Peripheral artery disease (PAD)

Overview

Peripheral artery disease (also called peripheral arterial disease) is a common circulatory problem in which narrowed arteries reduce blood flow to your limbs.

When you develop peripheral artery disease (PAD), your legs or arms — usually your legs — don't receive enough blood flow to keep up with demand. This may cause symptoms, such as leg pain when walking (claudication).

Peripheral artery disease is also likely to be a sign of a buildup of fatty deposits in your arteries (atherosclerosis). This condition may narrow your arteries and reduce blood flow to your legs and, occasionally, your arms.

You often can successfully treat peripheral artery disease by exercising, eating a healthy diet and quitting tobacco in any form.

Claudication Claudication

Symptoms

While many people with peripheral artery disease have mild or no symptoms, some people have leg pain when walking (claudication).

Claudication symptoms include muscle pain or cramping in your legs or arms that's triggered by activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is the most common location.

The severity of claudication varies widely, from mild discomfort to debilitating pain. Severe claudication can make it hard for you to walk or do other types of physical activity.

Peripheral artery disease signs and symptoms include:

  • Painful cramping in one or both of your hips, thighs or calf muscles after certain activities, such as walking or climbing stairs
  • Leg numbness or weakness
  • Coldness in your lower leg or foot, especially when compared with the other side
  • Sores on your toes, feet or legs that won't heal
  • A change in the color of your legs
  • Hair loss or slower hair growth on your feet and legs
  • Slower growth of your toenails
  • Shiny skin on your legs
  • No pulse or a weak pulse in your legs or feet
  • Erectile dysfunction in men
  • Pain when using your arms, such as aching and cramping when knitting, writing or doing other manual tasks

If peripheral artery disease progresses, pain may even occur when you're at rest or when you're lying down. It may be intense enough to disrupt sleep. Hanging your legs over the edge of your bed or walking around your room may temporarily relieve the pain.

When to see a doctor

If you have leg pain, numbness or other symptoms, don't dismiss them as a normal part of aging. Call your doctor and make an appointment.

Even if you don't have symptoms of peripheral artery disease, you may need to be screened if you are:

  • Over age 65
  • Over age 50 and have a history of diabetes or smoking
  • Under age 50 and have diabetes and other peripheral artery disease risk factors, such as obesity or high blood pressure

Causes

Peripheral artery disease is often caused by atherosclerosis. In atherosclerosis, fatty deposits build up on your artery walls and reduce blood flow.

Although discussions of atherosclerosis usually focus on the heart, the disease can and usually does affect arteries throughout your body. When it occurs in the arteries supplying blood to your limbs, it causes peripheral artery disease.

Less commonly, the cause of peripheral artery disease may be blood vessel inflammation, injury to your limbs, unusual anatomy of your ligaments or muscles, or radiation exposure.

Development of atherosclerosis Development of atherosclerosis

Risk factors

Factors that increase your risk of developing peripheral artery disease include:

  • Smoking
  • Diabetes
  • Obesity (a body mass index over 30)
  • High blood pressure
  • High cholesterol
  • Increasing age, especially after age 65 or after 50 if you have risk factors for atherosclerosis
  • A family history of peripheral artery disease, heart disease or stroke
  • High levels of homocysteine, an amino acid that helps your body make protein and to build and maintain tissue

People who smoke or have diabetes have the greatest risk of developing peripheral artery disease due to reduced blood flow.

Complications

If your peripheral artery disease is caused by a buildup of plaque in your blood vessels, you're also at risk of developing:

  • Critical limb ischemia. This condition begins as open sores that don't heal, an injury, or an infection of your feet or legs. Critical limb ischemia occurs when the injuries or infections progress and cause tissue death, sometimes requiring amputation of the affected limb.
  • Stroke and heart attack. The atherosclerosis that causes the signs and symptoms of peripheral artery disease isn't limited to your legs. Fat deposits also build up in arteries supplying blood to your heart and brain.

Prevention

The best way to prevent claudication is to maintain a healthy lifestyle. That means:

  • Quit smoking if you're a smoker.
  • If you have diabetes, keep your blood sugar in good control.
  • Exercise regularly. Aim for 30 to 45 minutes of exercise several times a week after you've gotten your doctor's OK.
  • Lower your cholesterol and blood pressure levels, if needed.
  • Eat foods that are low in saturated fat.
  • Maintain a healthy weight.

