Peripheral arterial disease (also called peripheral artery disease) is a common circulatory problem in which arteries become narrowed as a result of plaque buildup, reducing the flow of blood to your limbs.

This condition is a normal part of the aging process, and varies in severity from patient to patient. Over time, the decreased flow of oxygen-rich blood can cause a variety of symptoms, most frequently leg pain when walking.

It is possible, however, to have peripheral arterial disease and not know it, because the condition can take a lifetime to develop and symptoms do not become apparent until there is significant narrowing of the arteries.

As the disease progresses and blood flow becomes severely impaired or partially blocked in your leg or foot, pain and numbness in the affected areas can develop. A complete lack of blood flow can lead to gangrene (tissue death). 

The buildup of plaque, a process known as atherosclerosis, can occur anywhere in the body. The plaque, which is made up of fat, cholesterol, and other substances, hardens and may limit blood flow to major organs as well as your legs.

This hardening of the arteries, as it is often called, can be greatly mitigated by dietary changes and exercise. If you have unexplained leg or foot pain, don’t assume it is just a sign of aging. Contact your podiatrist to find out whether your pain may be part of more widespread disease.

If you are 70 years or older; 50 years or older and have a history of smoking or diabetes; or under 50 but have diabetes and one or more risk factors for atherosclerosis, you should ask your podiatrist about peripheral arterial disease even if you don’t have any symptoms.

What Are The Risk Factors for Peripheral Arterial Disease?

Certain factors are associated with an increased risk of peripheral arterial disease. These include:

Smoking: Your risk of peripheral arterial disease increases four times if you smoke or have a history of tobacco use.

Old age: Plaque builds up in your arteries as you age. About one in every 20 Americans over the age of 50 has peripheral arterial disease. The risk continues to rise as you get older. Old age combined with other risk factors, such as smoking or diabetes, also puts you at higher risk for P.A.D.

African American ethnicity: Although peripheral arterial disease affects millions of people in the United States, African Americans are affected more than any other racial or ethnic group.

Other health problems: Your risk of peripheral arterial disease is higher if you have one or more of the following health problems or a family history of them:

• Diabetes (About one in three people older than 50 who has diabetes also has peripheral arterial disease)
• High blood pressure
• High blood cholesterol
• Coronary heart disease
• Stroke
• Metabolic syndrome

Which Symptoms of Peripheral Arterial Disease Should I Know About?

Intermittent claudication—muscle pain in the leg or foot that typically occurs when walking or climbing stairs and subsides with rest—may be the first symptom of peripheral arterial disease.

This pain has been described as cramping, numbness, aching, and heaviness in the leg muscles. It occurs during activity, when your muscles need increased blood flow, and decreases while resting, when muscles need less blood flow.

Other signs and symptoms of peripheral arterial disease include:

• Weak or absent pulses in the legs or feet
• Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all
• A pale or bluish color to the skin
• A lower temperature in one leg compared to the other leg
• Poor nail growth on the toes and decreased hair growth on the toes, feet, and legs
• Erectile dysfunction, especially among men who have diabetes

How is Peripheral Arterial Disease Diagnosed?

An evaluation for peripheral arterial disease will include your medical and family histories, a physical examination, and a few tests.

This evaluation should be performed by a podiatrist. If you have advanced disease or signs of coronary heart disease, you will be referred to a vascular specialist or cardiologist for further evaluation.

During the history taking, your podiatrist will ask you questions about your diet and how often you smoke. It is very important that you be honest in your responses and accurate when describing your symptoms. You should also have a list of all medicines and supplements you are taking.

Part of the physical examination will include evaluation of the pulses in the feet, ankles, legs and thighs by palpation. The podiatrist uses his or her hands to feel for these pulses. This examination will help determine the strength of blood flow to the legs.

The podiatrist will also look for signs of poor wound healing and abnormalities in your hair, skin, or nails such as discoloration, dryness, brittle nails, thickening of the nails, thinning skin, etc.

