Peripheral Artery Disease in the Legs

What is PAD?

Peripheral Artery Disease, or PAD, is a general term that refers to artery disease anywhere outside of your heart, including the arteries that supply blood to your legs, arms, brain, kidneys, and other organs. This section focuses on disease in the arteries of the legs, the most common kind of PAD.

PAD reduces blood flow to the legs (sometimes referred to as “poor circulation”), and may cause pain or damage to tissues. Because PAD can make walking difficult, it can interfere with many aspects of your life. Women with PAD often have trouble performing daily tasks at work or at home and are forced to avoid activites they enjoy. Because the process that causes PAD affects blood vessels throughout your body, women with PAD have an increased risk of developing heart disease and stroke. Women with PAD are 2 to 6 times more likely to die of heart disease than women without PAD. Without proper treatment, your symptoms may gradually get worse over time. In severe cases, PAD can lead to problems that require amputation of a toe, foot, or leg.

The good news is that healthy lifestyle changes, medication, and procedures to clear blocked arteries can relieve PAD symptoms, improve your quality of life, and lower your risk of heart attack and stroke. If you don’t have PAD, you can take steps to prevent it altogether.

What causes PAD?

The most common cause of PAD is hardening of the arteries (atherosclerosis), the gradual buildup of fatty deposits (called plaque) on the walls of the arteries that slow or block blood flow. Plaque buildup also causes the artery walls to stiffen, making them unable to widen when the tissues need more blood, such as during exercise.

Atherosclerosis is the same process that causes coronary artery disease when it happens in the arteries that supply blood to the heart, and can cause a stroke when it blocks blood flow in the arteries that supply blood to the brain.

pad_plaqueAn illustration of how PAD impairs blood flow in the leg. PAD can occur anywhere in the leg arteries.

A: Blood flow through a normal leg artery.

B: Blood flow through an artery of a person with PAD.

How common is PAD?

PAD affects more than 8 million Americans, including nearly 4 million women. This is 1 out of every 16 people aged 40 and older, and 1 in 5 people aged 70 or older. PAD is slightly more common in men than in women (1 in 5 older men versus 1 in 6 older women). One study had doctors screen their own patients with a questionnaire and a simple painless test called the ankle-brachial index. Nearly 1 in 3 women and men older than 70, or older than 50 who smoked or had diabetes, were found to have PAD!

Despite how common PAD is and the serious risk of heart disease and stroke that goes along with it, awareness of PAD is low. In one survey of 2501 adults, only 1 in 4 were familiar with PAD. Among those who had heard of the disease, fewer than half were aware of the major risk factors, and only 25% knew that PAD increases your risk of heart attack and stroke. It is crucial to educate yourself about PAD so that you can recognize the symptoms and seek treatment before it causes serious problems.

What are the symptoms of PAD?

Because PAD develops gradually, in the early stages the disease may not cause any symptoms at all. As the disease progresses, most women will experience one or more of these common symptoms of PAD:

  • Cramping, aching, numbness, tiredness, weakness, or burning in your buttock, thigh, calf or foot that occurs when walking and goes away when you rest. This pain is called intermittent claudication. It does not usually occur while sitting or standing still.
  • Numbness in your legs or feet when you are at rest. Your skin may appear pale and feel cool to the touch.
  • Foot or toe pain or tingling that does not go away with rest, and may disturb your sleep. The pain may be worse when the leg is elevated and improve when you hang your legs over the side of the bed.
  • A feeling that the hip or leg is “giving out” during walking
  • Skin wounds or ulcers on your legs or feet that heal slowly or do not heal at all

While claudication is considered the “classic” sign of PAD, most women and men with PAD do not have typical leg symptoms during exercise. In one study of 7715 elderly subjects (60% were women), only 5% of women and 9% of men with PAD reported claudication. About half of women with PAD have leg symptoms other than claudication. Many women do not experience leg pain at all, and the only way to tell that they have PAD is during a doctor’s examination.

Although many women do not think of leg pain or tiredness as a serious problem, pain in your legs is not a normal sign of aging. Proven treatments are available to relieve PAD symptoms and prevent complications, so be sure to discuss with your doctor any symptoms you experience.

Who is at risk for PAD?

Your risk of PAD increases as you get older. Women 50 years or older have a higher risk of PAD than younger women, and women 70 or older are automatically considered at high risk for the disease. Your risk for PAD is also increased if you:

  • Smoke or used to smoke
  • Have diabetes
  • Have high blood pressure
  • Have high cholesterol
  • Have a family history of artery disease (PAD, heart attack, or stroke)
  • Have suffered a heart attack or stroke in the past
  • Are African-American
  • Have high levels of markers of inflammation in your blood, such as C-reactive protein and homocysteine

If these conditions sound familiar, it is because PAD shares many of the same risk factors with heart disease and stroke because they have a common cause (atherosclerosis). Diabetes and cigarette smoking have an especially powerful effect on your risk of developing PAD, with diabetes increasing your chances by up to 4 times and smoking by up to 6 times. Taking steps to prevent and control your risk factors for PAD will also reduce your risk of heart disease and stroke.

See Am I at Risk for PAD? (coming soon) to evaluate your risk.

PAD Diagnosis & Treatment

Should I be tested for PAD?

If you experience any of the symptoms of PAD, see your doctor so that you can be tested.