Diagnosis

Some of the tests your doctor may rely on to diagnose peripheral artery disease are:

  • Physical exam. Your doctor may find signs of PAD during a physical exam, such as a weak or absent pulse below a narrowed area of your artery, whooshing sounds over your arteries that can be heard with a stethoscope, evidence of poor wound healing in the area where your blood flow is restricted, and decreased blood pressure in your affected limb.
  • Ankle-brachial index (ABI). This is a common test used to diagnose PAD. It compares the blood pressure in your ankle with the blood pressure in your arm.

    To get a blood pressure reading, your doctor uses a regular blood pressure cuff and a special ultrasound device to evaluate blood pressure and flow.

    You may walk on a treadmill and have readings taken before and immediately after exercising to capture the severity of the narrowed arteries during walking.

  • Ultrasound. Special ultrasound imaging techniques, such as Doppler ultrasound, can help your doctor evaluate blood flow through your blood vessels and identify blocked or narrowed arteries.
  • Angiography. Using a dye injected into your blood vessels, this test allows your doctor to view blood flow through your arteries as it happens. Your doctor can trace the flow of the dye using imaging techniques, such as X-rays, magnetic resonance angiography (MRA) or computerized tomography angiography.

    Catheter angiography is an invasive procedure that involves guiding a small hollow tube (catheter) through an artery in your groin to the affected area and injecting the dye. This type of angiography allows your doctor to treat a blocked blood vessel at the time of diagnosis. After finding the narrowed area of a blood vessel, your doctor can then widen it by inserting and expanding a tiny balloon or by administering medication that improves blood flow.

  • Blood tests. A sample of your blood can be used to measure your cholesterol and triglycerides and to check for diabetes.

Treatment

Treatment for peripheral artery disease has two major goals:

  • Manage symptoms, such as leg pain, so that you can resume physical activities
  • Stop the progression of atherosclerosis throughout your body to reduce your risk of heart attack and stroke

You may be able to accomplish these goals with lifestyle changes, especially early in the course of peripheral artery disease. If you smoke, quitting is the single most important thing you can do to reduce your risk of complications. Walking or doing other exercise on a regular basis following a schedule, referred to as supervised exercise training, can improve your symptoms dramatically.

If you have signs or symptoms of peripheral artery disease, you likely will need additional medical treatment. Your doctor may prescribe medicine to prevent blood clots, lower blood pressure and cholesterol, and control pain and other symptoms.

Medications

  • Cholesterol-lowering medications. You may take a cholesterol-lowering drug called a statin to reduce your risk of heart attack and stroke.

    The goal for people who have peripheral artery disease is to reduce low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, to less than 100 milligrams per deciliter (mg/dL), or 2.6 millimoles per liter (mmol/L). The goal is even lower if you have additional major risk factors for heart attack and stroke, especially diabetes or continued smoking.

  • High blood pressure medications. If you also have high blood pressure, your doctor may prescribe medications to lower it.

    Your blood pressure treatment goal should be less than 130/80 millimeters of mercury (mm Hg). This is the guideline for anyone with coronary artery disease, diabetes or chronic kidney disease. Achieving 130/80 mm Hg is also the goal for healthy adults age 65 and older and healthy adults younger than age 65 with a 10% or higher risk of developing cardiovascular disease in the next 10 years.

  • Medication to control blood sugar. If you have diabetes, controlling your blood sugar levels becomes even more important. Talk with your doctor about your blood sugar goals and the steps you need to take to achieve these goals.
  • Medications to prevent blood clots. Because peripheral artery disease is related to reduced blood flow to your limbs, it's important to improve that flow.

    Your doctor may prescribe daily aspirin therapy or another medication, such as clopidogrel (Plavix).

  • Symptom-relief medications. The drug cilostazol increases blood flow to the limbs both by keeping the blood thin and by widening the blood vessels. It specifically helps treat leg pain in people who have peripheral artery disease. Common side effects of this medication include headache and diarrhea.

    An alternative to cilostazol is pentoxifylline (Pentoxil). Side effects are rare with this medication, but it's generally doesn't work as well as cilostazol.

Angioplasty and surgery

In some cases, angioplasty or surgery may be necessary to treat peripheral artery disease that's causing claudication:

  • Angioplasty. In this procedure, a catheter is threaded through a blood vessel to the affected artery. There, a small balloon on the tip of the catheter is inflated to flatten the plaque into the artery wall and reopen the artery while stretching the artery open to increase blood flow.

    Your doctor may also insert a mesh tube (stent) in the artery to help keep it open. This is the same procedure doctors use to open heart arteries.

