Condition Basics

What is peripheral arterial disease (PAD)?

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

The most common cause of PAD is the buildup of plaque on the inside of arteries. Over time, plaque builds up in the walls of the arteries, including those that supply blood to your legs. If you have PAD, you're likely to have plaque in other arteries in your body. This raises your risk of a heart attack and stroke.

Medicines and lifestyle changes may lower your risk of heart attack and stroke. They may also help if you have symptoms. In some cases, surgery or other treatment is needed.

Peripheral arterial disease is also called peripheral vascular disease.

What causes it?

The most common cause of PAD is the buildup of plaque inside of arteries, including the ones that supply blood to your legs. This buildup leads to poor blood flow. High cholesterol, high blood pressure, and smoking all contribute to plaque buildup.

What are the symptoms?

Many people who have PAD don't have any symptoms. If you have symptoms, they may include weak or tired legs, trouble walking or balancing, or pain. You might feel a tight, aching, or squeezing pain in your calf, thigh, or buttock. This pain usually happens after you have walked a certain distance.

How is it diagnosed?

Your doctor will check the pulse and blood pressure in different areas of your body. Your doctor may also look at the colour of your foot when it is raised up and after you exercise. You may have a Doppler ultrasound, which measures blood flow in the arteries.

How is PAD treated?

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

Cause

The most common cause of PAD 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 ones that feed your legs. The plaque narrows 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 usually happens throughout the body, including the leg arteries, coronary arteries, and carotid arteries. The buildup is called atherosclerosis or "hardening of the arteries." It slowly develops over a lifetime. High cholesterol, high blood pressure, and smoking help cause atherosclerosis and PAD.

In very rare cases, PAD can be unrelated to atherosclerosis. Instead, it is caused by inflammation of the blood vessels (vasculitis) and old injuries that damaged the blood vessels.

What Increases Your Risk

Many things can increase your risk for atherosclerosis and 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.

Prevention

• Quit smoking. Quitting smoking is one of the best things you can do to help prevent PAD. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.
• Stay at a healthy weight.
• Manage other health problems, including diabetes, high blood pressure, and high cholesterol.
• Be physically active. Try to do moderate to vigorous activity at least 2½ hours a week. You may want to walk or try other activities, such as running, swimming, cycling, or playing tennis or team sports.
• Eat a variety of heart-healthy foods.
  • Eat fruits, vegetables, whole grains, beans, and other high-fibre foods.
  • Eat lean proteins, such as seafood, lean meats, beans, nuts, and soy products.
  • Eat healthy fats, such as canola and olive oil.
  • Choose foods that are low in saturated fat and avoid trans fat.
  • Limit sodium and alcohol.
  • Limit drinks and foods with added sugar.

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Symptoms

Many people who have PAD don't have symptoms.

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

Other symptoms may include weak or tired legs. You might have trouble walking or balancing.

If PAD gets worse, you may have other symptoms caused by poor blood flow to your legs and feet. These symptoms aren't common. They may include cold or numb feet or toes, sores that are slow to heal, or leg or foot pain when you're at rest.

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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 colour.
• You have an open sore on your leg or foot that is infected.

Examinations and Tests

Your doctor will talk with you about your symptoms and past health and do a physical exam. Your doctor will check your pulse at your groin, behind your knee, on the inner ankle, and on the top of your foot. An absent or weak pulse in these spots is a sign of PAD. The pulse in your wrist, forearm, or neck may also be checked.

Your doctor may also look at the colour of your foot when it is higher than the level of your heart and after exercise.

Tests you may have to confirm PAD include:

• Ankle-brachial index (ABI) test. This checks blood flow by comparing blood pressure in the ankles and the arms.
• Doppler ultrasound. This 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. They might be done before a procedure or surgery.

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Treatment Overview

Treatment for PAD focuses on relieving symptoms and lowering your risk of heart attack and stroke. Making healthy lifestyle changes can help you lower this risk.

• If you smoke, quit. Quitting is the best thing you can do when you have PAD. Medicines and counselling can help you quit for good.
• Get regular exercise (if your doctor says it's safe). Try walking, swimming, or biking for at least 2½ hours a week. If you have leg symptoms when you exercise, your doctor might recommend a specialized exercise program that may relieve symptoms. The goal is to be able to walk farther without pain.
• Eat heart-healthy foods, such as vegetables, fruits, nuts, beans, fish, and whole grains. Limit foods that have a lot of salt, fat, and sugar.
• Stay at a healthy weight. Lose weight if you need to.

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.

People who have severe PAD may have bypass surgery or other procedures (such as angioplasty) to restore proper blood flow to the legs.

Self-Care

Making lifestyle changes can help you 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.

• Quit smoking, and avoid second-hand smoke.

  Smoking is a major risk factor for PAD. Quitting smoking may help prevent PAD or slow its progression.

• Get regular exercise (if your doctor says it's safe).

  Try to walk, swim, or bike for at least 30 minutes on most, if not all, days of the week. If you have leg pain (intermittent claudication) when you exercise, your doctor might recommend a specialized exercise program. This program might relieve your symptoms.

• Eat heart-healthy foods, and stay at a healthy weight.

  Heart-healthy foods include eating more fruits and vegetables and choosing foods low in saturated fat. Try a heart-healthy eating plan like the DASH diet or the Mediterranean diet.

• If you have diabetes, keep your blood sugar in your target range.
• Avoid infections such as COVID-19, colds, and influenza (flu).

  Get the flu vaccine every year. Get a pneumococcal vaccine. If you have had one before, ask your doctor whether you need another dose. Stay up to date on your COVID-19 vaccines.

• Consider a cardiac rehab program.

  In this program, a team of health professionals provides education and support to help you make new, healthy habits.

Take good care of your feet and legs

Take good care of your feet and legs. When you have PAD, 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 right. Prompt treatment can help you avoid this problem. It's even more 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.

  This helps prevent your skin from drying and cracking. Place cotton or lamb's wool between your toes to prevent rubbing and to absorb moisture.

• Watch for open sores.

  If open sores form, cover them with non-stick bandages. See your doctor as soon as you find an open sore.

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Medicines

Medicines are used to help manage other health problems that can raise your risk of heart attack and stroke.

Medicine options include:

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

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Surgery

Usually, surgery is only done in cases of severe PAD. These are cases that involve intermittent claudication; open sores; or serious skin, bone, and tissue problems (gangrene).

Bypass surgery redirects blood through a grafted blood vessel. This bypasses the blood vessel that is damaged. The grafted blood vessel may be a healthy vein from your body. Or the graft may be man-made.

The type of surgery used to treat PAD depends on the size and location of the affected leg artery or arteries. Surgeries include:

• Aortobifemoral bypass.
• Femoropopliteal (fem-pop) bypass.
• Femoral-tibial bypass.
• Endarterectomy. This isn't done as often as other surgeries for PAD. It's most often done on the large artery in your groin and upper thigh area (femoral artery).

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

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