Peripheral Vascular Disease

What happens in peripheral artery disease

Cholesterol, inflammatory cells and calcium build up in artery walls, narrowing them. During exercise, leg muscles need more blood than the narrowed arteries can deliver, causing pain (claudication). At rest, flow is usually enough, so pain fades. In severe disease, even resting flow is inadequate, leading to rest pain, ulcers and gangrene.

"Peripheral vascular disease" can also include vein problems, such as venous insufficiency, but in practice it usually refers to arterial disease. See peripheral artery disease.

Symptoms

• intermittent claudication: cramping, aching or tiredness in the calf (most common), thigh or buttock with walking, relieved within about 10 minutes of rest; it comes on at a predictable distance
• numbness or weakness in the legs
• cold feet, especially on one side
• shiny skin, hair loss on the legs and feet, thickened toenails
• weak or absent foot pulses
• sores on the toes, feet or legs that heal slowly (leg ulcers)
• erectile dysfunction in men
• rest pain: burning pain in the toes and foot at night, eased by dangling the leg

Up to half of people with PAD have no typical symptoms, partly because they reduce their walking.

Claudication vs spinal stenosis vs venous pain

Risk factors

• smoking: the single biggest risk factor
• diabetes
• age over 65
• high blood pressure and high cholesterol
• chronic kidney disease
• family history of vascular disease
• obesity and inactivity

Linked conditions

PAD is a marker of widespread atherosclerosis. People with PAD have a much higher risk of coronary artery disease, heart attack and stroke. Screening for abdominal aortic aneurysm may also be recommended.

Diagnosis

• Ankle-brachial index (ABI): compares blood pressure at the ankle and arm using a cuff and Doppler. A ratio of 0.90 or less indicates PAD; 1.00 to 1.40 is normal; above 1.40 suggests stiff, calcified arteries (common in diabetes), needing a toe-brachial index.
• Exercise ABI if resting ABI is normal but symptoms suggest PAD.
• Duplex ultrasound: shows where arteries are narrowed.
• CT or MR angiography, or catheter angiography, to plan procedures.
• Blood tests: cholesterol, blood sugar, kidney function.

Treatment

Lifestyle

• Stop smoking: the most important step; it slows disease and reduces amputation and death risk.
• Supervised exercise therapy: walking until moderate pain, resting, then repeating, for 30 to 45 minutes at least 3 times a week for 12 weeks. It can significantly increase pain-free walking distance.
• Healthy diet and weight management.
• Foot care: inspect feet daily, wear well-fitting shoes, keep skin moisturized, and have nails cut carefully, especially with diabetes.

Medicines

• Statins for everyone with PAD, to stabilize plaque and reduce heart attack and stroke.
• Antiplatelet therapy: aspirin or clopidogrel; low-dose rivaroxaban plus aspirin for some.
• Blood pressure control, often with ACE inhibitors or ARBs.
• Diabetes management, including medicines with cardiovascular benefits.
• Cilostazol to improve walking distance in claudication (not for people with heart failure).

Procedures

For lifestyle-limiting claudication despite therapy, or for chronic limb-threatening ischemia:

• angioplasty and stenting
• atherectomy
• bypass surgery using a vein or synthetic graft

Amputation is a last resort for non-healing wounds or gangrene.

Complications

• critical limb ischemia with rest pain, ulcers and gangrene
• amputation
• acute limb ischemia from a sudden clot
• heart attack and stroke

Frequently asked questions

What are the first signs of peripheral artery disease?

The most common first sign is cramping or aching in the calves, thighs or buttocks when walking that eases after a few minutes of rest. Other signs include cold feet, weak foot pulses, shiny hairless skin on the legs and slow-healing foot sores.

Is peripheral vascular disease serious?

Yes. It can lead to non-healing wounds and amputation, and it signals a high risk of heart attack and stroke. Treatment with smoking cessation, exercise and medicines greatly lowers these risks.

Does walking help peripheral artery disease?

Yes. Supervised walking programs are one of the most effective treatments for claudication. Walking until moderate pain, resting, then continuing helps build new small blood vessels and improves walking distance.

What is a normal ankle-brachial index?

A normal ABI is between 1.00 and 1.40. A value of 0.90 or less indicates peripheral artery disease. Values above 1.40 suggest stiff arteries, and other tests are needed.