Last reviewed: 3 Nov 2021
Last updated: 23 Sep 2021



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

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
  • thickened toenails
  • shiny/scaly skin
  • pale extremity
  • nerve loss

Risk factors

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

Diagnostic investigations

Investigations 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)

Treatment algorithm



Leila Mureebe, MD, MPH, MMCi, FACS

Associate Professor of Surgery

Duke University Health Care

VA Mid Atlantic Healthcare System




LM declares that she has no competing interests.


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




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




DM declares that he has no competing interests.

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