Peripheral Arterial Disease

PAD may cause leg pain, reduced walking capacity, cold feet, slow-healing wounds or, in advanced cases, pain at rest and tissue loss. It is also an important marker of broader cardiovascular disease, because the same atherosclerotic process can affect the arteries supplying the heart and brain.

Assessment aims to determine where circulation is reduced, how severely daily function or tissue health is affected, and whether treatment should involve cardiovascular risk reduction, exercise, medication or a procedure to restore blood flow.

Arteries carry oxygen-rich blood from the heart to the body's tissues. PAD most commonly develops when fatty deposits, known as plaque, accumulate within the arterial walls. This process is called atherosclerosis.

As plaque builds up, the artery becomes progressively narrower. Symptoms may initially occur only during exercise, because working muscles need more oxygen. If the disease becomes more severe, circulation may be insufficient to support the tissues even at rest.

PAD can affect arteries in the abdomen, pelvis, thighs, knees and lower legs. Some people have one localised narrowing, while others have disease at several arterial levels. Symptoms do not always match the appearance of the arteries on imaging, so assessment considers both the anatomy and the effect on the individual patient.

What causes PAD?

Atherosclerosis is the most common cause. Important risk factors include smoking, diabetes, high cholesterol, high blood pressure, chronic kidney disease, increasing age, reduced physical activity and a personal or family history of cardiovascular disease.

Smoking and diabetes are particularly important because they are associated with faster disease progression, poorer wound healing and a greater risk of limb-threatening complications. Less common causes include blood clots, arterial inflammation, injury, abnormal anatomy and compression of a blood vessel.

What is intermittent claudication?

Intermittent claudication is muscle discomfort that develops during walking or exercise because the working muscles are not receiving enough blood. Patients may describe cramping, aching, tightness, heaviness, weakness or fatigue.

Calf pain is most common, although symptoms may occur in the thigh, hip or buttock depending on where the narrowing lies. The discomfort often begins after walking a fairly predictable distance and eases after resting for several minutes. As PAD progresses, that distance may become shorter.

What is rest pain?

Rest pain is a sign of more advanced arterial disease. It commonly affects the foot or toes and may be worse at night when the leg is elevated in bed.

Some people obtain temporary relief by hanging the foot over the side of the bed or standing, allowing gravity to modestly improve blood flow. Persistent rest pain requires prompt vascular assessment because it may indicate that circulation is no longer sufficient to keep the tissues healthy.

How can PAD cause wounds and ulcers?

Poor arterial circulation reduces the oxygen and nutrients available for tissue repair, so a small blister, cut or pressure area may fail to heal. Arterial wounds commonly occur on the toes, heel, outer ankle or other pressure points and may appear pale, dry, dark or sharply defined.

Severely reduced circulation associated with rest pain, ulceration or gangrene is known as chronic limb-threatening ischaemia. Treatment may be required to restore blood flow, control infection, support wound healing and preserve the limb.

Common symptoms of PAD

The most recognised symptom is leg discomfort that develops during walking and improves with rest. Other possible signs include:

• Cramping, aching or tightness in the calf, thigh or buttock
• Heaviness or fatigue in the legs when walking
• A reduced walking distance
• Coldness in one foot or lower leg
• Numbness or weakness
• Changes in skin colour
• Slow-growing toenails or reduced leg hair
• Cuts, sores or ulcers that do not heal
• Pain in the foot or toes while resting

Some people have substantial arterial narrowing without obvious pain, particularly if they are not very active or have reduced sensation from diabetes or nerve disease.

When PAD requires urgent attention

A sudden reduction in blood flow to a limb is known as acute limb ischaemia. Warning signs include sudden severe pain, pallor or blue discolouration, unusual coldness, numbness, weakness, loss of movement or an absent pulse.

Rapidly worsening foot pain, spreading infection, blackened tissue or sudden neurological loss also need urgent medical attention. Acute limb ischaemia is a medical emergency. Call Triple Zero (000) or attend the nearest emergency department rather than waiting for a routine appointment.

Assessment begins with a medical history and physical examination. Your vascular surgeon may ask about walking distance, pain at rest, wounds, smoking, diabetes, previous vascular procedures and other cardiovascular conditions. The examination may include checking pulses, skin colour and temperature, wound appearance, sensation, movement and blood pressure in the limbs.

Ankle-brachial pressure index

An ankle-brachial pressure index compares blood pressure measured at the ankle with blood pressure in the arm. A lower pressure at the ankle may indicate reduced arterial circulation.

