Peripheral Artery Disease (PAD): Symptoms, Diagnosis, and Treatment

Assoc. Prof. Sezen Bağlan Uzunget, MD
Cardiologist

What Is Peripheral Artery Disease?

Peripheral artery disease (PAD) is a vascular condition characterized by narrowing or blockage of arteries outside the heart and brain.

It most commonly affects the arteries supplying the lower extremities.

The main cause is atherosclerosis, a chronic process involving the accumulation of cholesterol-containing plaques within arterial walls.

As the arteries narrow, blood supply to the leg muscles may become insufficient, particularly during walking or exercise.

Peripheral artery disease is not only a problem affecting the legs. It is also associated with an increased risk of heart attack, stroke, and other cardiovascular events.

What Are the Symptoms of Peripheral Artery Disease?

Symptoms depend on the location and severity of arterial narrowing.

Common symptoms include:

Pain in the calf, thigh, or buttock during walking
Muscle cramping that improves with rest
Leg fatigue
Reduced walking distance
Cold feet
Changes in skin color
Weak or absent foot pulses
Rest pain in advanced disease
Nonhealing wounds on the feet or toes

Some patients have PAD without typical symptoms.

What Is Intermittent Claudication?

Intermittent claudication is a characteristic symptom of peripheral artery disease.

Patients experience pain, cramping, or tightness in the leg muscles after walking a certain distance.

Symptoms usually improve within a few minutes of rest.

When walking resumes, discomfort may return after a similar distance.

The location of pain can provide clues about the affected artery.

For example:

Calf pain may suggest femoropopliteal disease.
Buttock or thigh pain may occur with iliac artery disease.

However, not all leg pain is caused by PAD.

Spinal stenosis, musculoskeletal conditions, and neurological disorders may produce similar symptoms.

What Causes Peripheral Artery Disease?

Major risk factors include:

Smoking
Diabetes
Elevated LDL cholesterol
Hypertension
Increasing age
Chronic kidney disease
Family history of premature vascular disease
Coronary artery disease
Physical inactivity

Smoking and diabetes are particularly important risk factors for disease development and progression.

Which Arteries Are Affected?

1. Aortoiliac Artery Disease

This involves the lower abdominal aorta and iliac arteries.

Patients may experience buttock, thigh, or calf discomfort.

2. Femoropopliteal Artery Disease

This affects arteries in the thigh and around the knee.

Calf claudication is a common presentation.

3. Infrapopliteal Artery Disease

This involves the tibial and other arteries below the knee.

It is particularly important in patients with diabetes or chronic kidney disease.

Advanced disease may lead to foot ulcers and tissue loss.

How Is Peripheral Artery Disease Diagnosed?

1. Physical Examination

The examination includes assessment of leg temperature, skin color, tissue changes, and peripheral pulses.

Weak or absent foot pulses may suggest arterial disease.

2. Ankle-Brachial Index (ABI)

The ankle-brachial index is one of the fundamental tests used to diagnose PAD.

It is calculated by dividing the systolic blood pressure measured at the ankle by the systolic blood pressure measured in the arm.

ABI value | General interpretation |
|---|---|
| 1.00–1.40 | Normal |
| 0.91–0.99 | Borderline |
| 0.90 or lower | Abnormal, consistent with PAD |
| Greater than 1.40 | Possible noncompressible arteries |

In patients with diabetes or chronic kidney disease, arterial calcification may produce falsely elevated ABI values.

Additional testing, such as the toe-brachial index, may be necessary.

Exercise ABI testing may be useful when resting ABI is normal despite suggestive symptoms.

3. Arterial Doppler Ultrasound

Doppler ultrasound evaluates arterial anatomy and blood flow.

It helps determine the location and severity of stenosis.

4. CT Angiography

CT angiography provides detailed imaging of lower extremity arteries.

It may be used when revascularization is being considered.

5. MR Angiography

MR angiography is an alternative method for evaluating arterial anatomy.

6. Catheter Angiography

Catheter angiography is an invasive imaging technique.

It is particularly useful when balloon angioplasty or stenting is planned.

Does Peripheral Artery Disease Increase Heart Attack Risk?

Yes.

Patients with PAD frequently have atherosclerosis in other vascular territories, including the coronary and cerebral arteries.

Therefore, overall cardiovascular risk assessment is essential.

Blood pressure, cholesterol, diabetes, and smoking should be addressed.

However, routine coronary angiography is not necessary for every asymptomatic patient with PAD.

How Is Peripheral Artery Disease Treated?

Treatment depends on symptoms, arterial anatomy, severity of ischemia, and limb risk.

1. Smoking Cessation

Smoking accelerates the progression of PAD.

Stopping smoking is one of the most important treatment measures.

2. Lipid-Lowering Therapy

High-intensity statin therapy is generally recommended for patients with atherosclerotic PAD.

