Peripheral artery disease (P.A.D.) 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.

P.A.D. 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. This article focuses on P.A.D. that affects blood flow to the legs.

Normal Artery and Artery With Plaque Buildup

Overview

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. Your body may have a hard time fighting the infection.

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 be P.A.D. Tell your doctor if you're feeling pain in your legs and discuss whether you should be tested for P.A.D.

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

Outlook

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

Atherosclerosis is the main cause of PAD.

Plaque buildup in the artery is called atherosclerosis. Atherosclerosis is a disease in which a waxy substance called plaque builds up on the inner lining of arteries. Plaque is made up of fat, cholesterol, fibrous tissue, and calcium. In PAD, plaque may reduce or fully block the flow of oxygen-rich blood through arteries to the body’s vital organs and the limbs.

This health topic focuses on PAD in the legs and feet, but other types of PAD block blood flow to the brain, kidneys, or the intestines. A person may have atherosclerosis in just a single artery or in many.

Scientists think atherosclerosis may start with damage to the inner wall of the artery. Cholesterol and cell waste traveling in the blood can build up in the damaged area. This video shows how buildup of cholesterol and other waste can lead to plaque buildup (atherosclerosis). The artery narrows as the plaque grows, reducing the flow of oxygen-rich blood to the limbs and organs. Over time, the plaque can break and flow into the bloodstream. This may lead to blood clots, which can block blood flow. If this happens, nearby tissue can't get enough oxygen and may die. Medical Animation Copyright © 2020 Nucleus Medical Media Inc. All rights reserved. 

PAD is a lifelong medical condition. Once you have been diagnosed with PAD, you will need to regularly see a doctor who specializes in vascular (blood vessel) diseases. You will need to take steps to prevent complications. Learn the warning signs of a medical emergency related to PAD, below.

A team of healthcare professionals can help you manage PAD and treat any complications. You may need to see specialists in vascular (blood vessel) medicine, cardiologists to treat heart disease, radiologists to do imaging tests, vascular surgeons to perform procedures to improve blood flow, infectious disease specialists to treat infections, physical therapists to guide your exercise program, podiatrists to provide foot care, and nutritionists to help you plan healthy meals.

Manage your condition

It is important to get routine medical care and to take all medicines as your doctor prescribes.

• Talk with your doctor about how often you should schedule office visits and blood tests or other tests.
• Call your doctor between visits if you start to have leg pain that does not go away after a few minutes of rest or if any other PAD symptoms get worse. Changes in symptoms could be a sign of PAD complications.
• Get recommended vaccines, including the pneumococcus and influenza (flu) shots, every year at the start of flu season. Anyone who lives with you or whom you see often should also get regular vaccines.

Follow up with your doctor regularly to check your risk factors, monitor symptoms, and assess your legs and feet.

Take care of your feet

Foot problems are a common complication of PAD. If you develop a foot sore, you’ll need regular care to help the sore heal and prevent infection.

Many people who have PAD also have diabetes, which raises the risk of complications that may lead to amputation, a type of surgery to remove all or part of a foot or leg. Diabetes may also cause nerve problems that make it hard to sense when you have injured your feet.

You can reduce your risk for foot ulcers and infections by taking care of your feet.

• Always wear socks and shoes. Socks should not have any seams. Wear comfortable shoes that fit well and protect your feet. Your shoes should have low heels and shock-absorbing soles to reduce pressure on the bottom of your foot. Shoes should have fasteners to prevent rubbing. Your doctor may recommend that you visit a specialist who can modify your shoes to reduce your chance of getting sores on your feet.
• Check your feet every day for injuries or sores. If you have PAD and diabetes, have your doctor examine your feet twice a year.
• Do not go barefoot. This will help prevent foot injury that can lead to ulcers and infections, which are more likely when you have poor circulation.
• Follow your doctor’s instructions about caring for incisions (openings) made in the skin of your legs or feet during surgery or a procedure for treating PAD. Return to Treatment to review possible treatment options for PAD.
• See your doctor for any foot problems. Do not treat corns, calluses, long or ingrown nails, or other foot problems yourself to avoid injuries that could lead to sores or infections.  

