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    Peripheral Arterial Disease of the Legs

    Peripheral Arterial Disease of the Legs

    Overview

    Cardiovascular system

    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. When you walk or exercise, your leg muscles don't 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.

    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. 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.

    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 aren't 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?

    Treatment for PAD relies mainly on healthy lifestyle changes and taking care to manage high blood pressure and cholesterol. You may need medicines to ease symptoms or to manage other health problems. 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 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.
    • Follow an exercise program.
    • 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.

    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

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

    For severe PAD, you may need a procedure called angioplasty or bypass surgery to open narrowed arteries or to reroute blood flow around them.

    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.

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    Decision Points focus on key medical care decisions that are important to many health problems. Decision Points focus on key medical care decisions that are important to many health problems.
    Peripheral Arterial Disease: Should I Have Surgery?

    Cause

    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. Over time, plaque builds 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.

    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. 1

    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 means that PAD is getting worse.
    • Erectile dysfunction.

    More severe symptoms, such as skin changes on the feet or legs, may be a sign of advanced PAD.

    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 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.

    Who to see

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

    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:

    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 . You may have tests for:

    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.

    If lifestyle changes don't help, or if your PAD gets very bad, you may need angioplasty or bypass surgery of the leg arteries.

    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 supervised exercise program if you have intermittent claudication.
    • Eat heart-healthy foods, such as fruits and vegetables.

    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 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 or who are at risk for losing a limb may need 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 walking 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

    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.

    Click here to view a Decision Point. 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 .

    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.

    Click here to view a Decision Point. Peripheral Arterial Disease: Should I Have Surgery?

    Complementary and alternative medicine

    Alternative treatments, such as ginkgo biloba and carnitine, might help leg pain and may improve how well you can walk. But these are not proven treatments and may not work for everyone.

    Other Places To Get Help

    Organizations

    American Heart Association (AHA)
    7272 Greenville Avenue
    Dallas, TX75231
    Phone: 1-800-AHA-USA1 (1-800-242-8721)
    Web Address: www.heart.org

    Visit the American Heart Association (AHA) website for information on physical activity, diet, and various heart-related conditions. You can search for information on heart disease and stroke, share information with friends and family, and use tools to help you make heart-healthy goals and plans. Contact the AHA to find your nearest local or state AHA group. The AHA provides brochures and information about support groups and community programs, including Mended Hearts, a nationwide organization whose members visit people with heart problems and provide information and support.


    National Heart, Lung, and Blood Institute (NHLBI)
    P.O. Box 30105
    Bethesda, MD20824-0105
    Phone: (301) 592-8573
    Fax: (240) 629-3246
    TDD: (240) 629-3255
    Email: nhlbiinfo@nhlbi.nih.gov
    Web Address: www.nhlbi.nih.gov

    The U.S. National Heart, Lung, and Blood Institute (NHLBI) information center offers information and publications about preventing and treating:

    • Diseases affecting the heart and circulation, such as heart attacks, high cholesterol, high blood pressure, peripheral artery disease, and heart problems present at birth (congenital heart diseases).
    • Diseases that affect the lungs, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema, sleep apnea, and pneumonia.
    • Diseases that affect the blood, such as anemia, hemochromatosis, hemophilia, thalassemia, and von Willebrand disease.

    References

    Citations

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

    Other Works Consulted

    • Alonso-Coello P, et al. (2012). Antithrombotic therapy in peripheral artery disease: Antithrombotic therapy and prevention of thrombosis, 9th ed.?American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2, Suppl): e669S?e690S.
    • Anderson JL, et al. (2012). Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 127(13): 1425?1443.
    • Creager MA, Libby P (2012). Peripheral arterial diseases. In RO Bonow et al., eds., Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed., vol. 2, pp. 1338?1358. Philadelphia: Saunders Elsevier.
    • Fowkes F, Leng GC (2008). Bypass surgery for chronic lower limb ischaemia. Cochrane Database of Systematic Reviews (2).
    • 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.
    • Olin JW, et al. (2010). ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance measures for adults with peripheral artery disease. Journal of the American College of Cardiology, 56(25): 2147?2181.
    • Smith SC, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation. Circulation, 124(22): 2458?2473. Also available online: http://circ.ahajournals.org/content/124/22/2458.full.
    • U.S. Preventive Services Task Force (2005). Screening for peripheral arterial disease. Available online: http://www.uspreventiveservicestaskforce.org/uspstf/uspspard.htm.
    • Wennberg PW, Rooke TW (2011). Diagnosis and management of diseases of the peripheral arteries and veins. In V Fuster et al., eds., Hurst's The Heart, 13th ed., vol. 2, pp. 2331?2346. New York: McGraw-Hill.

    Credits

    By Healthwise Staff
    Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology
    David A. Szalay, MD - Vascular Surgery
    Last Revised October 26, 2013

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