Peripheral Arterial Disease of the Legs

Topic Overview

What is peripheral arterial disease of the legs?

Peripheral arterial disease (PAD) is narrowing or blockage of arteries that causes poor blood flow to your arms and legs.

Peripheral arterial disease is also called peripheral vascular disease. This topic focuses on peripheral arterial disease of the legs, the area where it is most common.

What causes PAD?

The most common cause is the buildup of plaque on the inside of arteries. Plaque is made of extra cholesterol, calcium, and other material in your blood. Over time, plaque builds up in the walls of the arteries, including those that supply blood to your legs. High cholesterol, high blood pressure, and smoking all contribute to plaque buildup.

If plaque builds up in your arteries, there is less room for blood to flow. Every part of your body needs blood that is rich in oxygen. But plaque buildup prevents that blood from flowing freely and starves the muscles and other tissues in the lower body.

What are the symptoms?

Many people who have PAD don't have any symptoms.

If you do have symptoms, you may have weak or tired legs, difficulty walking or balancing, or pain. If you have pain, you might feel a tight, aching, or squeezing pain in the calf, thigh, or buttock. This pain, called intermittent claudication, usually happens after you have walked a certain distance. For example, your pain may always start after you have walked a block or two or after a few minutes. The pain goes away if you stop walking.

If PAD gets worse, you may have other symptoms caused by poor blood flow to your legs and feet. These include leg pain when you rest.

How is PAD diagnosed?

Your doctor will talk with you about your symptoms and past health and will do a physical exam. During the exam, your doctor will check your pulse at your groin, behind your knee, on the inner ankle, and on the top of your foot. Your pulse shows the strength of blood flow. An absent or weak pulse in these spots is a sign of PAD. Your doctor may also look at the color of your foot when it is higher than the level of your heart and after exercise. The color of your foot can be a clue to whether enough blood is getting through your arteries.

You will likely have a test that compares the blood pressure in your legs with the blood pressure in your arms. This test is called an ankle-brachial index. A test called an arterial Doppler ultrasound may be done to check the blood flow in your arteries.

Blood tests to check your cholesterol and blood sugar can tell whether you may have other problems related to PAD, such as high cholesterol and diabetes.

How is it treated?

Treatment for PAD includes ways to relieve symptoms and lower your risk of heart attack and stroke. Healthy lifestyle changes and medicines can help relieve symptoms and lower this risk. In some cases, you may need surgery or a procedure called angioplasty.

When you have PAD, you have a high risk of having a heart attack or stroke. Making healthy changes along with taking medicines can help reduce this risk.

Lifestyle changes

• If you smoke, quit. It's one of the most important things you can do. If you need help, talk to your doctor about programs and medicines that can help you stop.
• Eat healthy foods.
• Get regular exercise (if your doctor says it's safe). Try walking, swimming, or biking for at least 30 minutes on most, if not all, days of the week. If you have symptoms when you exercise, your doctor might recommend a specialized exercise program that might relieve your symptoms.
• Manage your cholesterol and blood pressure if they are high. You may need medicines to help you do this.
• If you have diabetes, keep your blood sugar in a target range.
• Lose weight if you need to, and maintain a healthy weight.
• Take good care of your feet and legs. When you have reduced blood flow to your legs, even minor injuries can lead to serious infections.

Your doctor may suggest that you attend a cardiac rehabilitation (rehab) program. In cardiac rehab, you will get education and support to help you make new, healthy habits.

Medicines and surgery

You may take medicine to lower your risk of heart attack and stroke. These medicines help prevent blood clots, manage blood pressure, and manage cholesterol.

If lifestyle changes don't help relieve symptoms, your doctor may prescribe a medicine that may relieve the pain when you walk.

If you have symptoms that make it hard for you to walk, you might choose to have a procedure called angioplasty or bypass surgery. These treatments open narrowed arteries or reroute blood flow around them. Angioplasty or surgery might also be done if blood flow to your leg is severely limited.

In rare cases, advanced PAD can cause tissues in the leg or foot to die because they don't get enough oxygen as a result of poor blood flow. If this happens, part of the leg or foot must be removed (amputated). This is more common in people who also have diabetes.

Frequently Asked Questions

Cause

The most common cause of peripheral arterial disease is the buildup of plaque inside blood vessels called arteries. Plaque is made up of excess cholesterol, calcium, and other substances in your bloodstream. Over time, plaque builds up in the walls of the arteries, including the arteries that feed your legs. The plaque deposits decrease the space through which oxygen- and nutrient-rich blood can flow. Poor blood flow "starves" the muscles and other tissues in the lower body.

This process of plaque buildup-called atherosclerosis or "hardening of the arteries"-usually happens throughout the body, including the leg arteries, coronary arteries, and carotid arteries.

Atherosclerosis gradually develops over a lifetime. High cholesterol, high blood pressure, and smoking contribute to atherosclerosis and peripheral arterial disease.

