Peripheral Arterial Occlusive Disease

Peripheral arterial occlusive disease is a common condition where narrowed arteries reduce blood flow to the legs, usually due to plaque buildup. While many people experience leg pain when walking, others have no symptoms at all—yet the condition signals important health risks that require attention.

Table of contents

• What Is Peripheral Arterial Occlusive Disease?
• Alternative Names for This Condition
• Areas of the Body Affected
• What Causes This Disease?
• Who Is at Risk?
• Signs and Symptoms
• How Doctors Diagnose the Condition
• Treatment Options
• Living With Peripheral Arterial Occlusive Disease

What Is Peripheral Arterial Occlusive Disease?

Peripheral arterial occlusive disease is a condition that occurs when the arteries that carry blood to your arms or legs—usually the legs—become narrowed or blocked^[1]. This narrowing reduces blood flow to your limbs. When your muscles don’t get enough blood during physical activity, you may feel pain or discomfort. The disease affects more than 10 million people in the United States and over 200 million adults worldwide^[4][5].

This condition is also commonly called peripheral artery disease, or PAD. The disease becomes more common as people age, affecting 12% to 20% of Americans aged 60 and older^[2]. The risk increases dramatically with age, reaching nearly 50% in people 85 years and older^[15].

Peripheral arterial occlusive disease is usually caused by atherosclerosis, which is the buildup of fatty deposits called plaque inside the artery walls^[2]. These deposits are made up of cholesterol and other fatty materials. As plaque accumulates, it gradually narrows the space inside the artery where blood flows, making it harder for blood to reach the muscles and tissues that need it^[1][5].

PAD, peripheral vascular occlusive disease (PVOD), peripheral arterial disease (PAOD), peripheral vascular disease, hardening of the arteries, peripheral atherosclerosis

Alternative Names for This Condition

Doctors and medical professionals may refer to this condition by several different names. You might hear it called peripheral artery disease (PAD), which is the most common term^[1]. Other names include peripheral vascular occlusive disease (PVOD), peripheral arterial occlusive disease (PAOD), peripheral vascular disease, or peripheral atherosclerosis^[4]. When the condition affects the lower body, it may be called lower-extremity peripheral artery disease or lower-extremity arterial occlusive disease^[5][10]. All these terms describe the same basic problem: narrowed or blocked arteries that reduce blood flow to the limbs.

Areas of the Body Affected

• Legs (most common)
• Iliac arteries (in the pelvis)
• Femoral arteries (in the thighs)
• Popliteal arteries (behind the knees)
• Tibial and peroneal arteries (in the calves)
• Abdominal aorta
• Arms (much less common)

Peripheral arterial occlusive disease most commonly develops in the arteries of the legs^[2]. The disease can affect several specific arteries, including the two branches of the aorta called the iliac arteries (located in your pelvic area), the main arteries of the thighs (femoral arteries), the arteries behind the knees (popliteal arteries), and the arteries in the calves (tibial and peroneal arteries)^[2][3].

Much less commonly, the disease develops in the arteries of the shoulders or arms^[2]. The condition may also affect the part of the aorta that passes through the abdomen or its branches^[3].

What Causes This Disease?

The primary cause of peripheral arterial occlusive disease is atherosclerosis, which is caused by a buildup of plaque in the walls of the arteries^[1][6]. Your arteries are shaped like hollow tubes with a smooth inner lining that allows blood to flow steadily. When you have this condition, plaque—made up of cholesterol, fats, and other substances—slowly forms inside your artery walls^[5].

As plaque builds up, it narrows the space where blood can flow. Calcium from your blood may also accumulate in the walls of the blood vessels, making the arteries stiff and even more narrow^[2][3]. Many plaque deposits are hard on the outside and soft on the inside. The hard surface can crack or tear, which allows small particles in your blood called platelets to gather at the site. Blood clots can then form around the plaque, making your artery even narrower^[5].

The disease may develop in two ways: gradual narrowing of an artery or sudden blockage of an artery^[2][3]. Gradual narrowing usually occurs due to atherosclerosis over time. Less commonly, arteries can be gradually narrowed by an abnormal growth of muscle in the artery’s wall, inflammation of blood vessels, or pressure from outside the blood vessel by a nearby mass such as a tumor^[2].

Sudden, complete blockage of an artery may result when a blood clot forms in an artery that is already narrowed. A sudden blockage may also occur when a clot breaks off from somewhere else, such as the heart or aorta, travels through the bloodstream, and lodges in an artery downstream^[2][3].

Who Is at Risk?

Peripheral arterial occlusive disease is common among older adults because atherosclerosis becomes more common with aging^[2][3]. The disease is more common among men than women^[2]. Black people face a higher risk compared to non-Hispanic white people, especially after age 50 in males and age 60 in females^[5].

The most significant risk factors for developing peripheral arterial occlusive disease include high cholesterol, high blood pressure, diabetes, chronic kidney disease, and smoking^[2][15]. Having three or more of these risk factors increases your chances of developing the disease by 10 times^[15].

Smoking is particularly important—it is the main risk factor for peripheral arterial occlusive disease^[7]. Smoking increases the risk of developing the condition by four times^[7]. More than 80% of patients with the disease are current or former smokers^[7].

Other factors that contribute to the development of peripheral arterial occlusive disease include having a family history of atherosclerosis, obesity, physical inactivity, and high blood levels of homocysteine (a component of protein)^[2][3][4]. Each of these factors not only contributes to the development of the disease but also to the worsening of the disease over time^[2].

Signs and Symptoms

Many people with peripheral arterial occlusive disease have no symptoms at all, especially in the early stages^[1][4]. About 40% of people with the condition have no leg symptoms^[1]. However, when symptoms do occur, they vary depending on which artery is affected, how completely the artery is blocked, and whether the artery is gradually narrowed or suddenly blocked^[2][3].

The most common symptom is leg pain when walking, called claudication, which means “to limp”^[7]. This occurs because your leg muscles don’t get enough blood during physical activity. The pain typically develops as muscle cramping, aching, or discomfort in your calves, thighs, or buttocks^[1][4]. This discomfort starts during physical activity like walking or climbing stairs and stops when you stop moving—typically within 10 minutes of rest^[1][5].

Usually, more than half of the artery’s interior has to be blocked before symptoms occur^[2][3]. The location where you feel discomfort depends on which artery is too narrow. Symptoms occur below the affected artery. If you have narrowing in your lower aorta or iliac arteries (in your pelvic area), you may feel discomfort in your buttocks, hip, or thigh. If you have narrowing in your femoral or popliteal arteries (in your thigh and knee area), you may feel discomfort in your calf^[5].

Other symptoms of peripheral arterial occlusive disease include^[1][4][5][9]:

• Coldness in the lower leg or foot, especially when compared to the other leg
• Leg numbness or weakness
• Change in skin color—the skin on your legs may turn pale, bluish, or have a shiny appearance
• Slow nail or hair growth on your legs—you may have little or no hair on the toes, feet, or lower legs
• Weak or absent pulse in the feet or legs
• Skin that is cool to the touch
• Sores or wounds on the feet, legs, or toes that heal slowly or not at all

As the disease progresses and becomes more severe, you may develop pain in your feet or toes when you’re resting, especially at night when lying flat^[1][4][5]. Dangling your leg or feet over the edge of your bed may relieve this pain^[5].

Males with narrowing of the lower aorta or iliac arteries might also experience erectile dysfunction related to peripheral arterial occlusive disease^[5].

In severe cases, you may develop sudden changes in skin color or temperature. A sudden blockage in your artery can make your skin turn purple, green, black, or very pale. Your skin may also feel cool to the touch or like “pins and needles.” These are signs of severe peripheral arterial occlusive disease and require immediate medical care^[5].

How Doctors Diagnose the Condition

To diagnose peripheral arterial occlusive disease, a healthcare professional will examine you and ask questions about your symptoms and medical history^[11]. If you have the condition, the pulse in the affected area may be weak or missing^[11].

The examination should include a complete lower-extremity evaluation and pulse examination. Your doctor will attempt to feel pulses from the abdominal aorta to the foot and will listen with a stethoscope for abnormal sounds called bruits in the abdominal and pelvic regions^[10]. When pulses cannot be felt, a handheld device called a Doppler may be used to assess circulation^[10].

A useful tool in assessing peripheral arterial occlusive disease is the ankle-brachial index (ABI), which is a simple, noninvasive way of establishing the presence of the disease^[10][11]. The ABI is calculated as the ratio of blood pressure at the ankle to blood pressure in the arm. A normal range is 0.9 to 1.1, and a value less than 0.9 indicates the presence of the disease^[10].

Current guidelines recommend resting ABI testing for patients with history or examination findings suggesting the disease^[15]. Patients with symptoms of the disease but a normal resting ABI can be further evaluated with exercise ABI testing^[15]. You may be asked to walk on a treadmill, and blood pressure readings may be taken before and right after exercising to check the arteries during walking^[11].

Blood tests are done to check for things that increase the risk of the disease, such as high cholesterol and high blood sugar^[11]. A laboratory workup is helpful for identifying accompanying problems in kidney function and elevated cholesterol levels^[10].

Several imaging tests may be used to see inside your arteries and determine the location and severity of blockages. These include^[10][11]:

• Ultrasound of the legs or feet—sound waves create pictures of how blood moves through the blood vessels. A special type called Doppler ultrasound is used to spot blocked or narrowed arteries.
• Angiography—this test uses imaging and a dye to look for blockages in the arteries. The dye is given through a blood vessel and helps the arteries show up more clearly on the images. Angiography is the most accurate arterial imaging test for diagnosis and is usually reserved for when an intervention is planned.
• Magnetic resonance angiography (MRA)—useful for imaging large and small vessels.
• Computed tomography angiography (CTA)—used to image arterial disease.

Treatment Options

The goals of treatment for peripheral arterial occlusive disease are to manage symptoms such as leg pain, improve artery health to reduce the risk of heart attack and stroke, reduce the risk of losing a limb, and improve quality of life^[11][12]. Treatment depends on how severe your disease is and what complications you may develop or already have^[12].

There is no cure for peripheral arterial occlusive disease, but lifestyle changes and medicine can help reduce the symptoms^[13][22]. These treatments can also help reduce your risk of developing other types of heart and blood vessel disease, such as heart attack or stroke^[13][22].

Lifestyle Changes

The two most important lifestyle changes you can make if you’re diagnosed with peripheral arterial occlusive disease are exercising more regularly and stopping smoking if you smoke^[13][22].

Stopping smoking is critical. Smoking is the main risk factor for the disease^[7]. Quitting smoking will reduce your risk of the disease getting worse and another serious heart or blood vessel problem developing^[13][22]. Research has found that people who smoke after receiving their diagnosis are much more likely to have a heart attack and die from a complication of heart disease than people who quit after their diagnosis^[13][22]. It is also important to avoid secondhand smoke^[12].

Exercise is one of the best treatments for peripheral arterial occlusive disease. Regular exercise helps reduce the severity and frequency of symptoms while also reducing the risk of developing another heart or blood vessel disease^[13][22]. Exercise can also boost your self-esteem, mood, sleep quality, and energy^[13][22].

Supervised exercise is recommended as one of the first steps for managing the disease^[13][22]. This may involve group exercise sessions led by a trainer. The exercise program usually involves 2 hours of supervised exercise a week for 3 months^[13][22]. Aim to exercise daily for the rest of your life, as the benefits of exercise are quickly lost if it’s not frequent and regular^[13][22].

One of the best exercises you can do is walking. It’s normally recommended that you walk as far and as long as you can before the symptoms of pain become intolerable. Then rest until the pain goes away. Begin walking again until the pain returns. Keep using this “stop-start” method until you’ve spent at least 30 minutes walking in total. Do this several times a week^[13][22].

Other important lifestyle changes include^[12][13][22]:

• Eating a balanced, heart-healthy diet that includes plenty of fruits, vegetables, whole grains, and limits saturated fats, sodium, added sugars, and alcohol
• Managing your weight—if you are overweight, losing just 3% to 5% of your current weight can help you manage some risk factors such as high cholesterol and diabetes
• Cutting down on alcohol

Medicines

Different medicines can be used to treat the underlying causes of peripheral arterial occlusive disease while also reducing your risk of developing other heart and blood vessel diseases^[13][22]. Some people may only need to take one or two of these medicines, while others may need to take several^[13][22].

Statins are prescribed if blood tests show that your levels of LDL cholesterol (sometimes called “bad cholesterol”) are high. Statins work by helping to reduce the production of LDL cholesterol by your liver^[13][22].

Antihypertensives are a group of medications used to treat high blood pressure. A common type is an angiotensin-converting enzyme (ACE) inhibitor, which blocks the actions of some hormones that help regulate blood pressure, thereby decreasing your blood pressure^[13][22].

Antiplatelet medicines help prevent blood clots. One of the biggest potential dangers if you have atherosclerosis is that a piece of fatty deposit (plaque) may break away from an artery wall and block the flow of blood^[13][22].

Your doctor may also prescribe medicine that helps get more blood to your legs and lowers your pain, which might make exercise easier^[19].

Procedures and Surgery

Surgery may be used in severe cases or when initial treatment has not effectively reduced your symptoms^[13][22]. Surgical revascularization should be considered for patients with lifestyle-limiting symptoms who have an inadequate response to lifestyle changes and medicines^[15].

Treatment options include^[6][8][11]:

Angioplasty—During this minimally invasive procedure, surgeons insert a catheter (a long, thin tube) into an artery through a small cut in your groin or arm. The catheter is guided to the narrowed artery. The catheter is then used to open the narrowed or blocked artery. Sometimes a small balloon on the catheter is inflated to stretch open the narrowed artery. Other times, catheters are used to remove plaque or place a stent (a small cylinder of metal) in the artery to help hold it open. After the procedure, you may go home the same day, or in some cases you will stay at the hospital for one or two nights.

