Peripheral arterial disease (PAD)

Overview

Peripheral arterial disease (PAD) is a common condition, in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It's also known as peripheral vascular disease (PVD).

Symptoms of peripheral arterial disease

Many people with PAD have no symptoms. However, some develop a painful ache in their legs when they walk, which usually disappears after a few minutes' rest. The medical term for this is "intermittent claudication".

The pain can range from mild to severe, and usually goes away after a few minutes when you rest your legs.

Both legs are often affected at the same time, although the pain may be worse in one leg.

Other symptoms of PAD can include:

hair loss on your legs and feet
numbness or weakness in the legs
brittle, slow-growing toenails
ulcers (open sores) on your feet and legs, which don't heal
changing skin colour on your legs, such as turning pale or blue
shiny skin
in men, erectile dysfunction
the muscles in your legs shrinking (wasting)

The symptoms of PAD often develop slowly, over time. If your symptoms develop quickly, or get suddenly worse, it could be a sign of a serious problem requiring immediate treatment.

When to see your GP

You should see your GP if you experience recurring leg pain when exercising.

Many people mistakenly think this is just part of growing older, but there's no reason why an otherwise healthy person should experience leg pain.

PAD is usually diagnosed through a physical examination by your GP, and by comparing the blood pressure in your arm and your ankle.

A difference between the two may indicate PAD and is called the ankle brachial pressure index (ABPI).

Read about diagnosing PAD.

Causes of peripheral arterial disease

PAD is a form of cardiovascular disease (CVD), meaning it affects the blood vessels.

It's usually caused by a build-up of fatty deposits in the walls of the leg arteries. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.

The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts blood flow to the legs. This process is called atherosclerosis.

There are certain things that can increase your chances of developing PAD and other forms of CVD, including:

smoking – the most significant risk factor
type 1 diabetes and type 2 diabetes
high blood pressure
high cholesterol
growing older

Treating peripheral arterial disease

PAD is largely treated through lifestyle changes and medication.

Exercising regularly and stopping smoking, if you smoke, are the main lifestyle changes that can ease the symptoms of PAD and reduce the chances of the condition getting worse. It's also important to:

eat a healthy diet
lose weight, if you're overweight or obese
moderate your consumption of alcohol

Read about:

The underlying causes should also be treated, including high blood pressure, high cholesterol, and diabetes. Medication, and in some cases surgery, can be used to improve the blood flow in your legs.

With treatment, most people's symptoms remain relatively stable and some people may experience an improvement in their pain.

If treatment is unsuccessful or you can't make appropriate lifestyle changes, there's a risk of potentially serious complications.

Read about treating PAD.

Complications of peripheral arterial disease

PAD isn't immediately life-threatening, but the process of atherosclerosis that causes it can lead to serious and potentially fatal problems.

Coronary heart disease (CHD)

The blockages in the arteries in the legs can also affect other areas of your body, such as the arteries supplying the heart and brain.

This means that having PAD makes you more likely to develop another form of cardiovascular disease (CVD), such as:

Critical limb ischaemia (CLI)

If the blood flow to the legs becomes severely restricted, critical limb ischaemia (CLI) can develop. CLI is an extremely serious complication that can be challenging to treat.

Symptoms of CLI include:

a severe burning pain in your legs and feet that continues even when you're resting
your skin turning pale, shiny, smooth and dry
wounds and ulcers (open sores) on your feet and legs that don't heal
loss of muscle mass in your legs
the skin on your toes or lower limbs becoming cold and numb, turning red and then black, and/or beginning to swell and produce foul-smelling pus, causing severe pain (gangrene)

If you think you're developing symptoms of CLI, contact your GP immediately. If this isn't possible, Call 111, NHS 111 Wales service.

An angioplasty or bypass graft is usually recommended if you have CLI, although these may not always be successful or possible. In a few cases, an amputation below the knee may be required.

Diagnosis

If your GP suspects peripheral arterial disease (PAD), they'll first carry out a physical examination of your legs .

