Peripheral arterial occlusive disease (PAOD) is one of the most common vascular diseases and is caused by narrowed or blocked arteries, most often in the legs. It leads to circulatory disorders that initially cause pain when walking and, in advanced stages, can even endanger tissue.
In Germany, around 4.5 to 5 million people are affected—many of them without knowing it, as the disease often remains undetected for a long time. Early diagnosis is therefore crucial to prevent serious consequences and maintain quality of life.
The editorial team of the Leading Medicine Guide had the opportunity to learn more about this in a conversation with vascular specialist Dr. med. Konstantinos Verginis.
Early detection of PAOD is challenging because many affected individuals initially have no symptoms or do not associate mild symptoms such as a feeling of cold, fatigue in the legs, or diffuse calf tightness with a vascular disease. Nevertheless, there are clear diagnostic pathways that enable reliable identification even in the early stages.
„Peripheral arterial occlusive disease (PAOD) often goes unnoticed in its early stages because the body can initially compensate for circulatory disturbances. Symptoms usually occur only during walking and subside quickly at rest.
A typical symptom is a feeling of fatigue or cramping in the calf. Nerve pain, such as that caused by sciatica, is usually position- or movement-dependent, radiates from the back into the leg, and is perceived as stabbing or burning. Early detection of PAOD is important because it indicates a generalized vascular disease and increases the risk of heart attack and stroke“, explains Dr. med. Konstantinos Verginis at the beginning of our conversation.
To accurately assess the individual progression of PAOD and make well-founded therapeutic decisions, a stepwise diagnostic approach is required that combines simple baseline procedures with high-resolution imaging and careful clinical follow-up. No single method is sufficient on its own—the key lies in their interplay.
„Various examinations are used to establish the diagnosis. First, the physician conducts a consultation and a physical examination. Typical symptoms are assessed, such as leg pain while walking, cold feet, or poorly healing wounds. The pulses in the legs are then palpated.
If these are weak or not palpable at all, this may indicate a circulatory disorder. An important and simple diagnostic method is the so-called ankle-brachial index, also known as ABI measurement (Ankle-Brachial Index). This involves measuring blood pressure in the arm and at the ankle and comparing the two. The examination is performed using a handheld Doppler ultrasound device, which makes blood flow in the vessels audible.
If the blood pressure in the leg is significantly lower than in the arm, this indicates PAOD. With a duplex ultrasound of the leg arteries, the physician can assess how well blood flows through the vessels and whether there are narrowings or occlusions. Duplex ultrasound is also painless and does not involve radiation exposure. If more detailed information is needed, for example for planning treatment or surgery, specialized imaging procedures are used.
These include CT or MR angiography, in which the blood vessels are visualized in detail using a contrast agent. In certain cases, angiography is also performed, where a thin catheter is inserted into a blood vessel to precisely visualize narrowings. In summary, the diagnosis of PAOD is carried out step by step—from simple, gentle examinations to highly precise imaging procedures. This allows the disease to be reliably identified and an appropriate treatment plan to be developed“, Dr. Verginis describes the diagnostic approach.
For guiding therapy, it is crucial how the combination of symptoms, ABI progression, duplex findings, and imaging evolves over time. If the disease remains stable under consistent conservative therapy (smoking cessation, walking training, pharmacological secondary prevention), invasive measures can often be avoided. However, if there is a clear deterioration in walking distance, a drop in ABI, or increasing stenosis on duplex ultrasound, endovascular or surgical revascularization comes into focus.
In cases of critical limb ischemia with rest pain or non-healing ulcers, diagnostics are used to rapidly plan the best possible revascularization strategy in order to avoid amputations.
Lifestyle factors play a much greater role in the development and progression of PAOD than many patients initially assume. While age and genetic predisposition may create the foundation, it is primarily modifiable behaviors that determine whether vascular disease actually develops and how quickly it progresses.
Dr. Verginis emphasizes: „Lifestyle factors play a central role in the development of PAOD and are often more important than genetic or age-related risks. While age and genetic predisposition determine the individual baseline, lifestyle significantly influences whether and how quickly the disease develops and progresses.
The most important modifiable risk factor is smoking. It leads to vascular constriction, promotes inflammatory processes in the vessel wall, and accelerates atherosclerosis. Smokers develop PAOD more frequently, earlier, and with more severe courses, and they have a significantly increased risk of complications such as amputations.
Smoking cessation is therefore the most effective single measure for prevention and slowing disease progression. Diet also influences PAOD risk, primarily indirectly, as an unhealthy diet promotes conditions such as diabetes mellitus, lipid metabolism disorders, and hypertension, which accelerate vascular calcification. Physical inactivity is also an important risk factor, whereas regular physical activity improves circulation and, particularly in the form of walking training, has therapeutic benefits.
Advancing age increases the risk of PAOD, especially after the age of 60, but is not the sole trigger. Genetic factors increase individual susceptibility but usually lead to disease only in combination with unfavorable lifestyle factors. Overall, age and genetics determine the baseline, while lifestyle is decisive for the development, course, and prognosis of PAOD“.
Conservative, endovascular, and surgical therapies all pursue the same goal in PAOD—improving blood flow, alleviating symptoms, and preventing complications—but differ significantly in their intensity, risk, and timing of use.
Which method is appropriate for a patient is determined by a combination of symptoms, anatomical findings, comorbidities, and the individual risk-benefit ratio.
„Conservative, endovascular, and surgical treatment approaches differ primarily in their degree of invasiveness, their risk, and their objectives. Conservative therapy includes measures such as medication, physiotherapy, compression, lifestyle changes, or watchful waiting. It often aims to relieve symptoms, slow disease progression, or prevent complications without directly eliminating the underlying cause.
