Last reviewed: July 2020
Last updated: November  2018



History and exam

Key diagnostic factors

  • asymptomatic
  • intermittent claudication
  • thigh or buttock pain with walking that is relieved with rest
  • diminished pulse
  • sudden onset of severe leg pain accompanied by numbness, weakness, pale and cold leg
  • no pulse in lower extremity

Other diagnostic factors

  • erectile dysfunction
  • pain worse in one leg
  • 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
  • trauma

Diagnostic investigations

Investigations to consider

  • toe-brachial index (TBI)
  • segmental pressure examination
  • duplex ultrasound
  • pulse volume recording
  • continuous wave Doppler ultrasound
  • exercise ABI
  • angiography
  • CT angiogram
  • Magnetic resonance angiography (MRA)
More investigations to consider

Treatment algorithm


Associate Professor of Medicine

Division of Cardiology

University of Colorado School of Medicine

Director, Interventional Cardiology

Director, Vascular Laboratory

VA Eastern Colorado Healthcare System




EA is an advisory board member for Abbott Vascular, Boston Scientific, Medtronic, and Philips.

Dr Ehrin Armstrong would like to gratefully acknowledge Dr Kosmas I. Paraskevas, a previous contributor to this monograph. KIP is an author of references cited in this monograph.

Peer reviewersVIEW ALL

Assistant Professor

Division of Cardiovascular Medicine

University of Kentucky




KZ declares that he has no competing interests.

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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