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Peripheral arterial disease

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
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Evidence last reviewed: 7 Sep 2026
Topic last updated: 07 Oct 2026

Summary

Definition

History and exam

Key diagnostic factors

  • asymptomatic
  • intermittent claudication
  • thigh or buttock pain with walking that is relieved with rest
  • diminished or absent pulse
  • sudden onset of severe leg pain accompanied by numbness, weakness, pale and cold leg
Full details

Other diagnostic factors

  • erectile dysfunction
  • leg pain at rest
  • gangrene
  • nonhealing wound/ulcer
  • muscle atrophy
  • dependent rubor
  • pallor when the leg is elevated
  • loss of hair over the dorsum of the foot
  • nail bed changes
  • shiny/scaly skin
  • pale extremity
  • nerve loss
Full details

Risk factors

  • smoking
  • diabetes
  • hypertension
  • hyperlipidemia
  • age >40 years
  • history of coronary artery disease/cerebrovascular disease
  • low levels of exercise
  • chronic kidney disease (CKD)
  • elevated C-reactive protein (CRP)
  • hyperhomocysteinemia
  • vasculitis/inflammatory conditions
  • arterial fibrodysplasia
Full details

Diagnostic tests

1st tests to order

  • ankle-brachial index (ABI)
Full details

Tests to consider

  • toe-brachial index (TBI)
  • segmental pressure examination
  • pulse volume recording
  • duplex ultrasound
  • continuous wave Doppler ultrasound
  • exercise ankle-brachial index (ABI)
  • catheter angiography
  • CT angiogram
  • magnetic resonance angiography (MRA)
Full details

Treatment algorithm

ACUTE

acute limb ischemia

ONGOING

claudication (not lifestyle-limiting)

claudication (lifestyle-limiting)

chronic limb-threatening ischemia (CLTI)

Contributors

Authors

Robert J. Beaulieu, MD, MSE

Clinical Associate Professor in Surgery

Department of Surgery, Section of Vascular Surgery

University of Michigan

Ann Arbor, MI

Disclosures

RJB has had travel sponsored by Endologix to visit manufacturing facilities of their aortic endograft.

Acknowledgements

Dr Robert J. Beaulieu would like to gratefully acknowledge Dr Leila Mureebe, Dr Ehrin Armstrong and Dr Kosmas I. Paraskevas, previous contributors to this topic.

Disclosures

EA is an advisory board member for Abbott Vascular, Boston Scientific, Medtronic, and Philips. EA and KIP are both authors of references cited in this topic.

Peer reviewers

Khaled Ziada, MD

Assistant Professor

Division of Cardiovascular Medicine

University of Kentucky

Lexington

KY

Disclosures

KZ declares that he has no competing interests.

Debabrata Mukherjee, MD

Gill Foundation Professor of Interventional Cardiology

Director of Cardiac Catheterization Laboratories

Gill Heart Institute

Division of Cardiovascular Medicine

University of Kentucky

Lexington

KY

Disclosures

DM declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J. 2024 Sep 29;45(36):3538-700.Full text  Abstract

Writing Committee Members; Gornik HL, Aronow HD, Goodney PP, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol. 2024 Jun 18;83(24):2497-604.Full text  Abstract

Norgren L, Hiatt WR, Dormandy JA, et al; TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(suppl S):S5-67.Full text  Abstract

Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014 Jan;59(1):220-34;e1-2.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

  • Differentials

    • Spinal stenosis
    • Arthritis
    • Venous claudication
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  • Guidelines

    • Management of peripheral artery disease in adults with diabetes: 2025 ACC scientific statement: a report of the American College of Cardiology
    • Society for Vascular Surgery clinical practice guideline on the management of intermittent claudication: focused update
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  • Patient information

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  • Calculators

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