University of California San Francisco

Peripheral Artery Disease (PAD)

Peripheral Artery Disease is a disease in which plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of fat, cholesterol, calcium, fibrous tissue, and other substances in the blood.

When plaque builds up in the body's arteries, the condition is called atherosclerosis. Over time, plaque can harden and narrow the arteries. This limits the flow of oxygen-rich blood to your organs and other parts of your body. PAD usually affects the arteries in the legs, but it also can affect the arteries that carry blood from your heart to your head, arms, kidneys, and stomach. As with clogged arteries in the heart, PAD raises the risk of heart attack, stroke, and even death.

Diabetes patients tend to develop vascular disease especially in the peripheral arteries of the feet and legs. Michael S. Conte, M.D., Chief of Vascular Surgery at UCSF, discusses the connection between peripheral artery disease (PAD) and diabetes with Andrew Schorr of Patient Power. PAD is underdiagnosed and undertreated in diabetics and often not properly treated even when identified. Early diagnosis is the key to saving limbs from amputation. Dr. Conte discusses the various approaches to treatment for PAD and the advantages to seeking care from a multidisciplinary team of specialists.

Blocked blood flow to your legs can cause pain and numbness. It also can raise your risk of getting an infection in the affected limbs, which your body may have a hard time fighting off.

If severe enough, blocked blood flow can cause gangrene (tissue death). In very serious cases, this can lead to leg amputation.

If you have leg pain when you walk or climb stairs, talk with your doctor. Sometimes older people think that leg pain is just a symptom of aging - however, the cause of the pain could actually be PAD. Tell your doctor if you're feeling pain in your legs and discuss whether you should be tested for PAD.

Smoking is the main risk factor for PAD. If you smoke or have a history of smoking, your risk of PAD increases. Other factors, such as age and having certain diseases or conditions, also increase your risk of PAD.

Normal Artery and Artery With Plaque Buildup

The illustration shows how PAD can affect arteries in the legs. Figure A shows a normal artery with normal blood flow. The inset image shows a cross-section of the normal artery. Figure B shows an artery with plaque buildup that's partially blocking blood flow. The inset image shows a cross-section of the narrowed artery.

The illustration above shows how PAD can affect arteries in the legs. Figure A shows a normal artery with normal blood flow. The inset image shows a cross-section of the normal artery. Figure B shows an artery with plaque buildup that's partially blocking blood flow. The inset image shows a cross-section of the narrowed artery.

Other Names for Peripheral Artery Disease

  • Atherosclerotic peripheral arterial disease
  • Claudication
  • Hardening of the arteries
  • Leg cramps from poor circulation
  • Peripheral arterial disease
  • Peripheral vascular disease
  • Poor circulation
  • Vascular disease

Causes

The most common cause of peripheral artery disease (PAD) is atherosclerosis. Atherosclerosis is a disease in which plaque builds up in your arteries. The exact cause of atherosclerosis isn't known.

The disease may start if certain factors damage the inner layers of the arteries. These factors include:

When damage occurs, your body starts a healing process. The healing may cause plaque to build up where the arteries are damaged.

Eventually, a section of plaque can rupture (break open), causing a blood clot to form at the site. The buildup of plaque or blood clots can severely narrow or block the arteries and limit the flow of oxygen-rich blood to your body.

Risk Factors

Peripheral artery disease (PAD) affects millions of people in the United States. The disease is more common in black people than any other racial or ethnic group. The major risk factors for PAD are smoking, older age, and having certain diseases or conditions.

Smoking

Smoking is the main risk factor for PAD, and your risk increases if you smoke or have a history of smoking. Quitting smoking slows the progress of PAD. People who smoke and people who have diabetes are at highest risk for PAD complications, such as gangrene (tissue death) in the leg from decreased blood flow.

Older Age

Older age also is a risk factor for PAD. Since plaque builds up in your arteries as you age, older age combined with other risk factors, such as smoking or diabetes, also puts you at higher risk for PAD.