Women and PAD

Certain conditions during pregnancy, such as preeclampsia (a high-blood pressure disorder) or gestational diabetes (high blood sugar during pregnancy), can raise a woman’s risk of developing PAD later in life. 

PAD affects women and men differently. Women’s PAD symptoms may be worse than men’s.  Women who have PAD often cannot walk as far or as fast as men who have PAD. They also report lower quality of life than men, perhaps because it’s harder to walk and take part in daily activities. Depression is also more common in women who have PAD than in men who have PAD.

Diseases linked with PAD

People who have PAD have lifestyle habits and other factors, such as a family history, that make it more likely that they will develop other diseases related to atherosclerosis, including the following:

• Coronary heart disease, in which plaque builds up in the arteries of the heart
• Diseases that affect the arteries of the brain, including stroke and vascular dementia
• Heart attack
• Carotid artery disease, which affects the arteries in the neck
• Atrial fibrillation, a type of irregular heart rhythm
• Heart failure
• Chronic kidney disease
• Sleep apnea

If you have PAD with symptoms, your doctor may use ultrasound to screen you for abdominal aortic aneurysm.

Control your blood pressure

If you have high blood pressure, it is important that you continue your treatment plan. Following your treatment plan, getting regular follow-up care, and learning how to monitor your condition at home are important. Let your doctor know if you are planning to become pregnant. These steps can help prevent or delay complications that high blood pressure can cause.

Your doctor may adjust your treatment plan as needed to lower or control your high blood pressure.

Follow your diabetes care plan

If you have diabetes, your doctor will recommend lifestyle changes, including a special eating plan, and may prescribe medicines to manage blood sugar levels. Managing diabetes carefully can lower your risk of complications.

Be alert for sores on your feet or legs, and call your doctor if you see signs of a sore getting infected, such as redness, swelling, pain, or pus, or if you have a fever or chills. To treat sores, your doctor may prescribe antibiotics, clean the sores, remove dead tissue with surgery and apply medicines and bandages to the area.

Manage your blood cholesterol levels

If you have unhealthy levels of blood cholesterol, it is important that you continue your treatment. Follow-up care depends on your cholesterol levels, your risk of complications such as a heart attack or a stroke, and your response to treatment.

Take care of your mental health

Living with PAD may cause fear, anxiety, depression, and stress. You may worry about having heart problems or making lifestyle changes that are necessary for your health. Some people become depressed because of problems with walking and daily activities. PAD might also lead to concerns about the risk of amputation.

By lowering stress levels and learning coping skills, you may be able to live longer and improve your quality of life. Talk with your healthcare team about how you feel. Your doctor may recommend you take steps such as these:

• Join a patient support group. This may help you adjust to living with PAD. You can find out how other people manage similar symptoms. Your doctor may be able to recommend local support groups, or you can check with an area medical center.
• Seek support from family and friends. Letting your loved ones know how you feel and what they can do to help you can help relieve stress and anxiety.
• Talk to a professional counselor. If you have depression or anxiety, your doctor may also recommend medicines or other treatments that can improve your quality of life.

Know when to call for help

PAD puts you at high risk of serious health problems. If you think that you are having symptoms of PAD, check with your doctor. For the following conditions, call 9-1-1 right away. Every minute matters.

Acute limb ischemia

Acute limb ischemia is a medical emergency that must be treated rapidly to avoid amputation or other serious problems. Seek medical help right away if:

• You cannot feel or move your foot
• Your leg or foot hurts or feels like “pins and needles” while resting
• One foot is paler or colder than the other

Bloodstream infection

When bacteria enter the blood from an infected sore, they can cause a bloodstream infection. Symptoms include fever and chills. Intravenous (IV) antibiotics need to be given right away in a hospital. If a blood infection is not treated in time, or if the immune system can’t control the infection, the body’s inflammatory response can lead to septic shock, organ failure, or even death.

