Peripheral Artery Disease (PAD)

Overview

What is peripheral arterial disease (PAD)?

Peripheral arterial disease (PAD), also known as peripheral vascular disease or peripheral artery disease, is plaque buildup in your leg arteries that carry oxygen and nutrient-rich blood from your heart to your arms and legs.

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) that forms gradually inside your artery walls slowly narrows your arteries. This plaque 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 your arteries become narrowed or blocked with plaque or a blood clot, 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 most often occurs in your toes and feet.

The rate at which PAD progresses varies with each person and depends on many factors, including where in your body the plaque forms and your overall health.

What are the risk factors for peripheral arterial disease?

Smoking is the most important risk factor for PAD. In fact, 80% of people with PAD are people who currently or were former smokers.

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. The U.S. National Institutes of Health estimates that a person with PAD has a six to seven times higher risk of coronary artery disease, heart attack, stroke or a transient ischemic attack (mini-stroke) than the general population. A person with heart disease has a 1 in 3 chance of having peripheral artery disease in the 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 coronary arteries.

As in coronary artery disease, many of these risk factors are out of your control. But, according to researchers, tobacco use is the single most important modifiable (changeable) risk factor for PAD and its complications. Tobacco use increases the risk for PAD by 400% and brings on PAD symptoms almost 10 years earlier. Compared with non-smokers of the same age, smokers with PAD are more likely to die of heart attack or stroke, have poorer results with heart bypass surgery procedures on their legs and are twice as likely to have a limb amputation.

How common is this condition?

PAD is common, affecting between 8 and 12 million Americans. Despite the prevalence of PAD, it’s surprisingly underdiagnosed and undertreated.

How does this condition affect my body?

The typical symptom of PAD is called “claudication,” a medical term that refers to pain in your leg that comes on 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, and the consequences can be far worse than missing a shopping trip or golf game. Peripheral artery disease increases the risk of developing a non-healing sore of the legs or feet. In cases of severe PAD, these sores can develop into areas of dead tissue (gangrene) that ultimately make it necessary to amputate your foot or leg.

Because your body’s circulatory system is interconnected, the effects of PAD can extend beyond the affected limb. People with atherosclerosis of their legs commonly have it in other parts of their bodies. People who have peripheral artery disease are at increased risk for having a heart attack, stroke, transient ischemic attack (mini-stroke) or problems with their kidney (renal) arteries.

If left untreated, people with PAD can develop serious health problems, including:

  • Heart attack: Permanent damage to your heart muscle caused by a lack of blood supply to your heart for an extended time.
  • Stroke: Interruption of the blood flow to your brain.
  • Transient ischemic attack (TIA): A temporary interruption in the blood supply to your brain.
  • Renal artery disease or stenosis: A narrowing or blockage of the artery that supplies blood to your kidney.
  • Amputation: The removal of part or all of your foot or leg (rarely your arm), especially in people who also have diabetes.

Symptoms and Causes

What are the symptoms of PAD?

Half of the people who have peripheral vascular disease don’t have any symptoms, but pain or discomfort in their legs is a common symptom. You may also feel weak or tired while walking. Affected parts of your leg may include your calves, thighs or buttocks.

PAD can build up over a lifetime, and the symptoms may not become obvious until later in life. For many people, the outward symptoms won’t appear until their artery has narrowed by 60% or more.

Early symptoms

The first noticeable symptom of PAD may be intermittent claudication ― leg discomfort, pain or cramping that:

  • Develops with activity.
  • Goes away with rest.
  • Comes back when you resume activity.

You may notice the pain in your calf, but you may also feel it in your buttocks or thighs. With intermittent claudication, your leg muscles may feel:

  • Numb.
  • Weak.
  • Heavy.
  • Tired.

The pain can be severe enough to limit your ability to participate in activities you enjoy, such as golfing or chasing after grandchildren.

Reduced blood flow to your leg muscles causes this type of cyclical pain, which goes away at rest because your muscles need less blood flow at rest.

Advanced symptoms

Symptoms of advanced PAD may 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 infections.
  • Toe and foot sores that don’t heal.

What causes PAD?

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, an accumulation 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 become blocked.

Diagnosis and Tests

How is PAD detected?

Talk to your doctor if you’re having symptoms of PAD so the cause of your symptoms can be identified and treatment can be initiated as soon as possible. Early detection of PAD is important so the right treatments can be provided before the disease becomes severe enough to lead to complications, such as heart attack or stroke.

A physical exam will be performed and your medical history and risk factors will be reviewed. Your doctor may order certain tests to help diagnose PAD and determine the severity of the disease.

  • The ankle/brachial index (ABI) is a measurement of the blood pressure in your lower legs compared to the blood pressure in your arms. During this test, blood pressure cuffs are placed on your arms and legs. The cuffs are inflated, while a hand-held device (called a Doppler) is used to listen to your blood flow. The ABI screening helps evaluate the amount of blood flow to your legs and feet, which is decreased in a person who has PAD. ABI is a highly accurate method for detecting PAD.
  • A pulse volume recording (PVR) is a noninvasive test that measures the blood volume changes that occur in your legs. During this test, a blood pressure cuff is placed on your arm and multiple cuffs are placed on your legs. The cuffs are inflated slightly while you’re lying down. As blood pulses through your arteries, the blood vessels expand, causing an increase or decrease in the volume of air within the cuff. A recording device displays these pulse volume changes as a waveform on a monitor. Blood pressures are measured before and after exercise on a treadmill and help define if your pain is due to PAD or other causes. The PVR test also helps locate the area of blockages in your legs.
  • A vascular ultrasound is a noninvasive test used to examine blood circulation. During a vascular ultrasound, a transducer (small hand- held device) is placed on your skin over the artery to be examined. The transducer emits sound waves that bounce off your artery. These sound waves are recorded, and an image of the vessel is created and displayed on a monitor. This test may be used to detect a blockage in your artery.