Additional testing may be required in people with diabetes or heavily calcified arteries, because these conditions can affect the reliability of the measurement. Toe pressures or other physiological tests may provide useful additional information.

Vascular ultrasound

A duplex vascular ultrasound uses sound waves to assess blood flow and identify narrowed or blocked arteries. It is non-invasive, does not use radiation and can help determine the location and severity of disease.

Ultrasound may also be used to monitor bypass grafts, stents and previously treated arteries. Findings are interpreted alongside symptoms and examination rather than in isolation.

CT, MR and catheter angiography

CT angiography and MR angiography provide detailed images of the arterial system and may be used when more precise anatomical information is required or when a procedure is being planned.

Catheter angiography involves passing a thin tube into an artery and injecting contrast to outline the blood vessels. It is commonly performed when angioplasty, stenting or another endovascular treatment may be undertaken during the same procedure.

Treatment depends on the severity of the disease, its effect on mobility and quality of life, and whether there is rest pain, ulceration or tissue loss. Not every person with PAD requires an operation. Many can be managed through cardiovascular risk reduction, exercise, medication and careful foot care.

Cardiovascular risk reduction

PAD is associated with an increased risk of heart attack and stroke. Treatment therefore aims to protect both the affected limb and the patient's broader cardiovascular health.

Management may include smoking cessation, diabetes control, blood pressure treatment, cholesterol reduction, regular physical activity and prescribed antiplatelet or other cardiovascular medication. The plan should be individualised with the GP, vascular surgeon and other treating specialists.

Exercise therapy

A structured walking program can improve walking distance and reduce claudication symptoms. This usually involves walking until moderate discomfort develops, resting until it settles and then walking again.

Repeating this process regularly can help the muscles use oxygen more efficiently. Exercise should be adapted to the person's mobility, balance, general health and cardiovascular capacity.

Foot care and wound management

People with reduced circulation should inspect their feet regularly and seek early treatment for cuts, blisters, pressure areas or skin changes.

Appropriate footwear, podiatry, diabetes management, early infection treatment and specialist wound care may reduce complications. Compression garments should not be commenced for swelling or an ulcer until adequate arterial circulation has been confirmed.

Angioplasty and stenting

Angioplasty is a minimally invasive procedure used to widen a narrowed or blocked artery. A small balloon is guided to the affected area and inflated to improve blood flow, and a stent may then be inserted to help hold the artery open.

Other endovascular technologies may be considered depending on the length, location and nature of the blockage. Suitability also depends on the quality of the arteries above and below the diseased segment.

Bypass surgery and endarterectomy

Bypass surgery creates a new pathway for blood to travel around a blocked artery using the patient's own vein or a synthetic graft. It may be recommended when disease is extensive, when a durable reconstruction is required or when minimally invasive treatment is unlikely to give an adequate result.

An endarterectomy involves surgically opening an artery and removing plaque from within the vessel. It may suit disease in certain accessible arterial segments and can sometimes be combined with endovascular treatment.

How is the right treatment selected?

The most appropriate treatment depends on the patient's symptoms, the location and length of the blockage, the condition of the arteries above and below it, the presence of wounds or tissue loss, previous treatment, general health and the expected durability of each option.

The least invasive option is not automatically the best one for every patient. Open surgery, endovascular treatment and hybrid approaches are weighed according to anatomy, procedural risk, urgency and long-term needs.

PAD is usually a long-term condition, even after blood flow has been improved with surgery or endovascular treatment. Atherosclerosis can progress in other arteries or recur within a previously treated area.

Ongoing care may include cardiovascular medication, smoking cessation, diabetes management, regular exercise, foot checks, vascular ultrasound surveillance and review of new or returning symptoms. Long-term follow-up helps identify changes before they lead to serious complications.

Yarra Vascular Surgeons provides assessment and treatment for the full spectrum of peripheral arterial disease, from early walking-related symptoms to complex limb-threatening circulation problems.

The group's vascular surgeons are experienced in medical management, minimally invasive endovascular procedures and open vascular surgery. This allows treatment recommendations to be based on the patient's symptoms, arterial anatomy and long-term needs rather than being limited to a single procedural approach.

Access to vascular ultrasound supports diagnosis, treatment planning and ongoing surveillance, while collaborative care can assist patients with diabetes, wounds, kidney disease and other complex health conditions.

Persistent walking pain, cold feet, rest pain or a non-healing wound may indicate reduced arterial circulation. Early specialist assessment can clarify the severity of disease and determine whether monitoring, medical treatment or a procedure to improve blood flow is appropriate. Contact the clinic to arrange an appointment with an experienced vascular surgeon.