Peripheral arterial disease

Last updated: September 13, 2023

Summarytoggle arrow icon

Peripheral arterial disease (PAD) is a condition characterized by the atherosclerotic narrowing of peripheral arteries, most commonly of the lower extremities. Lower extremity PAD may be asymptomatic or manifest with intermittent claudication, critical limb ischemia (CLI), or acute limb ischemia (ALI), which is a surgical emergency that is described in a separate article. In the absence of acute ischemia, the first-line diagnostic test for PAD is the ankle-brachial index (ABI). Imaging, preferably via MR angiography, is indicated if revascularization is planned or if the diagnosis remains uncertain. Structured exercise therapy and modification of cardiovascular risk factors may improve intermittent claudication significantly; cilostazol, a vasodilator, may be considered for symptomatic relief. Revascularization is indicated in patients with limb ischemia and those with life-limiting claudication despite exercise therapy. Additionally, management of atherosclerotic cardiovascular disease should be initiated in all patients.

Carotid artery stenosis and chronic mesenteric ischemia are less common types of peripheral arterial disease and are covered separately.

Epidemiologytoggle arrow icon

  • Prevalence: 8.5 million in the US
    • Prevalence increases with age, starting from the age of 40
    • US incidence rates are highest among African Americans, followed by Hispanics, who are at a slightly higher risk than non-hispanic whites.
  • Peak incidence: 60–80 years of age
  • Sex: = [1]

Peripheral arterial disease is equally common in women and men. [1]


Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

PAD usually coexists with coronary artery disease. Smoking is one of the most important risk factors for PAD!

Clinical featurestoggle arrow icon

Up to 20–50% of patients with PAD are asymptomatic.

Intermittent claudication

Rest pain

Rest pain occurs as disease progresses and indicates severe ischemia.

  • Typically occurs first in the toes and forefoot
  • Worsens with reclining (e.g., while sleeping)
  • Improves on hanging feet off the bed or on standing

Critical limb ischemia (CLI) [3]

  • Indicative of limb-threatening arterial occlusion
  • Characterized by the presence of any one of the following:

Examination findings

Classificationtoggle arrow icon

There are several classification systems for peripheral arterial disease, such as, the Rutherford classification, Global Limb Anatomic Staging System (GLASS), and the Trans-Atlantic Inter-Society Consensus (TASC). See “Overview of classification systems in peripheral artery disease” in the “Tips and Links” section below for details. [6]

Classification by clinical presentation [3][6]

Wound, Ischemia, and foot Infection (WIfI) classification [7][8]

  • Purpose
  • Description
    • The following factors are assigned values from 0 (normal) to 3 (severe abnormality):
      • Wound (W): depth and tissue involvement of existing ulcers
      • Ischemia (I): ankle systolic blood pressure and/or tissue oxygenation
      • Foot Infection (fI): local and systemic signs of infection
    • The benefit of revascularization and the risk of amputation can be estimated based on the three derived values.

Fontaine classification [6]

Diagnosticstoggle arrow icon

Approach [3][7]

ALI is an imminently limb-threatening emergency and treatment should not be delayed to investigate the underlying etiology. [10]

Ankle-brachial index (ABI) [7][10]

ABI is the ratio of systolic ankle blood pressure to systolic brachial blood pressure.

Resting ABI

  • Indications
  • Technique
    • Ask the patient to rest in the supine position for approx. 10 minutes.
    • Place the blood pressure cuffs on the ankles and the arms.
    • Locate the pulse using the Doppler.
    • Inflate the cuff until the pulse is no longer audible on the Doppler device, and then inflate the cuff by a further 20 mm Hg.
    • Deflate the cuff slowly, and note the pressure at which the pulse is audible again.
    • Calculate the ABI for each leg: Divide the highest ankle pressure by the highest brachial pressure.

Ankle–brachial index interpretation in patients with suspected PAD [7][10]
Resting ABI Interpretation Next steps
> 1.4
1–1.4 [14]
  • Normal
  • Borderline
≤ 0.9
  • Abnormal

A low ABI (≤ 0.9) and high ABI (> 1.4) are associated with an increased risk of all-cause and cardiovascular mortality! [15]

Exercise ABI [16]

  • Description: ABI testing following extended exercise of the lower extremity
  • Indication: suspicion of PAD in a patient with a normal or borderline ABI
  • Findings: Either of the following are consistent with PAD.
    • Post-exercise decrease in ABI by > 20%
    • Post-exercise decrease in ankle systolic blood pressure by > 30 mm Hg

Toe-brachial index [10][12][17]

  • Definition: the ratio of the systolic blood pressure of the first toe to the systolic brachial blood pressure
  • Indications
    • Suspicion of PAD in a patient with a normal or elevated ABI (i.e., ABI > 1.4)
    • Lower extremity wound suggestive of CLI
  • Findings: Toe-brachial index ≤ 0.70 is consistent with PAD.