In very rare cases, peripheral arterial disease can be unrelated to atherosclerosis and caused instead by inflammation of the blood vessels (vasculitis) and old injuries that damaged blood vessels.

Symptoms

Many people who have peripheral arterial disease (PAD) don't have symptoms.

If you do have symptoms, you may have a tight, aching, or squeezing pain in your calf, thigh, or buttock. This pain, called intermittent claudication, usually happens after you have walked a certain distance.

For example, your pain may always start after you have walked a block or two or after a few minutes. The pain goes away if you stop walking. As PAD gets worse, you may have pain in your foot or toe when you aren't walking.

Only about 1 out of 5 people with PAD have intermittent claudication.^{footnote 1}

Other symptoms of peripheral arterial disease of the legs may include:

• Weak or tired legs.
• Difficulty walking or balancing.

If PAD gets worse, you may have other symptoms that are caused by poor blood flow to your legs and feet. These symptoms are not common. They include:

• Cold or numb feet or toes.
• Sores that are slow to heal.
• Leg or foot pain while you are at rest.
• Feet and toes that become pale from exercise or when elevated.
• Feet that turn red when dangled.
• Blue or purple marks on your legs, feet, or toes.

What Increases Your Risk

Many things can increase your risk for atherosclerosis and peripheral arterial disease (PAD). These include:

• Smoking.
• High cholesterol.
• High blood pressure.
• Diabetes. People with diabetes often have arterial disease that is both more severe and more widespread than in people who don't have diabetes.
• A family history of atherosclerosis or coronary artery disease.

The risk for PAD also increases with age.

People who have the disease in one part of the body are likely to have it in other places, including the legs.

When to Call a Doctor

Call your doctor now or seek immediate medical care if:

• You have leg pain that does not go away even if you rest.
• Your leg pain changes or gets worse. For example, if you have more pain with normal activity or the same pain with decreased activity, you should call.
• You have cold or numb feet or toes.
• You have leg or foot sores that are slow to heal.
• The skin on your legs or feet changes color.
• You have an open sore on your leg or foot that is infected.

Who to see

Health professionals who may be involved in the diagnosis and treatment of peripheral arterial disease (PAD) include:

• Family medicine doctor.
• Internal medicine doctor (internist).
• Cardiologist.
• Vascular surgeon.

Exams and Tests

If your doctor thinks that you may have peripheral arterial disease (PAD), he or she will examine you for physical signs of the disease and will ask about your personal and family medical history. This is a good time to talk with your doctor about any symptoms you have noticed.

Diagnostic tests

Tests you may have to confirm PAD include:

• Pulse and blood pressure checks in different areas of your body. Your doctor may also look at the color of your foot when it is elevated and after you exercise.
• Ankle-brachial index (ABI) test checks blood flow by comparing blood pressure in the ankles and the arms.
• Doppler ultrasound. It may be used to measure blood flow in the arteries.
• Magnetic resonance angiogram (MRA) or computerized tomography (CT) angiography. These tests can also help diagnose PAD. These tests might be done before a procedure or surgery.

Tests for other health problems

Your doctor may also do other tests to find out if you have health problems that can cause PAD or make it worse. When you have PAD, you are at high risk for coronary artery disease, heart attack, and stroke. Your doctor will check your risk. You may have tests for:

• Cholesterol.
• Blood pressure.
• Blood glucose, which tests for diabetes.

Treatment Overview

Your treatment for peripheral arterial disease (PAD) will focus on healthy lifestyle changes first. You may need to take medicines to ease leg pain or to help you manage other health problems.

Some people have angioplasty or bypass surgery to improve blood flow to their legs.

It's important to do what you can to improve your health and possibly reverse the buildup of plaque in your arteries. When you have PAD, you have a high risk of having a heart attack or stroke. Making healthy changes and following your treatment plan can reduce this risk.

Healthy changes you can make

• If you smoke, quit. Quitting is the best thing you can do when you have peripheral arterial disease (PAD). Medicines and counseling can help you quit for good.
• Get regular exercise (if your doctor says it's safe). Try walking, swimming, or biking for at least 30 minutes on most, if not all, days of the week. Your doctor might recommend a specialized exercise program if you have intermittent claudication.
• Eat heart-healthy foods, such as fruits and vegetables.
• Stay at a healthy weight. Lose weight if you need to.
• Take good care of your feet and legs to prevent injuries and infections.

A cardiac rehab program can help you make lifestyle changes. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits.

See Living With PAD for more ideas about changes you can make and about support to help you make them.

Medicines

You may need medicines to help lower your risk of heart attack and stroke. These include medicine to prevent blood clots, improve cholesterol, or lower blood pressure. You might take a medicine that can help ease pain while you are walking.

Procedures and surgery

Sometimes peripheral arterial disease gets worse despite treatment. People who have severe PAD may have bypass surgery or other procedures (such as angioplasty) to restore proper blood flow to the legs.

Prevention

You can prevent or delay peripheral arterial disease (PAD) by taking steps toward a heart-healthy lifestyle. A heart-healthy lifestyle can also help you manage risk factors such as high cholesterol and high blood pressure.

