Peripheral artery disease (PAD) occurs when arteries supplying the legs become narrowed or blocked, reducing blood flow to the muscles and tissues.

The most common cause is atherosclerosis, the buildup of cholesterol-containing plaque within the arteries. PAD is important not only because it can affect circulation to the legs, but because it is also a sign of atherosclerosis elsewhere in the body and is associated with an increased risk of heart attack and stroke.

Risk Factors
 

Risk factors for PAD include:
 

• Cigarette smoking

• Diabetes

• High cholesterol

• High blood pressure

• Increasing age

• Chronic kidney disease

• Family history of cardiovascular disease

• Obesity and physical inactivity

Smoking and diabetes are particularly important risk factors for developing PAD and its complications.
 

Symptoms
 

Many people with PAD have mild symptoms or no symptoms at all.

The classic symptom is intermittent claudication — aching, cramping, heaviness, fatigue, or discomfort in a leg muscle that:
 

• Develops during walking or exercise

• Occurs fairly predictably with a certain amount of activity

• Improves after several minutes of rest

• Returns when activity resumes

The location of discomfort depends on which arteries are affected. The calf is a common location, although symptoms may also occur in the thighs or buttocks.

Other possible findings include:
 

• Coldness of one foot or leg compared with the other

• Weak or absent pulses in the feet

• Shiny or thin-appearing skin

• Decreased hair growth on the legs or feet

• Slow-growing toenails

• Numbness or weakness

• Wounds on the toes, feet, or legs that heal slowly

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As PAD progresses, blood flow may become inadequate even when a person is not exercising. Severe PAD can cause burning or aching pain in the foot or toes while resting, often becoming worse when the legs are elevated or while lying in bed.

Some people notice improvement when they hang the affected leg over the side of the bed or stand up, because gravity temporarily increases blood flow toward the foot.

Severely reduced circulation can eventually cause:

• Persistent ischemic rest pain

• Nonhealing wounds or ulcers

• Tissue death (gangrene)

This is called chronic limb-threatening ischemia (CLTI) and requires prompt vascular evaluation.

How Is PAD Diagnosed?
 

Diagnosis begins with your medical history and examination.

Your healthcare provider may evaluate:
 

• Pulses in the legs and feet

• Skin temperature and appearance

• Wounds or ulcers

• Differences between the legs

• Symptoms occurring during walking

Ankle-Brachial Index (ABI)

The ankle-brachial index (ABI) is a common initial test for PAD.

Blood pressure is measured at the ankle and arm, and the pressures are compared.

In general:
 

• 1.00–1.40: Normal

• 0.91–0.99: Borderline

• ≤0.90: Abnormal and consistent with PAD

• >1.40: Arteries may be poorly compressible, which can make the ABI unreliable

People with diabetes or chronic kidney disease are more likely to have stiff, poorly compressible arteries. If PAD is still suspected despite a normal or borderline resting ABI, an exercise ABI may help identify disease that becomes apparent during activity.

A toe-brachial index may be useful when the ABI is unreliable because the arteries cannot be adequately compressed.

Vascular Ultrasound and Imaging

Additional testing may include:

• Duplex arterial ultrasound

• CT angiography

• MR angiography

• Catheter angiography

Advanced imaging is generally used when more detailed information about the arteries is needed, particularly when a procedure is being considered.

Treatment
 

PAD treatment has two major goals:

1. Improve blood flow and leg symptoms

2. Reduce the risk of heart attack, stroke, and cardiovascular death

-Stop Smoking

For patients who smoke, smoking cessation is one of the most important treatments for PAD. Continuing to smoke accelerates atherosclerosis and substantially increases the risk of cardiovascular events, worsening limb ischemia, and amputation.

-Exercise

A structured walking program is one of the most effective treatments for intermittent claudication. Walking is typically continued until moderate leg discomfort develops, followed by a period of rest. Walking is then resumed. Repeating this cycle over time can substantially improve walking ability. Supervised exercise therapy may be recommended for some patients.

-Cholesterol Treatment

Patients with PAD generally require aggressive cholesterol management, most commonly with a high-intensity statin when appropriate. Lowering LDL cholesterol helps reduce the risk of heart attack, stroke, and other cardiovascular complications.

Antiplatelet Medication- Medications such as aspirin or clopidogrel may be recommended for patients with symptomatic PAD to reduce cardiovascular and vascular events. The appropriate medication depends on the patient's individual cardiovascular and bleeding risks.

-Blood Pressure and Diabetes Management is important for reducing cardiovascular risk and slowing progression of vascular disease.

Good control of:

• High blood pressure

• Diabetes

• Cholesterol

-Medications for Walking Symptoms

Cilostazol may improve walking distance and symptoms in some patients with intermittent claudication.

Cilostazol should not be used in patients with heart failure.

-Procedures to Restore Blood Flow

Some patients require revascularization, meaning a procedure to improve blood flow through a narrowed or blocked artery.

This may be considered when:

• Claudication remains significantly lifestyle-limiting despite appropriate medical therapy and structured exercise

• Chronic limb-threatening ischemia is present

• A nonhealing ischemic wound is present

Treatment may include:

• Angioplasty — a balloon is used to open the narrowed artery

• Stent placement — a small expandable device helps keep the artery open

• Atherectomy in selected circumstances

• Surgical bypass — blood is redirected around the blocked portion of the artery

The appropriate procedure depends on the location and severity of the arterial disease and the patient's overall health.

-Foot Care

Foot care is particularly important for people with PAD, especially those who also have diabetes. Poor circulation can make even relatively small injuries difficult to heal.

Patients should:

• Inspect their feet regularly for cuts, blisters, sores, or discoloration

• Wear properly fitting shoes

• Avoid walking barefoot

• Protect the feet from extreme temperatures

• Seek medical attention for wounds that are not healing

When to Seek Emergency Medical Care
 

A sudden blockage of an artery can cause acute limb ischemia, which is a medical emergency.Seek immediate emergency medical attention for the sudden development of:
 

• Pain — severe, sudden limb pain

• Pallor — pale appearance

• Pulselessness — absent pulse

• Paresthesia — new numbness or tingling

• Paralysis — new weakness or inability to move the limb

• Poikilothermia — the limb becomes unusually cold

These findings are sometimes remembered as the "6 Ps" of acute limb ischemia.

A suddenly painful, cold, pale, numb, or weak leg or foot requires immediate emergency evaluation.

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