Measures of tissue perfusion [13]

  • Examples: transcutaneous oximetry, fluorescent imaging of indocyanine green dye, skin perfusion pressure
  • Indication: nonhealing wounds or tissue loss suggestive of CLI

Imaging [7][18][19]

Differential diagnosestoggle arrow icon

Differential diagnosis of claudication
Patient characteristics Clinical features
Arterial occlusion or narrowing Vasculitides Takayasu arteritis
  • Asian females
  • 15–45 years
Thromboangiitis obliterans
  • 20–40 years
  • More common in males before the age of 45 years [20]
  • Significant history of tobacco consumption (e.g., smoking, chewing, vaping)
(Lower-extremity) fibromuscular dysplasia
  • Middle-aged women
Popliteal aneurysm
Arterial embolism
  • Sudden onset of symptoms
  • 6 Ps
Popliteal entrapment syndrome
  • Most commonly affects young men < 30 years
Cystic adventitial disease
  • Generally affects men between 30–50 years
  • Foot pulses may be present during rest and absent following exercise [21]
Mimics of arterial occlusion Deep vein thrombosis
  • Swelling
  • Warmth
  • Erythema
  • Progressive tenderness
  • Dull pain: worsened by walking, improved by resting
Spinal stenosis
  • Middle-aged to older patients
Diabetic neuropathy
  • Middle-aged to older patients
  • High BMI
  • Progressive symmetrical loss of or abnormal sensation in the distal lower extremities (glove and stocking sensation)
  • Normal ABI
  • Neuropathic diabetic foot: warm, dry skin, palpable foot pulses

Chronic exertional compartment syndrome [22][23][24]

  • Definition: recurrent reversible increase in pressure within a fascial compartment that results in pain and/or neurological symptoms due to compromised perfusion
  • Etiology: repetitive physical activity (e.g., athletes, military trainees)
  • Clinical features
    • Location: lower legs (most common), forearms, feet
    • Muscle pain, tightness, weakness, and swelling exacerbated by exercise and relieved with rest
    • Paresthesia, numbness, and/or transient nerve palsy (e.g., foot drop) may occur.
  • Diagnostics
  • Treatment

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Overview [7][10][25]

Prevention of progression and complications [3][28]

Start management of ASCVD in all patients, as patients with PAD are at increased risk of further ASCVD events, e.g., MI or stroke.

Intensive management of ASCVD and its risk factors improves outcomes in PAD and prevents ischemic events in other arterial beds, including the coronary arteries. [10]

Structured exercise therapy [3][25]

Exercise therapy may improve claudication symptoms but not the ABI, as it primarily promotes collateral blood circulation. [33]

Vasodilators [3][7][30]

Cilostazol improves claudication symptoms and walking distance but has not been shown to decrease major cardiovascular events. [3][35]

Pentoxifylline is not effective for treating claudication. [3]

Revascularization [7][10][26]

The primary goal of revascularization is to improve blood flow in at least one artery to the foot to prevent pain and tissue loss.

  • Indications
    • CLI, if the limb is viable
    • Lifestyle-limiting claudication despite optimal medical therapy and exercise
  • Modalities [10][36][37]
    • Endovascular or surgical revascularization
    • The choice of procedure depends on the location and morphology of the arterial disease and the patient's comorbidities.
Revascularization procedures for peripheral arterial disease
Endovascular revascularization Surgical revascularization
  • Peripheral artery bypass surgery: Open surgical bypass of the vascular stenosis with an autologous vein or prosthetic material
  • Endarterectomy (may be combined with endovascular treatment)
Indications [10][36][37]
  • Consider in the following situations:
    • Short segment disease: stenosis < 10 cm or occlusion < 5 cm
    • Aortoiliac disease
    • High-risk patients [10][36][37]
  • Consider in low- and average-risk patients with any of the following: [10][36][37]
    • Extensive and complex disease: long segment lesions (> 10 cm); multifocal lesions
    • Lesions of the common femoral artery
    • Purely infrapopliteal disease
    • Chronic total occlusion
  • Unsuccessful endovascular revascularization [10][36][37]

Supportive care [3][7]

  • Foot care
    • All patients with PAD should be educated on self-foot examination and healthy foot care.
    • Any sign of foot infection in a patient with PAD should prompt referral to an interdisciplinary care team.
  • Analgesia
  • Wound management
    • Provide multidisciplinary wound care to all patients with tissue loss.
    • Consider adjunctive therapies (e.g., intermittent pneumatic compression) in patients unfit for revascularization. [3]

Amputation [7][10]

Complicationstoggle arrow icon

Apart from ALI, which is described in a separate article, the following complications can occur due to PAD.