Bone infections

If you develop deep ulcers over bones, you are at risk for a bone infection called osteomyelitis. Symptoms include bone pain; excessive sweating; fever and chills; swelling, redness, pain, and warmth at the site of infection; and an open wound that may show pus. Treatment includes antibiotics, surgery to remove infected bone, and procedures to improve blood flow. Treatment may have to be given in a hospital.

Cellulitis

Cellulitis is a skin infection that can spread to the deep tissues of the skin and muscle. Symptoms include areas of the skin that are warm, swollen, and tender. Cellulitis can also cause fever, chills, swollen lymph nodes, and blisters.

Your doctor may prescribe antibiotics to take by mouth. If the infection gets worse or if you get very sick, you may need to stay in the hospital for treatment.

You may have a higher risk of lower extremity PAD because of your age, family history and genetics , lifestyle habits, other medical conditions, race, ethnicity, and sex. The risk factors for PAD are mostly the same as those for coronary heart disease and carotid artery disease, which are also caused by atherosclerosis.

Risk factors that you can change to decrease the chances of getting PAD include smoking, unhealthy blood cholesterol levels, high blood triglycerides, high blood pressure, overweight and obesity, and metabolic syndrome.

Age

You can develop PAD at any age, but your risk goes up as you get older. Most people in the United States who have PAD are age 65 or older.

Worldwide, the age group is younger (ages 45 to 49) in countries with lower incomes, compared to high-income countries.

Family history and genetics

A family history of PAD, heart disease, stroke, or blood vessel disease, such as some types of vasculitis, raises your risk for PAD. Researchers are studying genes variations that seem to increase the risk of PAD or could make the disease worse.

Genetic studies have found that certain gene variations are found in different types of atherosclerotic diseases, such as PAD, carotid artery disease, and coronary heart disease. An example is the gene variation that’s found in factor V Leiden disorder that increases the risk of blood clots .

Lifestyle habits

Over time, unhealthy lifestyle habits can lead to plaque buildup in leg arteries and PAD. These risk factors include:

• Smoking or regularly breathing in secondhand smoke. Tobacco smoke damages your blood vessels, raises your blood pressure, and causes unhealthy cholesterol levels. The nicotine in tobacco also makes your blood vessels tighten and reduces blood flow in your legs. Quitting smoking is a very important action to lower your risk of PAD.
• Not getting enough physical activity can worsen other PAD risk factors.
• Stress, which can make your arteries tighten.
• Unhealthy eating patterns, such as eating foods high in saturated fats. Saturated, or “bad,” fats come from animal sources such as butter, cheese, and fatty meats.

Other medical conditions

Medical conditions that raise your risk of developing PAD include:

• Diabetes
• Chronic kidney disease
• Disorders that cause blood clots, such as thrombocytosis or antiphospholipid antibody syndrome
• Fibromuscular dysplasia, which can cause the artery walls to grow too much, narrowing the artery
• High blood pressure
• Metabolic syndrome
• Obesity
• Unhealthy blood cholesterol levels or high blood triglycerides

Women who have had preeclampsia or gestational diabetes during pregnancy have a higher risk of developing PAD later in life.

Race or ethnicity

African Americans have a higher risk of PAD than people of other races or ethnicities. African Americans are also more likely to have complications of PAD, such as problems walking and loss of a limb.

American Indian women have a higher risk of PAD than white or Asian American women do. Hispanics and Latinos and whites have similar risk levels. However, NHLBI research found that rates of lower extremity PAD are higher among Hispanic and Latino adults who have highly sedentary lifestyles, even without any other risk factors.

Sex

Men and women have a similar risk of developing PAD, but PAD affects men and women differently.

Women are more likely than men to have PAD without symptoms. Women also often have more PAD complications, such as problems walking.

Your doctor will diagnose PAD based on your medical and family history, a physical exam, and the results from tests and procedures.

