This is usually the most helpful form of exercise for people with PAD.
• Eat heart-healthy foods: The Mediterranean Diet and DASH diet can help you manage PAD risk factors. Aim for plenty of veggies, fruits, nuts, whole grains and legumes.
• Stop smoking: Again, this is one of the most important things you can do to manage PAD. Your provider will help you make a plan for quitting. It might include things like nicotine replacement therapy, counseling and referral to a smoking cessation program.

Foot care

Taking good care of your feet is crucial with PAD. You should:

• Check your feet daily for signs of cracks or ulcers
• Wash and dry your feet every day to protect your skin
• Avoid walking barefoot
• Wear socks and shoes that fit well

Your provider can give you more advice, too. It’s important to know that wounds that develop have a more difficult time healing. And infections are difficult to clear when there’s reduced blood flow to your foot.

Procedures and surgeries

If other treatments don’t help enough or PAD grows severe, you may need a procedure or surgery. Examples include:

• Angioplasty: This procedure makes more space in your artery to help blood flow through. A provider inflates a tiny balloon to push plaque aside. They may also insert a stent to keep your artery open.
• Atherectomy: A provider uses a thin tube (catheter) to reach the affected artery and remove plaque. This is a minimally invasive procedure.
• Endarterectomy: This is the surgical removal of plaque.
• Peripheral artery bypass surgery: A provider makes a new route for blood to flow around the narrowed or blocked part of your artery.

When should I see my healthcare provider?

Contact your provider if you:

• Have new or worsening symptoms
• Can’t walk around enough to do normal activities
• Have pain in your legs when you’re resting
• Find an ulcer on your foot or toe

You should also talk to your provider if you have any risk factors for PAD, even if you don’t yet have symptoms. Your provider may run tests to look for signs of blood flow issues. Early diagnosis and treatment can save your limb and your life.

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 suddenly lost blood flow to your leg.

What can I expect if I have this condition?

When you’re living with PAD, you can expect to have frequent follow-up appointments with your provider. These are key to catching signs of problems that need prompt treatment.

Peripheral artery disease is a lifelong condition. Although there’s no cure, you can keep it from getting worse by:

• Taking your medicines
• Doing a supervised exercise program and other physical activity as your provider recommends
• Not smoking or being around secondhand smoke
• Eating nutritious foods
• Managing risk factors like diabetes, high cholesterol and high blood pressure

Quitting smoking is one of the best things you can do to improve your life expectancy. About 86 in 100 people who quit smoking after their PAD diagnosis live at least five more years. Of those who continue smoking, only 69 in 100 live at least five more years.