Due to its low risk, it is often the first treatment option for mild symptoms, early disease stages, or patients with a high surgical risk. Endovascular therapies represent a minimally invasive intermediate approach. They are performed using catheters inserted through blood vessels and allow procedures such as balloon dilation, stent implantation, or vessel occlusion without the need for open surgery.
As a result, they are generally less physically demanding, associated with shorter hospital stays, and are well suited even for patients with pre-existing conditions or advanced age. However, their limitations lie in the anatomy, the extent of the disease, and sometimes limited long-term durability. Surgical therapy is the most invasive form of treatment and involves open surgical procedures.
It is primarily used when diseases are advanced, complex, or life-threatening, or when conservative and endovascular measures have not been sufficiently effective. Surgical interventions often provide the most durable and effective solution but are associated with higher risks, longer recovery periods, and greater strain on the body“, explains Dr. Verginis and adds:
„The choice of therapy in each individual case is made on an individualized basis. Factors such as the severity and dynamics of the disease, its location and prognosis, as well as the patient’s age, general condition, comorbidities, and life expectancy all play a role. All factors are considered together. Technical feasibility, chances of success, risks, current guidelines, as well as the patient’s personal level of suffering and preferences are taken into account.
In principle, the goal is to choose a treatment that is as gentle as possible but as effective as necessary. To ensure optimal care for our patients, each therapy is tailored individually.
This includes teamwork, collaboration with other departments, and partnerships with affiliated hospitals in the surrounding area. For example, carotid surgery is performed within the neurovascular center in cooperation with neurologists, neuroradiologists, neurosurgeons, and us as vascular surgeons.
PAOD and aneurysm surgery are carried out in close collaboration with interventional radiology and the vascular surgery department of Sana Klinikum Düsseldorf-Gerresheim, under the direction of Prof. Dr. med. Ralf Kolvenbach. We provide optimal patient care through a strong network of specialists“.
The risk of severe complications such as critical limb ischemia or amputation can only be effectively reduced if PAOD is not viewed in isolation, but as part of a complex vascular condition that progresses much more aggressively, especially in people with diabetes, renal insufficiency, or other comorbidities. A combination of strategies is therefore essential, protecting the vessels themselves while controlling the factors that damage them.
„To reduce the risk of severe complications such as critical limb ischemia or amputation, consistent management of risk factors is crucial.
Complete smoking cessation has the greatest impact, as smoking significantly accelerates the progression of vascular disease. Particularly in patients with diabetes, good blood sugar control is important to prevent vascular damage, infections, and impaired wound healing.
Effective control of blood pressure and cholesterol also helps prevent further vascular narrowing. Regular walking training, where possible, can improve circulation by promoting the formation of collateral vessels. In addition, blood-thinning medications reduce the risk of vascular occlusions.
Another key aspect is regular foot care and monitoring, as small, often painless injuries must be detected and treated early. If signs of critical circulatory impairment occur, early interventional or surgical treatment is necessary to prevent tissue loss and amputations“, explains the vascular specialist.
Smoking cessation plays a central role. No other factor accelerates PAOD as strongly as nicotine. In people with diabetes, smoking acts like an “accelerant”: it worsens microcirculation, promotes inflammation, and significantly increases the risk of impaired wound healing. Avoiding tobacco is therefore one of the most effective measures to prevent amputations.
Effective long-term follow-up care in PAOD results from a continuous interplay of medical monitoring, lifestyle stabilization, and early intervention—and it does not begin only after a procedure but accompanies patients over the long term. The key is to understand follow-up care not as a “check-up appointment,” but as a structured process that prevents relapse, detects vascular occlusions early, and stabilizes quality of life.
Dr. Verginis concludes with the following recommendation: „Long-term follow-up care aims to detect new vascular occlusions at an early stage and sustainably improve patients’ quality of life. Regular medical check-ups are essential, during which symptoms, walking distance, pulses, and, if necessary, ultrasound examinations are assessed.
Equally important is the consistent management of risk factors through proper control of blood pressure, blood sugar, and cholesterol, as well as the long-term use of prescribed medications. A structured exercise plan, particularly regular walking training, helps promote circulation and maintain physical resilience.
In addition, smoking cessation, a healthy diet, and weight reduction play an important role. In patients with diabetes, regular foot examinations are also necessary to detect minor injuries early and prevent complications. Through this combination of medical monitoring, active patient participation, and targeted lifestyle changes, relapses can often be prevented and quality of life improved in the long term“.
Thank you very much, Dr. Verginis, for your insightful explanations!
- Board-certified specialist in vascular surgery and endovascular surgery at Sana Clinics Duisburg with extensive expertise in arterial and venous diseases.
- Specialized in complex procedures for PAOD, carotid stenosis, aneurysms, and diseases of the visceral and renal arteries.
- Outstanding expertise in rare visceral and retroperitoneal compression syndromes such as Dunbar, Wilkie, nutcracker, and May-Thurner syndrome.
- Performs numerous open and endovascular carotid reconstructions annually in the neurovascular center.
- Highly experienced in endovascular techniques, vascular reconstructions, shunt surgery, and port and pacemaker implantations.
- Extensive experience in the treatment of venous diseases such as varicose veins, deep vein thrombosis (DVT), and thrombophlebitis, as well as in the management of chronic wounds.
- Scientifically recognized expert in rare compression syndromes, which also form the focus of his doctoral thesis.
- Combines modern diagnostics, innovative technology, and surgical precision to deliver patient-centered, high-quality vascular care.
