What Is Peripheral Arterial Disease (PAD)?

Peripheral arterial disease (PAD) is a slow and progressive disorder of the blood vessels. PAD is a clogging of arteries in the leg that can be life-threatening if left untreated. PAD can decrease blood flow to the legs and feet, resulting in muscle fatigue and pain when walking and can lead to amputation, disability and diminished quality of life.

An estimated 12 million Americans have PAD, increasing their risk of death from heart attack and stroke by two to six times. Peripheral arterial disease is also called peripheral vascular disease (PVD). 

What Causes Peripheral Arterial Disease?

Peripheral arterial disease (PAD) develops when cholesterol deposits, known as plaque, cause narrowing in an artery and this plaque build-up, called atherosclerosis, can decrease blood flow to the lower extremities. Blood clots can migrate down the blood stream and cause a total blockage of that narrowed artery, starving the limbs of oxygen beyond the blockage which can lead to tissue death. 

Other causes of peripheral arterial disease may include:

• Injury to the arms or legs
• Irregular anatomy of muscles or ligaments
• Infection

People with coronary artery disease (CAD) often have PAD. 

Am I At Risk For Peripheral Arterial Disease?

“A key to managing peripheral arterial disease is to manage your risk factors,” said Rahul Arya, MD, an independent, board-certified vascular and interventional radiologist who chooses to practice at Franciscan Health. “The leading risk factors for PAD include smoking, high blood pressure, hyperlipidemia, age and diabetes – the same factors that can lead to heart disease and stroke.”

Other risk factors for PAD include:

• Age (higher risk over age 50)
• History of heart disease
• Male gender
• Postmenopausal women
• Family history of high cholesterol, high blood pressure, or peripheral vascular disease
• Coronary artery disease
• Diabetes
• High cholesterol
• High blood pressure
• Overweight
• Physical inactivity
• Smoking or use of tobacco products

Those who smoke or have diabetes have the highest risk of complications from PAD. This is because these risk factors cause impaired blood flow. 

How Can I Prevent Peripheral Arterial Disease?

Many risk factors for PAD can be modified through changes in your daily routine and lifestyle. These changes include:

• Quit smoking. Ask your doctor or healthcare professional about ways to quit smoking. “It's incredibly rare to see any of this in someone who is not a smoker,” J.D. Graham, MD, FACC, a cardiologist with Franciscan Physician Network Indiana Heart Physicians, told WCBK radio.
• Exercise. An often effective treatment for PAD symptoms is regular physical activity.  Even if there is pain while walking, most patients are instructed to continue walking through the pain so the blood vessels can create new pathways of oxygen delivery to the muscles.
• Reaching a healthier weight. Maintaining a healthier weight can reduce your risk for not only PAD, but also coronary heart disease, high blood pressure, high cholesterol, diabetes and other chronic diseases.
• Eating a diet rich in whole grains, colorful fruits and vegetables, low-fat dairy choices and lean proteins
• Control your chronic health conditions. If you have type II diabetes, high blood pressure, or high cholesterol, it is important to get these conditions under control to help prevent further progress of PAD, stroke and heart attack.

“It's a combination of healthy eating, weight loss, not smoking, and getting your other risk factors –diabetes, high blood pressure and cholesterol – treated as best you can with your family doctor,” Dr. Graham said.

What Are Symptoms of Peripheral Arterial Disease?

About half the people diagnosed with PAD have no symptoms. For those with symptoms, the most common first symptom is painful leg cramping that occurs with exercise and is relieved by rest.

“Mild to moderate spectrum PAD ranges from people who have no symptoms to those who have leg pain during walking or exercise,” Dr. Arya said. “With severe spectrum PAD, people can have pain at rest.”

This leg pain occurs from a condition called claudication.