PAD can cause various symptoms – some of which your GP will be able spot, but you may not – such as:

shiny skin
brittle toenails
hair loss on your legs and feet
the pulse in your leg being very weak or undetectable
leg ulcers

Your GP may also ask about your symptoms and your personal and family medical histories.

The ankle brachial pressure index

The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assess how well you're responding to treatment.

while you lie on your back, the GP or practice nurse will measure the blood pressure in your upper arms and ankles using a cuff and a Doppler probe. A Doppler probe uses sound waves to determine the blood flow in your arteries
after your scan, the GP will divide your blood pressure's second results (from your ankles) by the first results (from your arms)

If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same, and the result of your ABPI would be one.

However, if you have PAD, the blood pressure in your ankle will be lower because of a reduction in blood supply, so the results of the ABPI would be less than one.

In some cases, ABPI may be carried out after getting you to run on a treadmill or cycle on an exercise bike. This is a good way to see the effect of physical activity on your circulation.

This is usually carried out in hospital because most GP surgeries do not have the facilities to perform this test.

Further testing

In most cases, your GP will be able to confirm a diagnosis of PAD by doing a physical examination, asking about your symptoms and checking your ABPI score.

Further testing is usually only required if:

there's uncertainty about the diagnosis – for example, if you have leg pain but your ABPI score is normal
you don't fit the expected profile of somebody with PAD – for example, you're young and have never smoked
the restriction of blood supply in your leg is severe enough that treatment, such as surgery, may be required

Additional hospital-based tests that can be used include:

an ultrasound scan – where sound waves are used to build up a picture of arteries in your leg; this can identify exactly where in your arteries there are blockages or narrowed areas
an angiogram – wherea special liquid known as a contrast agent is injected into a vein in your arm; the agent shows up clearly on a CT scan or MRI scan and produces a detailed image of your arteries

In some cases, the contrast agent may be injected directly into the arteries of your leg, and X-rays may be used to produce the images.

Treatment

There's no cure for peripheral arterial disease (PAD), but lifestyle changes and medication can help reduce the symptoms.

These treatments can also help reduce your risk of developing other types of cardiovascular disease (CVD), such as:

Treatment is very important, because having PAD is a sign that your blood vessels are unhealthy.

Surgery may be used in severe cases or when initial treatment has not effectively reduced your symptoms.

Lifestyle changes

The two most important lifestyle changes that you can make if you're diagnosed with PAD are exercising more regularly and stopping smoking, if you smoke.

Exercise

Evidence suggests that regular exercise helps to reduce the severity and frequency of PAD symptoms, while also reducing the risk of developing another CVD. Exercise can also boost your self-esteem, mood, sleep quality and energy.

The National Institute for Health and Care Excellence (NICE) recommends supervised exercise as one of the first steps for managing PAD. This may involve group exercise sessions with other people with CVD, led by a trainer.

The exercise programme usually involves two hours of supervised exercise a week for three months. Aim to exercise daily for the rest of your life, as the benefits of exercise are quickly lost if it's not frequent and regular.

One of the best exercises you can do is walking. It's normally recommended that you walk as far and as long as you can before the symptoms of pain become intolerable. Once this happens, rest until the pain goes, and begin walking again until the pain returns. Keep using this "stop-start" method until you've spent at least 30 minutes walking in total. This should ideally be repeated several times a week.

The exercise course is challenging, as the frequent episodes of pain can be upsetting. However, it should improve your symptoms.

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Exercise

Stop smoking

Stopping smoking will reduce your risk of PAD getting worse and another serious CVD developing.

Research has found that people who continue to smoke after receiving their diagnosis are much more likely to have a heart attack and die from a complication of heart disease than people who quit after receiving their diagnosis.

Medication

Different medications can be used to treat the underlying causes of PAD, while also reducing your risk of developing another CVD.

Some people may only need to take one or two of the medications discussed below, while others may need all of them.

Statins

If blood tests show that your levels of LDL cholesterol ("bad cholesterol") are high, you'll be prescribed a type of medication called a statin.