PAD often does not cause symptoms in the early stages. The only way to detect the disease early is to have regular physical examinations with your doctor, especially if you have characteristics that put you at high risk for PAD (See below, How is PAD Diagnosed?). You should be tested for PAD if:

  • You are 70 or older
  • You are 50 and older and
    • 1.) have diabetes, or
    • 2.) have ever smoked
  • You have other risk factors that put you at high risk for PAD (see Am I at Risk)

How is PAD diagnosed?

The first step in diagnosing PAD is a review of your symptoms and medical history, especially conditions that put you at risk for PAD. Your doctor will also do a physical exam to check for signs of PAD, including:

  • Checking the pulses in your legs and feet to see if there is enough blood flowing
  • Examining the appearance of your legs and feet, including skin color and temperature
  • Checking your legs and feet for slow or non-healing wounds

Your doctor may also perform a simple, painless and reliable test for diagnosing PAD, called the ankle-brachial index, or ABI. This test uses blood pressure cuffs to compare blood pressure in your ankle compared to that in your arms. If your ABI number is low (less blood flow in your legs than your arms) it is a sign that PAD is affecting your leg arteries.

Other tests may also be used to get a better look at the arteries and blood flow in your legs, including:

  • Ultrasound that uses sound waves (like those used to view the fetus when you are pregnant) to produce pictures of your arteries
  • CT angiography or MR angiography, tests that use imaging machines to look at the shape and blood flow in your arteries
  • Contrast angiography of the leg arteries that uses an injected dye to show the shape and blood flow of blood vessels on an x-ray

How is PAD treated?

PAD is treated with a combination of lifestyle changes, medications, and if necessary stents or other procedures. Proper treatment can relieve PAD symptoms, slow the progression of the disease, and improve the health of the arteries not just in your legs but throughout your body. This will allow you to live longer with a lower risk of heart attack and stroke.

Lifestyle & Medication

All women with PAD will be advised to make healthy lifestyle changes:

  • Eat a heart-healthy diet low in saturated fat and cholesterol. Get plenty of whole grains, vegetables, and fruits.
  • Exercise regularly (at least 30 minutes a day 5 or more days a week)
  • Control your weight if you are overweight or obese
  • Quit smoking
  • Control your diabetes—blood sugar control and proper foot care are especially important in women with PAD

Women with PAD, especially those with claudication pain, may also benefit from a supervised exercise program to improve walking ability and quality of life.9,10 See Exercise and Lower Extremity PAD Rehabiliation (coming soon) for more.

Lifestyle changes can go a long way, but you may also need medication to control high blood pressure and drugs such as statins to lower your cholesterol. Most women with PAD should also take daily aspirin to prevent blood clots; talk to your doctor before starting an aspirin regimen. Some women with other conditions that put them at high risk for blood clots may need to take additional blood thinning drugs.

In addition to medication to control your risk factors, medicines such as cilostazol may be able to improve your walking ability.

Further Treatment

For many women, lifestyle changes and medications are enough to improve PAD symptoms and reduce the chances of future problems. However, if you have severe symptoms caused by arteries that are very narrowed or blocked you may benefit from procedures to open the arteries.

Procedures that may be used to treat more severe cases of PAD include:

  • Angioplasty or stent placement – a long thin tube called a catheter is inserted into an artery in your leg and guided to the affected artery. The artery is opened with a balloon, and a small wire mesh tube may be left in the artery to prop it open
  • Peripheral artery bypass surgery – a blood vessel from another part of your body is used to make an alternate path for blood to flow around a blocked artery, much like bypass surgery to treat coronary artery disease
  • Amputation – in the most severe cases, removing part of your foot or leg may be the only option to prevent potentially deadly complications of PAD. If you identify and treat your PAD early, this is rarely necessary.

See our Overview of PAD Treatment (coming soon) for much more on the different treatments for PAD and how well they work in women.

How can I prevent PAD?

Many of the lifestyle changes recommended to prevent PAD from getting worse may also prevent PAD in women who have not developed it. A heart-healthy lifestyle that includes a healthy diet and regular exercise can prevent PAD and other forms of heart and blood vessel disease, including heart attack and stroke.

You should also work with your doctor to identify characteristics or conditions that are putting you at risk for PAD and take steps to get them under control, including:

  • Quitting smoking
  • Controlling your weight
  • Controlling high blood pressure
  • Lowering your LDL cholesterol
  • Talk to your doctor about medications to prevent blood clots
  • If you have diabetes, manage your blood sugar levels and practice proper foot care
  • Take good care of your feet. Inspect them every night, particulary between the toes and on the heels.

See Preventing PAD: The Basics (coming soon) for more on steps you can take to protect your arteries and prevent PAD.

Information on other Types of PAD

The term “Peripheral Artery Disease” includes disease in all the arteries outside the heart, including those that supply blood to the brain and other organs. For information on artery disease other than the lower limbs, see these other articles on our site:

  • For information on disease in the arteries that supply the brain, Carotid Artery Disease. Stroke section for information about blood vessel disease in the brain and its complications.
  • For information on disease of the renal arteries that supply blood to the kidneys, Renal Artery Disease.
  • Aortic Disease for information on disease of the large artery that carries blood away from the heart and distributes it to the rest of the body.

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