Peripheral Artery Disease: Symptoms, Diagnosis, and Treatment

Peripheral artery disease isn't just about leg pain. It's a warning sign that your arteries are clogging up-not just in your legs, but possibly in your heart and brain too. If you're over 50, smoke, have diabetes, or high blood pressure, you're at higher risk. Yet most people don't know they have it until something serious happens. About 8.5 million Americans have it, and nearly half of them don't even feel symptoms. That’s dangerous. PAD doesn’t go away on its own. But if caught early, it can be managed-and major complications like heart attack, stroke, or amputation can be prevented.

What Does Peripheral Artery Disease Actually Feel Like?

Many assume leg pain during walking is just aging or being out of shape. But if you get cramping, aching, or tiredness in your calves, thighs, or hips when you walk-especially if it goes away after resting for a few minutes-you could have claudication. That’s the classic sign of PAD. It’s not muscle strain. It’s your muscles starving for oxygen because blood flow is blocked.

Some people don’t feel pain at all. Instead, they notice their legs feel colder than the rest of their body. Their skin might look shiny or pale. Hair stops growing on their shins. Toenails thicken and grow slowly. Men might experience erectile dysfunction-yes, that’s linked. In fact, nearly 6 in 10 men with PAD have it. These aren’t random changes. They’re signs your circulation is failing.

The worst case is critical limb ischemia. This means pain even when you’re lying down. Sores on your feet or toes won’t heal. Skin turns dark or black. This is an emergency. Without treatment, amputation becomes likely within months. About 1 in 100 people with PAD reach this stage, but the risk jumps if you smoke, have diabetes, or skip checkups.

How Do Doctors Know You Have It?

There’s no single symptom that confirms PAD. That’s why testing matters. The first and easiest test is the ankle-brachial index, or ABI. It’s like checking your blood pressure in your arm and then your ankle. If the pressure in your ankle is significantly lower than in your arm, your leg arteries are narrowed. An ABI of 0.90 or less means you have PAD. It’s accurate in 95% of cases and takes less than 10 minutes.

For people with diabetes or kidney disease, the ABI can be misleading because their arteries become stiff. That’s when doctors use the toe-brachial index (TBI). If the TBI is below 0.70, PAD is likely. Both tests are non-invasive, painless, and done right in the doctor’s office.

If the ABI is abnormal, the next step is usually a Doppler ultrasound. This uses sound waves to show how blood flows through your arteries and where blockages are. It’s safe, doesn’t use radiation, and can pinpoint exactly how bad the narrowing is. For more complex cases, doctors might order a CT angiogram or an MRI. These give detailed 3D images of your arteries. But they’re not always needed. Many people never need imaging beyond the ABI and ultrasound.

The American Heart Association says everyone over 65 should get screened. So should anyone over 50 who smokes or has diabetes. Even if you feel fine. If you’re 40 or older and have high blood pressure, high cholesterol, or obesity, talk to your doctor about getting tested. Most people don’t. Only about 1 in 5 eligible patients actually get an ABI test.

Can You Reverse It Without Surgery?

Yes. And it starts with two things: moving your body and quitting smoking.

Supervised walking programs are the most effective non-drug treatment for PAD. Not just walking around the house. A structured program means walking until you feel moderate pain, resting until it goes away, then walking again. Do this 3 to 5 times a week for 30 to 45 minutes. After 12 weeks, most people can walk 50% to 100% farther without pain. That’s more than many medications achieve. It’s not magic-it’s science. Exercise tells your body to grow new tiny blood vessels around the blockages. Your legs learn to work with less blood flow.

Quitting smoking is even more important. Smokers with PAD are 8 times more likely to need an amputation than those who quit. Their risk of dying from heart disease triples. Nicotine tightens arteries and speeds up plaque buildup. Even one cigarette a day makes things worse. If you’re struggling, ask about nicotine patches, gum, or prescription meds like varenicline. Your doctor can help.

What Medications Are Used?

There are three key drugs for PAD, and most people need at least two of them.

First, antiplatelets. These thin your blood slightly to prevent clots. Aspirin (81 mg daily) is common. But clopidogrel (75 mg daily) works better for PAD patients. Studies show it cuts the risk of heart attack, stroke, or death by 20% more than aspirin alone.

Second, statins. These aren’t just for cholesterol. For PAD patients, they stabilize plaque, reduce inflammation, and lower the chance of heart problems by 25% to 30%. Guidelines say everyone with PAD should be on a high-dose statin, even if their cholesterol is normal. The goal is to get LDL cholesterol below 70 mg/dL.

Third, cilostazol. This drug helps improve walking distance by relaxing arteries and reducing blood stickiness. It can boost how far you walk without pain by 50% to 100%. But it’s not for everyone. If you have heart failure, it can make things worse. Your doctor will check before prescribing it.

When Do You Need Surgery or Procedures?

If you’re still in pain after 3 months of exercise and medication, or if you have open sores or rest pain, it’s time to consider revascularization. That means reopening blocked arteries.

The least invasive option is angioplasty. A tiny balloon is threaded into the blocked artery and inflated to flatten the plaque. Often, a metal mesh tube called a stent is left behind to keep the artery open. For short blockages, this works well-90% of patients see improvement right away. But over time, the artery can narrow again, especially in diabetics.

For longer or more calcified blockages, atherectomy might be used. This removes the plaque with a tiny rotating blade or laser. It’s effective for stubborn deposits that balloons can’t crush.

If the blockage is very long or in a major artery, bypass surgery is an option. Surgeons take a vein from your leg or use a synthetic tube to reroute blood around the blocked section. Vein grafts last longer-about 80% stay open after 5 years. But recovery takes weeks.

The BASIL trial showed that for people with claudication, exercise alone gives the same long-term results as surgery. But surgery gives faster relief. If your life is being limited by pain, and you can’t stick to walking, then a procedure makes sense.

Why So Many People Are Still Left Behind

Here’s the hard truth: PAD is underdiagnosed and undertreated. Only 20% of people who should get screened actually do. Black and Hispanic patients are 30% to 40% less likely to get revascularization than white patients-even when their disease is just as bad. That’s not about medical need. It’s about access, bias, and awareness.

The 5-year death rate for PAD patients is 30% to 40%. That’s higher than many cancers. Yet most people don’t treat it like a life-threatening condition. They treat it like “just leg pain.”

The PAD Awareness Act of 2022 started funding screening programs in the U.S. in early 2024. But awareness is still low. If you’re at risk, don’t wait for symptoms. Get tested. If you have it, follow your treatment plan. Quit smoking. Walk regularly. Take your meds. Your legs-and your heart-depend on it.

What’s Next for PAD Treatment?

Research is moving fast. One promising area is combining low-dose rivaroxaban (a blood thinner) with aspirin. Early results from the VOYAGER PAD trial show this combo reduces the risk of limb-related complications by 15% after revascularization. It’s not yet standard, but it’s coming.

Stem cell therapy is also being tested. In early trials, injecting a patient’s own blood stem cells into their leg muscles helped heal non-healing wounds in 65% of cases-compared to just 35% with standard care. It’s experimental, but for people with no other options, it’s hope.

Advanced imaging like optical coherence tomography (OCT) lets doctors see plaque details at a microscopic level. This helps them choose the best treatment-balloon, stent, or removal-based on exactly what’s inside the artery.

The goal isn’t just to keep people from losing limbs. It’s to help them live longer, healthier lives. PAD isn’t a death sentence. But ignoring it is.