Diseases and Conditions

Many diseases and conditions can raise your risk of PAD, including:

Signs and Symptoms

Many people who have peripheral artery disease (PAD) don’t have any signs or symptoms.

Even if you don't have signs or symptoms, ask your doctor whether you should get checked for PAD if you're:

Intermittent Claudication

People who have PAD may have symptoms when walking or climbing stairs, which may include pain, numbness, aching, or heaviness in the leg muscles. Symptoms also may include cramping in the affected leg(s) and in the buttocks, thighs, calves, and feet, which may ease after resting. These symptoms are called intermittent claudication.

During physical activity, your muscles need increased blood flow. If your blood vessels are narrowed or blocked, your muscles won't get enough blood, which will lead to symptoms. When resting, the muscles need less blood flow, so the symptoms will go away.

Other Signs and Symptoms

Other signs and symptoms of PAD include:

  • Weak or absent pulses in the legs or feet.
  • Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all.
  • A pale or bluish color to the skin.
  • A lower temperature in one leg compared to the other leg.
  • Poor nail growth on the toes and decreased hair growth on the legs.
  • Erectile dysfunction, especially among men who have diabetes.

The UCSF Vascular Surgery program offers seamless state-of-the-art multidisciplinary care for PAD. As the leading tertiary referral center for the region, our surgeons treat the most complex, technically challenging cases, such as in patients who also suffer from diabetic peripheral nerve damage and are at risk for limb amputation. 

Diagnosis

Peripheral artery disease (PAD) is diagnosed based on your medical and family histories, a physical exam, and test results.

PAD is often diagnosed after symptoms are reported. A correct diagnosis is important because people who have PAD are at higher risk for coronary heart disease (CHD), heart attack, stroke, and transient ischemic attack ("mini-stroke"). If you have PAD, your doctor may also want to check for signs of these diseases and conditions.

Specialists Involved

Primary care doctors, such as internists and family doctors, may treat people who have mild PAD. For more advanced PAD, a vascular specialist may become involved. This is a doctor who specializes in treating blood vessel diseases and conditions.

A cardiologist may also be involved in treating people who have PAD. Cardiologists treat heart problems, such as CHD and heart attack, which often affect people who have PAD.

Medical and Family Histories

Your doctor may ask:

  • Whether you have any risk factors for PAD. For example, he or she may ask whether you smoke or have diabetes.
  • About your symptoms, including any symptoms that occur when walking, exercising, sitting, standing, or climbing.
  • About your diet.
  • About any medicines you take, including prescription and over-the-counter medicines.
  • Whether anyone in your family has a history of heart or blood vessel diseases.

Physical Exam

During the physical exam, your doctor will look for signs of PAD. He or she may check the blood flow in your legs or feet to see whether you have weak or absent pulses.

Your doctor may also check the pulses in your leg arteries for an abnormal whooshing sound called a bruit. He or she can hear this sound with a stethoscope. A bruit may be a warning sign of a narrowed or blocked artery.

Your doctor may compare blood pressure between your limbs to see whether the pressure is lower in the affected limb. He or she may also check for poor wound healing or any changes in your hair, skin, or nails that may be signs of PAD.

Diagnostic Tests

Ankle-Brachial Index

A simple test called an ankle-brachial index (ABI) is often used to diagnose PAD. The ABI compares blood pressure in your ankle to blood pressure in your arm. This test shows how well blood is flowing in your limbs.

ABI can show whether PAD is affecting your limbs, but it won't show which blood vessels are narrowed or blocked.

A normal ABI result is 1.0 or greater (with a range of 0.90 to 1.30). The test takes about 10 to 15 minutes to measure both arms and both ankles. This test may be performed yearly to see whether PAD is getting worse.

Ankle-Brachial Index

The illustration shows the ankle-brachial index test. The test compares blood pressure in the ankle to blood pressure in the arm. As the blood pressure cuff deflates, the blood pressure in the arteries is recorded. 