Open bypass surgery—In a bypass operation, surgeons use a portion of a vein or artery from another part of the body to create a detour around a section of artery that has a plaque blockage inside it. The new portion of vein is attached to the partially blocked artery and blood flows through the new portion. These procedures are more invasive than angioplasty but may be more durable.

Patients with acute or limb-threatening ischemia (severely reduced blood flow) should be referred immediately to a vascular surgeon^[15].

Living With Peripheral Arterial Occlusive Disease

Peripheral arterial occlusive disease is a lifelong medical condition^[26]. Once you have been diagnosed with the disease, you will see a healthcare provider regularly who specializes in blood vessel diseases. You will need to take steps to prevent complications^[26].

Having peripheral arterial occlusive disease is a sign that your blood vessels are unhealthy. It is also a sign of a buildup of fatty deposits in the arteries, a condition called atherosclerosis^[1]. Treatment is very important because the blockages in the arteries in your legs can also affect other areas of your body, such as the arteries supplying the heart and brain^[9]. This means that having the disease makes you more likely to develop other forms of heart and blood vessel disease, such as heart attack, stroke, or heart failure^[9].

Daily Self-Care

There are several things you can do in your daily life to manage symptoms and reduce your risk of complications^[19][21][23]:

Take care of your feet and legs. People feel the disease most often in their legs, especially the calves or thighs. Check your feet and toes every day for sores, cracks, or anything that doesn’t look right. Sores may not heal well. Look for even minor problems such as scratches, blisters, or small cuts. Wear shoes that fit you well to be as comfortable as possible when you walk. It’s best to skip compression socks—they don’t help with the disease and can actually cause more harm.

Stay warm. When blood can’t flow freely, you may feel cold or numb in your legs or feet. Keeping warm can help you feel more comfortable.

Plan for rest. Incorporate breaks into your routine. If walking or standing for long periods, sit and rest. When engaging in daily activities, choose accessible locations that are easy to navigate with seating areas and short walking distances.

Eat well. A healthy diet can help improve overall circulation and reduce plaque buildup in the arteries. Focus on whole foods such as fruits, vegetables, whole grains, and lean proteins. Limit saturated and trans fats to help lower cholesterol levels. Drinking enough water is also crucial for overall health and helps maintain circulation.

Manage diabetes. Having poorly controlled diabetes can make your symptoms worse and raise your chances of developing other forms of heart and blood vessel disease. It’s important to manage your diabetes properly, which may involve lifestyle changes and taking medicines to lower your blood sugar level^[13][22].

Mental Wellbeing

Peripheral arterial occlusive disease can cause severe pain and disrupt your life. The condition can affect not only physical health but also mental well-being. If you’re dealing with depression or anxiety, it’s important to access support to look after your mental wellbeing^[13][22].

Seeking Support

Living with the disease can sometimes feel isolating. It is essential to seek support and stay informed about the condition. Connecting with others who understand the challenges can provide valuable encouragement and insight^[23]. Consider joining a support group where individuals share their experiences and coping strategies. Stay in touch with your healthcare providers—regular check-ups can help monitor the condition and adjust treatment plans. Educating yourself about the disease through resources like pamphlets, websites, and community seminars can empower you to make informed decisions about your health.

Warning Signs of Complications

Peripheral arterial occlusive disease can lead to serious complications. Learn the warning signs of a medical emergency related to the disease^[26]:

• Acute limb ischemia—a sudden drop in blood flow to your leg is a serious medical emergency. Call emergency services or seek medical help right away if you suddenly lose feeling in your foot and cannot move it and if it is blue or paler and colder than the other foot.
• Critical limb ischemia—chronic poor blood flow in your leg can lead to pain during rest, sores, infections, and death of tissue called gangrene because of lack of blood flow. Gangrene is a severe complication that may require amputation (surgical removal) of the affected body part.
• Serious infections—these can develop as a result of sores on your feet that get infected. Infections in the foot can usually be treated with antibiotics, but you may have to be treated in the hospital if the infection is serious.

If the blood flow to the legs becomes severely restricted, critical limb ischemia can develop. Symptoms include a severe burning pain in your legs and feet that continues even when you’re resting; your skin turning pale, shiny, smooth, and dry; wounds and sores on your feet and legs that do not heal; and changes in skin color on your toes or lower limbs^[9]. If you think you’re developing these symptoms, contact a healthcare provider immediately^[9].