What is PAD?

The arteries in your legs carry oxygen and nutrient-rich blood from your heart to your arms and legs. Peripheral artery disease is a buildup of plaque in those arteries. This makes it harder for your blood to carry oxygen and nutrients to the tissues in those areas, which limits their ability to function at capacity.

“Our arteries have a smooth lining that prevents blood from clotting and promotes steady blood flow,” says Cleveland Clinic internal and vascular medicine specialist G. Jay Bishop, MD, who sees patients on the West Side at Cleveland Clinic Richard E. Jacobs Health Center at Richard E. Jacobs Campus in Avon; he also practices at Cleveland Clinic main campus, Twinsburg and Willoughby Hills family health centers, and Mentor Medical Office Building. “When you have peripheral artery disease, plaque – made of fat, cholesterol and other substances – gradually forms inside your artery walls and slowly narrows your arteries. That plaque is also known as atherosclerosis.”

PAD is similar to coronary artery disease (blockage in arteries that supply blood to the heart muscle) and carotid artery disease (blockage in arteries leading to the brain). With PAD, it's the arteries leading to areas outside the brain and heart that become blocked, including the neck, arms and belly, but most often the legs and feet.

While PAD affects between 8 and 12 million Americans, it often goes undiagnosed and untreated.

Treatment of PAD

If you have PAD, you may be referred to a vascular medicine specialist or a vascular surgeon.

Vascular medicine specialists are often best able to help with risk factor modification, including blood pressure, lipid and antithrombotic regimens. In addition, they provide comprehensive medical management of patients before and after open surgical and endovascular procedures by vascular surgeons.

Vascular surgeons specialize in the surgical treatment of all types of peripheral vascular disorders, including minimally invasive and open surgery procedure for aneurysms and obstructive arterial disease.

“Many patients with PAD never require surgery,” says vascular surgeon W. Michael Park, MD, who treats patients at Richard E. Jacobs Health Center and West Valley Medical Building. “When they do, vascular medicine specialists and vascular surgeons work together to provide cohesive service for patients.”

Vascular Medicine Specialists

Vascular Surgeons

Symptoms of PAD

“Half of people with PAD have no symptoms, but the most typical symptom of PAD is muscle pain in your leg, called claudication. This occurs because your leg muscles aren’t getting enough oxygen,” says Cleveland Clinic vascular surgeon J. Eduardo Corso, MD, who treats patients at Richard E. Jacobs Health Center in Avon and West Valley Medical Building in Fairview Park.

“In early stages of PAD, the pain occurs with activity and goes away with rest. In later stages, the pain can limit your ability to do daily activities and you may also have pain while resting or at night.”

Advanced PAD can lead to the development of non-healing sores on the legs or feet; the sores can turn into gangrene and possibly lead to amputation of the foot or leg. Left untreated, PAD can also lead to other serious health problems including heart attack, stroke and kidney disease.

Contact your healthcare provider if you:

• Get a bad infection in a sore on your foot. The infection can expand into your muscles, tissues, blood and bone. If your infection is severe, you may need to go to the hospital.
• Can’t walk around enough to do day-to-day activities.
• Have pain in your legs when you’re resting. This is a sign of poor blood flow.

Diagnosis of PAD is conducted using a simple test to check the pulses in your feet to determine whether blood flow is normal. An ankle brachial index test uses blood pressure cuffs to compare the pressure in the lower leg with that in the arm. If ankle pressure is half your arm pressure or lower, it could be a sign that your leg arteries are narrowed.

Go to the emergency department for immediate help if you can’t feel or move your foot or if it looks different from your other foot’s skin color. This means you’ve lost blood flow to your leg without warning.

PAD risk factors

“Individuals with heart disease have a 1 in 3 chance of having PAD. People with diabetes and those who use tobacco products are also at high risk of developing PAD,” says Leben Tefera, MD, an internal and vascular medicine specialist at Richard E. Jacobs Health Center and Cleveland Clinic main campus. “Uncontrolled diabetes and resulting high blood sugar levels can make artery walls rough, leading to plaque buildup. Of people with PAD, 80% currently smoke or are former smokers.”

Other risk factors for PAD include:

• Age 50 or older.
• Being African American.
• Personal or family history of heart or blood vessel disease.
• High blood pressure.
• High cholesterol.
• Abdominal obesity.
• Blood clotting disorders.
• Kidney disease.

Medical treatment of PAD

“With early diagnosis, lifestyle changes and treatment, you can stop PAD from getting worse,” says Dr. Corso. “When I’m not doing surgery, 80% of my time in the office is spent trying to convince people to stop smoking. Other lifestyle changes include eating a balanced diet, following a regular exercise program, managing stress levels and practicing good foot and skin care.”

Supervised exercise programs can improve the symptoms of pain in your legs with walking, allowing you to walk farther. A structured program typically includes walking on a treadmill in a supervised setting at least three times per week.

Medications to help control high blood pressure (antihypertensive medications), lower cholesterol and manage diabetes are also key to treating the risk factors of PAD and reducing risk of stroke and heart attack. Cilostazol may also be prescribed to allow you to exercise or walk longer before developing leg pain.

Antiplatelet and anticoagulant medications such as aspirin, Plavix® (clopidogrel) or Xarelto® (rivaroxaban) are often used to treat PAD. These have the added benefit of reducing the risk of stroke and heart attack in patients with PAD.

Minimally invasive or surgical treatments

When advanced PAD causes severe pain and limited mobility, endovascular (minimally invasive) or endarterectomy (traditional open surgical removal of plaque from a blood vessel) surgical treatment may be needed.

“Minimally invasive surgeries include balloon angioplasty and stenting to open up space in an artery, and atherectomy to remove plaque buildup using a catheter with a blade.” Lower extremity or peripheral artery bypass surgery — similar to a heart bypass — is used to create a new route for blood flow around the blocked area in a leg artery,” says Dr. Park.

In some situations, surgeons may group minimally invasive treatments, for example, performing atherectomy in combination with a balloon or stent.

“As with any surgery, recovery varies by procedure and individual. Atherectomy patients may need just a few days to recover, while it can take six to eight weeks to recover from an open endarterectomy procedure,” says vascular surgeon Roy Miler, MD, who treats patients at Richard E. Jacobs Health Center and West Valley Medical Building.