Peripheral Arterial Disease

The arteries in your legs carry oxygen-rich blood to your muscles and feet. When they narrow, the blood supply falls short – causing pain on walking and, in severe cases, skin ulcers or gangrene.

Peripheral Arterial Disease

Peripheral arterial disease (PAD), also called leg artery disease, is a narrowing of the arteries that supply your legs. It is caused by plaque (cholesterol and calcium) building up in the artery walls and hardening them – a process called atherosclerosis. It becomes more common with age – especially over 50, and more so after 70 – and smoking and diabetes bring it on sooner.

As the arteries narrow, your legs get less blood and oxygen. This can cause pain on walking and, in severe cases, sores or gangrene.

PAD is also an important warning sign: the same plaque often affects the arteries to the heart and brain. So treating PAD matters not only to protect your legs, but to lower your risk of a heart attack or stroke.

Vascular Disease: An Overview

Symptoms

Claudication
Many people have no symptoms at all. The most common symptom, when it occurs, is intermittent claudication – cramp, ache, heaviness or tiredness in the legs that comes on with walking and eases with rest. It often starts sooner uphill or on stairs, and over time after shorter distances.

Chronic limb-threatening ischaemia (CLTI)
This is the advanced stage (previously called critical limb ischaemia), where the leg is short of blood even at rest. It can cause pain in the feet or toes at rest, sores (ulcers) that will not heal, or gangrene (dead tissue), and needs prompt treatment.

Sudden pain, coldness, numbness or weakness in a leg is different – it may be acute limb ischaemia, an emergency.

Causes

PAD is caused by atherosclerosis. Your risk rises with age (especially over 50) and is higher in men. Other things that raise your risk:

Smoking
Diabetes
High blood pressure
High cholesterol
Being overweight

Tests

I begin by asking about your symptoms and health, and feeling the pulses in your legs and feet.

Ankle-brachial pressure index (ABPI)
Compares the blood pressure at your ankle with that in your arm; a lower ankle reading points to narrowed leg arteries.

Duplex ultrasound
A painless scan that shows blood flow and locates the blockages.

Other scans
Pulse-volume recordings, an MRA (magnetic resonance angiogram) or angiography (dye and x-rays) may be used to map the disease in detail, usually when planning a procedure. Blood tests check your cholesterol and other risk factors.

Treatment Options

Optimal Medical Therapy

A structured walking programme is the most effective non-surgical treatment: regular walking, ideally supervised, trains your legs to walk further with less pain. Stopping smoking is essential.

Medication protects your arteries: an antiplatelet (aspirin or clopidogrel) to lower the risk of heart attack, stroke and clots, a statin for cholesterol, and treatment for your blood pressure and diabetes. In selected patients, a low dose of the blood thinner rivaroxaban (2.5 mg twice a day) added to aspirin further lowers the risk of heart attack, stroke and serious leg complications, at the cost of more bleeding (COMPASS and VOYAGER PAD trials). Cilostazol may modestly improve how far you can walk; it must not be used if you have heart failure.

Endovascular

For more advanced disease, angioplasty and stenting may be advised. A thin tube (catheter) is passed from an artery in the groin or arm to the narrowed area, where a small balloon widens the artery. A small mesh tube (stent) may be left in place to hold it open. It is less invasive than open surgery, and blood then flows more freely.

Surgery

Endarterectomy
Through an incision in the leg, I remove the plaque from the lining of the artery, opening it up and restoring blood flow.

Bypass surgery
A graft – one of your own veins or a fabric tube – is used to route blood around the blocked section, creating a new path to your leg.

Choosing between bypass and a keyhole procedure
For severe disease that threatens the leg (chronic limb-threatening ischaemia), the BEST-CLI trial found that bypass using a good-quality vein from your own leg gave better results than an endovascular procedure. Angioplasty remains a good choice for many patients, particularly when no suitable vein is available or surgery carries a high risk. I will discuss which option suits your arteries and general health.

Amputation
This is a last resort, considered only when the circulation is too poor to restore and the tissue cannot be saved. Seen early by a vascular specialist, many people with gangrene can avoid a major amputation, or limit it to a small part of the foot or toes.

Exercise Program for Peripheral Arterial DiseaseApproach to Superficial Femoral Artery Disease

General Guidelines

Day-to-day steps that help control PAD and protect your heart and brain:

Stop smoking
Walk regularly – aim for at least 30 minutes, most days
Control diabetes, blood pressure and cholesterol
Eat a Mediterranean-style diet
Keep to a healthy weight

References
European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg, 2024.
Society for Vascular Surgery Clinical Practice Guideline on the Management of Intermittent Claudication: Focused Update. J Vasc Surg, 2025.
Anand SS, Bosch J, Eikelboom JW, et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease (COMPASS). Lancet 2018;391(10117):219–229. doi:10.1016/S0140-6736(17)32409-1
Bonaca MP, Bauersachs RM, Anand SS, et al. Rivaroxaban in Peripheral Artery Disease after Revascularization (VOYAGER PAD). N Engl J Med 2020;382(21):1994–2004. doi:10.1056/NEJMoa2000052
Conte MS, Bradbury AW, Kolh P, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019;58(1S):S1–S109. doi:10.1016/j.ejvs.2019.05.006
Farber A, Menard MT, Conte MS, et al. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia (BEST-CLI). N Engl J Med 2022;387(25):2305–2316. doi:10.1056/NEJMoa2207899

Patient Roadmap for Femoropopliteal Bypass SurgeryFemoro-popliteal Bypass - Informed ConsentFemoro femoral Bypass - Informed ConsentPostoperative Protocol - Femoro-Popliteal Bypass

Our Services

Arterial Procedures

Standard open arterial surgical procedures to repair or reconstruct blood flow to extremities.

Femoropopliteal bypass
Femoral endarterectomy
Femoropopliteal thrombectomy
Femorotibial bypass

Endovascular Procedures

When a procedure is needed – for claudication that remains disabling despite exercise and medication, or for limb-threatening disease – these less invasive procedures are often the first choice, particularly when no suitable vein is available for bypass.

Angioplasty with / or without stent of
Superficial femoral artery
Popliteal artery
Tibial arteries

Peripheral arterial catheter directed thrombolysis

Hybrid Procedures

Combined endovascular and open surgical procedures are selectively utilised to repair or restore blood flow to the extremities.

Femoral endarterectomy with peripheral angioplasty
Femoropopliteal thrombectomy with peripheral angioplasty with /or without stent

If you have any problems with any of these conditions, please contact your General Practitioner, or your Vascular Surgeon. If you live in Pretoria and have not seen a Vascular Surgeon before, you are more than welcome to contact our rooms for a formal consultation.