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Peripheral artery disease is narrowing or blockage of the arteries supplying the legs, caused by atherosclerosis, the same build-up of fatty plaque that causes heart attacks and strokes. Muscles that do not get enough blood during walking produce cramping pain called intermittent claudication. It affects up to 1 in 5 people over 70.

For most people the leg itself is not the chief danger. Only a small minority progress to limb-threatening ischaemia, whereas the risk of heart attack and stroke is several times higher than average. Treatment therefore has two aims: protect the heart and brain, and improve walking. Stopping smoking and a walking programme achieve more than most procedures.

Symptoms

• Cramping, aching or tightness in the calf, thigh or buttock on walking a predictable distance, relieved within minutes by standing still
• Shorter walking distance uphill or when hurrying
• One foot colder or paler than the other
• Shiny, hairless skin on the shins and slow-growing, thickened toenails
• Erectile dysfunction when the pelvic arteries are involved
• Burning pain in the toes or forefoot at night, eased by hanging the leg out of bed
• Ulcers on toes, heels or ankles that do not heal, or blackened toes
• No symptoms in about half of affected people

Causes and risk factors

The cause is atherosclerosis. Smoking is the most powerful risk factor, multiplying risk two to four times, followed by diabetes. High blood pressure, raised LDL cholesterol, chronic kidney disease, age over 60, and a family history of vascular disease add to it. People who already have coronary or carotid disease very often have leg artery disease as well. Less common causes in younger people include Buerger's disease in heavy smokers, popliteal artery entrapment in athletes, vasculitis, and damage from radiotherapy or trauma.

How it is diagnosed

• Pulse examination: Feeling the groin, knee, ankle and foot pulses, and inspecting skin, colour and any wounds.
• Ankle-brachial pressure index: Compares ankle and arm blood pressure with a Doppler probe. A ratio of 0.9 or below confirms the diagnosis; below 0.4 indicates severe disease. Stiff arteries in diabetes can give falsely high readings, so toe pressures are used.
• Exercise ABI: Repeats the measurement after treadmill walking when resting values are normal.
• Duplex ultrasound: Maps the site and severity of narrowings without radiation or contrast.
• CT or MR angiography: Provides the full road map needed to plan angioplasty or bypass.
• Catheter angiography: Now mostly performed at the time of treatment.
• Cardiovascular risk tests: Lipids, HbA1c, kidney function and an ECG.

Treatment options

• Stopping smoking: Reduces progression, amputation and cardiac events more than any other step.
• Supervised exercise therapy: Walking to near-maximal pain, resting, and repeating, for 30 to 45 minutes three times a week over 12 weeks. It can double walking distance.
• Cardiovascular protection: A high-intensity statin, an antiplatelet such as clopidogrel or aspirin, blood pressure and diabetes control. Low dose rivaroxaban with aspirin suits some higher-risk patients.
• Cilostazol or naftidrofuryl: Can modestly improve walking distance. Cilostazol is not used in heart failure.
• Angioplasty and stenting: Balloon, stent, drug-coated devices or atherectomy through a groin puncture, for lifestyle-limiting claudication after exercise therapy, or for limb-threatening disease. Often a day case or one night.
• Bypass surgery: Using your own vein or a graft for long blockages, giving the most durable result in suitable patients.
• Endarterectomy: Surgical removal of plaque, typically at the groin artery.
• Wound and foot care: Specialist dressings, offloading, infection control and podiatry. Amputation is reserved for cases where blood supply cannot be restored.

When it is urgent

A leg that suddenly becomes painful, pale, cold, numb or weak may have an acutely blocked artery and needs emergency vascular care within hours to save the limb. Also seek urgent local assessment for foot pain at rest, a new ulcer, black discolouration or spreading redness and infection, particularly if you have diabetes.

Travelling to Türkiye for treatment

Stable claudication can be assessed and, where indicated, treated on a planned visit: duplex scan, CT angiography and consultation in 1 to 2 days, and angioplasty with a 3 to 5 day stay, or around 10 to 14 days for bypass. Long-haul flights are generally fine with stable disease; walk the aisle and stay hydrated. Rest pain, ulcers or gangrene require urgent treatment near home and close wound follow-up, so travel is not appropriate. Risk factor treatment and surveillance scans of any stent or graft are lifelong and local.

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