Peripheral artery disease (PAD) affects over 200 million people worldwide, yet it remains one of the most underdiagnosed vascular conditions in India. The reason is deceptively simple: its most characteristic early symptom, leg cramping or heaviness during walking that eases with rest, is routinely dismissed as muscle fatigue, ageing, or a back problem. This misattribution delays diagnosis by an average of several years, during which arterial narrowing progresses silently toward more serious consequences.
What makes PAD particularly significant is that it is not only a leg problem. As an international group of cardiologists and vascular surgeons confirmed in updated 2024 guidelines published in ScienceDaily, PAD caused by blocked arteries in the legs is often an early sign of artery blockages in the brain and heart. Early detection and treatment of PAD greatly reduces the risk of serious conditions such as amputations, heart attacks, and stroke.
At Dr. Humayun Speciality Hospital, T. Nagar, Chennai, PAD is diagnosed and managed with the same clinical urgency as coronary artery disease, because the underlying disease process is the same.
What PAD Is and Why It Matters Beyond the Legs
Peripheral artery disease is a condition in which the arteries that supply blood to the limbs, most commonly the legs, become narrowed or blocked due to atherosclerosis. As Cleveland Clinic explains, PAD is when arteries in your limbs are narrowed, limiting blood flow, with atherosclerosis being the most common cause.
Atherosclerosis is the same process that narrows the coronary arteries in heart disease and the carotid arteries in stroke. Fatty plaque accumulates within the arterial wall, progressively reducing the lumen through which blood flows. In the legs, this reduced flow becomes symptomatic during exercise, when the muscles demand more oxygen-rich blood than the narrowed arteries can deliver.
The reason PAD demands attention beyond its local symptoms is this systemic reality: the same plaque process narrowing a femoral artery is almost certainly present in other arterial territories. A person with PAD has a significantly elevated risk of heart attack and stroke, independent of any cardiac symptoms they may or may not have. The leg is the window through which systemic atherosclerosis first becomes symptomatic.
This is confirmed by the American Heart Association's 2024 PAD guideline: early detection and coordinated, multispecialty care for PAD reduces the risk of amputation, heart attack, stroke, and death. Treating only the leg symptom without addressing the systemic cardiovascular risk misses the most important dimension of PAD management.
The Early Signs Most People Dismiss as Something Else
PAD is underrecognised because many patients have atypical symptoms or are not active enough to generate them. As confirmed by Merck Manual (revised February 2026), peripheral artery disease is underrecognised because many patients have atypical symptoms or are not active enough to have symptoms.
The early and intermediate signs of PAD include:
Intermittent claudication is the hallmark symptom. It presents as cramping, aching, heaviness, or fatigue in the calf, thigh, or buttock that consistently appears after walking a predictable distance and disappears within minutes of resting. The pattern is highly specific: the pain starts with activity and stops with rest, every time. The walking distance before pain begins (claudication distance) shortens as PAD progresses.
Cold or pale legs and feet even in warm weather, caused by reduced arterial blood flow reaching the extremities.
Decreased or absent foot pulses detectable on physical examination by a doctor palpating the dorsalis pedis and posterior tibial pulses.
Skin changes on the lower legs and feet including dry, shiny, thinning skin and slow-growing or thickening toenails, which reflect chronically reduced tissue perfusion.
Leg or foot wounds that heal slowly or not at all are a later sign indicating that tissue oxygenation is insufficient for normal wound repair.
Erectile dysfunction in men is a recognised early marker of peripheral vascular disease, sharing the same atherosclerotic mechanism affecting penile arterial blood flow.
The critical point is that many people with PAD attribute their leg symptoms to muscle strain, age-related weakness, or arthritis and never report them to a doctor. If you or someone you know experiences leg pain specifically triggered by walking and relieved by rest, this pattern warrants vascular assessment.
The 4 Stages of PAD: From Silent to Limb-Threatening
PAD is classified using the Fontaine staging system, which grades severity by the impact of reduced blood flow on the limb:
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Stage I (Asymptomatic): Arterial narrowing is present on investigation, but blood flow is sufficient for the patient's activity level. No symptoms. This stage is only detected through proactive screening in high-risk individuals using the ankle-brachial index test.
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Stage II (Claudication): Intermittent claudication begins. Stage IIa: claudication at a walking distance above 200 metres. Stage IIb: claudication within 200 metres. Most PAD presentations to clinical care occur at Stage II.
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Stage III (Ischaemic Rest Pain): Blood flow is no longer sufficient to maintain tissue oxygenation at rest. The patient experiences burning pain in the foot and toes, particularly at night and when lying down. Hanging the foot over the side of the bed temporarily improves symptoms by using gravity to increase distal perfusion.