“If you have a narrowed artery in the thigh, it's restricting the blood getting down to your calf and your foot, so that when you walk you'll start having what's called ‘claudication,’ which is a crampy discomfort that feels like an acid burn.  This can cause a person to grab hold of that muscle,” Dr. Graham said. “With arms and legs, it's almost always this claudication sensation, and it's pretty predictable. If you have PAD, and you can walk 100 feet before they start to burn, every time you walk, you'll get to 100 feet and it'll start to burn.”

 Other symptoms of peripheral arterial disease may include:

• Changes in the skin, including decreased skin temperature, or thin, brittle, shiny skin on the legs and feet
• Weak pulses in the legs and the feet
• Gangrene (dead tissue due to lack of blood flow)
• Hair loss on the legs
• Impotence
• Wounds that won't heal over pressure points, such as heels or ankles
• Numbness, weakness, or heaviness in muscles
• Pain (described as burning or aching) at rest, commonly in the toes and at night while lying flat
• Paleness when the legs are elevated
• Reddish-blue discoloration of the extremities
• Restricted mobility
• Severe pain when the artery is very narrow or blocked
• Thickened, opaque toenails

“Even more severe disease can lead to ulcerations and non-healing wounds,” Dr. Arya said. “A superinfection may result which can spread to other areas of the body.”

What Should I Do If I Have Symptoms of Peripheral Arterial Disease?

Diagnosis and treatment can help with symptoms, help heal wounds and even save patients from amputation. An arterial brachial index (ABI) is a quick, non-invasive screening tool that uses Doppler ultrasound, and can indicate the presence and severity of peripheral arterial disease. An ABI compares the blood pressure in your ankle with the blood pressure in your arm using a regular blood pressure cuff and a special ultrasound device to evaluate blood pressure and flow.

“It's a blood flow measurement that's primarily for the legs, but it can be done with the arm,” Dr. Graham said.

If significant disease is present during the ABI test, a CT angiogram (CTA) or MR angiogram (MRA) can be performed to determine if it can be treated. Based on the results of these tests, the next step is an angiogram with possible interventions.

“During an angiogram, we access the artery via the groin and inject contrast dye to evaluate where the disease is located,” Dr. Arya said. “Based on the findings, an intervention may be performed during the same procedure, or in stages. If there is a significant vascular narrowing, one procedure, atherectomy, basically gently sands down the plaque within the artery. Following this, angioplasty is usually performed, which involves inserting a balloon into the artery and inflating it where the narrowing occurs in order to open the vessel. The balloon is then removed. A stent may be placed to keep the blood vessel open. Newer technology balloons and stents are drug eluting, meaning they deliver medication to prevent the recurrence of blood vessel narrowing.”

Are There Treatments For PAD That Don’t Require Surgery?

The main goals for treatment of PAD are to control the symptoms and halt the progression of the disease. This is important to lower the risk for heart attack, stroke, and other problems. 

“A simple little analogy I like to make is, let's say you have a three-story house, and the basement pipes are corroded and have lime buildup, and they're kind of blocked up. It's most likely that the main level and the upstairs level will have the same problem in the pipes, because they're all exposed to the same wear and tear over time,” Dr. Graham said. “So if you've got a problem with the leg arteries, which would be the basement, you've got to worry about the heart arteries, which would be the main level, and the brain arteries, which would be the upper level.”

Treatment for peripheral arterial disease may include lifestyle changes to control risk factors, including regular exercise, good nutrition, and not smoking.

“The idea is to encourage this blood vessel growth, and that way you might, over the course of time, see that, ‘OK, I could walk 100 feet before. Now I'm doing 150,’” Dr. Graham said. “Hopefully you get up to 200, and eventually get to a point where these extra blood vessels have taken over adequately that you're not slowed down by discomfort.”

In cases of more severe disease, surgical interventions may be needed to open up the blocked artery.

“In cases of severe disease where patients are unable to get sufficient blood supply to heal their lower extremity wounds, performing these interventions can go a long way toward healing those wounds and even preventing an amputation,” Dr. Arya said.