Management and Treatment

How is PAD treated?

The two main goals in the treatment of PAD include:

  • Reducing the risk of heart attack and stroke.
  • Improving quality of life by easing the pain that occurs with walking.

With early diagnosis, lifestyle changes and treatment, you can stop PAD from getting worse. In fact, some studies have shown that you can reverse peripheral vascular disease symptoms with exercise combined with careful control of cholesterol and blood pressure. 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 as soon as possible.

Lifestyle changes, medications and interventional procedures can treat your PAD.

Lifestyle changes

Initial treatment of PAD includes 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 available in your community.
  • 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. If you’re overweight, losing weight will help you lower your total cholesterol and raise your HDL (good) cholesterol. A registered dietitian can help you make the right dietary changes.
  • Exercise. Begin a regular exercise program, such as walking. Walking is very important and can aid in the treatment of PAD. People who walk regularly can expect a definite improvement in the distance they’re able to walk before experiencing leg pain.
  • 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 drugs treat the risk factors of PAD and decrease your risk of stroke and heart attack.

An antiplatelet medication such as aspirin or clopidogrel may reduce the risk of heart attack and stroke.

Your healthcare provider may prescribe cilostazol to improve your walking distance. This medication helps people with intermittent claudication exercise longer before they develop leg pain. However, not everyone is eligible to take this medication. Your healthcare provider will tell you if you are.

Supervised exercise programs

A supervised exercise program will improve the symptoms of pain in your legs with walking (claudication), 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 “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.

For some people with more severe PAD, the claudication symptoms may still cause problems in daily life, even after a few months of exercise and medications. In more severe cases, restoration of blood flow is necessary to relieve pain at rest or to heal a wound. To restore blood flow, the first step is usually an angiogram. A healthcare provider who specializes in invasive vascular procedures can do this.

Minimally invasive or surgical treatments

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. Treatments include:

  • Balloon angioplasty: In this procedure, your healthcare provider passes a miniature balloon through a catheter into your arteries. As the balloon expands inside of your artery, it pushes against the plaque and opens up space inside of your artery.
  • Stents: These are tiny metal support coils that your healthcare provider inserts into your arteries through a small opening using catheters (long, thin tubes). Once they’re in place, stents expand against the inner blood vessel wall to support it and hold it open.
  • Peripheral artery bypass surgery: Similar to a heart bypass, a surgeon uses a section of your healthy vein or a synthetic replacement to create a bypass for blood flow around the blocked area in your leg artery. This is usually reserved for the most severe PAD.
  • Atherectomy: Your healthcare provider uses a catheter with a blade at the end to remove plaque buildup in your blood vessel.

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 this treatment?

You may have soreness for a few days where your healthcare provider had to cut into your skin. It can take six to eight weeks to recover completely from the surgery. You may only need a few days to recover from your atherectomy.

Prevention

How can I prevent PAD?

Being aware that you have risk factors for PAD may motivate you to take action to prevent PAD from developing. The same advice for maintaining a healthy heart applies to maintaining healthy circulation overall:

  • 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 and report any symptoms you’re having, such as pain, weakness or numbness in your legs.

Outlook / Prognosis

What can I expect if I have this condition?

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

Outlook for this condition

Peripheral artery disease is a condition you’ll have for the rest of your life. Although there’s no cure for PAD, it’s treatable. 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.

Living With

How do I take care of myself?

It’s very important that you take especially good care of your feet to prevent non-healing 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 bone. If your infection is severe, you may need to go to the hospital.
  • Can’t walk around enough to do day-to-day 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?

A note from Cleveland Clinic

You have the ability to prevent PAD or keep it from getting worse by making lifestyle changes. Keep all of your follow-up appointments with your healthcare provider and vascular specialist, and take the medicines they prescribe for all of your conditions. Knowing the warning signs of PAD complications helps you know when to ask for help, too.

Last reviewed by a Cleveland Clinic medical professional on 01/19/2022.

References

  • CDC. Peripheral Arterial Disease (PAD). (https://www.cdc.gov/heartdisease/PAD.htm) Accessed 1/19/2022.
  • MedlinePlus. Angioplasty and stent placement ― peripheral arteries ― discharge. (https://medlineplus.gov/ency/patientinstructions/000234.htm) Accessed 1/19/2022.
  • MedlinePlus. Peripheral artery bypass ― leg ― discharge. (https://medlineplus.gov/ency/patientinstructions/000239.htm) Accessed 1/19/2022.
  • National Heart, Lung, and Blood Institute. Peripheral Artery Disease. (https://www.nhlbi.nih.gov/health-topics/peripheral-artery-disease) Accessed 1/19/2022.

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