Peripheral Artery Disease (PAD) happens when the arteries in the legs become narrowed or blocked, most often because of atherosclerosis — the buildup of fatty deposits inside the vessel walls. These arteries start high in the pelvis, where the aorta divides into the iliac arteries, then continue through the groin as the femoral artery, behind the knee as the popliteal artery, and finally branch into the three small arteries that supply the foot. Together, they form the circulation that allows us to walk, stay active, and heal wounds.

When these arteries are healthy and open, the legs receive enough oxygen‑rich blood to meet the body’s needs, even during exercise. But as PAD progresses, one or more arteries can become so narrowed that blood flow is no longer sufficient. This can cause leg pain when walking, slow wound healing, and in very advanced stages, tissue loss or gangrene.

Atherosclerosis is the main cause of PAD. It is linked to smoking, high blood pressure, high cholesterol, diabetes, and age over 60, although genetics also play a role. Some people develop PAD without obvious risk factors, while others with several risk factors never do. Because the same process affects arteries throughout the body, PAD often occurs together with heart disease or carotid artery disease. Less common, non‑atherosclerotic causes include conditions such as Buerger’s disease and Raynaud’s phenomenon.

Peripheral Artery Disease (PAD) can develop silently for many years, especially in its early stages. Many people have no symptoms at all.

Some individuals may even have moderate or advanced PAD without noticing problems. This can happen when:

• They have reduced pain sensation, as in diabetes with peripheral neuropathy.

• The disease progresses slowly, allowing the body to form collateral circulation (natural bypass vessels).

• They are not walking enough to trigger the increased blood flow demand that would reveal symptoms.

Intermittent Claudication — the Typical First Symptom

The most common early symptom is a tight, aching, squeezing pain or cramp in the calf, thigh, or buttock when walking a certain distance.

• The pain disappears when you stop walking.

• It returns at the same distance when you start walking again.

• Over the years, this walking distance gradually becomes shorter.

This pattern is called intermittent claudication.

Other Possible Symptoms

• Weak or tired legs

• Difficulty walking or maintaining balance

• Thin, shiny, or fragile skin on the legs or feet

• Loss of hair on the feet

• Wounds or sores that heal slowly

• Thickened or opaque toenails (sometimes with fungal infection)

• Erectile dysfunction in men

Advanced Stages — Critical Limb Ischemia

In severe PAD, pain may occur even at rest, especially in the foot or toes. This is called critical limb ischemia, meaning the limb is at risk due to severely reduced blood flow.

Critical limb ischemia is a surgical emergency. It may also present with:

• Cold, numb feet or toes

• Burning or aching pain when lying flat, relieved by sitting up

• Pale color when the legs are elevated

• Redness when the legs are hanging down (dependent rubor)

• Reddish‑blue discoloration of the toes or foot

Peripheral Artery Disease (PAD) often progresses slowly and silently, especially in people who do not walk enough to trigger leg pain. For this reason, diagnosis relies on a combination of medical history, physical examination, and vascular tests.

If there are signs of critical limb ischemia, these tests are performed urgently. Always inform your doctor if you have experienced any of the symptoms described earlier.

Physical Examination

Your doctor will examine your legs and check the pulses at key points:

• In the groin

• Behind the knee

• At the inner ankle

• On the top of the foot

A weak or absent pulse suggests reduced blood flow and may indicate PAD.

Diagnostic Tests

• Doppler Ultrasound

A simple, non‑invasive test that evaluates blood flow in the leg arteries.

A handheld device sends ultrasound waves toward the moving blood cells. The returning signal produces a waveform and sound.

A faint or absent signal may indicate a blockage.

• Ankle‑Brachial Index (ABI)

A quick, non‑invasive, highly accurate test comparing blood pressure in the ankle with blood pressure in the arm.

A low ABI confirms PAD and helps assess its severity. It is useful for screening and follow‑up.

• Pulse Volume Recording (PVR)

Often performed together with the ABI.

Blood pressure cuffs are placed at different levels of the leg to measure changes in blood volume.

The results appear as pulsatile waveforms. Loss of pulsatility suggests an arterial obstruction.