  • Bypass surgery. Your doctor may create a path around the blocked artery using either a blood vessel from another part of your body or a synthetic vessel. This technique allows blood to bypass the blocked or narrowed artery.
  • Thrombolytic therapy. If you have a blood clot blocking an artery, your doctor may inject a clot-dissolving drug into your artery at the point of the clot to break it up.

Supervised exercise program

Your doctor likely will prescribe a supervised exercise training program to increase the distance you can walk pain-free. Regular exercise improves symptoms of PAD in a number of ways, including helping your body use oxygen more efficiently.

Graft bypass for peripheral artery disease Graft bypass for peripheral artery disease

Lifestyle and home remedies

Many people can manage the symptoms of peripheral artery disease and stop the progression of the disease through lifestyle changes, especially quitting smoking. To stabilize or improve PAD:

  • Stop smoking. Smoking contributes to constriction and damage of your arteries and is a significant risk factor for the development and worsening of PAD. If you smoke, quitting is the most important thing you can do to reduce your risk of complications.

    If you're having trouble quitting on your own, ask your doctor about smoking cessation options, including medications to help you quit.

  • Exercise. This is a key component. Success in the treatment of PAD is often measured by how far you can walk without pain. Proper exercise helps condition your muscles to use oxygen more efficiently.

    Your doctor can help you develop an appropriate exercise plan. He or she may refer you to a claudication exercise rehabilitation program.

  • Eat a healthy diet. A heart-healthy diet low in saturated fat can help control your blood pressure and cholesterol levels, and that can lower your risk of atherosclerosis.
  • Avoid certain cold medications. Over-the-counter cold remedies that contain pseudoephedrine (Advil Cold & Sinus, Aleve-D Sinus & Cold, others) constrict your blood vessels and may increase your PAD symptoms.

Careful foot care

In addition to the above lifestyle changes, take good care of your feet. People with PAD, especially those who also have diabetes, are at risk of poor healing of sores and injuries on the lower legs and feet.

Poor blood flow can postpone or prevent proper healing and increases the risk of infection. Follow this advice to care for your feet:

  • Wash your feet daily, dry them thoroughly and moisturize often to prevent cracks that can lead to infection. Don't moisturize between the toes, however, as this can encourage fungal growth.
  • Wear well-fitting shoes and thick, dry socks.
  • Promptly treat any fungal infections of the feet, such as athlete's foot.
  • Take care when trimming your nails.
  • Inspect your feet daily for injuries.
  • Have a foot doctor treat bunions, corns or calluses.
  • See your doctor at the first sign of a sore or injury to your skin.

Coping and support

Peripheral artery disease can be frustrating, especially when the exercise that will help you get better causes you pain. Don't get discouraged, however. As you continue exercising, you'll increase the distance you can walk without pain.

You may find it helpful to raise the head of your bed by 4 to 6 inches (10 to 15 centimeters), because keeping your legs below the level of your heart usually lessens pain.

Another tip for reducing your symptoms is to avoid cold temperatures as much as possible. If you can't avoid the cold, be sure to dress in warm layers.

Preparing for an appointment

You're likely to start by seeing your family doctor. However, you may then be referred to a doctor who specializes in disorders of blood vessels (vascular specialist) or a doctor who specializes in the heart and circulatory system (cardiologist).

Because appointments can be brief and there's often a lot to discuss, it's a good idea to arrive well prepared. Here's some information to help you get ready for your appointment and know what to expect from your doctor.

What you can do

  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Make a list of all medications, vitamins or supplements that you're taking, and include dosage information.
  • Write down questions to ask your doctor.

For peripheral artery disease, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • Are there other possible causes for my symptoms?
  • What kinds of tests do I need? Do these tests require any special preparation?
  • Is peripheral artery disease temporary or long lasting?
  • What treatments are available, and which do you recommend?
  • What types of side effects can I expect from treatment?
  • Are there any alternatives to the primary approach that you're suggesting?
  • What can I do on my own that might help me get better?
  • I have other health conditions. How can I best manage these conditions together?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

Don't hesitate to ask additional questions during your appointment if you don't understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Are your symptoms continuous or occasional?
  • Do your symptoms get worse when you exercise?
  • How severe are your symptoms?
  • Do your symptoms get better when you're resting?
  • Do you use tobacco products? If yes, how often?

What you can do in the meantime

If you're a smoker, it's never too soon to quit smoking. Smoking increases the risk of peripheral artery disease and can make existing PAD worse. Eating less saturated fat and adding more fruits and vegetables to your diet are two other healthy lifestyle habits you can immediately adopt.


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