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Stage IV (Tissue Loss): Ischaemic ulcers, gangrene, and tissue necrosis develop in the foot or lower leg. This is chronic limb-threatening ischaemia (CLTI), the most severe manifestation of PAD. Without revascularisation, limb amputation is the outcome. As the American Heart Association confirms, among those aged 65 and older, nearly 50% who underwent limb amputation died within one year after surgery.
This mortality statistic underscores why early-stage diagnosis and treatment are not optional. The trajectory from Stage II claudication to Stage IV limb loss is not inevitable, but it requires intervention to interrupt.
Risk Factors: Who Is Most Vulnerable in India
PAD shares its primary risk factors with coronary artery disease and stroke. In the Indian context, several of these are disproportionately prevalent:
- Diabetes mellitus: India carries the second-largest diabetes burden globally. Diabetes is the single most powerful risk factor for PAD in Indian patients, increasing both the risk and the severity of disease. Diabetic PAD is more likely to be asymptomatic, progress faster, and involve smaller distal arteries, making it harder to diagnose and treat.
- Smoking: A major risk factor for PAD in India, with rural and lower-income populations carrying disproportionate tobacco burden. Smoking accelerates atherosclerosis in all arterial territories and dramatically worsens claudication symptoms.
- Hypertension: Chronically elevated blood pressure damages arterial walls and accelerates plaque formation. Hypertension is highly prevalent across urban India and frequently poorly controlled.
- Dyslipidaemia (high cholesterol): Elevated LDL and low HDL cholesterol drive plaque accumulation. Dietary shifts toward refined carbohydrates and processed foods in Indian urban populations contribute significantly.
- Age above 50: PAD prevalence rises sharply from age 50 onward. Indian men and women with any of the above risk factors should consider PAD screening from this age. Chronic kidney disease: CKD independently increases PAD risk through mechanisms involving calcified, stiffened arteries.
How PAD Is Diagnosed: The Ankle-Brachial Index and Beyond
The primary diagnostic test for PAD is the Ankle-Brachial Index (ABI): a simple, non-invasive, inexpensive test performed in a clinical setting that measures the ratio of blood pressure at the ankle to blood pressure at the arm.
In a person with normal arterial circulation, blood pressure at the ankle is equal to or slightly higher than at the arm. When arteries are narrowed, blood pressure downstream of the blockage falls. An ABI of 0.9 or below confirms the presence of PAD. An ABI below 0.4 indicates severe disease consistent with chronic limb-threatening ischaemia.
As Merck Manual confirms, diagnosis is typically made by history, physical examination, and measurement of the ankle-brachial index.
Alongside the ABI, the diagnostic evaluation includes:
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Duplex ultrasound: Combines ultrasound imaging of the arterial walls with Doppler flow velocity measurements to identify the specific location and degree of arterial stenosis or occlusion. It is the primary imaging tool for anatomical mapping of PAD.
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CT angiography: Provides detailed arterial anatomy from the aorta to the foot, essential for revascularisation planning. Uses contrast dye injected intravenously.
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MR angiography: An alternative to CT angiography, particularly useful in patients with kidney impairment for whom contrast dye carries additional risk.
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Treadmill exercise testing: Measures the walking distance before claudication onset and ABI changes after exercise, providing a functional assessment of disease severity that complements resting measurements.
Peripheral Artery Disease Treatment: The Full Range
Peripheral artery disease treatment is comprehensive and follows a structured approach based on disease stage, symptom severity, and cardiovascular risk profile. The 2024 ACC/AHA guideline emphasises that treatment of all patients with lower extremity PAD includes risk factor modification and lifestyle modification, including exercise.
Lifestyle Modification and Medical Therapy
Smoking cessation is the single most impactful intervention available. Smoking cessation reduces PAD progression, improves claudication symptoms, and dramatically lowers the risk of amputation and cardiovascular events.
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Antiplatelet therapy: Aspirin (75 to 100 mg daily) or clopidogrel is recommended for all symptomatic PAD patients, reducing the risk of heart attack, stroke, and cardiovascular death associated with systemic atherosclerosis.
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Statins: High-intensity statin therapy (atorvastatin 40 to 80 mg) reduces LDL cholesterol, stabilises existing plaque, and reduces cardiovascular event risk across all PAD stages.
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Blood pressure control: ACE inhibitors or ARBs and other antihypertensives are used to maintain blood pressure below 130/80 mmHg, slowing arterial disease progression.
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Diabetes management: Optimising HbA1c in diabetic PAD patients reduces microvascular complications and the risk of infected, non-healing foot ulcers that drive amputation.