Medical history and physical exam

To help diagnose PAD, your doctor will want to learn about your signs and symptoms, risk factors, personal health history, and family health history. This discussion may include questions about the following:

• Other medical conditions, including diabetes, heart disease, and chronic kidney disease
• Pain or cramps in your legs while walking or exercising
• Problems with your legs and feet, including swelling, redness, trouble with walking, and wounds that are slow to heal
• Smoking, either currently or in the past
• Your family history of PAD, heart disease, and other blood vessel diseases

During an exam to look for signs of PAD, your doctor will take these steps:

• Check for weak pulses in your legs.
• Listen for poor blood flow in your legs. Your doctor will use a stethoscope to listen for an abnormal whooshing sound, called a bruit.
• Look for problems on your legs and feet, including swelling, sores, or pale skin.

Conditions that can seem like PAD

Some conditions, such as arthritis or problems with the veins, can cause leg pain, but the symptoms are different from PAD. By doing a physical exam and taking your medical history, your doctor can often rule out these conditions.

However, problems with nerves can cause pain that may be confused with PAD. Sometimes a nerve is squeezed where it exits the spinal column. The result is pain that radiates, or spreads, from the hips or buttocks and down the leg.

To confirm that your pain is the result of PAD, your doctor may ask you to stand up or change your position. Those movements often trigger nerve-related pain. In contrast, PAD pain is often brought on by leg exercise and is quickly relieved by rest with no need to change position.

Diagnostic tests and procedures

The ankle-brachial index (ABI) test is usually the first test used to diagnose PAD. The test compares blood pressure in your ankle with the blood pressure in your arm. Your doctor uses a blood pressure cuff and  ultrasounds device for this painless test.

A healthy ABI result is 1.00 or greater. If you have an ABI of less than 0.90 while resting, you may have PAD. An ABI of less than 0.40 is a sign of severe PAD. If there are problems with the arteries in your ankle, your doctor may do a toe-brachial index (TBI) test instead, which measures the blood pressure in your big toe. A TBI less than 0.7 is abnormal. Be aware of your ABI, just as you know and keep track of your blood cholesterol level.

To diagnose PAD, your doctor may also order some of the following tests and procedures:

• Blood tests to check your cholesterol, triglyceride, and blood sugar levels.
• Exercise ABI to show the severity of your leg symptoms and the level of physical activity that produces them. Your doctor will do the ABI test after having you walk on a treadmill. This test may help your doctor diagnose PAD when you have symptoms, but your resting ABI test result is only slightly low. A drop of 20% or more in post-exercise ABI is abnormal.
• Six-minute walking test to measure how far you can walk in a hallway in six minutes. Your doctor may do this test to see how much PAD affects your ability to function and the severity of the PAD.
• Doppler ultrasound to locate areas of reduced blood flow or blockages and measure how fast blood is flowing through the arteries. A handheld device is passed over your skin. A computer converts sound waves into pictures of blood flow in your arteries. Ultrasound can help diagnose PAD and monitor how well PAD treatments have worked.
• Segmental Doppler pressure testing to check different parts of your legs for narrowed or blocked arteries. This test is similar to ABI testing but uses blood pressure cuffs placed at thigh, calf, and ankle levels. The ultrasound device amplifies the sounds of blood flow in your arteries, making it easier to measure the blood pressure in these areas of your leg.
• Computed tomography angiography (CTA) to see the arteries in your legs and feet. A special dye is injected, then X-ray are taken to show the location and extent of any blood vessel blockages.
• Magnetic resonance angiography (MRA) to examine the structure of your leg arteries. Magnetic resonance angiography may not be safe for people who have metal implants in their body.
• Catheter-based angiography to see inside the arteries of your legs. Your doctor inserts a catheter, or tube, into an artery in your groin and guides it to the affected area. A special dye is released through the catheter, then X-rays are taken. Your doctor may suggest this procedure for serious pain in the legs or feet or when treatments for PAD have not worked or other testing has not been helpful.

Treatment depends on how severe your PAD is and what complications you may develop or may already have. Your treatment plan will be designed to help you reach key goals:

• Reduce your risk of a major health problem such as a heart attack or stroke
• Reduce symptoms of PAD
• Improve your ability to walk, climb stairs, and perform other daily activities
• Lower your risk of losing a limb
• Improve your quality of life

To treat PAD, your doctor may recommend heart-healthy lifestyle changes, an exercise program, medicine, or a procedure to open or bypass blockages in your arteries.