Arterial ulcer

Dry gangrene

  • Definition: a type of gangrenous necrosis caused by ischemia that is characterized by coagulative necrosis on histopathologic examination
  • Clinical features
    • Areas with gray-black discoloration showing a clear demarcation between necrotic and viable tissue
    • Autoamputation is possible.
  • Diagnosis: based on clinical features
  • Management
  • Complications: wet gangrene

Wet gangrene

We list the most important complications. The selection is not exhaustive.

Preventiontoggle arrow icon

See “Prevention of atherosclerotic cardiovascular disease.”

Related One-Minute Telegramtoggle arrow icon

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

Referencestoggle arrow icon

  1. Hiramoto JS, Katz R, Weisman S, Conte M. Gender‐Specific Risk Factors for Peripheral Artery Disease in a Voluntary Screening Population. J Am Heart Assoc. 2014; 3 (2).doi: 10.1161/jaha.113.000651 . | Open in Read by QxMD
  2. Peripheral Arterial Disease (PAD) Fact Sheet. Updated: June 16, 2016. Accessed: December 8, 2016.
  3. Hardman R, Jazaeri O, Yi J, Smith M, Gupta R. Overview of Classification Systems in Peripheral Artery Disease. Semin Intervent Radiol. 2014; 31 (04): p.378-388.doi: 10.1055/s-0034-1393976 . | Open in Read by QxMD
  4. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease. J Am Coll Cardiol. 2017; 69 (11): p.e71-e126.doi: 10.1016/j.jacc.2016.11.007 . | Open in Read by QxMD
  5. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019; 69 (6): p.3S-125S.e40.doi: 10.1016/j.jvs.2019.02.016 . | Open in Read by QxMD
  6. Mills JL, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). J Vasc Surg. 2014; 59 (1): p.220-234.e2.doi: 10.1016/j.jvs.2013.08.003 . | Open in Read by QxMD
  7. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  8. Bailey M, Griffin K, Scott D. Clinical Assessment of Patients with Peripheral Arterial Disease. Semin Intervent Radiol. 2014; 31 (04): p.292-299.doi: 10.1055/s-0034-1393964 . | Open in Read by QxMD
  9. Blaisdell F. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovasc Surg. 2002; 10 (6): p.620-630.doi: 10.1016/s0967-2109(02)00070-4 . | Open in Read by QxMD
  10. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary. J Am Coll Cardiol. 2017; 69 (11): p.1465-1508.doi: 10.1016/j.jacc.2016.11.008 . | Open in Read by QxMD
  11. Khan T, Farooqui F, Niazi K. Critical Review of the Ankle Brachial Index. Curr Cardiol Rev. 2008; 4 (2): p.101-106.doi: 10.2174/157340308784245810 . | Open in Read by QxMD
  12. Tran B. Assessment and management of peripheral arterial disease: what every cardiologist should know. Heart. 2021: p.heartjnl-2019-316164.doi: 10.1136/heartjnl-2019-316164 . | Open in Read by QxMD
  13. Misra S, Shishehbor MH, Takahashi EA, et al. Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices: A Scientific Statement From the American Heart Association. Circulation. 2019; 140 (12).doi: 10.1161/cir.0000000000000708 . | Open in Read by QxMD
  14. Aboyans V, Criqui MH, Abraham P, et al. Measurement and Interpretation of the Ankle-Brachial Index. Circulation. 2012; 126 (24): p.2890-2909.doi: 10.1161/cir.0b013e318276fbcb . | Open in Read by QxMD
  15. Resnick HE, Lindsay RS, McDermott MM, et al. Relationship of High and Low Ankle Brachial Index to All-Cause and Cardiovascular Disease Mortality. Circulation. 2004; 109 (6): p.733-739.doi: 10.1161/01.cir.0000112642.63927.54 . | Open in Read by QxMD
  16. Mehta A, Sperling LS, Wells BJ. Postexercise Ankle-Brachial Index Testing. JAMA. 2020; 324 (8): p.796.doi: 10.1001/jama.2020.10164 . | Open in Read by QxMD
  17. Høyer C, Sandermann J, Petersen LJ. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg. 2013; 58 (1): p.231-238.doi: 10.1016/j.jvs.2013.03.044 . | Open in Read by QxMD
  18. Expert Panel on Vascular Imaging: Ahmed O, Hanley M, et al. ACR Appropriateness Criteria Vascular Claudication-Assessment for Revascularization. J Am Coll Radiol. 2017; 14 (5S): p.S372-S379.doi: 10.1016/j.jacr.2017.02.037 . | Open in Read by QxMD
