News & Events

The painful truth about PAD

By Joanne Pallotta, Tufts Medical Center Correspondent 

Here is a number you can’t ignore: 8.5 million.  If it were a lottery jackpot, you’d play, but according to the Centers for Disease Control and Prevention, 8.5 million people in the United States have Peripheral Arterial Disease (PAD)—painful muscle cramping and numbness in the lower legs or the feet that can keep you awake at night. However, ignoring the symptoms could be quite unlucky, indeed–even dangerous. 

Dr. Mark IafratiPaying attention to PAD

Peripheral Arterial Disease is the narrowing of arteries to the legs, stomach, arms and head. This most commonly affects the lower extremities because of a build-up of plaque.

“The blood needs to get from your heart to the muscles and skin in your legs,” says Mark Iafrati, MD, Chief of Vascular Surgery and the Vascular Medicine Division in the CardioVascular Center at Tufts Medical Center. If the blood doesn’t get there, it may lead to leg pain, unhealed ulcers, or even loss of limbs. There are about 200,000 major limb amputations that occur in the U.S. every year from this condition. 

Risk factors include:

  • smoking,
  • diabetes,
  • high blood pressure,
  • high cholesterol,
  • and genetics.  

Symptoms of PAD

The prevalence of PAD increases over the age of 60, but the earliest effects of PAD on the artery walls may be seen in people as young as teenagers. Blockages tend to develop slowly, over decades. Most people can tolerate up to a 50 percent blockage of a leg artery before noticing any symptoms. 

Once the blockages exceed a critical threshold, the lack of blood flow can start to cause noticeable problems. The earliest symptom of PAD is usually claudication or difficulty walking distances because of pain in the calves, thighs, or buttocks due to poor circulation.  This problem can greatly diminish a person’s walking ability and quality of life. 

More advanced PAD can cause pain when you are not on your feet.  Pain while resting is mainly in a person’s feet and can be excruciating, especially when a person is sleeping or resting horizontally.  

The most serious sign of PAD is loss of tissue—gangrene or ulcers that don’t heal. Those patients are at high risk of amputation, if not treated early.


“Visually, you might notice a lack of hair on your toes or calves,” explains Dr. Iafrati. “Hair dies off when there is insufficient circulation.  Also, legs may be cool, pale or purple and the pulse in the foot, ankle or groin is diminished.”

Detecting + diagnosing PAD

An easy, non-invasive, risk-free test for detection of PAD is the Ankle-Brachial Index (ABI). ABI compares the blood pressure in the arms to blood pressure in the ankles to detect a blockage.

For more specifics on a blockage, a physician may call for imaging: Ultrasound, CT Scan, Angiogram, or MRI. Dr. Iafrati says the most important part of the diagnosis of PAD is the medical history and physical exam.

“People who have PAD are more likely to also suffer from heart disease,” said Dr. Iafrati. “The same type of calcified or fatty deposits that build up in heart arteries can do the same in other arteries, reducing the blood’s ability to flow normally.”

Treatment + prevention

It is important to aggressively identify PAD to maximize medical therapy including daily aspirin, blood pressure management, high cholesterol therapy with a statin medication, and an exercise program.

When these efforts fall short, a vascular specialist may decide to more directly increase the blood flow to the legs.  This can be accomplished by bringing blood around the blockages with a bypass operation or by crossing the blockages and opening them with catheter based procedures.  

”In general, bypass surgery is considered the most durable procedure for lower extremity PAD, especially when a patient’s own vein is available for the bypass. We expect that about 80 percent of patients will have a functioning bypass to and beyond five years,” says Dr. Iafrati.  

Less invasive catheter-based procedures are available to cross and open blockages. In recent years there have also been significant advances in stent technology making them better able to withstand the constant flexing in the legs. Drugs attached to balloons and stents have recently been used in PAD in an effort to reduce scar formation in the treated arteries, however there are current concerns about long term safety of these drug delivering devices that are limiting utilization.  

Choosing between the various options takes into account many factors including specifics on exactly where the blockage is, how severe and long it is, as well as many patient factors such as the presence of heart disease, prior procedures, etc. 

The best advice is to do all you can to prevent PAD in the first place.  “Exercise and avoid tobacco, control blood pressure and high cholesterol,” advises Dr. Iafrati. 

The future

Fortunately, the future of treatment for patients with Peripheral Arterial Disease is bright. Dr. Iafrati has been involved in several clinical trials involving the use of cell therapy in patients with advanced tissue loss that could result in amputation. Cells from the patient’s own bone marrow or from donated placenta have shown great promise. 

“Though the individual trials are small, when you combine them, there appears to be a significant reduction in the risk of major limb amputations,” says Dr. Iafrati, noting that in one study, pain at rest was reduced, improving the patient’s life.

To make an appointment with a vascular surgeon at Tufts Medical Center, call 617-636-7761.

Posted January 2020

The above content is provided for educational purposes by Tufts Medical Center. It is free for educational use. For information about your own health, contact your physician.