Heart-healthy lifestyle changes

Your doctor may recommend that you adopt lifelong heart-healthy lifestyle changes.

• Quit smoking. Smoking is the main risk factor for PAD. Quitting can reduce your symptoms and your risk of complications. It is also important to avoid secondhand smoke. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute’s Your Guide to a Healthy Heart. Although these resources focus on heart health, they include basic information about how to quit smoking. For free help and support to quit smoking, call the National Cancer Institute’s Smoking Quitline at 1-877-44U-QUIT (1-877-448-7848).
• Choose heart-healthy foods, such as those in the DASH eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, sodium (salt), added sugars, and alcohol.
• Aim for a healthy weight. If you are overweight, losing just 3% to 5% of your current weight can help you manage some PAD risk factors, such as high blood cholesterol and diabetes. Losing even more weight can lower your blood pressure.
• Get regular physical activity. Staying physically active can help you manage PAD risk factors such as high blood cholesterol, high blood pressure, and overweight or obesity. Before starting any exercise program, ask your doctor what level of physical activity is right for you.
• Manage stress. Learning how to manage stress, relax, get good-quality sleep, and cope with problems can improve your emotional and physical health.

Exercise programs

Physical activity often works well to relieve PAD symptoms and improve your ability to walk and carry out daily activities. Regular physical activity can improve the circulation in your legs. Exercise can reduce inflammation and help your blood vessels work better.

Supervised exercise

Your doctor may recommend a supervised exercise program that takes place in a clinic or a hospital. The exercise program may be part of a more complete cardiac rehabilitation program.

PAD exercise programs usually meet at least three times a week and last between 12 and 36 weeks. The most common type of exercise is walking on a treadmill. Other programs may use a device to exercise the upper body. Talk with your doctor about your options for exercise programs.

Home exercise programs

Your doctor may recommend a home-based exercise program with coaching that is similar to a supervised exercise program in a clinic. Home-based programs usually involve walking outside instead of on a treadmill. Your doctor will talk with you to help you understand how to do the program. Each exercise session lasts about 30 to 50 minutes. The goal is to work up to at least 30 minutes of continuous walking.

The programs include health coaching or activity monitors. Some home-based programs include regular check-ins with a coach by telephone. Talk with your doctor regularly about your progress.

Medicines

Your doctor may prescribe medicines to treat PAD and prevent its complications.

• Antiplatelet medicines, such as aspirin or clopidrogrel, to prevent blood clots from forming and narrowing the arteries even further. These medicines also lower the risk of heart attack or stroke. Possible side effects include bleeding or an allergic reaction. One type of antiplatelet medicine, cilostazol, may also improve your symptoms and make walking easier. Possible side effects of cilostazol include headache, diarrhea, heart palpitations, and dizziness. Doctors may also recommend an anticoagulant medicine, or blood thinner, to help prevent blood clots.
• Statins  to slow the progression of plaque buildup in the arteries that are causing symptoms and to lower your risk of complications from PAD. Side effects are rare but may include muscle pain or damage.
• ACE inhibitors and angiotensin II receptor blockers (ARBs) or other medicines to lower blood pressure and prevent blood vessels from narrowing.

Procedures or surgery

If lifestyle changes, an exercise program, and medicines do not work well enough, your doctor may recommend a medical procedure or surgery.

• angioplasty to open narrowed or blocked arteries. Your doctor may inflate a small balloon in the artery to flatten the plaque. Sometimes the balloon is coated with medicine to help the artery heal. Your doctor may also insert a small mesh tube called a stent to reduce the chances of the artery from narrowing again.

• Bypass surgery to treat severe pain, heal wounds, or save a damaged foot or leg when angioplasty is not as likely to work. Your doctor uses one of your other blood vessels or an artificial vessel to create a path around the blocked artery in your leg.