Statins work by helping to reduce the production of LDL cholesterol by your liver.

Many people who take statins experience no or very few side effects, although others experience some troublesome – but usually minor – side effects, such as:

indigestion
headaches
feeling sick (nausea)
muscle aches

Antihypertensives

Antihypertensives are a group of medications used to treat high blood pressure (hypertension).

It's likely that you'll be prescribed an antihypertensive drug if:

you don't have diabetes and your blood pressure is higher than 140/90mmHg
you have diabetes and your blood pressure is higher than 130/80mmHg

Read more about diagnosing high blood pressure.

A widely used type of antihypertensive is an angiotensin-converting enzyme (ACE) inhibitor, which block the actions of some hormones that help regulate blood pressure. This will decrease your blood pressure.

Side effects of ACE inhibitors include:

dizziness
tiredness or weakness
headaches
a persistent dry cough

Most of these side effects pass in a few days, although some people find they have a dry cough a bit longer.

If your side effects become particularly troublesome, a medication that works in a similar way to ACE inhibitors, known as an angiotensin-2 receptor antagonist, may be recommended.

Blood-thinning medicines

One of the biggest potential dangers if you have atherosclerosis is a piece of fatty deposit (plaque) breaking off from your artery wall. This can cause a blood clot to develop at the site of the broken plaque.

If a blood clot develops inside an artery that supplies the heart with blood (a coronary artery), it can trigger a heart attack. Similarly, if a blood clot develops inside any of the blood vessels going to the brain, it can trigger a stroke.

If you have PAD, you'll probably be prescribed a blood-thinning medicine to reduce your risk of blood clots. This medicine works by thinning your blood so it's less likely to clot.

Blood-thinning medicines you may be prescribed if you have PAD include:

Low-dose aspirin
clopidogrel
rivaroxaban

Naftidrofuryl oxalate

NICE recommends naftidrofuryl oxalate for the treatment of leg pain triggered by exercise (intermittent claudication) in people with PAD.

This medication may improve blood flow in the body, and is very occasionally used if you prefer not to have surgery or your supervised exercise programme hasn't led to a satisfactory improvement in your condition.

Side effects of naftidrofuryl oxalate can include:

feeling sick
abdominal pain
diarrhoea
rashes

You'll normally be advised to take naftidrofuryl oxalate for around three to six months, to see if it improves your symptoms. If the treatment isn't effective after this time, it will be stopped.

Surgery and procedures

In a few cases, a procedure to restore the flow of blood through the arteries in your legs may be recommended. This is known as revascularisation.

Revascularisation may be recommended if your leg pain is so severe it prevents you from carrying out everyday activities, or if your symptoms have failed to respond to the treatments mentioned above.

There are two main types of revascularisation treatment for PAD:

angioplasty – where a blocked or narrowed section of artery is widened by inflating a tiny balloon inside the vessel
artery bypass graft – where blood vessels are taken from another part of your body and used to bypass the blockage in an artery

Which procedure is best?

You may not always be able to choose between having an angioplasty or a bypass graft, but if you are, it's important to be aware of the advantages and disadvantages of each technique.

An angioplasty is less invasive than a bypass – it doesn't involve making major cuts (incisions) in your body – and is usually performed under local anaesthetic as a day procedure. This means you'll be able to go home the same day you have the operation, and you may recover more quickly.

For this reason, angioplasty is generally preferred to bypass surgery, unless angioplasty isn't suitable or has failed previously.

However, the results of a bypass are generally considered to be longer-lasting than those of an angioplasty, and the procedure may need to be repeated less often than an angioplasty.

Both angioplasty and bypass surgery carry a small risk of serious complications, such as a heart attack, stroke and even death. While there are few studies comparing the two techniques for PAD, there's some evidence to suggest that the risk of serious complications is similar in both bypass surgery and angioplasty.

Before recommending treatment, a team of specialist surgeons, doctors and nurses will discuss options with you – including the potential risks and benefits.

The information on this page has been adapted by NHS Wales from original content supplied by

NHS website nhs.uk