  19. Pollak AW, Norton PT, Kramer CM. Multimodality Imaging of Lower Extremity Peripheral Arterial Disease. Circulation. 2012; 5 (6): p.797-807.doi: 10.1161/circimaging.111.970814 . | Open in Read by QxMD
  20. Perttu ET Arkkila. Thromboangiitis obliterans (Buerger's disease). Orphanet Journal of Rare Diseases. 2006.
  21. Kawarai S, Fukusawa M, Kawahara Y. Adventitial Cystic Disease of the Popliteal Artery. Ann Vasc Dis. 2012; 5: p.190-193.doi: 10.3400/ . | Open in Read by QxMD
  22. Vogels S, Ritchie ED, van der Burg BLSB, Scheltinga MRM, Zimmermann WO, Hoencamp R. Clinical Consensus on Diagnosis and Treatment of Patients with Chronic Exertional Compartment Syndrome of the Leg: A Delphi Analysis. Sports Medicine. 2022.doi: 10.1007/s40279-022-01729-5 . | Open in Read by QxMD
  23. Buerba RA, Fretes NF, Devana SK, Beck JJ. Chronic exertional compartment syndrome: current management strategies. Open Access J Sport Med. 2019; Volume 10: p.71-79.doi: 10.2147/oajsm.s168368 . | Open in Read by QxMD
  24. Wilder RP, Magrum E. Exertional Compartment Syndrome. Clin Sports Med. 2010; 29 (3): p.429-435.doi: 10.1016/j.csm.2010.03.008 . | Open in Read by QxMD
  25. Firnhaber JM, Powell CS. Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. Am Fam Physician. 2019; 99 (6): p.362-369.
  26. Conte MS, Pomposelli FB, Clair DG, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication. J Vasc Surg. 2015; 61 (3): p.2S-41S.e1.doi: 10.1016/j.jvs.2014.12.009 . | Open in Read by QxMD
  27. Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database of Syst Rev. 2017.doi: 10.1002/14651858.cd000990.pub4 . | Open in Read by QxMD
  28. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 140 (11): p.e596-e646.doi: 10.1161/cir.0000000000000678 . | Open in Read by QxMD
  29. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 139 (25).doi: 10.1161/cir.0000000000000624 . | Open in Read by QxMD
  30. Bevan GH, White Solaru KT. Evidence-Based Medical Management of Peripheral Artery Disease. Arterioscler Thromb Vasc Biol. 2020; 40 (3): p.541-553.doi: 10.1161/atvbaha.119.312142 . | Open in Read by QxMD
  31. Khan SZ, Rivero M, Nader ND, et al. Metformin Is Associated with Improved Survival and Decreased Cardiac Events with No Impact on Patency and Limb Salvage after Revascularization for Peripheral Arterial Disease. Ann Vasc Surg. 2019; 55: p.63-77.doi: 10.1016/j.avsg.2018.05.054 . | Open in Read by QxMD
  32. Fakhry F, Rouwet EV, den Hoed PT, Hunink MGM, Spronk S. Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial. Br J Surg. 2013; 100 (9): p.1164-1171.doi: 10.1002/bjs.9207 . | Open in Read by QxMD
  33. Akerman AP, Thomas KN, van Rij AM, Body ED, Alfadhel M, Cotter JD. Heat therapy vs. supervised exercise therapy for peripheral arterial disease: a 12-wk randomized, controlled trial. American Journal of Physiology-Heart and Circulatory Physiology. 2019; 316 (6): p.H1495-H1506.doi: 10.1152/ajpheart.00151.2019 . | Open in Read by QxMD
  34. Alonso-coello P, Bellmunt S, Mcgorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 (2 Suppl): p.e669S-690S.doi: 10.1378/chest.11-2307 . | Open in Read by QxMD
  35. Bedenis R, Stewart M, Cleanthis M, Robless P, Mikhailidis DP, Stansby G. Cilostazol for intermittent claudication. Cochrane Database of Syst Rev. 2014.doi: 10.1002/14651858.cd003748.pub4 . | Open in Read by QxMD
  36. Wiseman JT, Fernandes-Taylor S, Saha S, et al. Endovascular Versus Open Revascularization for Peripheral Arterial Disease. Ann Surg. 2017; 265 (2): p.424-430.doi: 10.1097/sla.0000000000001676 . | Open in Read by QxMD
  37. Tang Q-H, Chen J, Hu C-F, Zhang X-L. Comparison Between Endovascular and Open Surgery for the Treatment of Peripheral Artery Diseases: A Meta-Analysis. Ann Vasc Surg. 2020; 62: p.484-495.doi: 10.1016/j.avsg.2019.06.039 . | Open in Read by QxMD
  38. Arterial Ulcers. Updated: March 8, 2017. Accessed: March 8, 2017.

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer