Peripheral Arterial Disease of the Legs

	Overview
	Health Tools
	FAQs
	Cause
	Symptoms
	What Increases Your Risk
	When to Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Living With PAD
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

What is peripheral arterial disease of the legs?

Peripheral arterial disease (PAD) is narrowing or blockage of arteries that results in poor blood flow to your arms and legs. When you walk or exercise, your leg muscles do not get enough blood and you can get painful cramps.

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.

See a picture of peripheral arterial disease of the legs.

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 along the inner walls of the arteries, including those that supply blood to your legs.

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. See a picture of peripheral arterial disease of the legs.

This process of plaque buildup usually happens at the same time throughout the body. It is called atherosclerosis or hardening of the arteries. If you have this problem in your legs, you most likely will have it in the arteries that supply blood to your heart and brain. This increases your chance of having a heart attack or stroke.

Plaque builds up bit by bit over a lifetime, but symptoms often do not start until after age 65. High cholesterol, high blood pressure, and smoking make you more likely to get atherosclerosis and peripheral arterial disease.

What are the symptoms?

Many people who have PAD do not have any symptoms.

But if you do have symptoms, you may have 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. As PAD gets worse, you may have pain in your foot or toe when you are not walking.

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?

One of the most important things you can do for PAD is to quit smoking. If you need help quitting, talk to your doctor about programs and medicines that can help you stop. These can increase your chances of quitting forever.

There are also products that gradually wean you off nicotine. These include nicotine patches, chewing gums, nasal sprays, inhalers, and lozenges. These treatments help people have better success in the long term.¹

Your doctor may tell you to eat healthy foods and to get more exercise. You may need to take aspirin and medicines to lower your cholesterol and control your symptoms. If you have diabetes, you will need to carefully control your blood sugar.

Combined, these measures can help control your symptoms and reverse the blockage of your arteries. Keeping your arteries open can help lower your risk of heart attack and stroke. And it may also improve the quality and length of your life.

If your leg pain does not get better after a few months of treatment, your doctor may prescribe a medicine called cilostazol (Pletal) to help with the pain when you walk.

If you still do not get better, you may need a procedure called angioplasty or bypass surgery to open narrowed arteries or reroute blood flow around them. These treatments are usually used for severe peripheral arterial disease.

In rare cases, advanced PAD can cause tissues in the leg or foot to die because they do not 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.

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The most common cause of peripheral arterial disease is the buildup of plaque on the inside of arteries. Plaque is made up of excess cholesterol, calcium, and other substances in your bloodstream that, over time, build up along the inner 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. See a picture of peripheral arterial disease of the legs.

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. For more information on risk factors, see the What Increases Your Risk section of this topic. See pictures of atherosclerosis and how high blood pressure damages arteries.

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.

Many people who have peripheral arterial disease (PAD) do not have symptoms.

If you do have symptoms, you may have 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. As PAD gets worse, you may have pain in your foot or toe when you are not walking.

But, not everyone has intermittent claudication. About 1 out of 5 people with PAD may have intermittent claudication.² Some people with PAD do not have leg pain simply because they do not walk far enough to bring intermittent claudication on.

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

• Weak or tired legs.
• Difficulty walking or balancing.
• Cold and numb feet or toes.
• Sores that are slow to heal.
• Foot pain while you are at rest, which indicates that PAD is getting worse.
• Erectile dysfunction.

Physical signs of advanced peripheral arterial disease of the legs may appear, such as:

• Feet and toes that become pale from exercise or when elevated.
• Loss of hair on the feet and toes.
• Feet that turn red when dangled.
• Blue or purple marks on the legs, feet, or toes, caused by reduced oxygen flow to the tissues.
• Ulcers on the feet or toes.
• Gangrene infection (death of tissue), indicated by black skin on the legs or feet.

More severe symptoms may indicate advanced PAD. But symptoms can be affected by or confused with other health conditions the person also has, such as arthritis.

Peripheral arterial disease also can be confused with other conditions with similar symptoms.

Symptoms of leg pain associated with PAD may be mentioned less often by people who have a high pain tolerance, by people with conditions like diabetes who have numbness in their legs that prevents them from sensing pain, or by people who never exert themselves long enough for leg pain to start. These factors may keep peripheral arterial disease from being diagnosed.

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

• Smoking.
• High cholesterol.
• High blood pressure.
• Diabetes.
• A family history of atherosclerosis or coronary artery disease.
• A high homocysteine level.

Call your doctor immediately if you suddenly have severe leg pain, numbness, or pale, blue-black skin.

Call your doctor if you have:

• Leg pain that begins after you walk a certain distance and that goes away when you rest (intermittent claudication).
• Foot or toe pain when you are resting.

Watchful Waiting

Taking a wait-and-see approach, called watchful waiting, is not appropriate for peripheral arterial disease. Ongoing, unexplained leg pain should be checked by a doctor.

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.

If your doctor thinks that you may have peripheral arterial disease (PAD), he or she will examine you for any physical signs of the disease and will ask about your personal and family medical history. In addition, you should discuss any symptoms you have noticed.

As part of the physical exam, your doctor will feel for absent or weak pulses at your groin, behind your knee, on the inner ankle, and on the top of your foot. He or she may also look at the color of your foot when it is elevated and after you exercise. See a picture of peripheral arterial disease of the legs.

If these first tests suggest that you have PAD, you may have an ankle-brachial index test to confirm the diagnosis and to help determine how severely your arteries are narrowed. This test compares the blood pressure at your ankle and your arm, both at rest and after light exercise, to determine whether the blood flow is reduced. Some doctors measure blood flow through the arteries with a Doppler ultrasound exam. Both are simple tests.

Other tests may be helpful. Doctors sometimes use magnetic resonance angiogram (MRA). Computerized tomography (CT) angiography is also widely used to help diagnose PAD. These advanced, computer-enhanced tests may be more accurate than standard angiograms.

Images from these tests can help identify areas that may be blocked or narrowed by atherosclerosis. This may be helpful if you are considering surgery.

Other tests that may help your doctor include:

• Cholesterol testing. If you have high cholesterol, you may have atherosclerosis, which causes PAD.
• Blood pressure checks. High blood pressure increases the chance that you will develop atherosclerosis and have a heart attack or stroke. For more information, see the topic High Blood Pressure (Hypertension).
• Homocysteine level testing. An elevated level of homocysteine may increase your chance of having PAD.
• A blood glucose test. If your blood sugar is high, you may have diabetes, which also increases your chance of having PAD.

If you have PAD, your doctor may also do tests to see whether you have any narrowing in the arteries that supply blood to your heart and brain. When you have PAD, you also have a higher risk for coronary artery disease, heart attack, or stroke. For more information on testing for these conditions, see the topics Coronary Artery Disease, Heart Attack, Transient Ischemic Attack (TIA), and Stroke.

As you begin your treatment for peripheral arterial disease (PAD), one of the first things you need to do is to make some lifestyle changes. These changes will improve your health and possibly reverse the buildup of plaque in your arteries. This can reduce your risk of heart attack and stroke.

Initial treatment

One of the single most important treatments for peripheral arterial disease (PAD) is to quit smoking. Quitting smoking is difficult, but you do not have to do it on your own. Your doctor can give you medicines such as bupropion (Zyban or Wellbutrin, for example) or varenicline (Chantix), to help you stop craving nicotine. Avoid secondhand smoke too.

There are also products that wean you off nicotine without using tobacco. This is called nicotine replacement therapy, and it helps you gradually stop using nicotine. Products include nicotine patches, gums, nasal sprays, inhalers, and lozenges. These treatments are proven to help people quit smoking for a longer time.¹ For more information, see the topic Quitting Tobacco Use.

