Peripheral arterial disease (PAD)

Peripheral artery disease can have serious symptoms and complications. Call 999 if one or both of your legs suddenly becomes cold, painful or pale with a weak or unidentifiable pulse or if any other symptoms get worse quickly.

Peripheral arterial disease (PAD) is the most common type of peripheral vascular disease (PVD) and specifically affects the arteries in your arms and legs. 

Narrowing of arteries (atherosclerosis) or blockages within them reduce the amount of blood that can reach the legs and as a result people often feel pain in their legs when walking (claudication) and other symptoms. 

Stages of peripheral arterial disease

There are five stages of PAD, each with a varying severity of symptoms. 

• Asymptomatic: People may have PAD but not experience any symptoms associated with the condition.
• Mild claudication: Feeling discomfort or mild pain in the legs when walking or exercising which typically goes away after rest.
• Moderate to severe claudication: Increased pain in the lower limbs which may become more severe over time.
• Ischaemic rest pain: Symptoms of PAD producing pain in the legs even when resting or during the night. 
• Ulcers or gangrene: Skin sores may appear due to a lack of blood reaching the body's extremities. 

PAD vs PVD

In essence, PAD is a form of PVD. Peripheral vascular disease (PVD) is a term for conditions that affect how the blood flows around the body in both veins and arteries. PVD can lead to reduced blood flow in areas such as the brain, arms, legs and intestines. The most common causes of PVD are fatty plaque deposits within the veins and arteries, blood clots, diabetes and vasculitis. 

While PVD refers to any circulatory disorder affecting blood vessels outside of the heart, peripheral artery disease (PAD) specifically refers to arterial issues, usually in the lower limbs.

The narrowing of arteries is often caused by fatty, cholesterol-containing plaque that builds up on artery walls and restricts blood flow. As the plaque continues to build, the artery may eventually become blocked. When this occurs in the arteries supplying blood to the legs, it causes peripheral arterial disease.

Other, less common causes of PAD include:

• Exposure to radiation
• Blood vessel inflammation

What are the risk factors for peripheral arterial disease?

Several factors can significantly increase the risk of developing PAD and other forms of cardiovascular disease (CVD).

One in five people aged 55-75 are estimated to have some degree of PAD. No matter your age, you are more likely to develop peripheral arterial disease if the following applies:

• Smoking or using tobacco products
• Having high blood pressure
• Having high cholesterol
• Having diabetes
• Being of Afro-Caribbean descent
• Having a family history of cardiovascular disease
• Obesity
• Having kidney disease
• Having a blood clotting disorder

While peripheral artery disease is not immediately life-threatening, the process of atherosclerosis can cause serious or potentially fatal complications. If blood flow to the heart's muscles is limited, it can result in chest pain (angina).

Critical limb ischaemia (CLI)

When blood flow to the lower limbs becomes restricted, it can cause serious complications that can prove to be challenging to treat. Symptoms of critical limb ischaemia can include:

• Wounds or open sores on your legs or feet that do not heal
• Severe burning sensation in your legs and feet that does not subside even when resting
• Loss of muscle mass in your legs
• Skin turning pale, smooth and dry
• Gangrene

In the most severe cases, an amputation below the knee may be required if the symptoms of CLI are not addressed immediately.

Associated conditions

Certain conditions are closely associated with (but not caused by) PAD. If you have PAD, you may be at higher risk of:

Coronary artery disease (CAD)

CAD is essentially the same condition as PAD, although it affects the blood vessels that directly serve the heart. Left untreated, CAD can result in the heart muscles being depleted of oxygen and an individual having a heart attack.

Stroke

Narrowed or blocked arteries and veins increase the risk of blood clots forming. If a blood clot becomes loose and travels to the brain, it can limit the supply of oxygen and result in a stroke. 

If your GP suspects that you may have PAD, the first thing they will do is carry out a physical examination and review your medical history.

During the physical examination, your doctor will look for symptoms such as brittle toenails, shiny skin, or a loss of hair on the feet or legs. A weak pulse in your legs, ulcers forming and pain in the limbs are other indicators.

If your assessment suggests symptoms of PAD, your consultant can conduct a series of tests to determine the severity of your peripheral artery disease and how best to proceed with treatment. 

These non-invasive tests will help to ascertain if you have a blockage in your arteries:

• Ankle brachial pressure index: This test is widely used to diagnose PAD. During the test, your consultant measures the blood pressure in both your upper arm and your ankle. If your circulation is healthy, the readings should be the same in both parts of your body. If the pressure in your ankle is lower, this suggests a reduction in blood supply and a case of PAD.
• Vascular ultrasound: This test is used to evaluate blood flow in the arteries in the arms, neck and legs, and can help to diagnose PAD and blood clots. 

Should you require further testing, you may need a test to locate artery blockages:

• Angiogram: This procedure can show how well your blood is flowing around the body and highlight any areas where there could be potential blockages. A dye is injected and will show up clearly on an X-ray to produce a detailed image of your arteries.

Lifestyle changes

Making lifestyle changes is one of the first places to start when it comes to treating PAD as this helps reduce the risk of complications and alleviates pain. 

• Stop smoking or using tobacco products: Smoking dramatically increases your chance of developing PAD. Compared to non-smokers, people who have PAD and smoke or use tobacco products are more likely to die of heart attack or stroke.
• Exercise regularly: Walking is one of the best ways to combat the symptoms of PAD. It's recommended that you build up the amount you walk in slow increments, resting each time that you feel pain in your legs before starting to walk again. 
• Eat a balanced diet: Concentrate on eating foods that are high in fibre and low in saturated fat, sodium and cholesterol.
• Combat your stress levels: Practising yoga, meditation and exercising can help reduce your stress and improve your mental health.
• Other health conditions: Managing other health conditions such as diabetes, high blood pressure and high cholesterol can help improve your symptoms of peripheral artery disease.

Medication for peripheral arterial disease

Medications can be used to treat the underlying causes of peripheral artery disease, and in turn help to reduce your risk of developing another form of cardiovascular disease.

• Statins: If blood test results show that you have high cholesterol, you could be prescribed statins to help reduce the production of 'bad cholesterol' by your liver.
• Antiplatelets: Medications such as aspirin or clopidogrel can help to prevent the body's ability to form blood clots within narrowed arteries.
• Antihypertensives: A group of medications used to treat high blood pressure. 
• Naftidrofuryl oxalate: This medicine may be offered to you if you have leg pain from PAD that is triggered by exercise, as it can help to improve the blood flow in the body.

Surgical treatment and procedures for peripheral arterial disease

People with more severe PAD, where pain limits simple everyday activities, may be offered endovascular or surgical treatment to help restore blood flow in the legs. This is known as revascularisation. 

There are two types of revascularisation procedure for the treatment of PAD:

• Angioplasty: This procedure is used to widen blocked or narrowed coronary arteries that supply blood to the heart. A small balloon is inserted within the artery to allow blood to flow more freely. 
• Artery bypass graft: A surgical procedure that involves taking a blood vessel from another part of the body, most commonly the chest or arm, and using it to bypass a blockage within an artery.

Risks associated with peripheral artery disease procedures

Your consultant will help you weigh up the potential risks and benefits of surgery for PAD to help you make an informed decision.

If you experience any of the below after your procedure, contact your healthcare provider or the emergency services immediately:

• Bleeding
• Bruising
• Pain in a specific part of your body