The goal is to lower LDL cholesterol and reduce cardiovascular events.

Additional lipid-lowering medications may be necessary.

3. Antithrombotic Therapy

Antiplatelet therapy is recommended for appropriate patients with symptomatic PAD.

In selected patients, particularly after lower extremity revascularization or in those at increased cardiovascular risk, low-dose rivaroxaban combined with aspirin may be considered when bleeding risk is acceptable.

This treatment is not suitable for everyone and requires individualized medical assessment.

4. Diabetes and Blood Pressure Management

Appropriate glycemic and blood pressure control are essential.

5. Exercise Therapy

Structured walking exercise is a key treatment for patients with intermittent claudication.

Supervised exercise programs can improve walking distance and quality of life.

Exercise should be adapted to the patient's symptoms and general health.

6. Medication for Claudication

Cilostazol may improve walking performance in selected patients.

However, cilostazol is contraindicated in patients with heart failure.

When Is Balloon Angioplasty or Stenting Necessary?

Not every arterial stenosis requires intervention.

Revascularization may be considered for:

Functionally limiting claudication despite appropriate medical and structured exercise therapy
Ischemic rest pain
Nonhealing ischemic foot wounds
Gangrene or tissue loss
Acute limb ischemia

Treatment depends on vascular anatomy, clinical status, and expected benefit.

How Is Peripheral Balloon Angioplasty Performed?

Peripheral balloon angioplasty is a catheter-based procedure used to widen narrowed or blocked arteries.

The procedure is generally performed through the groin or another appropriate vascular access site.

Procedure Steps

A catheter is introduced into the artery.
Angiography identifies the narrowing or blockage.
A guidewire is advanced across the lesion.
A balloon is inflated to widen the artery.
A stent or other endovascular treatment may be used when necessary.
Final angiography evaluates blood flow.

Drug-coated balloons, specialized stents, or vessel preparation techniques may be appropriate in selected cases.

Treatment selection depends on lesion length, calcification, and anatomical location.

What Is Peripheral Artery Stenting?

Peripheral artery stenting involves placing a metal scaffold within a narrowed arterial segment.

The stent helps maintain vessel patency.

Stenting is commonly used in appropriate iliac artery lesions.

However, stent placement is not necessary for every lesion or vascular territory.

When Is Bypass Surgery Necessary?

Surgical bypass may be more suitable for certain long or complex arterial occlusions.

A new pathway is created to direct blood around the blocked arterial segment.

The patient's own vein or a synthetic graft may be used.

The choice between bypass surgery and endovascular treatment depends on anatomy, available conduit, limb risk, and overall clinical condition.

What Is Chronic Limb-Threatening Ischemia?

Chronic limb-threatening ischemia (CLTI) is an advanced form of PAD associated with severely impaired blood supply to the lower extremity.

It may present with:

Ischemic rest pain
Nonhealing foot ulcers
Gangrene

CLTI is associated with an increased risk of limb loss.

Patients with suspected CLTI require prompt evaluation by a vascular specialist team.

What Is Acute Limb Ischemia?

Acute limb ischemia occurs when blood flow to an arm or leg suddenly decreases severely.

Symptoms may include:

Sudden severe pain
Pallor
Loss of pulses
Coldness
Numbness
Weakness or paralysis

Acute limb ischemia is a vascular emergency requiring immediate medical attention.

Why Is PAD Particularly Important in Diabetes?

PAD may be more extensive and complex in patients with diabetes.

Below-the-knee arteries are frequently affected.

Diabetic neuropathy may reduce pain sensation, allowing advanced disease to develop without typical symptoms.

Regular foot examination and assessment of arterial circulation are therefore important.

Can Peripheral Artery Disease Be Cured?

Atherosclerosis is a chronic vascular condition.

Medication, smoking cessation, and exercise can slow progression and improve symptoms.

Balloon angioplasty, stenting, or bypass surgery may improve blood flow in selected patients.

However, cardiovascular risk factor management remains necessary after intervention.

Who Should Be Evaluated for PAD?

Evaluation is particularly important for:

Patients with leg pain during walking
Individuals with weak peripheral pulses
Patients with nonhealing foot wounds
People with diabetes or smoking history and increased vascular risk
Selected patients with known coronary or other atherosclerotic vascular disease

Routine vascular imaging is not necessary for every healthy individual.

When Should You Consult a Cardiologist?

Recurrent leg pain during walking, cold feet, reduced walking distance, or nonhealing foot wounds should prompt vascular assessment.

Sudden severe limb pain, coldness, pallor, numbness, or loss of movement requires emergency medical attention.

This content is provided for general educational purposes. The diagnosis and treatment of peripheral artery disease should be individualized according to clinical findings, vascular anatomy, and the risk of limb loss.