Because you have PAD, you have a high risk of having a heart attack or stroke. Your doctor will probably recommend that you follow a heart-healthy diet and increase your physical activity by walking. Even though walking causes you pain, it may be the best exercise you can get. You will need to rest as soon as the pain starts and walk a little farther after it goes away. Make sure you talk to your doctor first, before you start an exercise plan.

For more information on eating well, see:

Eating a heart-healthy diet

You will probably need to take medicines, such as statins, to lower your cholesterol. You may also need to take aspirin or other antiplatelet medicines to help prevent blood clots from forming. If you have high blood pressure, you may need to take medicines to lower it. If you have diabetes, you will need to strictly control your blood sugar levels.

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Ongoing treatment

A major part of treating leg pain from peripheral arterial disease is exercise. Studies show that walking 3 times a week for 3 to 6 months lengthens the distance you can walk before you need to stop because of leg pain.³ Being able to walk farther may mean that you are getting better blood flow to the muscles in your legs. An exercise program that is designed specifically for you may help you the most.

In many people, leg pain eases up after they have followed an exercise program for several months. But, if your leg pain does not get better, your doctor might prescribe a medicine called cilostazol (Pletal). This drug has been shown to help people walk longer before their pain starts, but it may have side effects.¹

If you are still smoking, your doctor will want you to quit and to stay on the heart-healthy diet. Keep taking any medicines your doctor prescribed at the beginning of your treatment.

If you have diabetes, your doctor will want you to closely monitor and control your blood sugar levels and your blood pressure. Studies have shown that controlling blood pressure can lower the risk of heart attack and stroke in people with diabetes and PAD.⁴

Additionally, watch for foot or leg sores, and treat them immediately. These sores may be slower to heal and more likely to become infected because of the reduced blood supply. People with diabetes need to be especially aware because they often have peripheral neuropathy, a problem with the nerves that makes it harder to feel an injury to the legs or feet.

Treatment if the condition gets worse

Sometimes peripheral arterial disease continues to get worse despite treatment. This may be caused by continued smoking or other unhealthy choices. Other times, symptoms get worse because the disease has already progressed too far.

People who have severe PAD or who are at risk for losing a limb may need bypass surgery or other procedures (such as angioplasty and stenting) to restore proper blood flow to the legs. You may need surgery or angioplasty if you have symptoms of intermittent claudication and one of the following conditions:

• Your lifestyle or job is limited because of your symptoms.
• Exercise has not relieved your symptoms.
• Medicines have not relieved your symptoms.

Should I have surgery (angioplasty or bypass surgery) for peripheral arterial disease?

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. Clot-dissolving medicines, surgical removal of the clot, or bypass surgery may be needed to restore blood flow.

People with diabetes often have arterial disease that is both more severe and more widespread than in people who don't have diabetes. They commonly have neuropathy, which is a problem with the nerves that makes it harder to feel pain from an injury to the legs or feet. Ulcers can occur. These ulcers and injuries may be more prone to infection and gangrene (tissue death) because of the poor blood supply and poor function of the white blood cells in people with diabetes.

You can prevent or delay peripheral arterial disease (PAD) by controlling risk factors and changing your lifestyle. Discuss with your doctor the following advice for preventing PAD:

• Quit smoking. Smoking is a major risk factor for peripheral arterial disease. For more information on how to stop smoking, see the topic Quitting Tobacco Use.
• Lower your cholesterol. For more information, see the topic High Cholesterol.
• Lower your blood pressure. For more information, see the topic High Blood Pressure (Hypertension).
• Get regular exercise.
• Stay at a healthy weight.
• Control your diabetes.
• Eat a heart-healthy diet.

How you can manage peripheral arterial disease

• Quit smoking and avoid secondhand smoke. Smoking is a major risk factor for peripheral arterial disease (PAD). Quitting smoking may help prevent PAD or slow its progression. For more information on how to stop smoking, see the topic Quitting Tobacco Use.
• Lower your cholesterol. For more information, see the topic High Cholesterol.
• Lower your blood pressure. For more information, see the topic High Blood Pressure (Hypertension).
• Get regular exercise.
• Stay at a healthy weight.
• Eat a heart-healthy diet.
• If you have diabetes, carefully monitor and control your blood sugar levels. For more information, see the topics:
  • Type 1 Diabetes: Living With the Disease.
  • Type 1 Diabetes: Living With Complications.
  • Type 2 Diabetes: Living With the Disease.
  • Type 2 Diabetes: Living With Complications.
• Avoid getting sick from the flu. Get a flu shot every year.

Home treatment for PAD

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 cuts and scrapes on your legs right away. Poor blood flow to the legs caused by PAD can result in small cuts and scrapes that do not heal 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, which can make worse the circulation problems and symptoms associated with PAD.
• 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 absorb moisture.
• If open sores develop, keep them dry and cover them with nonstick bandages. See your doctor as soon as you discover an open sore.

Medicines are sometimes used to treat peripheral arterial disease (PAD). Cholesterol-lowering medicines may slow atherosclerosis, the main cause of PAD. You may need additional medicines if you have high blood pressure or diabetes. Both of these conditions can speed up the development of PAD.

Medicines to control pain may also be used when treating PAD. In very rare cases, doctors use anticoagulants, such as warfarin (Coumadin, for example), to help prevent blood clots.

Medication Choices

Medicines that may be used to treat peripheral arterial disease (PAD) include:

• Cilostazol (Pletal) to treat leg pain that comes on with activity (intermittent claudication). This medicine may cause serious side effects.
• Aspirin and other antiplatelet medicines to reduce the risk of heart attack and stroke.
• Statins, to lower cholesterol levels. Lowering cholesterol levels may help prevent the progression of PAD. Studies show that people with intermittent claudication report less leg pain and can walk farther when cholesterol levels are lowered with statins.^{5, 6} For more information on cholesterol-lowering drugs, see to the topic High Cholesterol.
• Medicines to control high blood pressure. For more information on drug treatment for high blood pressure, see the topic High Blood Pressure (Hypertension).
• Drugs to help you stop smoking, such as:
  • Nicotine replacement therapy.
  • Bupropion hydrochloride (Zyban or Wellbutrin).
  • Varenicline (Chantix).
• Anticoagulants. Anticoagulants, such as warfarin (Coumadin) or heparin, are not generally used to treat PAD unless you have a higher chance of forming blood clots.
• Medicines to control diabetes. For more information on drug treatment for these diseases, see the topics:
  • Type 1 Diabetes: Living With the Disease.
  • Type 1 Diabetes: Living With Complications.
  • Type 2 Diabetes: Living With the Disease.
  • Type 2 Diabetes: Living With Complications.

What to Think About

Cilostazol (Pletal) has been shown to increase the time that people who have intermittent claudication can walk before developing leg pain. But side effects such as headache, diarrhea, and heart palpitations are common with this medicine.⁷

Studies show that antiplatelet medicines reduce the number of heart attacks and strokes in people with PAD when compared with a placebo. One study showed that clopidogrel (Plavix) worked better than aspirin in reducing the number of heart attacks and strokes for some people with PAD.⁵ But clopidogrel is not always prescribed, because it is more expensive than aspirin.

Bypass surgery in the leg arteries may be used to treat severe or limb-threatening peripheral arterial disease (PAD) that is causing symptoms. 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.

You may need surgery if you have symptoms of intermittent claudication and one of the following conditions:

• Your lifestyle or job is limited because of your symptoms.
• Exercise has not relieved your symptoms.
• Medicines have not relieved your symptoms.

The methods of bypass surgery vary depending on the size of the affected artery and the location of the artery.

Surgery Choices

The types of surgery used to treat PAD are categorized according to the location of the affected leg artery or arteries. See a picture of peripheral arterial disease of the legs.