The illustration shows the ankle-brachial index test. The test compares blood pressure in the ankle to blood pressure in the arm. As the blood pressure cuff deflates, the blood pressure in the arteries is recorded.

Doppler Ultrasound

A Doppler ultrasound looks at blood flow in the major arteries and veins in the limbs. During this test, a handheld device is placed on your body and passed back and forth over the affected area. A computer converts sound waves into a picture of blood flow in the arteries and veins.

The results of this test can show whether a blood vessel is blocked. The results can also help show the severity of PAD.

Treadmill Test

A treadmill test can show the severity of symptoms, and the level of exercise that will trigger them. You'll walk on a treadmill for this test. This shows whether you have any problems during normal walking.

You may have an ABI test before and after the treadmill test. This will help compare blood flow in your arms and legs before and after exercise.

Magnetic Resonance Angiogram

A magnetic resonance angiogram (MRA) uses magnetic and radio wave energy to take pictures of your blood vessels. This test is a type of magnetic resonance imaging (MRI).

An MRA can show the location and severity of a blocked blood vessel. If you have a pacemaker, man-made joint, stent, surgical clips, mechanical heart valve, or other metallic devices in your body, you might not be able to have an MRA. Ask your doctor whether an MRA is an option for you.

Arteriogram

An arteriogram provides a "road map" of the arteries. Doctors use this test to find the exact location of a blocked artery.

For this test, dye is injected through a needle or catheter (tube) into one of your arteries. This may make you feel mildly flushed. After the dye is injected, an x-ray is taken. The x-ray can show the location, type, and extent of the blockage in the artery.

Some doctors use a newer method of arteriogram that uses tiny ultrasound cameras. These cameras take pictures of the insides of the blood vessels. This method is called intravascular ultrasound.

Blood Tests

Your doctor may recommend blood tests to check for PAD risk factors. For example, blood tests can help diagnose conditions such as diabetes and high blood cholesterol.

Treatment

Treatments for peripheral artery disease (PAD) include lifestyle changes, medicines, and surgery or procedures.

The overall goals of treating PAD include reducing risk of heart attack and stroke; reducing symptoms of claudication; improving mobility and overall quality of life; and preventing complications. Treatment is based on your signs and symptoms, risk factors, and the results of physical exams and tests.

Treatment may slow or stop the progression of the disease and reduce the risk of complications. Without treatment, PAD may progress, resulting in serious tissue damage in the form of sores or gangrene (tissue death) due to inadequate blood flow. In extreme cases of PAD, also referred to as critical limb ischemia (CLI), amputation (removal) of part of the leg or foot may be necessary.

Lifestyle Changes

Treatment often includes making long-lasting lifestyle changes, such as:

Physical Activity

Routine physical activity can improve PAD symptoms and lower many risk factors for atherosclerosis, including LDL (“bad”) cholesterol, high blood pressure, and excess weight. Exercise can improve the distances you can comfortably walk.

Talk with your doctor about taking part in a supervised exercise program. If a supervised program is not an option, ask your doctor to help you develop an exercise plan. Most exercise programs begin slowly, which includes simple walking alternating with rest. Over time, most people build up the amount of time they can walk before developing pain. The more active you are, the more you will benefit.

Quitting Smoking

If you smoke, quit. Smoking raises your risk for PAD. Smoking also raises your risk for other diseases, such as coronary heart disease and heart attack, and worsens other coronary heart disease risk factors. Talk with your doctor about programs and products that can help you quit smoking. Also, try to avoid secondhand smoke.

If you have trouble quitting smoking on your own, consider joining a support group. Many hospitals, workplaces, and community groups offer classes to help people quit smoking.

Read more about quitting smoking at Smoking and Your Heart.

Heart-Healthy Eating

Your doctor may recommend heart-healthy eating to treat atherosclerosis, the most common cause of PAD. Following heart-healthy eating can help control blood pressure and cholesterol levels, which can lead to atherosclerosis.