Living With PAD

There are many things you can do to keep peripheral arterial disease (PAD) from getting worse. These steps may also help lower your blood pressure and cholesterol, which can help control PAD.

And doing any one of these things can help you reduce your risk of heart attack and stroke, which is important to do when you have PAD.

Focus on a healthy lifestyle

• Quit smoking and avoid secondhand smoke. Smoking is a major risk factor for peripheral arterial disease. Quitting smoking may help prevent PAD or slow its progression. For more information on how to stop smoking, see the topic Quitting Smoking.
• Get regular exercise (if your doctor says it's safe). Try walking, swimming, or biking for at least 30 minutes on most, if not all, days of the week. If you have intermittent claudication when you exercise, your doctor might recommend a specialized exercise program that might relieve your symptoms.
• Stay at a healthy weight.
• Eat heart-healthy foods, such as fruits and vegetables.
• If you have diabetes, keep your blood sugar in your target range.
• Avoid getting sick from the flu. Get a flu shot every year.

A cardiac rehab program can help you make lifestyle changes. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits.

Care for your feet and legs

Take good care of your feet and legs. When you have reduced blood flow to your legs, even minor injuries can lead to serious infections.

• Treat wounds, cuts, and scrapes on your legs right away. Poor blood flow to the legs caused by PAD can keep wounds, cuts, and scrapes from healing properly. Prompt treatment can help you avoid this problem and is especially important for people who also have diabetes.
• Avoid shoes that are too tight or that rub your feet. Shoes should be comfortable and fit well. Avoid socks or stockings that are tight enough to leave elastic-band marks on your legs. They can make circulation problems and symptoms from PAD worse.
• Keep your feet clean and moisturized to prevent your skin from drying and cracking. Place cotton or lamb's wool between your toes to prevent rubbing and to absorb moisture.
• If open sores form, keep them dry and cover them with nonstick bandages. See your doctor as soon as you discover an open sore.

Medications

Medicines are used to treat symptoms of peripheral arterial disease (PAD) or to help manage other health problems that can raise your risk of heart attack and stroke.

Medicine choices

Medicines that help lower your risk of heart attack and stroke:

• Aspirin and other antiplatelet medicines to prevent blood clots.
• Statins to help lower cholesterol levels.
• Medicines to control high blood pressure.
• Medicines to control diabetes.

Medicine to relieve symptoms:

• Cilostazol (Pletal) to treat leg pain that comes on with activity (intermittent claudication).

Surgery

Most of the time, surgery is only done in cases of severe peripheral arterial disease (PAD), such as disabling intermittent claudication; open sores (ulcers that won't heal); or serious skin, bone, and tissue problems (gangrene).

Bypass surgery redirects blood through a grafted blood vessel to bypass the blood vessel that is damaged. The grafted blood vessel may be a healthy natural vein or artery, or it may be man-made.

The methods of bypass surgery vary depending on the size of the affected artery and where it is located.

Peripheral Arterial Disease: Should I Have Surgery?

Surgery choices

The type of surgery used to treat PAD will depend on the location of the affected leg artery or arteries.

• Aortobifemoral bypass is done for PAD that affects the major abdominal artery (aorta) and the large arteries that branch off of it.
• Femoropopliteal (fem-pop) bypass is done for PAD that affects the arteries above and below the knee.
• Femoral-tibial bypass is done for PAD that affects the arteries in the lower leg or foot.

Endarterectomy is a less common surgery. It is typically done on the large femoral artery, which is in your groin and upper thigh area.

This surgery is done to remove fatty buildup (plaque) and to increase blood flow to the leg. This surgery is done by cutting open the femoral artery and removing the plaque. This surgery may be done by itself, or it may be done at the same time as bypass surgery or angioplasty.

What to think about

In rare cases, peripheral arterial disease gets so bad that some people need to have a leg, a foot, or part of the foot amputated. People with diabetes are at increased risk for amputation. Amputation is used only when the damage is very severe, possibly life-threatening, and after all other treatment options have been tried.

Also in rare cases, a blood clot in an artery can suddenly and completely block blood flow to a leg or foot. Often, severe pain, numbness, and coldness develop within 1 hour. This blockage is an emergency. Clot-dissolving medicines, surgical removal of the clot, or bypass surgery is needed to restore blood flow.

Other Treatment

Angioplasty

Angioplasty is used for severe disease that causes pain and limping during exercise, pain when at rest, or open sores. Angioplasty can increase blood flow in a narrowed artery.

During this procedure, a small, thin tube called a catheter is inserted through a blood vessel in the groin and guided to the affected artery. When the catheter reaches the narrowed part of the artery, the surgeon inflates a balloon. The balloon presses the plaque against the wall of the artery. This improves blood flow.

A small, expandable tube called a stent may be placed in a blood vessel to help hold it open.

Peripheral Arterial Disease: Should I Have Surgery?