Peripheral arterial disease (PAD) is a chronic vascular condition characterized by a lack of oxygen in the legs. These circulatory problems result from the progressive hardening of the arteries in the legs. The consequences include pain when walking and a reduced ability to walk.
Those affected are forced to stop after walking a certain distance until the pain subsides. When strolling through town, they therefore often stop in front of store windows. This gave rise to the colloquial term “window-shopping disease.”
Those affected experience pain when walking and must therefore stop more frequently © Viacheslav Iakobchuk | AdobeStock
Doctors also refer to PAD as claudication intermittens (Latin for “intermittent limping”). Colloquially, the condition is also known as “smoker’s leg,” since smoking is a major risk factor.
PAVK is a widespread vascular disease. According to the German Society for Angiology (DGA), approximately 4.5 million people in Germany suffer from it. In the age group of those over 65, a total of about 20 percent of all people are estimated to be affected.
Smokers are particularly prone to PAD.
People over 65 and smokers are particularly likely to be affected by PAD © Hunor Kristo | AdobeStock
Peripheral arterial disease is caused by
- a narrowing (stenosis) or
- an occlusion
of the leg arteries. In about 90 percent of cases, this is caused by vascular calcification, also known as atherosclerosis. The remaining 10 percent of cases of peripheral arterial disease are attributable to inflammatory vascular diseases.
The following video explains how atherosclerosis—and thus peripheral arterial disease—develops:
The most important risk factors for the development of atherosclerosis—and consequently PAD—include
Symptoms depend on the severity of the narrowing or blockage of the blood vessels. In the early stages of the disease, the narrowing of the arteries in the legs is not yet very pronounced. Therefore, PAD does not initially cause any symptoms.
The narrowing of the blood vessels increases over time. As soon as the tissue can no longer be adequately supplied with nutrients and oxygen, pain and symptoms occur.
Typical symptoms of PAD include:
- Pain when walking—depending on the location of the narrowing, either in the calves, buttocks, or thighs
- a progressive reduction in walking distance
- later, pain in the feet and toes even at rest
Pain in the calves is typical of peripheral arterial disease © Satjawat | AdobeStock
Other common symptoms of intermittent claudication include
- a sensation of coldness and weakness in the legs,
- paleness of the affected leg, and
- muscle pain during physical activity.
In advanced stages, the lack of blood flow can also lead to serious complications
- such as lower leg ulcers and
- tissue death in the toes, ankles, and heels
.
In most cases, PAD is caused by atherosclerosis. As a result, PAD patients also have an increased risk of suffering a heart attack or stroke. Heart attack is the leading cause of death among PAD patients.
PAD patients have an increased risk of stroke © Alexandr Mitiuc | AdobeStock
Depending on the severity of symptoms, doctors distinguish four stages of PAD:
- Stage I: No symptoms yet (asymptomatic PAD)
- Stage II: Symptoms while walking and limited walking distance
- Stage III: Pain now also occurs at rest
- Stage IV: Tissue deprived of blood supply dies (necrosis, gangrene)
Stages III and IV carry an immediate risk of amputation.
In the final stage, tissue death in the lower extremities can occur as a serious complication © DOUGLAS | AdobeStock
If PAD is suspected, the doctor can perform a series of tests to confirm the diagnosis. These include, for example
- a physical examination, during which the doctor feels for the pulses in the affected leg, and
- a Doppler pressure measurement (duplex sonography) using a special ultrasound device to determine the so-called ankle-brachial index.
The ankle-brachial index measures blood pressure at the ankle and at the arm. If the blood pressure at the ankle is significantly lower than that at the arm, this indicates a narrowing of the leg arteries. This suggests that PAD is likely.
Using duplex sonography, the examiner can examine the arteries from the pelvis to the foot. In doing so, they assess the condition of the vessel wall and the blood flow within the artery.
Duplex ultrasound of the leg arteries © New Africa | AdobeStock
First, the patient must eliminate all risk factors. This includes quitting smoking and controlling blood pressure.
Depending on the stage of the vascular disease, various treatment methods are available for PAD. These include, among others,
- medication to improve blood flow in the vessels,
- structured walking training, preferably in PAD exercise groups,
- interventional procedures such as vascular dilation with stents, and
- surgical procedures such as bypass surgery.