Medicines

Your doctor may prescribe medicines to:

  • Prevent blood clots from forming due to low blood flow with anticlotting medicines, such as aspirin.
  • Treat unhealthy cholesterol levels with statins. Statins control or lower blood cholesterol. By lowering your blood cholesterol level, you can decrease your chance of developing complications from PAD.
  • Treat high blood pressure with one of many high blood pressure medicines.
  • Help ease leg pain that occurs when you walk or climb stairs.
  • Reduce the symptoms of intermittent claudication, measured by increased walking distance with certain platelet-aggregation inhibitors.

Surgery or Procedures

Bypass Grafting

Your doctor may recommend bypass grafting surgery if blood flow in your limb is blocked, or nearly blocked. For this surgery, your doctor uses a blood vessel from another part of your body, or a synthetic tube, to make a graft.

This graft bypasses (that is, goes around) the blocked part of the artery. The bypass allows blood to flow around the blockage. This surgery doesn’t cure PAD, but it may increase blood flow to the affected limb.

Angioplasty and Stent Placement

Your doctor may recommend angioplasty to restore blood flow through a narrowed or blocked artery.

During this procedure, a catheter (thin tube) with a balloon at the tip is inserted into a blocked artery. The balloon is then inflated, which pushes plaque outward against the artery wall. This widens the artery and restores blood flow.

A stent (a small mesh tube) may be placed in the artery during angioplasty. A stent helps keep the artery open after angioplasty is done. Some stents are coated with medicine to help prevent blockages in the artery.

Atherectomy

Atherectomy is a procedure that removes plaque buildup from an artery. During the procedure, a catheter is used to insert a small cutting device into the blocked artery. The device is used to shave or cut off plaque.

The bits of plaque are removed from the body through the catheter or washed away in the bloodstream (if they’re small enough).

Prevention

Taking action to control your risk factors can help prevent or delay peripheral artery disease (PAD) and its complications. Know your family history of health problems related to PAD - if you or someone in your family has the disease, be sure to tell your doctor. Controlling risk factors includes the following:

  • Be physically active.
  • Get screened for PAD. A simple office test, called an ankle-brachial index or ABI, can help determine whether you have PAD.
  • Follow heart-healthy eating.
  • If you smoke, quit. Talk with your doctor about programs and products that can help you quit smoking.
  • If you’re overweight or obese, work with your doctor to create a reasonable weight-loss plan.

The lifestyle changes described above can reduce your risk of developing PAD. These changes can also help prevent and control conditions that can be associated with PAD, such as coronary heart disease, diabetes, high blood pressure, high blood cholesterol, and stroke.

Living With Peripheral Artery Disease

If you have peripheral artery disease (PAD), you’re more likely to also have coronary heart disease, heart attack, stroke, and transient ischemic attack ("mini-stroke"). However, you can take steps to treat and control PAD and lower your risk for these other conditions.

Living With Peripheral Artery Disease Symptoms

If you have PAD, you may feel pain in your calf or thigh muscles after walking. Try to take a break and allow the pain to ease before walking again. Over time, this may increase the distance that you can walk without pain.

Talk with your doctor about taking part in a supervised exercise program. This type of program has been shown to reduce PAD symptoms.

Check your feet and toes regularly for sores or possible infections. Wear comfortable shoes that fit well. Maintain good foot hygiene and get professional medical treatment for corns, bunions, or calluses.

Ongoing Health Care Needs and Lifestyle Changes

See your doctor for checkups as he or she advises. If you have PAD without symptoms, you still should see your doctor regularly. Take all medicines as your doctor prescribes.