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

Should I have surgery (angioplasty or bypass surgery) for peripheral arterial disease?

What to Think About

Surgery for peripheral arterial disease is used for people who have disabling intermittent claudication; pain when at rest; open sores (ulcers) that won't heal; or dying skin, muscle, bone, and nerve tissue in their legs or feet (gangrene).

In rare cases, some people need to have a leg, foot, or part of the foot amputated. Over a year's time, less than 1% of people with intermittent claudication need to have amputation for peripheral arterial disease that gets worse.¹ 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.

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.

If a short section of artery in the leg is affected by peripheral arterial disease (PAD), angioplasty may be used. This is a procedure in which a small, thin tube called a catheter is inserted through a blood vessel in the groin and guided to the affected artery. Diagnostic and treatment procedures are performed through the catheter.

A support device called a stent may be placed in a blood vessel to help hold it open. The stent is placed during angioplasty.

Should I have surgery (angioplasty or bypass surgery) for peripheral arterial disease?

Alternative treatments, such as ginkgo biloba and carnitine, may be used to help leg pain and to improve walking ability.

What to Think About

Angioplasty is used for severe localized disease that causes pain and limping during exercise (intermittent claudication), pain when at rest, or open sores (ulcers).

In general, angioplasty works best in larger arteries. Angioplasty has the best rates of success in the aorta and in the iliac arteries, which branch from the lower aorta. In the femoral arteries, angioplasty works better if the area of narrowing is short. In the past, doctors have preferred bypass surgery over angioplasty when the narrowing or blockages are in the popliteal and tibial arteries (which are small arteries). But angioplasty in these arteries is becoming more successful with advances in angioplasty.

The choice of angioplasty or bypass surgery depends on all of the following factors:

• Risks of the procedure.
• Size of the arteries.
• Number and length of the blockages or narrowing in the arteries.

Angioplasty may not be as effective as bypass surgery, especially in cases where multiple areas of blood vessels are narrowed or blocked.

Online Resources

Organizations

• Coronary Artery Disease
• Heart Attack and Unstable Angina
• High Blood Pressure (Hypertension)
• High Cholesterol
• Stroke

Citations

1. Burns P, et al. (2003). Management of peripheral arterial disease in primary care. BMJ, 326(7389): 584–588.

2. White C (2007). Intermittent claudication. New England Journal of Medicine, 356(12): 1241–1250.

3. Hirsch AT, et al. (2006). ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation, 113(11): e463–e654.

4. Mehler PS, et al. (2003). Intensive blood pressure control reduces the risk of cardiovascular events in patients with peripheral arterial disease and type 2 diabetes. Circulation, 107(5): 753–756.

5. Regensteiner JG, Hiatt WR (2002). Current medical therapies for patients with peripheral arterial disease: A critical review. American Journal of Medicine, 112(1): 49–57.

6. Mohler ER III, et al., (2003). Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. Circulation, 108(12): 1481–1486.

7. Cassar K, Bachoo P (2006). Peripheral arterial disease, search date December 2005. Online version of Clinical Evidence (15).

Other Works Consulted

• American Heart Association and American College of Cardiology (2006). AHA/ACC Guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation, 113(19): 2363–2372. [Erratum in Circulation, 113(22): 847.]

• Hiatt WR (2001). Medical treatment of peripheral arterial disease and claudication. New England Journal of Medicine, 344(21): 1608–1621.

• Husten CG, Thorne SL (2008). Tobacco: Health effects and control. In RB Wallace, ed., Maxcy-Rosenau-Last Public Health and Preventive Medicine, 15th ed., pp. 953–998. New York: McGraw-Hill.

• Norgren L, et al. (2007). Inter-society consensus for the management of peripheral arterial disease (TASC II). European Journal of Vascular Surgery, 33 (Suppl 1): S1–S70.