This test is simple, fast, non‑invasive, and reliable.

• Peripheral Arterial Duplex / Triplex Ultrasound

A detailed ultrasound that visualizes the arteries, identifies the location of blockages, and estimates the severity of narrowing.

Non‑invasive, fast, and widely used.

• Computed Tomography Angiography (CTA)

A highly accurate imaging test providing high‑resolution 3D images of the leg arteries.

Useful for planning interventions.

It requires radiation and iodinated contrast dye, which may affect kidney function.

Not routinely ordered unless treatment is being considered.

• Magnetic Resonance Angiography (MRA)

As accurate as CTA, but without radiation.

If contrast is used (gadolinium), it is generally safer for the kidneys.

Limitations include higher cost, longer exam time, and contraindications in patients with claustrophobia or metal implants.

• Traditional Angiography

An invasive test performed in a surgical or interventional setting.

A catheter is inserted through the groin to inject contrast directly into the arteries.

It uses radiation and contrast dye.

Today, it is not routinely used for diagnosis, but becomes part of treatment when angioplasty or stenting is planned.

The treatment of Peripheral Artery Disease (PAD) depends on your symptoms, the severity of the disease, and your overall health. Management may include:

• Lifestyle changes and medical therapy

• Minimally invasive endovascular procedures (balloon angioplasty and/or stenting)

• Open surgical repair (endarterectomy or bypass)

All three approaches have a role in modern vascular care. Your vascular surgeon will guide you toward the option that best fits your situation.

Treatment is individualized. In general, claudication (pain when walking) is treated conservatively unless it becomes severely limiting. Minimally invasive techniques are preferred when feasible, while open surgery is reserved for cases where endovascular treatment is not possible or has failed. For some patients in good overall health, open surgery may offer a more durable solution.

A thorough discussion with your vascular surgeon—reviewing risks, benefits, alternatives, and your personal preferences—will help determine the best plan.

Lifestyle Changes and Medical Treatment

Lifestyle modification and appropriate medical therapy are the foundation of PAD treatment, whether or not a procedure is needed.

Your vascular surgeon will work with you to:

• Control blood pressure and cholesterol with medication (antihypertensives, statins) and dietary changes

• Optimize blood sugar levels if you have diabetes

• Start antiplatelet therapy (such as low‑dose aspirin or clopidogrel)

• Support smoking cessation, which is essential

• Encourage regular physical activity, especially daily walking, which improves walking distance over time

PAD does not “go away,” but proper medical treatment and lifestyle changes can slow or stop disease progression and allow the body to develop collateral circulation.

Regular follow‑up with your vascular surgeon is crucial, as the disease may progress even without symptoms.

Open Surgery (Endarterectomy and Bypass)

Open surgical treatment includes:

• Endarterectomy — removal of the atherosclerotic plaque from inside the artery

• Bypass surgery — rerouting blood flow using your own vein or a synthetic graft

Under general anesthesia, a small incision is made—usually in the groin or along the inner knee—at the site of the blockage. The artery is opened, the plaque is removed, and the artery is repaired. If the blockage is extensive, a bypass is created to restore blood flow.

Patients typically stay in the hospital 2–5 days after surgery. Some postoperative leg discomfort is expected but usually manageable with standard pain medication.

As with any operation, there are risks such as bleeding or thrombosis (clot formation), which can worsen ischemia. These risks should be discussed thoroughly with your vascular surgeon.

Angioplasty and Stenting

Angioplasty and stenting are minimally invasive procedures performed without a leg incision, through a small puncture in the groin.

Using X‑ray guidance, thin wires and catheters are advanced through the arteries to the site of the blockage. A balloon is inflated to open the artery. If the result is not optimal, a stent (a small metal mesh tube) is placed to keep the artery open.

Patients are usually treated in an outpatient basis (without hospitalisation) however one or two days stay in the hospital might be required depending on your overall health and the complexity of the procedure.

As with any intervention, angioplasty and stenting carry risks such as bleeding or thrombosis, which can worsen ischemia. These should be discussed with your vascular surgeon.