Heart-healthy lifestyle changes can help prevent or delay PAD and other related problems, such as coronary heart disease, heart attack, stroke, and transient ischemic attack. Heart-healthy lifestyle changes include physical activity, quitting smoking, and heart-healthy eating. Your doctor may recommend heart-healthy eating, which should include:

  • Fat-free or low-fat dairy products, such as low-fat milk
  • Fish high in omega-3 fatty acids, such as salmon, tuna, and trout, about twice a week
  • Fruits, such as apples, bananas, oranges, pears, and prunes
  • Legumes, such as kidney beans, lentils, chickpeas, black-eyed peas, and lima beans
  • Vegetables, such as broccoli, cabbage, and carrots
  • Whole grains, such as oatmeal, brown rice, and corn tortillas

When following a heart-healthy diet, you should avoid eating:

  • A lot of red meat
  • Palm and coconut oils
  • Sugary foods and beverages

Two nutrients in your diet make blood cholesterol levels rise:

  • Saturated fat—found mostly in foods that come from animals
  • Trans fat (trans fatty acids)—found in foods made with hydrogenated oils and fats, such as stick margarine; baked goods, such as cookies, cakes, and pies; crackers; frostings; and coffee creamers. Some trans fats also occur naturally in animal fats and meats.

Saturated fat raises your blood cholesterol more than anything else in your diet. When you follow a heart-healthy eating plan, only 5 percent to 6 percent of your daily calories should come from saturated fat. Food labels list the amounts of saturated fat. To help you stay on track, here are some examples:

If you eat:

Try to eat no more than:

1,200 calories a day                             

 8 grams of saturated fat a day             

1,500 calories a day

10 grams of saturated fat a day

1,800 calories a day

12 grams of saturated fat a day

2,000 calories a day

13 grams of saturated fat a day

2,500 calories a day

17 grams of saturated fat a day

However, not all fats are bad - monounsaturated and polyunsaturated fats actually help lower blood cholesterol levels. Some sources of monounsaturated and polyunsaturated fats include:

  • Avocados
  • Corn, sunflower, and soybean oils
  • Nuts and seeds, such as walnuts
  • Olive, canola, peanut, safflower, and sesame oils
  • Peanut butter
  • Salmon and trout
  • Tofu

Sodium

You should try to limit the amount of sodium that you eat - this means choosing and preparing foods that are lower in salt and sodium. Try to use low-sodium and “no added salt” foods and seasonings at the table, or while cooking. Food labels tell you what you need to know about choosing foods that are lower in sodium. Try to eat no more than 2,300 milligrams of sodium a day. If you have high blood pressure, you may need to restrict your sodium intake even more.

Dietary Approaches to Stop Hypertension

Your doctor may recommend the Dietary Approaches to Stop Hypertension (DASH) eating plan if you have high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and low in fat, cholesterol, and sodium and salt.

The DASH eating plan is a good heart-healthy eating plan, even for those who don’t have high blood pressure. Read more about DASH.

Alcohol

Try to limit alcohol intake. Too much alcohol can raise your blood pressure and triglyceride levels, a type of fat found in the blood. Alcohol also adds extra calories, which may cause weight gain.

Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day. One drink is:

  • 12 ounces of beer
  • 5 ounces of wine
  • 1½ ounces of liquor

Doctors also can perform atherectomy using a special laser that dissolves the blockage.

Other Types of Treatment

Researchers are studying cell and gene therapies to treat PAD. However, these treatments aren’t yet available outside of clinical trials. Read more about clinical trials.

Outlook

PAD increases your risk of coronary heart disease, heart attack, stroke, and transient ischemic attack ("mini-stroke"). Although PAD is serious, it's treatable. If you have the disease, see your doctor regularly and treat the underlying atherosclerosis. PAD treatment may slow or stop disease progress and reduce the risk of complications. Researchers continue to explore new therapies for PAD.

Links to Other Information About Peripheral Artery Disease

Vascular Cures

Focus on Ischemia (Vascular Cures)

Educational Flyer on PAD (Vascular Cures)

Educational Flyer on Foot Care and PAD (Vascular Cures)

NHLBI Resources

Non-NHLBI Resources