For drug therapy, the doctor may prescribe anticoagulants or active ingredients such as acetylsalicylic acid.
Surgical procedures such as a vascular bypass, however, are performed by the PAD specialist only in later stages of the disease.
The following video demonstrates how vascular dilation with stents is performed:
Advanced atherosclerosis—and thus PAD—is irreversible. However, starting treatment early can significantly slow the progression of the disease. In some cases, it can even be stopped entirely.
A good prognosis depends above all on the patient’s cooperation. To eliminate risk factors, PAD patients should, among other things,
- quit smoking,
- monitor their blood sugar, blood pressure, and cholesterol levels,
- eat a healthy diet,
- get enough exercise,
- and lose weight.
PAVK is a disease of the blood vessels. Therefore, treatment is usually provided by experts in the medical fields of angiology and vascular surgery.
Peripheral arterial disease (PAD) specialists can use the diagnostic methods described above to determine
- whether the symptoms are caused by PAD,
- where the problems lie, and
- how blood flow can best be restored.
In this regard, the vascular surgeon has the widest range of treatment options. He or she is skilled in
- conservative treatment methods,
- endovascular methods (balloon catheters, stents), and
- open vascular surgery.
How can you recognize PAD in its early stages, and when should you see a doctor to determine whether you have a circulatory disorder?
PAD usually develops gradually. In Stage 1, there are often no symptoms yet, even though narrowings in the leg arteries may already be present. Early signs include cold feet, reduced physical performance, or mild cramping pain during physical activity. A medical examination should be conducted as soon as PAVK is suspected. An ultrasound is often used during this examination to visualize plaques and narrowings and to assess blood flow in the legs. The earlier the diagnosis is made, the better complications can be prevented.
What are the symptoms of stage 2 peripheral arterial disease, and why do patients with PAD often have to stop walking?
In stage 2, the narrowing of the blood vessels causes typical pain when walking. The muscles do not receive enough oxygen, causing cramp-like pain in the calf, thigh, or buttocks. Patients with PAD must then stop walking until the symptoms subside. This form of peripheral arterial disease leads to a progressively shorter walking distance. People with PAD should take such symptoms seriously, as the risk of further cardiovascular events increases starting in Stage II.
What risk factors contribute to the development of PAD, and what individual risk factors play a role?
The most important risk factors for PAD include smoking, diabetes mellitus, high blood pressure, elevated blood lipid levels, and pre-existing atherosclerosis. Genetic factors, advanced age, and physical inactivity also increase the risk. Many of these potential risk factors overlap with the risk factors for atherosclerosis in general. Regular medical monitoring of blood pressure in the upper arms, cholesterol, and blood sugar, as well as an analysis of individual risk factors, is crucial to preventing the condition from worsening.
What diagnostic procedures are important for determining whether PAD is present?
If PAD is present, this can be confirmed through several tests. Basic diagnostics begin with a physical examination and measurement of the ankle-brachial index. If this index is significantly reduced, it strongly suggests a circulatory disorder in the legs. This is followed by ultrasound examinations, which visualize the vessel walls, narrowings, and blood flow. If the findings are inconclusive, further imaging procedures may be performed. Early diagnosis improves life expectancy, as complications such as blood clots or advanced narrowings can be detected in a timely manner.
How does the disease progress through the various stages, and what happens in stages 3 and 4?
Peripheral arterial disease (PAD) is medically classified into four stages. In stage 1, there are no symptoms. In stage 2, pain occurs when walking. In Stage 3, pain occurs even at rest. Stage 4 is characterized by tissue damage such as ulcers or gangrenous toes. Starting in Stage II, the risk of serious complications increases significantly. In stages 3 and 4, interventional treatment is often necessary, such as dilating the narrowed area with a balloon or implanting a stent. The goal is to improve blood flow and prevent amputations.
What treatment options are available, and when are procedures necessary?
Treatment for PAD depends on the stage and the symptoms. The first step is to manage all risk factors, such as smoking, blood pressure, diabetes, and cholesterol. Walking training is considered a key therapy, as it can promote the formation of new blood vessels and increase the distance a person can walk pain-free. If there is a severe narrowing, interventional therapy using a balloon or stent may be necessary. The procedure restores blood flow and reduces the risk of serious complications such as heart attack or stroke.