Testing for peripheral arterial disease may include:

Blood tests: Your doctor may order a complete blood cell count, chemistry test, enzyme test, blood clotting tests, and and other blood tests to assess heart disease risk.

Non-invasive testing:

Ankle-brachial index: This test shows how well blood is flowing in your lower limbs, and it takes about 10 to 15 minutes. A blood pressure cuff is placed on each ankle and either arm, one at a time, to compare blood pressure in these areas. The pressures of the ankle are compared to the arm to arrive at a value that determines the severity of lower limb PAD.

Segmental Pressures:  This test is performed much like the ankle-brachial test, except that various pressure cuffs are used all along the leg from the ankle up to the groin. The pressures in the respective limbs are compared to one another.

PPG: Photoplethysmography: This test measures pressures in the limb. It is particularly good for measuring toe pressures, as these vessels are small and cannot be tested by other non-invasive means.

Tanscutaneous oximetry: This test measures the oxygen level at the skin’s surface; it is also non-invasive.

Treadmill test: Walking on a treadmill can reveal the severity of symptoms and the level of exercise that brings them on. Your doctor may perform an ankle-brachial indextest before and after this exercise.

Doppler ultrasound: This test produces images of the blood flow in the major arteries and veins of your limbs. The results can help determine the severity of disease.

Invasive Testing:

Magnetic resonance angiogram (MRA): This test can show the location and severity of a blocked blood vessel. It requires contrast dye to be injected.

Arteriogram: A dye is injected through a needle or catheter into one of your arteries to help pinpoint the exact location of a blocked artery.

How Is Peripheral Arterial Disease Treated?

Peripheral arterial disease may be treated with medicine and/or surgical intervention, but how well your body responds depends largely on your ability to make lifestyle changes. Treatment combined with lifestyle changes can slow or stop disease progression and reduce the risk of complications.

A variety of factors will determine whether you require medication or surgical intervention or a combination of both.

Your doctor may prescribe statins to reduce cholesterol, antihypertensive medication to reduce high blood pressure, anticoagulants to prevent clots, and narcotic pain relievers or neuropathic pain relievers to help ease leg or foot pain.

Surgical interventions include bypass grafting to bypass the blocked part of the artery using a graft (a harvested vein from another part of the leg); angioplasty and stenting to restore blood flow through a narrowed or blocked artery; or atherectomy to remove plaque buildup from an artery.

Lifestyle changes often require a great deal of commitment to alter deleterious behaviors and habits. The following actions are recommended for all patients with peripheral arterial disease:

• Quit smoking
• Be physically active
• Eat healthy foods that are low in fat, cholesterol, and sodium (for example, fruits, vegetables, and low-fat dairy products)
• Lose weight if you are overweight or obese
• Manage any underlying health problems (high cholesterol, high blood pressure, etc.) by following your doctor’s instructions and returning for follow-up as directed
• Practice good foot and skin care (see foot hygiene tips below)

Foot Hygiene Tips for Patients With Peripheral Arterial Disease

To maintain good foot hygiene, keep the following tips in mind:

• Examine your legs and feet daily for any wounds, blisters, redness, increased warmth, ingrown toenails, corns, or calluses. If you can’t see an area, use a mirror or have a family member look for you. Patients with PAD should see a podiatrist at least twice per year if they are at higher risk or have already developed compounding problems. A podiatrist can make that assessment based on their experience with working with patients with PAD.
• Apply a moisturizing cream or lotion to your legs and feet once or twice a day to prevent dry skin and cracking. Do not apply moisturizer between the toes. Keep your feet clean and dry, especially between the toes.
• Have your nails trimmed regularly.
• Get regular physical examinations from a podiatrist.
• Wear comfortable shoes that fit well.
• Seek professional medical treatment from your podiatrist for corns, bunions, or calluses.
• Follow your podiatrist’sadvice regarding management of minor foot and skin problems.