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Cilostazol: A phosphodiesterase inhibitor recommended for intermittent claudication when supervised exercise is insufficient. It improves walking distance by vasodilatory and antiplatelet mechanisms.
Supervised Exercise Therapy
Structured walking exercise is among the most evidence-supported treatments for intermittent claudication. As Merck Manual confirms, referral for supervised exercise training is recommended for patients with claudication. Patients walk to the point of moderate claudication pain, rest, and repeat, progressively extending the claudication distance over 12 weeks. Supervised exercise produces walking distance improvements comparable to angioplasty in many Stage II patients.
Endovascular Revascularisation
When medical and exercise therapy do not provide adequate relief, or when disease is at Stage III or IV, revascularisation restores blood flow mechanically.
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Percutaneous transluminal angioplasty (PTA): A balloon-tipped catheter is inserted through the femoral artery and inflated at the site of stenosis, compressing the plaque and widening the arterial lumen. Often performed with stent insertion to maintain patency.
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Drug-eluting stents and drug-coated balloons: Advanced devices that release antiproliferative medications at the treatment site to reduce the risk of re-stenosis.
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Atherectomy: Mechanical removal of plaque material from within the arterial lumen, used for heavily calcified lesions that do not respond well to balloon angioplasty.
Surgical Bypass
For patients with extensive or complex arterial occlusions not amenable to endovascular treatment, surgical bypass creates a new route for blood flow around the blocked segment. A vein graft (typically the great saphenous vein) or synthetic graft is attached above and below the obstruction. Bypass surgery is particularly relevant for long-segment femoral and popliteal occlusions in patients with limb-threatening ischaemia.
Limb Care and Wound Management
For patients at Stage III and IV, meticulous foot and limb care is as important as revascularisation. Daily inspection of the feet for early ulceration, professional wound care, offloading pressure from ischaemic wounds, and antibiotic management of infected ulcers are integral to limb salvage. A multidisciplinary approach involving vascular surgery, endocrinology, wound care nursing, and podiatry produces the best outcomes.
The Heart-Leg Connection: PAD as a Systemic Warning
This section addresses the aspect of PAD that most competitors overlook: the diagnosis in the leg is a marker of disease throughout the body.
A person diagnosed with PAD has a 20 to 60% increased risk of heart attack and stroke compared to someone without PAD, independent of other risk factors. The same atherosclerotic process building plaque in the femoral artery is active in the coronary and carotid circulations. In many patients, PAD is the first clinical manifestation of systemic atherosclerosis to produce symptoms, precisely because walking stress-tests the leg circulation in a way that does not happen automatically for the heart or brain.
This is why the 2024 ACC/AHA guideline emphasises coordinated, multispecialty management. Vascular care, cardiology review, diabetology, and nephrology working together around a PAD patient provides a level of cardiovascular risk reduction that vascular care alone cannot achieve. The leg is treated. But the system is managed.
Why Early Treatment Changes Everything
The contrast between early-stage and late-stage PAD outcomes is stark and clinically well-documented.
Stage I and Stage II PAD treated with medication, exercise, and risk factor modification prevents progression to critical limb ischaemia in the majority of patients. Claudication improves. Amputation is avoided. Cardiovascular risk is meaningfully reduced.
Stage IV PAD with tissue loss requiring amputation carries a one-year mortality of nearly 50% in older patients. For patients who survive, quality of life, mobility, and independence are dramatically reduced.
The window between these two outcomes is opened by early recognition of the symptoms, early diagnostic testing with the ABI, and early initiation of peripheral artery disease treatment. The leg pain that starts when you walk is not a message to walk less. It is a message to act now.
Vascular and Cardiology Care at Dr. Humayun Speciality Hospital, T. Nagar, Chennai
At Dr. Humayun Speciality Hospital, peripheral artery disease is evaluated and managed through an integrated approach combining vascular assessment, cardiology review, and the medical management infrastructure needed to address PAD's systemic dimensions. Services include:
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Ankle-brachial index testing as part of cardiovascular risk screening for patients with diabetes, hypertension, smoking history, or leg symptoms.
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Duplex ultrasound for arterial assessment, providing detailed localisation of stenotic segments and guiding revascularisation planning.
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Comprehensive cardiovascular risk assessment including lipid profile, blood glucose, kidney function, and ECG, addressing the systemic atherosclerosis burden that PAD represents.
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Medical management of PAD including antiplatelet therapy, statin initiation, blood pressure and diabetes optimisation, and cilostazol prescription for claudication.
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Exercise therapy programme coordination for eligible Stage II patients, with structured walking protocols and monitoring.
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Specialist referral coordination for endovascular or surgical revascularisation when indicated, with complete clinical documentation ensuring continuity of care with the treating interventional or vascular surgical team.
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